Periodic Health Exam Flashcards
What is primary prevention
identify risk factors for common diseases; counsel patients to promote healthy
behaviour
What is secondary prevention
presymptomatic detection of disease to allow early treatment and to prevent
disease progression
What is strength of recommendation vs quality of evidence?
Strength of recommendation - ex. strong is when there is a high level of confidence that the desirable effects outweigh the undesirable effects (or vice versa for evidence against)
Quality of evidence - high means there is a high level of confidence that the true effect lies close to the estimate of the effect
What are the recommendations for folic acid supplementation in pregnancy?
• To prevent neural tube defects in all women
capable of becoming pregnant
• Low risk women (no personal health risks,
planned pregnancy):
0.4-1.0 mg daily folic acid supplementation for at least 2-3 mo before conception and throughout
pregnancy and postpartum period
• High risk women (health risks including
epilepsy, insulin dependent diabetes, BMI
>35, family history of NTD, high risk ethnic
group):
at least 3 mo prior to conception until 10-12 wk post conception: daily supplementation with multivitamins with 5 mg folic acid
• From wk 12 post-conception until
postpartum period (4-6 wks or as long as
breastfeeding continues):
0.4-1.0 mg of folic acid supplementation is sufficient
• Women with additional lifestyle issues (poor compliance with medications, no consistent birth control, taking possible teratogenic substances): higher folic acid dose of 5 mg and counselling about
prevention of birth defects
Periodic health exam therapy provided for general population
Folic acid supplementation to women of child-bearing
age
Pharmacologic treatment of HTN (Refer to CHEP Guidelines)
Varicella vaccine for children age 1-12 and susceptible
adolescents/adults
Rubella vaccine for all non-pregnant women of child-bearing age unless there is proof of immunity via immunization records or serology
Tetanus vaccine: routine booster q10yr if had 1° series
Pertussis vaccine: adults <65 should receive one booster
given as Tdap– Adacel® or Boostrix®
Herpes zoster vaccine for adults ≥60
PHE therapy provided for pediatric population
Routine immunizations, Hepatitis B, HPV and Meningococcal immunizations are offered in schools in
most Canadian provinces
PHE therapy provided for high risk TB population
INH prophylaxis for household contacts or skin test converters
INH prophylaxis for high risk sub-groups
PHE therapy provided for Immunocompromised, Age≥65, COPD, Asthma, CHF, Asplenia, Liver Disease, Renal Failure or DM
Pneumococcal vaccine (Pneumovax)
PHE investigations that should be done for pediatric patients
Routine hemoglobin for high risk infants
Blood lead screening of high risk infants
What are the Canadian Task Force guidelines for breast cancer screening for average risk women
Mammography
• age 40-49: none
• age 50-74: routine screening q2-3yr
• age 75+: screen on a case by case basis
MRI
• no routine
Clinical Breast Examination
• no routine
Breast Self-Examination
• no routine
What does the Canadian Task Force consider average risk women for breast cancer screening
Women age 40-74 with no personal history of breast cancer, history of breast cancer in 1st degree relatives, known mutations of the BRCA1/BRCA2 genes or previous exposures of the chest wall to radiation
Canadian Task Force lung cancer screening guidelines
• apply to adults aged 18 and older who are not suspected of having lung cancer
• annual screening with low dose CT for adults aged 55-74 with at least a 30 pack-year smoking history
who currently smoke or quit less than 15 years ago, up to three consecutive times
Colorectal screening guidelines
• recommendations for average risk individuals (asymptomatic, no family history of UC, polyps, or CRC)
• average risk testing should begin at age 50, but assessment for risk factors should begin earlier to
identify high-risk individuals
◆ FIT q2yr OR flexible sigmoidoscopy q10yr
◆ no colonoscopy as a screening test
◆ no screening after age 75 is recommended for average risk patients, but it may be assessed on an
individual basis for ages 76-85
What is the approach to higher risk screening for colorectal cancer
See FM 4
Cervical screening tests that can be used
either conventional Papanicolaou (Pap) smear or liquid based cytology testing
What types of cells are sampled in cervical cancer screening
endocervical and exocervical cell sampling (aim is to sample the transitional zone)
What type of abnormalities is cervical cancer screening best at identifying
best identifies squamous cell abnormalities, less reliable for glandular abnormalities
What is the false positive and false negative rate for cervical cancer screening for a single test
■ false positives 5-10%
■ false negatives 10-40% (for single test)
■ false negative rate 50% for existing cervical cancer
What is the effect of PSA screening for prostate cancer on mortality
PSA-based screening significantly reduced
prostate cancer-related mortality but did not affect all-cause mortality.
What are the Ontario guidelines for cervical cancer screening
■ screen all women age ≥21 who are or have ever been sexually active (includes intercourse or digital/
oral activity with partner of either sex)
■ if cytology is normal, can screen every 3 yr
■ women age ≥70: if 3 successive negative Pap tests in last 10 yr, can discontinue screening
■ women who are not sexually active by age 21 should delay cervical cancer screening until sexually
active
■ pregnant women and women who have sex with women should follow the routine cervical screening
regimen
• women who have had a hysterectomy
■ total: discontinue screening if hysterectomy was for benign disease and no history of cervical dysplasia or HPV infection, continue to swab vaginal vault if history of uterine malignancy/dysplasia
■ subtotal: continue screening according to guidelines
• exceptions to guidelines
■ immunocompromised (transplant, steroids, diethylstilbestrol exposure, HIV)
■ previously unscreened patients
Decision making chart on next steps for cervical cancer screening
FM5
Canadian Task Force prostate cancer screening guidelines
No routine
What are the stages of change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Recommendations for Vitamin D intake in Canada
- 800-1,000 IU for individuals age <50 yr
- 800-2,000 IU for individuals ≥50 yr
• Adults living in Canada should consider taking Vitamin D supplementation of 1,000 IU a day during the fall and winter
• Adults at higher risk of having lower Vitamin D levels should consider taking Vitamin D supplementation of 1,000 IU/d all year round.
This includes people: who are older, with dark skin, who do not go outside often, and who wear clothing that covers most of their skin
• Babies who are exclusively breast-fed:
400 IU/d
Recommendations for calcium intake in Canada
• 1,000 mg daily from all sources for individuals 19-50 yr and pregnant/lactating women
• 1,200 mg daily for individuals >50 yr (recommended to obtain calcium from nutrition whenever possible
vs. supplementation)
Alcohol consumption recommendations
≤3 drinks/d for men, max 15/wk
≤2 drink/d for women, max 10/wk
Salt consumption recommendations
≤2,400 mg/d
What are normal waist circumference cut offs
Men >102 cm (40 in)
Women >88 cm (35 in)
What is the MOA of Orlistat
Orlistat: gastrointestinal lipase inhibitor,
reduces fat absorption by 30% by inhibition
of pancreatic lipase
What is a practice recommendation for the use of Orlistat that is important to keep in mind when prescribing
• Orlistat is associated with several adverse
effects and not approved for clinical use
longer than 2 yr
In what populations should Orlistat be avoided
• Orlistat should be avoided in people with
inflammatory or chronic bowel disease
Indications for pharmacotherapy in weight loss
BMI ≥27 kg/m2 + risk factors
or
BMI ≥30 kg/m2
Indications for bariatric surgery in weight loss
BMI ≥35 kg/m2 + risk factors
or
BMI ≥40 kg/m2
What are signs of hyperlipidemia that can be seen on physical exam?
• Atheromata: plaques in blood vessel walls
• Xanthelasmata: a sharply demarcated
yellowish deposit of cholesterol underneath
the skin, usually on or around the eyelid
• Tendinous xanthoma: lipid deposit in
tendon (especially Achilles)
• Eruptive xanthoma: hypertriglyceridemia
induced reddish yellow, pruritic, and painful
papular or nodular rash
• Lipemia retinalis: thin atheromata seen in
the retinal blood vessels
• Corneal arcus (arcus senilis): lipid deposit
in cornea
When can LDL not be calculated
LDL cannot be calculated when
TG ≥4.5 mmol/L
In what population and how often should lipid screening be completed
q1-3yr
males >40 yr
females >50 yr or who are menopausal
any age for adults with additional dyslipidemia risk factors
What is a factor that doubles the risk calculated by the Framingham Risk Score
family history of CVD <55 male relative or <65 in female relative
What treatment decision thresholds should be used for a moderate risk patient with LDL-C <3.5
Shifted to apo B >1.2 g/L or nonHDL C >4.3 mmol/L
What is a risk of prescribing fibrates and statins
Use with caution when prescribing combined
statin and fibrate therapy as there has been
concern regarding the safety of certain
combinations (potential increased risk of
myopathy and rhabdomyolysis)
What is a risk of using statins and what weight does it hold in prescribing decisions
Trials have shown that statin therapy slightly
increases the incidence of diabetes; however the
absolute risk is small. Relative to the reduction in
coronary events, the clinical significance is not
great enough to recommend against their use.
What is the meaning of the Framingham Risk Score
gender-specific algorithm used to estimate the 10-year cardiovascular risk (coronary heart disease) of an individual
In what population and how often should the Framingham Risk Score be calculated
Repeat screening every 5 years for FRS <5% or every year for FRS ≥5%
to be completed for men age 40-75, and women age 50-75 q3-5yr
What is the Framingham risk score calculation based off of
gender
age
HDL-C
total cholesterol
sBP
smoking
DM
What patients require no pharmacotherapy for dyslipidemia?
Low risk (FRS <10%)
What patients require primary prevention methods to manage dyslipidemia?
Intermediate Risk: FRS 10-19% and LDL-C ≥3.5 mmol/L or Non-HDL ≥4.3 mmol/L or ApoB ≥1.2 g/L or Men≥50 and women ≥60 with 1 additional risk factor: low HDL-C, impaired fasting glucose, high waist circumference, smoker, hypertension
High Risk:
FRS ≥20%
or
alternative method
What are statin indicated conditions in dyslipidemia
Clinical atherosclerosis
Abdominal aortic aneurysm
Most diabetes including:
Age ≥40 yr
Age ≥30 yr and 25 yr duration (type 1 DM)
Microvascular disease
Chronic kidney disease
LDL-C ≥5 mmol/L
genetic dyslipidemia
What is the LDL target for patients with an LDL 5+?
LDL-C >50% reduction
What is the LDL target for patients with an LDL <5?
LDL-C <2.0 mmol/L
or >50% reduction
or apoB <0.8 g/L
or non-HDL-C <2.6 mmol/L
What is your approach to management for patients with dyslipidemia?
- Discuss behavioural management
- Smoking cessation
- Diet: adopt a health dietary pattern
- Exercise: for adults 150 min/wk of moderate-vigorous aerobics - Initiate Statin Treatment: Treat to Target Approach (confirm adherence and barriers to use)
- If target achieved monitor response to tx and health behaviours
- If target not achieved with maximally tolerated dose discuss add-on therapy with patient (evaluate reduction in CVD risk vs. additional cost & side effects)
1st line: Ezetimibe (BAS as alternative)
2nd line: PCSK9 inhibitors (add-on to other drugs)
What is the extent of improvement that can be seen with health behaviours in LDL level
Can decrease LDL-C by up to 10%
When should pharmacotherapy (timeline wise) in patients with dyslipidemia
Employ consistent lifestyle modifications for at least 3 mo before considering drug therapy
High risk patients should start treatment immediately with concurrent health behaviour interventions
What is the extent of improvement that can be seen with pharmacological therapy in LDL level
can decrease LDL-C by up to 40%
What is the clinical definition of metabolic syndrome
- Central obesity
Men – waist circumference ≥94 cm
Women – waist circumference ≥80 cm - Plus any TWO of the following four factors
TG level ≥1.7 mmol/L (150 mg/dL)
HDL-C level:
Men <1.0 mmol/L (40 mg/dL)
Women <1.3 mmol/L (50 mg/dL)
Blood pressure ≥130/85 mmHg
Fasting glucose level ≥5.6 mmol/L (100 mg/dL)
What is the mechanism of action of a statin
HMG-CoA reductase inhibitors
What are the potential adverse effects of statins
myopathy and hepatotoxicity
What is the MOA of ezetimibe
cholesterol absorption inhibitor
What effect on LDL is usually seen with ezetimibe
19% reduction in LDL-C
What medications should be used in individuals with dyslipidemia post acute coronary syndrome
Cholesterol absorption inhibitors (e.g. ezetimibe) in addition to simvastatin reduced mortality, attained lipid targets <1.8, and improved outcomes in high risk
individuals
What monitoring should take place when a patient is placed on a statin
◆ ALT, CK, creatinine at baseline then 6 wk later for signs of transaminitis or myositis
tolerate rise in CK up to 10 times upper limit of normal vs 2-3 times if symptomatic, or serum creatinine
rise of ≤25%
◆ no routine repeated measures of ALT and CK necessary in asymptomatic patients using statin
therapy
◆ if adequate response is achieved, evaluate fasting lipids q6-12mo
What is the effect of isolated hypertriglyceridemia on cardiovascular risk
does not increase cardiovascular risk
What are the management strategies of hypertriglyceridemia
• principal therapy is lifestyle modification
• drug therapy
■ nicotinic acid
■ fibrates
What is severe hypertriglyceridemia (>10 mmol/L) associated with
■ severe hypertriglyceridemia (typically >10 mmol/L) is associated with an increased risk of acute
pancreatitis
What is the purpose of drug therapy in hypertriglyceridemia
Used to prevent pancreatitis, NOT cardiovascular disease!
What is the single most preventable cause of premature illness and death
smoking
What are the 5 A’s for patients willing to quite smoking
Ask if the patient smokes Advise patients to quit Assess willingness to quit Assist in quit attempt Arrange follow up
What are the symptoms of nicotine withdrawal
low mood, irritability, anxiety insomnia, restlessness difficulty concentrating decreased heart rate increased appetite
What is the 2-3 pattern of smoking cessation
- Onset of withdrawal is 2-3 h after last cigarette
- Peak withdrawal is at 2-3 d
- Expect improvement of withdrawal symptoms at 2-3 wk
- Resolution of withdrawal at 2-3 mo
- Highest relapse rate within 2-3 mo
How can you help patients develop a quit plan
STAR Set quit date Tell family and friends (for support) Anticipate challenges (e.g. withdrawal) Remove tobacco-related products (e.g. ashtrays/lighters)
When should NRT be used with caution
Immediately post-MI
serious/worsening angina
Serious arrhythmia
What should be advised for patients using NRT
NO smoking while using NRT
What is the MOA of Varenicline
Partial nicotinic receptor agonist (to reduce cravings) and partial competitive nicotinic receptor
antagonist (to reduce the response to smoked nicotine)
What is the most effective type of NRT available
All commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation.
They increase the rate of quitting by 50-70% regardless of setting and independent on the level of additional support provided to the smoker.
Compared to a single form of NRT, combining a nicotine patch with a rapid delivery form of NRT may be more effective.
Nicotine gum dosing
2 mg if <25 cig/d
4 mg if >25 cig/d
1 piece q1-2h for 1-3 mo (max 24 pieces/d)
Nicotine gum instructions
Chew until “peppery” taste then “park” between
gum and cheek to facilitate absorption
Continue to chew-park intermittently for 30 min
Nicotine gum side effects
Mouth soreness Hiccups Dyspepsia Jaw ache Most are transient
Nicotine patch dosing
Use for 8 wk
21 mg/d x 4 wk
14 mg/d x 2 wk
7 mg/d x 2 wk
Start with lower dose if <10 cig/d
Nicotine patch instructions
Change patch q24h and alternate sides
Nicotine patch side effects
Skin irritation
Insomnia
Palpitations
Anxiety
Nicotine inhaler dose
6-16 cartridges/d
up to 12 wk
Where is product of nicotine inhaler absorbed
Nicotine inhaled through mouth, absorbed in mouth
and throat not in lungs
Nicotine inhaler and nasal spray side effects
Local irritation
Coughing
Buproprion MOA, side effects, dosage, prescribing and contraindications
Inhibits re-uptake of dopamine and/or norepinephrine
Side effects: insomnia, dry mouth
- 150 mg qAM x 3 d
- Then 150 mg bid x 7-12 wk
- For maintenance consider 150 mg bid for up to 6 mo
- Decide on a quit date
- Continue to smoke for first 1-2 wk of treatment and then completely stop (therapeutic levels reached in 1 wk)
Seizure disorder, eating disorder
MAOI use in past 14 d
Simultaneous use of bupropion (Wellbutrin®) for depression
Varenicline MOA, side effects, dosage, prescribing and contraindications
Partial nicotinic receptor agonist, and partial nicotinic receptor competitive antagonist
Side effects: nausea, vomiting, constipation, headache, dream disorder, insomnia, increased risk of psychosis, depression, suicidal ideation
- 0.5 mg qAM x 3 d
- Then 0.5 mg bid x 4 d
- Continue 1 mg bid x 12 wk ± additional 12 wk as maintenance
- Decide on a quit date
- Continue to smoke for first wk of treatment and then completely stop
Caution with pre-existing psychiatric condition (stable depression is not a contraindication)
What are standard drink equivalents
One standard drink = 14 g of pure alcohol • Beer (5% alcohol) = 12 oz • Wine (12-17% alcohol) = 5 oz • Fortified wine = 3 oz • Hard liquor (40%) = 1.5 oz
What laboratory investigations are important to monitor in a patient with alcohol abuse history
- AST, ALT (usually AST:ALT approaches 2:1 in an alcoholic)
- CBC (anemia, thrombocytopenia)
- INR (decreased clotting factor production by liver)
What is the MOA of disulfiram (Antabuse)
impairs metabolism of alcohol by blocking conversion of acetaldehyde to acetic acid, leading to flushing, headache, N/V, hypotension if alcohol is ingested (available in U.S., but no longer available in Canada)
What is the MOA of naltrexone
competitive opioid antagonist that reduces cravings and pleasurable effects of drinking
may trigger withdrawal in opioid-dependent patients
What is the MOA of acamprosate
glutamate receptor modulator that also reduces craving
What are pharmacological measures that can be used for patients with alcohol abuse issues
Diazepam for withdrawal
Disulfiram
Naltrexone
Acamprosate
Outline the continuum of alcohol use
- Abstinence
- Low Risk Drinking
<2 drinks/d
<10 drinks/wk for women
<15 drinks/wk for men - At Risk Drinking
Consumption above low-risk level but no alcohol-related physical or social problems
4. Alcohol Use Disorder Physical or social problems Continued use despite consequences Inability to fulfill life roles Legal problems No evidence of dependence
- Alcohol Use Disorder
