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PCM 2 > PCM 2 Exam 2 > Flashcards

PCM 2 Exam 2 Flashcards

1
Q

What should you ALWAYS do before taking a radiograph?

A
  • 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
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2
Q

What are the commonly ordered view for a chest x-ray?

A
  • PA or AP<br></br>- lateral<br></br>- portable
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3
Q

What are the commonly ordered view for an upper or lower extremity x-ray?

A
  • AP<br></br>- Lateral <br></br>- Oblique
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4
Q

What are the commonly ordered view for an abdominal x-ray?

A
  • supine<br></br>- upright<br></br>- decubitus<br></br>- AAS
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5
Q

What are the commonly ordered view for a pelvic x-ray?

A
  • AP (inlet/outlet)<br></br>- Lateral<br></br>- Frog-leg
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6
Q

What are the commonly ordered view for a skull/facial bone x-ray?

A
  • Frontal<br></br>- Lateral<br></br>- Upright water’s <br></br>- Nasal views
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7
Q

What are the commonly ordered view for a cervical spine x-ray?

A
  • AP<br></br>- Lateral<br></br>- Oblique<br></br>- Flexion/extension<br></br>- open-mouth
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8
Q

What are the commonly ordered view for a thoracic or lumbar x-ray?

A
  • AP<br></br>- Lateral<br></br>- Oblique
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9
Q

What are the commonly ordered view for a sacral x-ray?

A
  • AP pelvis views<br></br>- CT is ideal modality<br></br>- MRI if neurologic injuries
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10
Q

What are the 5 different radiodensities?

A
  • air<br></br>- fat<br></br>- soft tissue<br></br>- bone<br></br>- metal
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11
Q

Which CXR view does NOT magnify the cardiac silhouette?

A

PA view

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12
Q

What are abdominal x-rays commonly used for?

A
  • evaluate intestines for any foreign objects, bowel obstruction, etc<br></br>- kidney stones can also be seen on abdominal x-rays
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13
Q

What are the patterns of plain old misdiagnosis?

A
  • normal anatomy and variants
    pattern recognition failure
    associated pathology
    suboptimal positioning and number of projections
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14
Q

What clue on a plain film radiograph of an extremity indicates that it is a child?

A

presence of a growth plate

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15
Q

What can x-rays of bones be useful for?

A
  • fracture<br></br>- tumors<br></br>- infections of joint spaces<br></br>- arthritis<br></br>- dislocations
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16
Q

How does computed tomography work?

A
  • 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
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17
Q

What are hounsfield units?

A
  • 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
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18
Q

What is CT windowing?

A
  • allows evaluation of each organ within a single image<br></br>- i.e. subdural window, brain window (parenchyma), bone window, etc
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19
Q

What is important for the clinician to know on a CT scan?

A
  • slice thickness<br></br>- location of first and last slices<br></br>- type of contrast agent
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20
Q

How is the view of the CT read?

A

looking up from the feet

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21
Q

How can CT images be reformatted?

A

can make coronal, saggital, oblique, or 3D images

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22
Q

What is CT angiography?

A
  • similar to conventional angiography<br></br>- same information, but much less invasive <br></br>- similar use of radiation and IV contrast
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23
Q

What color is water on T1 MRI images?

A

black

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24
Q

What color is water on T2 MRI images?

A

”- white<br></br>- ““WWII = white water on 2”””

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25
Q

What are the advantage of MRI?

A
  • greater differentiation of soft-tissue structures<br></br>- acquire in any plane<br></br>- can get vascular study w/out IV contrast (TOF imaging)
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26
Q

What are the disadvantages of MRI?

A
  • longer time of acquisition<br></br>- motion artifact is VERY sensitive (respiration and cardiac in chest and abdomen imaging)
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27
Q

What are the advantages of ultra sound?

A
  • 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
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28
Q

What are the disadvantages of ultra sound?

A
  • 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
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29
Q

Which radiographs have concerns during pregnancy?

A
  • 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
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30
Q

What is the definition of CKD?

A
  • 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
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31
Q

What defines acute kidney injury?

A

any of the CKD criteria that is present for <3 months

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32
Q

What is stage 1 CKD?

A
  • GFR ≥90 (normal)<br></br>- in the absence of evidence of kidney damage, this does not fulfill the criteria for CKD alone
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33
Q

What is stage 2 CKD?

A
  • GFR 60 - 89 (mild decrease)<br></br>- in the absence of evidence of kidney damage, this does not fulfill the criteria for CKD alone
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34
Q

What is CKD stage 3a and 3b?

A
  • 3a is a GFR 45-59 (mild to moderate decrease)<br></br>- 3b is a GFR 30-44 (moderate to severe decrease)
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35
Q

What is CKD stage 4?

A

GFR of 15-29 (severe disease)

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36
Q

What is stage 5 CKD?

A

GFR <15 (kidney failure/ESRD)

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37
Q

What is A1, A2, and A3 categories of persistent albuminuria?

A
  • 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)
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38
Q

What is considered low risk CKD using GFR and albuminuria?

A

G1 or G2 GFR with A1 albuminuria category

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39
Q

What is considered moderately increased risk CKD using GFR and albuminuria?

A
  • G1 or G2 GFR with A2 albuminuria category<br></br>- G3a GFR with A1 albuminuria category
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40
Q

What is considered high risk CKD using GFR and albuminuria?

A
  • G3b GFR with A1 albuminuria category<br></br>- G3a GFR with A2 albuminuria category <br></br>- G1 or G2 GFR with A3 albuminuria category
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41
Q

What is considered very high risk CKD using GFR and albuminuria?

A
  • 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
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42
Q

What are the major risk factors for CKD?

A
  • 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
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43
Q

What is the clinical presentation of CKD?

A
  • 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)
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44
Q

What are the three simple tests to identify CKD in most patients?

A
  • eGFR<br></br>- Urine albumin-to-creatinine ratio or urine protein-to-creatinine ratio<br></br>- urinalysis
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45
Q

What are the real ultrasound findings for CKD?

A
  • atrophic or small kidneys<br></br>- cortical thinning<br></br>- increased echogenicity <br></br>- elevated resistive indices
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46
Q

How does GFR change as you age?

A

GFR declines by 1 ml/min/year after the age of 30-40

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47
Q

What are some of the complications of CKD?

A
  • 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
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48
Q

What are the majority of causes of death in ESRD patients?

A

CVD disorders

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49
Q

What are the indications for dialysis?

A

AEIOU<br></br>- Severe Acidosis<br></br>- Electrolyte disturbance<br></br>- Ingestion<br></br>- Volume overload<br></br>- Uremia

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50
Q

What is azotemia?

A

elevated BUN w/out Sx

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51
Q

What is Uremia?

A

elevated BUN w/Sx (N/V, confusion, pruritus, metallic taste in mouth, fatigue, etc)

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52
Q

What is stage 1 AKI?

A
  • 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
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53
Q

What is stage 2 AKI?

A
  • 2.0 - 2.9 times baseline<br></br>OR<br></br>- <0.5 ml/kg/h for ≥12 hours
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54
Q

What is stage 3 AKI?

A
  • 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
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55
Q

What are the major risk factors for AKI?

A
  • 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
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56
Q

Which drugs account for >75% of all acute interstitial nephritis cases?

A
  • Antibiotics<br></br>- NSAIDs<br></br>- PPI’s
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57
Q

What are the complications of AKI?

A
  • development of CKD<br></br>- progression of CKD<br></br>- ESRD<br></br>- CVD
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58
Q

What is the common diagnostic test for AKI?

A
  • <b>urinalysis with urine microscopy</b><br></br>- <b>Urina albumin/cr ratio or urine protein/cr ratio</b><br></br>- Renal U/S
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59
Q

What is the purpose of ordering a FeNa or FeUrea?

A

to differentiate prerenal azotemia from intrinsic renal injury

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60
Q

What is anuria, oliguria, and polyuria?

A
  • Anuria is <50-100 ml/day<br></br>- Oliguria is <400 to 500 ml/day<br></br>- Polyuria is >3000 ml/day
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61
Q

Which type of patients can FeNa or FeUrea tests be ordered for?

A
  • 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
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62
Q

What should be on the DDX for eosinophiluria?

A
  • AIN<br></br>- Pyelonephritis or UTI<br></br>- atheroembolic renal disease<br></br>- various glomerulonephritides <br></br>- CKD
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63
Q

What is the treatment of AKI?

A
  • 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
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64
Q

Which labs are included in a CBC?

A
  • <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>
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65
Q

What labs are included in a CBC with differential?

A

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

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66
Q

Which labs are included in a BMP?

A
  • 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
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67
Q

What labs are included in a CMP?

A

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

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68
Q

“In the ““X”” what are the lab values that make up the top, bottom, left, and right?”

A
  • 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
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69
Q

In the -|-|-

A

”- 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 “”

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70
Q

What is the purpose of ordering a BMP?

A

used to monitor kidney function, electrolytes, acid-base and fluid balance

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71
Q

What does BUN increase in?

A
  • 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&raquo_space;10) typically due to an obstructive uropathy
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72
Q

What does BUN decrease in?

A
  • decreased production in severe liver disease and malnutrition<br></br>- dilution states (SIADH, third trimester pregnancy)
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73
Q

What are sodium levels important in?

A

neurological disorders (seizures, trauma)

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74
Q

What is the osmolar gap?

A
  • 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)
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75
Q

What are the three types of hyponatremia?

A
  • 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)
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76
Q

What is hypernatremia common in?

A
  • 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
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77
Q

What are some causes of hyperkalemia?

A
  • pseudohyperkalemia due to hemolysis, prolonged tourniquet application during venipuncture<br></br>- reduced excretion<br></br>- Cellular shifts <br></br>- Medications that decrease RAAS
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78
Q

What are some causes of hypokalemia?

A
  • 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
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79
Q

When would you order a CMP?

A

usually when you suspect a liver dysfunction, however it does also include, Mg, PO4, and Ca

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80
Q

What is calcium important in?

A

Important in cardiac dysrhythmias

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81
Q

What makes up total calcium?

A

Protein-bound calcium + free ionized calcium

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82
Q

What is hypercalcemia most commonly caused by?

A

hyperparathyroidism or malignancy

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83
Q

What is hypocalcemia most commonly caused by?

A
  • hypoalbuminemia and hypomagnesemia<br></br>- may also be caused by CKI, vit-D deficiency, acute pancreatitis, rhabdomyolysis
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84
Q

What is corrected calcium?

A

[0.8 X (4.0mg/dL - measured pt albumin)] + serum Ca++

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85
Q

What diseases/symptoms is magnesium useful in measuring?

A
  • cardiac dysrhythmias <br></br>- neuromuscular irritability <br></br>- patients taking medications causing electrolyte abnormalities (loop and thiazide diuretics, digitalis, aminoglycosides, pentamidine, cyclosporine, cisplatin)
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86
Q

Which liver enzyme is specific to the liver?

A

ALT

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87
Q

What amylase and lipase levels are highly specific for pancreatitis?

A
  • amylase > 3X the normal upper limits<br></br>- lipase 5X the normal upper limits
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88
Q

What are non-pancreatic causes for elevated amylase/lipase?

A
  • Both: renal failure<br></br>- Lipase: cholecystitis, perforated peptic ulcer<br></br>- Amylase: intestinal perforation, ischemia, obstruction, DKA, rupture ectopic pregnancy
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89
Q

Which test is most specific for myocardial infarction?

A
  • <b>Troponin I</b><br></br>- earlier tests included CK, CK-MB, LDH, AST, and myoglobin
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90
Q

When is troponin I detectable and when does it peak?

A
  • detectable 1-6 hours after onset of cardiac chest pain<br></br>- Peaks at 12-16 hours and remain elevated for 5-9 days
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91
Q

What other conditions can lead to an increased troponin I level?

A
  • myocarditis<br></br>- cardiac surgery<br></br>- angina<br></br>- unstable angina<br></br>- CHF<br></br>- renal failure<br></br>- pulmonary embolism
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92
Q

What is BNP?

A
  • 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
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93
Q

What is a d-dimer test?

A

used to rule-out DVT or PE in low risk patients

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94
Q

What is a PT and PTT?

A
  • PT tests function of the extrinsic pathway<br></br>- PTT tests function of the intrinsic pathway
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95
Q

What does a UA test for?

A
  • glucose<br></br>- ketones<br></br>- specific gravity<br></br>- protein<br></br>- myoglobin <br></br>- RBCs, WBCs<br></br>- casts
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96
Q

Presence of what indicates a UTI in a UA?

A
  • nitrates<br></br>- leukocyte esterase<br></br>- WBCs<br></br>- bacteria
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97
Q

What is a fecal occult blood test used for?

A

detect hidden (occult) blood loss in stool

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98
Q

What is an arterial blood gas used for?

A
  • access the adequacy of ventilation and perfusion<br></br>- provides critical information about acid/base status
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99
Q

How does aspirin toxicity usually present?

A
  • mixed acid-base disturbance<br></br>- early respiratory alkalosis followed by an elevated anion gap metabolic acidosis and possibly late respiratory acidosis
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100
Q

What is CRP used for?

A
  • 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
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101
Q

What is ESR elevated in?

A
  • inflammatory states<br></br>- rates >100 mm/hr are strongly associated with serious underlying disease
102
Q

What is the definition of vaccine and vaccination?

A
  • 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
103
Q

What is the definition of immunization?

A

the process whereby a person is made immune or resistant to an infectious disease by artificial or natural means

104
Q

What are the two main benefits of vaccination?

A
  • individual immunity<br></br>- herd immunity
105
Q

What are the benefits of herd immunity?

A
  • 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
106
Q

What can happen if community vaccination rates drop below the threshold of herd immunity?

A

widespread disease outbreaks can occur

107
Q

What are the benefits of vaccinating?

A
  • 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
108
Q

What is active immunization?

A
  • 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
109
Q

What is passive immunization?

A
  • transfer of immunity to a host using pre-formed immunologic products like immunoglobulins or products of the cellular immune system
110
Q

What is passive immunization useful for?

A
  • 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
111
Q

What are the potential complications for human IG?

A

rare, but transient hypotension and pruritus, occasional hypersensitivity rxn

112
Q

What are the potential complications from animal IG?

A
  • potential for anaphylaxis to serum sickness<br></br>- must test for hypersensitivity to animal serum prior to administration
113
Q

What are credible internet sources for child and adolescent vaccination schedules?

A
  • 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)
114
Q

What are credible internet sources for adult vaccination schedules?

A
  • ACIP<br></br>- AAFP<br></br>- ACOG<br></br>- ACP (American college of physicians)<br></br>- ACNM (American college of nurse-midwives)
115
Q

What are subunit/conjugate vaccines?

A
  • 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
116
Q

What are live attenuated vaccines?

A
  • 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
117
Q

What are inactivated vaccines?

A
  • organism is carefully killed either thermally or chemically <br></br>- immunogenicity is retained, though
118
Q

What are inactivated toxins/toxoid vaccines?

A
  • 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
119
Q

What are examples of conjugate vaccines?

A
  • meningococcal<br></br>- pneumococcal<br></br>- Hib<br></br>- Hepatitis B<br></br>- Influenza (injection)<br></br>- HPV
120
Q

What are examples of inactivated/killed vaccines?

A
  • Hepatitis A<br></br>- Polio<br></br>- Rabies
121
Q

What are examples of live, attenuated vaccines?

A
  • MMR<br></br>- Varicella<br></br>- Rotavirus<br></br>- Influenza (nasal spray)<br></br>- Zoster
122
Q

What are examples of toxoid vaccines?

A
  • tetanus<br></br>- diphtheria
123
Q

What are 4 vaccine myths?

A
  • 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
124
Q

What is an endemic?

A
  • 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
125
Q

What is the purpose of a primary and booster vaccine?

A
  • 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
126
Q

How do you take a history when a patient comes in for a wellness visit?

A
  • complete a normal history<br></br>- include a full social history<br></br>- include an in depth family medical history
127
Q

What makes up the evidence pyramid?

A

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

128
Q

What is the purpose of using evidence based medicine?

A
  • 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
129
Q

What are the 4 categories of preventative service?

A
  • screening<br></br>- immunizations<br></br>- general health guidance<br></br>- counseling to reduce risk
130
Q

What is primary prevention?

A
  • intervention to prevent disease <br></br>- vaccines<br></br>- diet counseling, tobacco counseling etc
131
Q

What is secondary prevention?

A
  • 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
132
Q

What is tertiary prevention?

A
  • 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
133
Q

What USPSTF grades are recommended and should be offered?

A

grade A or B

134
Q

Which USPSTF grade should be offered in select patients?

A

grade C

135
Q

Which USPSTF grade is discouraged against using?

A

Grade D

136
Q

What can the agency for healthcare research and quality be used for?

A

determine which services are considered USPSTF grade A or B for a patient

137
Q

What is the purpose of a wellness visit?

A

used to appropriately treat current medical conditions and also provide preventative care in an effort to decrease health deterioration in the future

138
Q

What is the clinical rule of thumb for when wellness checkups are recommended?

A
  • every 3 years for <49 years old without chronic medical conditions<br></br>- every 1 year for >50 years old without chronic medical problems
139
Q

What is the general rule for colon cancer screening in males and females?

A

males and females should receive a colonoscopy from age 50-75

140
Q

What is the general rule for a lung cancer screen males and females?

A

both should receive a low dose lung CT for ages 55-74 years old with at least a 30 pack year history of smoking

141
Q

What is the general rule for cervical cancer screening?

A

Pap smear aged 21-65 years old

142
Q

What is the general rule for breast cancer screening?

A
  • mammogram age 50-65 years old<br></br>- varies, and can start as early as 40 based on the organization recommending,
143
Q

What should you screen for when screening for cardiovascular risk?

A
  • diet<br></br>- smoking<br></br>- physical activity<br></br>- HTN<br></br>- dyslypidemia <br></br>- DM<br></br>- Obesity
144
Q

When should you screen for cardiovascular risk factors?

A
  • ≥20 years old should undergo CV risk every 3-5 years<br></br>- more frequently if Patience’s has risk factors
145
Q

How frequently should you receive a Tdap vaccine?

A

every 10 years

146
Q

When should you receive the HPV vaccine?

A

up to age 26

147
Q

What should you receive the zoster vaccine?

A

50 years and older

148
Q

What should you receive the pneumococcal vaccine?

A

19-64 year olds at increased risk, all ≥65 years old

149
Q

When should adults receive the hepatitis B vaccine?

A

65 years old and older with diabetes, or anyone at an increased risk

150
Q

What does OARS stand for in motivational interviewing?

A
  • 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
151
Q

What is the effect of counseling in tobacco use?

A
  • 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
152
Q

How do you counsel on nutrition and exercise?

A
  • 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
153
Q

What is unique about motivational interviewing?

A
  • Patient-oriented<br></br>- goal-directed<br></br>- non-confrontational<br></br>- no scare tactics, persuasion, or threats
154
Q

What are the general techniques of motivational interviewing?

A
  • open-ended question<br></br>- Affirmations<br></br>- Reflective listening<br></br>- Summaries
155
Q

What is the precontemplation stage of change?

A
  • 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
156
Q

What is the physician’s goal with a patient that is in the precontemplation stage?

A
  • 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
157
Q

What is the contemplation stage?

A

patient is considering the possibility of making changes, but still uncertain

158
Q

What is the physician’s goal during the contemplation stage?

A
  • 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
159
Q

What is the preparation stage?

A

patient is committed to making a change in the near future, but still considering what to do

160
Q

What is the physician’s goal during the preparation stage?

A
  • 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
161
Q

What is the action stage?

A

patient is actively making changes

162
Q

What is the physician’s goal during the action stage?

A
  • 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
163
Q

What is the maintenance stage?

A

patient has made the change

164
Q

What is the physician’s goal during the maintenance stage?

A
  • reinforce and support changes<br></br>- give affirmations<br></br>- develop a plan for any regression
165
Q

What should be documented in a SOAP note for a patient here with a lifestyle change undergoing motivational interviewing?

A
  • 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
166
Q

What would contemplation look like in a smoking cessation case?

A

I’m thinking of quitting smoking, but I’m not sure I want to

167
Q

What would preparation look like in a case?

A

“I want to change ““xyz””, but I just don’t know how to do it”

168
Q

What would action look like in a case?

A

I have quit smoking for about 2 weeks, but now that I’m stressed I want to smoke again

169
Q

What would maintenance look like in a case?

A

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

170
Q

What are the steps in a type 1 hypersensitivity?

A
  • 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
171
Q

What are examples of a type 1 hypersensitivity?

A
  • pollen allergies<br></br>- dust mite allergies<br></br>- bee sting
172
Q

What is a type 2 hypersensitivity?

A
  • IgM or IgG antibody destroys cells by…<br></br>- opsonization<br></br>- complement-mediated lysis<br></br>- or antibody-dependent cellular cytotoxicity
173
Q

What are examples of a type 2 hypersensitivity?

A
  • ABO mismatch<br></br>- Grave’s disease<br></br>- Myasthenia gravis
174
Q

What is the mechanism of myasthenia gravis?

A

antibodies to ach receptor which prevents each from binding

175
Q

What is a Type III hypersensitivity reaction?

A
  • 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
176
Q

What are examples of a Type III hypersensitivity?

A
  • SLE<br></br>- RA<br></br>- Farmer’s lung
177
Q

What is a type IV hypersensitivity reaction?

A
  • 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
178
Q

What are examples of a type IV hypersensitivity?

A
  • poison ivy rash<br></br>- PPD testing for TB
179
Q

What is rheumatoid arthritis?

A
  • 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
180
Q

What is the clinical presentation of a patient with RA?

A
  • 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
181
Q

How is OA differentiated from RA?

A
  • 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
182
Q

What is the treatment for RA?

A
  • DMARDs (disease-modifying anti-rheumatic drugs)<br></br>- NSAIDs<br></br>- Steroids<br></br>- PT
183
Q

What are the risks associated with RA?

A
  • 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
184
Q

What is juvenile idiopathic arthritis?

A
  • 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
185
Q

What is the presentation of a JIA patient?

A
  • 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)
186
Q

How is JIA diagnosed?

A
  • CBC<br></br>- ESR<br></br>- RF/ANA<br></br>- X-rays<br></br>- synovial fluid shows leukocytosis and elevated protein
187
Q

What is the treatment for JIA?

A
  • NSAIDs<br></br>- Steroids<br></br>- Methotrexate<br></br>- anti-TNF therapy<br></br>- stretching<br></br>- morning baths<br></br>- weight-bearing exercises
188
Q

What is Systemic lupus erythematosus?

A
  • 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
189
Q

What are the manifestations of SLE?

A
  • 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
190
Q

What are three major differentiating factors for SLE and RA?

A
  • 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
191
Q

What is the treatment and prognosis for SLE?

A
  • 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
192
Q

What is psoriasis?

A
  • chronic, hyper proliferative inflammatory disorder characterized by thick adherent scales<br></br>- same in males and females
193
Q

What is the presentation of psoriasis?

A
  • 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)
194
Q

What is the treatment for psoriasis?

A
  • topic steroids<br></br>- topical vitamin D analogs<br></br>- UV light<br></br>- systemic immunosuppression
195
Q

What are the complications of psoriasis?

A
  • 7-48% of patients have psoriatic arthritis <br></br>- higher frequency or CVD, malignancy, DM, HTN, metabolic syndrome, IBD, serious infections, other autoimmune disorders
196
Q

What is MS?

A
  • demyelinating disease of the CNS<br></br>- females > males<br></br>- peak incidence 20-40 years old
197
Q

What is the presentation of MS?

A
  • 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
198
Q

What is the treatment for MS?

A
  • immunomodulatory <br></br>- immunosuppression <br></br>- IV steroids for acute exacerbations<br></br>- PT
199
Q

What is the prognosis of MS?

A
  • 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
200
Q

What is an example of a T-cell primary immunodeficiency?

A
  • 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
201
Q

What is an example of a primary B-cell immunodeficiency?

A
  • 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
202
Q

What is an example of a T-cell and B-cell combined primary immunodeficiency?

A
  • 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
203
Q

What is an example of a phagocytic primary immunodeficiency?

A
  • 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
204
Q

What is the presentation of HIV?

A
  • 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
205
Q

How is HIV diagnosed?

A
  • ELISA screen<br></br>- Western blot confirmation <br></br>- HIV RNA viral load
206
Q

What is the treatment for HIV/AIDS?

A
  • highly active antiretroviral therapy<br></br>- prophylaxis of opportunistic infections
207
Q

What is the AIDS diagnosis criteria?

A
  • CD4 count <200 cells/mm3<br></br>or<br></br>- Presence of an AIDS-defining illness like cytomegalovirus, mycobacterium aviumintracullulare, candidal esophagitis, etc
208
Q

What are food sources of vitamin A?

A
  • eggs, dairy, meat, oily salt-water fish<br></br>- <b>dark green and yellow vegetables, and tomatoes</b>
209
Q

What are food sources of vitamin D?

A
  • fortified milk, orange juice and cereal, cod liver oil, swordfish, salmon, herring, trough, egg yolks<br></br>- <b>mushrooms</b>
210
Q

What are food sources of Vitamin E?

A
  • <b>wheat germ, avocado</b><br></br>- sunflower seeds, almonds, peanuts, sunflower oil. abalone, Atlantic salmon, rainbow trout
211
Q

What are food sources of vitamin K?

A
  • green leafy vegetables, fruits, dairy products, vegetable oils and cereals<br></br>- intestinal microbiota
212
Q

What are food sources of vitamin B1?

A
  • whole and enriched grains, lean pork<br></br>- <b>legumes</b>
213
Q

What are food sources of B2?

A
  • dairy products, meat, poultry<br></br>- <b>wheat germ, leafy vegetables</b>
214
Q

What are sources of B3?

A
  • meats, poultry, fish<br></br>- <b>legumes, wheat</b>
215
Q

What are sources of B6?

A

animal products, vegetables, and whole grains

216
Q

What are sources of B9?

A

raw leafy vegetables, fruits, whole grains, wheat germ, beans, nuts

217
Q

What are sources of B12?

A
  • eggs, dairy, liver, meats<br></br>- <b>none in plants</b>
218
Q

What are sources of vitamin C?

A

fruits and vegetables

219
Q

What are sources of calcium?

A
  • dairy products, flax seed, beans, and lentils<br></br>- <b>dark leafy green vegetables, tofu, broccoli, cauliflower</b>
220
Q

What are sources of iron?

A
  • nuts seeds, quinoa, fortified cereal, lean meat, clams, oysters, dried prunes and raisins<br></br>- <b>Dark leafy vegetables, broccoli, cauliflower, lentils, tofu</b>
221
Q

What is the metabolic role of retinol, retinal?

A

vision

222
Q

What is the metabolic role of retinoic acid?

A
  • embryonic development<br></br>- maintenance of epithelia<br></br>- cell growth, proliferation, and differentiation
223
Q

What is the metabolic role of cholecalciferol?

A

bone metabolism and calcium homeostasis

224
Q

What is the metabolic role of tocopherols?

A

ROS scavenger

225
Q

What is the metabolic role of vitamin K?

A

blood clotting ( II, VII, IX, X)

226
Q

What is the metabolic role of B1 (thiamine)?

A

carbohydrate metabolism, amino acid metabolism

227
Q

What is the metabolic role of B2 (riboflavin)?

A

oxidoreductases, FMN, FAD

228
Q

What is the metabolic role of B3 (niacin)?

A

Oxidoreductases, NAD, NADP

229
Q

What is the metabolic role of B6 (pyridoxine)?

A
  • carbohydrate, lipid, and AA metabolism<br></br>- synthesis of neurotransmitters, sphingolipids, and heme
230
Q

What is the metabolic role of B9 (folate)?

A
  • one-carbon-transfer reactions<br></br>- choline synthesis of AA<br></br>- synthesis of purines and pyrimidine (thymine)
231
Q

What is the metabolic role of B12 (cobalamin)?

A

heme structure, folate recycling

232
Q

What is the metabolic role of vitamin C?

A

antioxidant function, collagen synthesis, bile acid synthesis, neurotransmitter synthesis

233
Q

What is the metabolic role of calcium?

A
  • muscle contraction<br></br>- cell transport<br></br>- bone metabolism
234
Q

What is the metabolic role of iron?

A
  • Hemoglobin<br></br>- myoglobin<br></br>- cytochromes a, b, and c
235
Q

How do you counsel patients on food choices?

A
  • 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
236
Q

How should you counsel patients on exercise?

A
  • 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
237
Q

What are some exam findings of a pt with a vitamin C deficiency?

A
  • 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
238
Q

What is the recommended amounts of vegetables, fruits, grains, dairy, protein, and oils per day?

A
  • 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
239
Q

What is the Mediterranean diet?

A
  • 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
240
Q

What deficiency are vegetarian vegan diets are at risk for?

A

B12 (cobalamin)

241
Q

What is the recommended daily intake of salt?

A

<b>2300 mg/day</b>

242
Q

What does salt/sodium free, very low sodium, and low sodium label mean?

A
  • 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
243
Q

What does reduced sodium mean?

A

25% less sodium that in the original product

244
Q

What does light in sodium mean?

A

50% less sodium than the original product

245
Q

What does no salt added or unsalted mean?

A

no salt was added during processing, does NOT mean there is no sodium in the product

246
Q

What could help increase the absorption of a fat soluble vitamin (A, E, D, and K)?

A

increase the fat ingested with the vitamin

247
Q

What nutritional deficiency results in night blindness?

A

vitamin A

248
Q

How does a vitamin A deficiency lead to night blindness?

A

epithelial metaplasia

249
Q

How many pounds will a 500 calorie deficit per day result in?

A

1 pound per week

250
Q

How many fruits and vegetables should you eat per day?

A

6-9/day

251
Q

What leads to a successful team approach to weight loss?

A
  • dietician or nurse counselor<br></br>- regular check-in with provider<br></br>- integrate family/friends into changes for a support system

PCM 2 (2 decks)

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