PreTest Family Medicine: "Chronic Complaints" Flashcards
The most common cause of failure to achieve an erection in a man who has an intact sexual desire is ____________.
vascular problems
Mood disorders, stressors, and alcohol can play a role, but vascular disorders are more common.
When should you test the levels of testosterone in a man with sexual complaints?
If the man complains of decreased sexual interest and has a normal physical exam and no risk factors for other causes of sexual dysfunction in his history (e.g., no bitemporal hemianopsia, no headaches, no history of head trauma or irradiation).
Test ____________ when evaluating testosterone deficiency.
free testosterone in the morning (when it peaks)
True or false: beta-blockers can treat premature ejaculation.
False
Beta-blockers can cause erectile dysfunction, but they do not affect the ejaculation threshold.
SSRIs can be used to treat erectile dysfunction.
What test can confirm a vascular source of erectile dysfunction?
Penile-brachial index
How should low testosterone be managed?
•First, test the FSH, LH, and prolactin levels. If all three levels are low, then it is hypothalamic/pituitary failure. If the FSH and LH are low but the prolactin is high, then it is a prolactinoma. IF the FSH and LH are high, then it is testicular failure.
The best therapy for women with primary orgasmic disorder is _______________.
directed self-stimulation
What is the most sensitive test for detecting long-term alcohol abuse?
Gamma-glutamyl transferase
Ethyl glucuronide is the most sensitive test for detecting recent intoxication, but it does not tell you if the person drank a lot or has drunk alcohol for a long time. GGT will be elevated in those who abuse alcohol long-term.
An elevated _______________ is 96% specific for alcohol abuse.
MCV
_____________ has been shown to be the best treatment for preventing relapse in recovering alcoholics.
Acamprosate
If a person fails to quit smoking with one form of nicotine replacement, then _______________.
add a second form (e.g., gum + patch)
List the side effects of varenicline.
- Nausea
- Insomnia
- Abnormal dreams
Varenicline is metabolized in the ____________.
urine
“Urinicline.”
The most supported therapies for smoking cessation are ________________.
nicotine replacement, varenicline, and bupropion
Nicotine replacement should be used with caution in those with ______________.
unstable angina
What is the role of PCPs in treating rheumatoid arthritis?
It used to be recommended that PCPs manage RA symptoms with NSAIDs until no longer effective, but with the advent of disease-modifying antirheumatic agents (DMARDs), it is now recommended that PCPs refer RA patients to rheumatologists.
How often can steroid injections be done?
No more than two per year
Describe the crystals seen in pseudogout.
Positively birefringent, rhomboid-shaped crystals
A joint aspirate shows elevated WBCs that are 20% PMNs. What is the likely diagnosis?
Osteoarthritis
List the three medicines that can treat acute gouty attacks and what order they should be used.
1) NSAIDs
2) Colchicine
3) Corticosteroids
The most common extra-articular manifestation of RA is _______________.
interstitial lung disease
The strongest predictor of future asthma development is _________________.
history of atopy (even more than family history of asthma!)
Why is methacholine rarely used to diagnose asthma?
It can induce life-threatening bronchospasm in some cases.
Asthma daytime attacks more than twice a month but less than once a day is classified as ____________.
mild persistent
What are “peak flow” levels?
They are an easy and inexpensive way for patients to monitor asthma status. Peak expiratory flow parallels FEV. Patients should compare their current peak flow to their personal best.
- 80% to 100% = green zone = ok
- 50% to 79% = yellow zone = review medication regimen
- Below 50% = red zone = patient needs immediate medical attention
Describe the movement of spondylolisthesis.
The superior moves anterior in relation to the inferior.
How can you differentiate low back strain from spondylolisthesis?
- Low back strain usually occurs after an inciting event. (“I was putting the groceries in the trunk and suddenly my back ‘gave out’.”)
- Spondylolisthesis is more common in those who are younger than 26 and athletic, while low back strain is more common in older people.
True or false: low back strain should be treated with NSAIDs and bed rest.
False.
While NSAIDs are a key component of therapy, bed rest has not been shown to be helpful. Return to activity is the best recommendation.
Which antidepressants have been shown to help treat chronic pain?
SNRIs and TCAs
What two interventions have been shown to improve the prognosis of COPD?
- Smoking cessation
* Supplemental oxygen
What is the best first-line agent in COPD?
Ipratropium
If a person with chronic COPD has an acute exacerbation, treat them with ________________.
azithromycin, ciprofloxacin, or Augmentin
The best predictor of renal failure in a diabetic is ______________.
estimated GFR
What lab abnormality is the first sign of chronic renal failure?
Anemia
Electrolytes are not usually affected until the GFR is less than 30 mL/min, so those remain normal well into kidney failure. Anemia, however, can present when GFR is 60 mL/min.
Those with chronic kidney disease are most likely to die from ___________.
cardiovascular causes
For a person who’s on the max dose of NSAIDs and opioids for pain and who still reports worsening pain, a good option is to _____________.
switch to a different kind of opioid at a lower dose
The best test for evaluating longterm liver disease is __________.
low albumin
The most common cause of death in those with chronic liver disease is ________________.
bleeding varices
List the absolute contraindications to liver transplant.
- Hepatobiliary sepsis
- Severe medical illness
- Malignancy
- Portal vein thrombosis
What tests are routinely done in the initial evaluation of heart failure?
- Echocardiography (to look for structural causes like valve defects)
- Urinalysis and creatinine (to evaluate for renal failure as a cause)
- Thyroid function tests (because hyperthyroidism can cause heart failure)
- Albumin levels (as chronic liver disease can induce heart failure)
- Potassium
Go through the four NYHA classes.
- I: no symptoms
- II: no symptoms at rest but symptoms with ordinary activity
- III: no symptoms at rest but symptoms with “less than ordinary” activity
- IV: symptoms at rest
What lifestyle intervention is extremely helpful in improving the functionality of heart failure?
Cessation of alcohol
Alcohol can induce cardiomyopathy, so it is important to have heart failure patients stop drinking.
What chronic drug is first-line in treating CHF?
ACE inhibitors
Beta-blockers are also helpful, but have less evidence. d
A person has refractory edema even when taking furosemide and lisinopril. What two medications could you add to enhance diuresis?
- Spironolactone
* Metolazone
Describe what research shows about adding an ARB to an ACEi in a person with CHF.
Adding valsartan to ACEi use has been shown to reduce hospitalizations for CHF but not change long-term outcomes.
What is the best predicting factor of Alzheimer disease?
Advancing age
Which usually goes first in Alzheimer disease, social skills or visuospatial skills?
Visuospatial
Social skills are usually preserved until late in the disease.
What tests should you do to confirm the diagnosis of Alzheimer’s?
MMSE
Note: you should do other things to rule out medical causes (like TSH, B12, RPR, LFTs), but Alzheimer’s is diagnosed by history.
What drug has been shown to have a statistically significant benefit in those with severe dementia?
Memantine
What is the best test for screening for diabetes?
The best is technically the two-hour glucose challenge, but because that is more expensive and time-consuming, the fasting glucose is usually done.
True or false: the random and two-hour glucoses are positive if greater than 180.
False
They are positive if greater than 200.
Diabetics should be given ACE inhibitors if their systolic BP is greater than _____________.
100
A ___________ diet has been shown to improve glycemic control.
high-fiber
When doing basal-bolus insulin, what percent should each be?
Roughly 50% should be basal and 50% bolus
If a type 2 diabetic maximizes their oral agents and lifestyle efforts, what form and dose of insulin should you start them on?
0.1 U/kg of long-acting insulin at night
The ATP-3 task force used to recommend that LDL be below 100 or 70 depending on risk factors. What are the new recommendations?
No target
Now, just treat with high-intensity statins based on risk factors and avoid treating to a target.
What lifestyle factors can raise HDL?
- Exercise: Can raise HDL by 15 points!
- Weight loss: 5-10 points
- Smoking cessation: 5-10 points
- Decreasing lifestyle stress: 5 points
- Increased fiber intake: 5 points
Triglycerides can increase by about _________ after eating.
50
What non-lipid serum value correlates with a high MI risk?
High CRP (particularly above 3.0)
Which lipid value puts you at the highest risk of a negative outcome?
Low HDL
Which lipid is affected by smoking?
HDL
List three lipid medications that can decrease triglycerides.
- Statins: mild
- Fibrates: moderate
- Fish oil: moderate
How often should HIV-positive women get Pap tests?
6 months after the baseline test
12 months repeating
Go through the three tiers of PPD interpretation.
- 15 mm: people with no known risk factors
- 10 mm: healthcare workers; recent immigrants; injection drug users
- 5 mm: HIV-positive individuals; immunocompromised individuals; people with known TB contacts
Prophylaxis against ________ should be done in those with CD4s less than 65.
MAC
Those with PCP pneumonia should be treated with ____________.
Bactrim and steroids
Go through the lifestyle modifications that can lower SBP and how much each does so by.
- Weight loss: 15 mm Hg
- DASH diet: 10 mm Hg
- Sodium reduction, alcohol moderation, and exercise: 5-10 mm Hg
True or false: always start with one drug in treating essential hypertension.
False
If the patient’s BP is more than 20/10 mm Hg greater than the goal BP, then you should consider starting with two.
True or false: those with coarctation of the aorta will not need to take antihypertensives after correction of the defect.
False
If they have the defect for many years, the RAA system can produce hypertension even after the defect is corrected.
What workup should you do in newly diagnosed hypertension?
- CBC (looking for anemia)
- BMP (looking for renal failure)
- Urinalysis (also looking for renal failure)
- Echocardiogram (looking for negative remodeling)
- Lipid profile (to assess heart disease risk)
- Calcium
- Glucose
Note: only do a renal ultrasound if they have abdominal bruits or other indications of renal vascular anomalies.
What test can identify renal vascular causes of hypertension?
An ACE-inhibitor scan
What antihypertensive treatment regimen has been shown to decrease the risk of recurrent stroke?
ACEi and thiazide
List the four initial antihypertensives recommended by the JNC 8.
- ACEi (ARBs if untolerated)
- CCB
- Thiazides
Caveats:
- CCBs and thiazides seem to work better in African Americans
- ACEis or ARBs in those with CKD
What is the difference between atypical angina and angina equivalent?
- Atypical angina is angina that does not occur with exertion.
- Angina equivalent is exertional dyspnea without chest pain.
What are poor prognostic indicators in an exercise stress test?
- Max HR less than 120 bpm
- ST elevation at less than 120 bpm
- ST depression in multiple leads
- ST changes persisting for greater than 6 minutes
- Max stage of Bruce protocol II
Beta-blockers should be targeted to what in treating angina?
HR between 50 and 60
What is the success rate of using diet alone to lose and maintain 20 lbs for two years?
20%
20 lbs 20% 20 months
Gastric bypass is officially reserved for those in what BMI range?
- Greater than 40 without comorbid conditions
* Greater than 35 with comorbid conditions
The complication rate for Roux-en-Y bypass is _________.
40%
Describe the utility of weight-loss medications.
- Most can help people lose up to 9% of their weight
- All show weight regain after discontinuation
- Many work by stimulating the adrenergic system (phentermine, sibutramine)
True or false: hyperthyroidism can accelerate osteoporosis.
True
True or false: history and physical can sufficiently detect osteoporosis.
False
While a patient’s history can tell you about increased risk factors, DEXA or bone density imaging are needed for diagnosis of osteoporosis.
Which osteoporosis medication also had an analgesic effect in those with osteoporotic fractures?
Calcitonin
“CALCitonin makes the patient change the CALCulation of pain scores.”
Explain how the attitude toward eating is different in bulimia and anorexia.
- In anorexia, the person feels a strong sense of control over eating.
- In bulimia, the person feels no control over eating.
Which ADHD symptoms is most likely to persist into adulthood?
Inattention
What labs should you screen in a suspected ADHD case?
TSH
Hashimoto’s disease is also called _______________.
chronic lymphocytic thyroiditis
What are the two most common symptoms of hyperthyroidism?
- Tachycardia
* Fatigue
Describe subclinical hypothyroidism.
When the TSH is high but the T4 is normal
Monitor at yearly intervals due to a 2% yearly progression to hypothyroidism.
