Swanson - Primary Care Flashcards
What is likelihood ratio of a positive result?
Probability of that test result in the presence of disease divided by probability of test result in absence of disease
A / (A + C) divided by B / (B + D)
What is length time bias?
Bias from detection of slow growing tumors (detected more frequently in cancer screening programs, vs usual medical care)
How should individuals who smoke when under stressful work situations be managed?
Behavior modification techniques, and possibly bupropion
What is the difference between alcoholic dementia and alcohol amnestic disorder?
Amnestic disorder involves more difficulty with short-term memory (serial 7’s), dementia more for long term (information recall)
What BAL is noted to cause impairment in most state? Under the influence?
Impaired - 0.05%
DUI - 0.10%
Which drugs can be useful in the treatment of alcohol withdrawal?
- Long-acting benzos (diazepam, librium)
- Clonidine (for NE sx)
- Antipsych (haldol, for hallucination and agitation)
- Barbiturates and anticonvulsants
What is the best definition of alcoholism?
Alcohol abuse and alcohol dependency
What combination therapy is considered to be most effective for alcohol dependence?
Naltrexone + CBT
What are two major documented side effects of anorexic drugs?
HTN and renal failure (weight loss at 1 month, but not beneficial long-term)
Which drugs may promote weight loss?
Orlistat, bupropion, fluoxetine and topiramate
What are potential secondary causes to obesity? How frequently does this occur?
Iatrogenic disease (drugs), depression, cushings, hypothyroid
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How can you differentiate eruptions of variola vs. varicella?
Variola are centripetal and come all at once.
Varicella are centrifugal and come in crops
What tests should be done for elderly nursing home patients presenting with fever and URTI sx?
CXR if + extra breath sounds on auscultation
CBC and blood culture to rule out bacteremia or secondary pneumonia
What may result in vaccinated individuals who still get the flu?
Reduced severity and duration of illness
What should be given to high risk individuals in whom influenza vaccine is contraindicated?
Oseltamivir or zanamivir prophlyaxis (only tamiflu in children
What is the optimal treatment of elderly patients with agitated depression?
TCAs and anxiolytics as needed
How do you treat anorexia in late stage cancer palliative care?
Prednisone or Megestrol Acetate
What is the first line for treating cancer associated nausea?
Thorough search for underlying cause, then begin with prochlorperazine, dimenhydrinate, or metoclopramide (alone or in combo as needed)
What is the most common sx in advanced cancer? What is the most common cause of N/V in advanced cancer?
Asthenia (fatigue)
Bowel obstruction from pressure of intrabdominal tumor on bowel
What is first line treatment for pleural effusion in a palliative care cancer patient?
Thoracentesis as needed and sclerosing agent if severe
If still not improving or recurs frequently can use bed elevation, O2, decreases fluid and or steroids as needed for sx relief
What effects may St Johns wort have on other drugs?
Cytochrome P450 inducer leading to subtherapeutic levels of some drugs like digoxin and OCPs
What is the first priority in patients presenting with history, physical exam, and ECG findings suspicious of MI?
Ascertain patent airway, without obstruction vomit or any blockage, and administer 100% O2
Up to how much time after onset of pain is tPA shown to be helpful in MI? Which patients do not benefit?
Up to 12 hours after onset of pain
Patients with non-Q wave infarcts and prior CABG not shown to benefit
What key drugs are needed concomitantly when treating MI with thrombolytic therapy? Which patients is this contraindicated in?
Aspirin and HEPARIN
No heparin given in uncontrolled HTN
What is the treatment for PVCs post-MI?
Nothing! Ppx with Anti-arrhythmics post MI have even been show to increase mortality
Which drugs have been shown to improve the prognosis after MI?
Beta blockers, aspirin, and Coumadin
What type of shock can occur following an acute MI?
Hypovolemic hypotension or persistent hypotension and poor cardiac index
What type of drug is Ticlipidine and what are its side effects?
Anti-platelet agent (ADP receptor blocker) that may cause neutropenia and thrombocytopenia
What drug regimen should patients with chronic stable angina absolutely be on?
Aspirin, beta blocker, and statin
What is the acute treatment of unstable angina?
- ASPIRIN
- Nitrates or morphine for pain
- Beta blocker, clipidogrel, heparin/LMWH, glycoprotein IIB/IIIA inhibitor
What drugs should be used for prinzmetal angina?
Calcium channel blockers and beta blockers can be used
In what cases are CABG procedures best indicated for?
Left main stem disease and diabetics with multiple vessel disease
Although any case of vessel disease may benefit
What is the primary treatment for a patient with angina and HTN?
Cardio selective beta blocker is first line (verapamil may be added)
What are the symptomatic characteristics of unstable angina?
- Angina at rest
- Accelerating angina
- New onset angina (3x per day)
What are the 5 major risk factors for CAD?
- HTN
- Smoking
- Diabetes
- Age >45 in men, >55 women
- Family Hx of early MI in 1st degree relative
What are elevated Triglycerides most closely associated with?
Diabetics with poor glucose control
What is the treatment of choice for hypercholesterolemia?
DIET THERAPY
What natural substance can decrease LDL levels?
Plant stanol esters
What are the beneficial effects of fish/fish oil to plasma lipid levels?
- Reduce lipid levels (especially Trigs) and increase HDL
- Inhibit platelet aggregation
- decrease BP and viscosity
Which conditions are associated with elevations of cholesterol?
Hypothyroidism, lupus, pregnancy, OCP and Nephritic syndromes
What may be seen on chest radiography in a patient with diastolic heart failure?
Congestion with or without cardiomegaly
What are the cardinal features of diastolic heart failure on echo? Systolic?
Dia - Normal LVEF and usually normal LV cavity size (concentric LV hypertrophy usually present)
Sys - LVEF
What is the recommended blood pressure for a patient with diabetes and CHF?
Systolic
What is the most important acute therapy for exacerbation of CHF? What should be initiated for long term care?
acute - Diuretic (furosemide) and O2 supplementation
chronic - ACEI or ARB, and slow initiation of beta-blocker
What are possible underlying pathophysiological mechanisms for systolic heart failure?
LV chamber remodeling, CAD, valve disease, abnormal excitation-contraction coupling
What are the main indications for using digoxin (digitalis)?
CHF with reduced EF and A-fib with RVR
What are the clinical features of digoxin use?
Dig decreases sx of worsening heart failure, lower doses are as effective as higher, and use can reduce rate of hospitalizations in CHF
What is the most important characteristic found on echo in evaluating patients with systolic dysfunction?
low ejection fraction (
Which treatments have been shown to reduce hospitalizations and mortality in selective patients with CHF?
Beta blockers, spironolactone, ACEI, biventricular pacing
what is the minimum level for BP to attain in antihypertesnive therapy?
below 140/90
what is the first step in treating elevated blood pressure?
non-pharmacological therapy (weight loss, stop alcohol and cigarette smoking, aerobic exercise 4 hours per week, reduce salt, reduce fat)
What is the best antihypertensive therapy in CHF?
ACEI, beta block, and aldosterone inhibitors
What is the best antihypertensive therapy in patients with recurrent strokes?
ACEI and thiazide diuretics
What is the greatest utility of calcium channel blockers as an antihypertensive agent?
reducing cardiovascular disease and stroke in patients with diabetes
What is the utility of beta blockers outside of antihypertensive or cardiovascular treatment?
useful in migraine headache ppx
What is the utility of thiazides besides as an antihypertensive and diuretic?
treat osteoporosis by slowing demineralization process
Which patients may be more at risk of developing HTN secondary to another pathology (as opposed to essential)?
age >50 (e.g. renal artery stenosis); usually patients with essential HTN get it before 50
What are the main metabolic side effects of thiazide diuretic use and in which patients is it contraindicated?
hyperglycemia, hyperuricemia, hyperlipidemia
hypomagnesemia, hyponatremia, hypokalemia
sulfa allergies more at risk to be allergic
What medications are often needed in the treatment of HTN in CKD and what drugs should be avoided?
Need ACEI or ARB and loop diuretic to maintain fluid balance
avoid triamterene which may lead to hyperkalemia
What are the recommended first line antihypertensive tx for african american patients?
thiazide diuretics initially, and Ca channel blockers
Which antiHTN drugs are contraindicated in patients with hypercholesterolemia?
high dose beta block without ISA, high dose diuretics
What is preferred to treat HTN in pregnant women? what should be avoided?
Alpha methyldopa, Mg sulfate, hydralazine
Avoid ACEI or diuretics
What is the acute treatment for A-Fib?
if hemodynamically unstable, synchronized cardioversiom
if stable, calcium channel or beta blockers
What is the treatment for PSVT in a stable patient?
Vagal maneuvers and adenosine
When and where do fat emboli mostly occur? how may they appear clinically?
FE is on upper body 2-3 days after major long bone injury
hallmark is presence of purpura
What are the indications for IVC filter placement?
Indicated in patients with Venous thromboembolism and contraindication to anticoagulation, recurrence of VTE despite anticoag
What is the difference between COPD and asthma in terms of relationship between smooth muscle hyperplasia and bronchodilator responsiveness or methacoline sensitivitY?
In COPD no clear link between the hyperplasia and responsiveness/meth sensitivity
What clinical feature is most worrisome in an elderly patient with COPD?
Change in mental status
What is the basic pathophysiological process that leads to asthma? Which substances released by cells are responsible for this?
Inflammatory process that can lead to/involve bronchoconstriction and bronchial hyperreactivity
Mast cell release of histamine, proteolytic enzymes, heparin and chemotactic factors are all implicated
What are the components that may lead to reversible airflow obstruction in asthma?
bronchoconstrction, mucous plug formation, and edema
What is the best pre-exercise preventitive treatment for exercise induced bronchospasm?
INhaled beta 2 agonist 1st line, cromolyn or nedocromil can also be used
What is the best 1st line treatment for long term management of difficult to treat EIB?
Inhaled corticosteroids followed by montelukast, LABA then theophylline
What is the most usual cause of vocal cord dysfunction?
Largely psychogenic, found mainly in 20-40 yo females with anxiety/depression/other psych DO
What is exercise induced hyperventilation?
Common problem in athletes where they lose control of breathing and breathe high in chest with rapid shallow breaths vs using abdominal muscles
What is the treatment of moderate persistent asthma?
Inhaled corticosteroids, and if needed LABA
What is the treatment for severe asthma exacerbation (e.g. PEF
SABA x3 by inhaler or x1 by nebulizer
If PEF emains low or wheezing/SOB persist repeat SABA and go to ER
What are the most common exam findings in patients with asthma exacerbation?
Increased RR, use of accessory muscles, followed by dyspnea/anxiety and then wheezes
What are the main risks of using a Long acting beta agonist for asthma?
associated with increased asthma related hospitalization and death (likely from tolerance development) –> never use as rescue inhaler
How can you differentiate mycoplasma pneumo from other causes?
Young adult, harsh nonproductive constant cough (no shaking chills or fever)
What should be empirical antibiotic treatment for presumed strep pneumo in a hospitalized patient?
Beta Lactam and a macrolide Abx OR quinolone monotx until susceptibilities are found
What should be considered in immunocompromised o COPD patients with presumed pneumonia who fail standard Abx therapy? How should you treat them?
Likely Legionella pneumonia, newer macrolides and quinolones should be given
What is the treatment of choice to cover Klebsiella pneumo?
3rd generation cephalosporin OR a carbapanem, aminoglycoside, or quinolone alone or in combo
What is the most common cause of nosocomial pneumo?
Aerobic gram negative bacteria
What is the underlying cause of GERD?
Transient relaxation of LES
What are the associated clinical signs of pharyngeal paralysis?
Dysphagia solids and liquids and aspiration into windpipe or regurgitation into nose common
Associated with neuromuscular disorder (myasthenia gravis, ALS, stroke)
How long should it take for H pylori to be treated and heal completely?
3-6 weeks
What medication is cytoprotective in PUD?
Misoprostol (prostaglandin analogue) protects GI mucosa
What must be used with Dexamethasone therapy?
H2 antagonist or PPI, because dexa is a potent stimulator of gastric acid secretion
Which test is not useful to detect eradication of H pylori?
ELISA
What is the treatment of ascites and associated edema?
Sodium restriction, Spironolactone, paracentesis
If unresponsive, Add diuretic furosemide or thiazide
If refractory, paracentesis with albumin infusion
What is one of the most important physical exam findings in a patient with malignant pancreatic neoplasm?
Provocative maneuver, reproduce pain gently by assuming supine position, pain relief with spine flexion
What is the most likely cause of a palpable abdominal mass in a patient with acute pancreatitis? What is the most likely plain film abdomen finding in any case of acute pancreatitis?
Pseudocyst
Sentinel loop on plain film (isolated dilation of gut segment adjacent to pancreas)
Which treatments may be indicated in the management of the acute phase of ulcerative colitis?
Steroid enemas, oral corticosteroids, parenteral steroids
What is the treatment of choice for active or chronic UC, remission etc?
5ASAs
What is the utility of metronidazole in Crohn’s disease?
Crohns colitis and Perianal Crohns
What is the utility of Alosetron (lotronex)?
Women with severe diarrhea predominant IBS
What conditions are frequently associated with IBS?
Functional disorders - fibromyalgia, interstitial cystitis, and migraine headaches
What is the preferred test to confirm appendicitis in pediatric patients?
Ultrasonography to avoid radiation
What are hyper plastic polyps?
Totally benign unclassified colon polyps
What is the definitive treatment for protruding internal hemorrhoids?
Rubber band ligation
