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Project - USMLE Step 3 > Step Up - Ambulatory Medicine > Flashcards

Step Up - Ambulatory Medicine Flashcards

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USMLE® Step 1 flashcards
1
Q

Pathophysiology of the effects of HTN on the heart:

A

A. Incr. systemic vascular resistance (afterload) –> concentric LVH –> Decr. LV function. As a result, the chamber dilates –> Symptoms and signs of HF.
B. HTN accelerates atherosclerosis, leading to higher incidence of CAD (as well as peripheral vascular disease and stroke).

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2
Q

HTN - Target organ damage:

A 
Heart --> LVH, MI, CHF.
Brain --> Stroke, TIA.
Chronic kidney disease.
Peripheral vascular disease.
Retinopathy.
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3
Q

Most deaths due to HTN are ultimately due to:

A

MI or CHF.

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4
Q

Goals in evaluating a patient with HTN:

A
  1. Look for 2o causes - may be treatable.
  2. Assess damage to target organs (heart, kidneys, eyes, CNS).
  3. Assess overall cardiovascular risk.
  4. Make therapeutic decisions based on the above.
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5
Q

HTN diagnosis - Important to keep in mind:

A

Unless the patient has severe HTN or evidence of end-organ damage, never diagnose HTN on the basis of one BP reading.
–> Establish the diagnosis on the basis of at least 2 readings over a span of 4 or more weeks.

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6
Q

Observe the following to obtain an accurate BP reading:

A
  1. The arm should be at heart level, and the patient should be seated comfortably.
  2. Have the patient sit quietly for at least 5min before measuring the BP.
  3. Make sure the patient has not ingested caffeine or smoked cigarettes in the past 30mins (both elevate BP temporarily).
  4. Use cuff of adequate size - a small cuff can falsely elevate BP readings). The bladder within the cuff should encircle at least 80% of the arm.
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7
Q

Order the following lab tests to evaluate target organ damage and assess overall cardiovascular risk:

A
  1. Urinalysis.
  2. Chemistry panel: K, BUN, Cr.
  3. Fasting glucose - If diabetic, check microalbuminuria.
  4. Lipid panel.
  5. ECG.
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8
Q

Always obtain a … in reproductive age women before starting an antihypertensive medication.

A

Pregnancy test.

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9
Q

Which antihypertensives are toxic to pregnant women?

A
  1. Thiazides.
  2. ACEIs.
  3. CCBs.
  4. ARBs.
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10
Q

Which antihypertensives are safe in pregnancy?

A

Beta-blockers and hydralazine.

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11
Q

If a patient presents with moderate-to-severe HTN, consider:

A

Initiating THERAPY right away instead of waiting 1-2 months to confirm diagnosis and start treatment.

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12
Q

HTN - Pharmacologic Treatment - 7 Classes of drugs:

A
  1. Thiazides.
  2. Beta-blockers.
  3. ACEIs.
  4. ARBs.
  5. CCBs.
  6. Alpha-blockers.
  7. Vasodilators (hydralazine, minoxidil).
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13
Q

Unless there is a compelling indication to use a specific HTN drug class, it makes…:

A

Little difference whether the initial drug is a β-blocker, ACEI, ARB, CCB, diuretic.

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14
Q

Thiazide diuretics are the best initial choice for:

A

African-Americans, because “salt-sensitive” HTN is more common in them.
–> HOWEVER, if an African-American patient has diabetes, an ACEI is still the INITIAL agent of choice.

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15
Q

ACEIs are preferred in ALL diabetic patients because of:

A

their protective effects on kidneys.

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16
Q

ABRs in HTN treatment:

A

Recent studies suggest that ARBs have the same beneficial effects on the kidney in diabetic patients as ACEIs.

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17
Q

CCBs in HTN treatment:

A

Cause arteriolar vasodilation.

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18
Q

3 classes of HTN drugs that are used for initial monotherapy are:

A
  1. Thiazides.
  2. Long-acting CCBs (most often a dihydropyridine).
  3. ACEIs/ARBs.
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19
Q

HTN Treatment - ACCOMPLISH trail:

A

Showed that treatment with antihypertensive combination therapy - Benazepril + Amlodipine - was more effective than treatment with the ACEI + diuretic.
–> DESPITE these findings, thiazides remain a common initial drug choice.

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20
Q

HTN treatment - When to start treatment:

A
  1. Based on the patients total cardiovascular risk, not just elevation in BP.
  2. For any level of BP elevation, the presence of cardiovascular risk factors and/or comorbid conditions dramatically accelerates the risk from HTN, and therefore modifies the treatment plan.
    - -> Estimation of overall risk depends on cardiovascular risk factors and clinical risk factors.
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21
Q

HTN treatment - Cardiovascular risk factors:

A
  1. Smoking.
  2. Diabetes.
  3. Hypercholesterolemia.
  4. > 60.
  5. Family history.
  6. Male sex (higher than for female only until menopause).
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22
Q

HTN treatment - Clinical risk factors:

A
  1. Presence of CAD.
  2. PVD.
  3. Prior MI.
  4. Any manifestation of target organ disease.
  5. LVH.
  6. Retinopathy.
  7. Nephropathy.
  8. Stroke or TIA.
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23
Q

All people should be screened with fasting lipid profile every … starting at … .

A

5yrs. age 20.

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24
Q

Risk factors for coronary artery disease (CAD) in evaluation of patients with hyperlipidemia:

A
  1. Current cigarette smoking (dose-dependent risk).
  2. HTN.
  3. DM.
  4. Low HDL (60mg/dL) is a negative risk factor (substract 1 from total).
  5. Age:
    - -> Male: >45.
    - -> Female: >55.
  6. Male gender - if you count as a risk factor, do not count age.
  7. Family history of premature CAD.
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25
Q

Threshold levels for hyperlipidemia - Total cholesterol:

A

Ideal –> 200-240.

High –> >240.

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26
Q

Threshold levels for hyperlipidemia - LDL:

A

Ideal –> 130-160.

High –> >160.

27
Q

Threshold levels for hyperlipidemia - TGs:

A

Ideal –> 125-250.

High –> >250.

28
Q

The goal of LDL in a diabetic patient is … .

A

100mg/dL or LOWER.
All diabetics with an LDL above 100 should be started on a statin.
–> If a patient has CAD and DM, goal for LDL is 70mg/dL or LESS.

29
Q

Statins and fibrates can induce… :

A

Transient elevation in serum transaminases. LFT must be monitored.

30
Q

Statins have been shown to significantly reduce…:

A

Rates of MI, stroke, and CAD and all-cause mortality in prospective placebo-controlled trials.

31
Q

Potency of statins increases in the following order (cost increases with potency):

A

Fluvastatin (Lescol) < lovastatin (Mevacor) and pravastatin (Pravachol) < simvastatin (Zocor) and atorvastatin (Lipitor).

32
Q

All patients on statins should have their AST and ALT monitored even if asymptomatic:

A

About 1% of patients on statins will develop such elevations in AST and ALT that the statin will need to be discontinued.

33
Q

Emergency evaluation of headache:

A
  1. Obtain a noncontrast CT scan to first rule out any type of intracranial bleed.
  2. However, small bleeds (subarachnoid hemorrhage) may be missed bt CT scan, so a lumbar puncture may be necessary.
34
Q

Brief DDX of headache:

A
  1. Primary headache syndromes - migraines, cluster headache, tension headache.
  2. Secondary causes of headache (“VOMIT”).
35
Q

Secondary causes of headache - VOMIT - Vascular:

A
  1. Subarachnoid hemorrhage.
  2. Subdural hematoma.
  3. Epidural hematoma.
  4. Intraparenchymal hemorrhage.
  5. Temporal arteritis.
36
Q

Secondary causes of headache - VOMIT - Other causes:

A
  1. Malignant HTN.
  2. Pseudomotor cerebri.
  3. Postlumbar puncture.
  4. Pheochromocytoma.
37
Q

Secondary causes of headache - VOMIT - Medication/drug-related:

A
  1. Nitrates.
  2. Alcohol withdrawal.
  3. Chronic analgesic use/abuse.
38
Q

Secondary causes of headache - VOMIT - Infections:

A
  1. Meningitis.
  2. Encephalitis.
  3. Cerebral abscess.
  4. Sinusitis.
  5. Herpes zoster.
  6. Fever.
39
Q

Secondary causes of headache - VOMIT - T for:

A

Tumor.

40
Q

Visual aura in migraine:

A
  1. Classic presentation is a bilateral homonymous scotoma.
  2. Bright, flashing, crescent-shaped images with jagged edges often appear on a page, obscuring the underlying print.
    - -> Usually lasts 10-20mins.
    - -> A patient may have isolated visual migraines (as above) without headaches.
41
Q

Many patients who are labeled as having migraines actually have … ?

A

Rebound analgesic headaches.
These occur more frequently (every 1 to 2 days) than migraines.
–> These headaches do NOT respond to drugs used to treat migraines.
–> Wean patient from analgesic. Do NOT use narcotics.

42
Q

Beware of the patient with “migraine headache” for whom no medications work:

A

The probability of that patient having migraine headache as the primary headache is very low.

43
Q

Cough due to postnasal drip:

A

The mucosal receptors in the pharynx and larynx are stimulated by secretions of the nose and sinuses that drain into the hypopharynx.

44
Q

Causes of chronic cough in adults:

A
  1. Smoking.
  2. Postnasal drip.
  3. GERD.
  4. Asthma.
45
Q

Isolated cough in patients with normal chest radiograph:

A
  1. Smoking.
  2. Postnasal drip.
  3. GERD - Especially if nocturnal cough.
  4. Asthma - cough may be the only symptom in 5% of cases.
  5. ACEIs - May cause a dry cough (due to bradykinin production).
46
Q

Tests in a patient with acute cough:

A

No tests are indicated, usually.

47
Q

Cough - When to do a CXR:

A

CXR is indicated only:

  1. If a pulmonary cause is suspected.
  2. If the patient has hemoptysis.
  3. If the patient has chronic cough.
  4. In a life-long smoker in whom COPD or lung cancer is a possibility.
48
Q

Non specific antitussive treatment:

A
  1. Unnecessary in most cases, because cough usually resolves with specific treatment of the cause.
  2. May be helpful in the following situations:
    a. If cause is unknown (and thus specific therapy cannot be given).
    b. If specific therapy is NOT effective.
    c. If cough serves no useful purpose, such as clearing excessive sputum production or secretions.
49
Q

Non specific antitussive treatment - Medications:

A
  1. Codeine.
  2. Dextromethorphan.
  3. Benzonatate (Tessalon Perles) capsules.
50
Q

Common cold - Viral causes:

A
  1. Rhinovirus (at least 50% of cases).
  2. Coronavirus.
  3. Parainfluenza (A, B, and C).
  4. Adenovirus.
  5. Coxsackievirus.
  6. RSV.
51
Q

Common cold - MC route of transmission:

A

Hand-to-Hand transmission.

52
Q

Common cold is synonymous with:

A

Acute rhinosinusitis - Inflammation + congestion of mucus membranes or nasal and sinus passages.

53
Q

Many of the symptoms seen in common cold are also seen in?

A

Influenza, but are more severe in the latter.

  1. Fever.
  2. Headache.
  3. Myalgias.
  4. Malaise.
54
Q

Sinusitis is usually self-limited, but… :

A

Can be associated with high morbidity. It can be life-threatening if the infection spreads to bone or to the CNS.

55
Q

Sinusitis - Classification:

A
  1. Acute bacterial sinusitis - usually due to S.pneumoniae, H.influenza, or anaerobes.
  2. Other types - viral, fungal, or allergic.
56
Q

Sinusitis - MC sinuses involved are:

A

The maxillary sinuses.

57
Q

If a patient has a cold beyond 8-10 days, or if the cold symptoms improve and then worsen after a few days, consider:

A

Acute bacterial sinusitis - may be a 2o bacterial infection after a primary viral illness.

58
Q

Chronic sinusitis - By definition, symptoms should be present for:

A

At least 2-3months.

59
Q

Acute bacterial sinusitis - Treatment:

A
  1. Treat with antibiotics and decongestants for 1 to 2 weeks, depending on severity.
  2. If there is no improvement after 2 weeks of therapy, then sinus films and a penicillinase-resistant antibiotic are appropriate.
  3. Consider ENT consultation.
  4. Because of the anatomic difficulties in drainage, the course of acute sinusitis takes longer to resolve than other URIs.
60
Q

Sinusitis - Complications:

A
  1. Mucocele, polyps.
  2. Orbital cellulitis - usually originating from ethmoid sinusitis.
  3. Osteomyelitis of the frontal bones or maxilla.
  4. Cavernous sinus thrombosis (rare).
  5. Very rare - epidural abscess, subdural empyema, meningitis, and brain abscess - due to contiguous spread through bone or via venous channels.
61
Q

Laryngitis - Etiology:

A

Usually viral - May be caused by Moraxella catarrhalis and H.influenza.

62
Q

Laryngitis - Clinical course:

A

Common cause of hoarseness - cough may be present along with other URI symptoms.

  • -> Typically self-limiting.
  • -> Patients should rest voice until laryngitis resolves to avoid formation of vocal nodules.
63
Q

MCC of 2o HTN in young women:

A

Birth control pills.

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