Week 1 Flashcards
Stress Incontinence Tx
- kegel exercises: 3-6 weeks of daily exercises, 200/day
- vaginal estrogens
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pessary
- SEs: vaginal irritation, foul-smelling discharge, UTIs
- surgery → mid-urethral sling
- weight loss
Prostate Cancer Etiology, S/sxs, PE, Dx, Tx
- most are adenocarcinomas
- associated with the BRCA1 gene
- Risk factors: african american, old age, family hx
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S/sxs: urinary retention (more likely sign of BPH), decrease in urine stream strength
- back pain (metastatic disease)
- painful ejaculation
- PE: DRE: hard, nodular, enlarged, and asymmetrical prostate
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Dx:
- indications for transrectal biopsy with normal rectal exam → PSA > 10 or abnormal transrectal U/S
- PSA > 4: U/s with needle biopsy
- PSA >10: bone scan to r/o metastases
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Tx;
- radical prostatectomy → complication = erectile dysfunction & urinary incontinence
- with metastases: need androgen deprivation therapy (leuprolide) → type of medical castration, but can be reversible
*
Calcium Nephrolithiasis Risk factors and Prevention
- calcium oxalate = most common
- Radiopaque
- Risk factors: decreased fluid intake, high urinary calcium or pH, high animal protein intake, hypercalcemia, males, medications (loop diuretics, acetazolamide, antacids)
- Prevention: increased fluid intake, thiazide diuretics, citrate, low sodium diet, decreased animal protein diet
When to screen for PSA
DISCUSS WITH PATIENT
- men age 55-69 yo
- 50 years old if first degree family hx
- 45-50 if african american
BPH S/sxs, PE, Dx, & Tx
Benign Prostatic Hyperplasia
- 50% of men have BPH by age 60, >90% by age 85
-
S/sxs: difficulty starting stream, post-void dribbling, hesitancy (start and stop)
- nocturia
- weak urinary stream
- PE: digital rectal exam → uniformly enlarged firm and rubber prostate
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Dx:
- DRE +PSA
- PSA < 4 = normal
- PSA > 4 → BPH, prostate cancer, prostatitis
- UA to r/o other causes
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Tx:
- if mild → watchful waiting
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alpha blockers can provide the most rapid relief (smooth muscle relaxation of porstate and bladder neck
-
tamsulosin, prazosin, terazosin (shrink size of prostate)
- finasteride & dutasteride
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tamsulosin, prazosin, terazosin (shrink size of prostate)
- TURP (transurethral resection of the prostate) if unresponsive to meds
- 5-alpha reductase inhibitors
UTI prevention
- drink adequate amount of water
- avoid delay in voiding
- personal hygiene
- cranberry juice/tablets
- abx prophylaxis for 3 UTIs/12 months
- Bactrim/Cipro
Major Risk Factors of Coronary Artery Disease (CAD)
- Diabetes Mellitus (Worst risk factor, considered a CAD equivalent)
- Smoking (Most important modifiable risk factor)
- Hyperlipidemia, HTN
- Men >45yo, Women >55yo
- Fam Hx of CAD: (first degree relative – father or brother before age 55, mother or sister before age 65)
Post MI Complications
- Pericarditis: 1-3 weeks post MI (Dressler Syndrome)
- VSD (ventricular septal defect: 1-5 days post MI: shock, new murmur, pulmonary edema
- Acute Mitral Regurg: shock, apical murmur, pulmonary edema
- new or recurrent MI: chest pain, new ECG changes possible, new bump in troponins
Acute vs. Chronic Heart Failure
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S/sxs:
-
Chronic Heart Failure (compensated):
- congestion
- laterally displaced apical impulse
-
Acute Heart Failure:
- breathlessness
- rapid weight gain
- fluid build-up in the lungs and around the body
- inadequate time for compensation: largely systolic (HTN crisis, acute MI, papillary muscle rupture); often fatal
-
Chronic Heart Failure (compensated):
Systolic Heart Failure
-
Definition: heart failure with decreased ejection fraction
- impaired contractility
- thin ventricular walls (DILATED)
- S3 gallop (sys-tol-ic)
-
Etiology:
- ischemic heart disease, rapid HTN, dilated cardiomyopathy (LEADING CAUSE), myocarditis, congenital, post-surgical, PE, sepsis
Diastolic Heart Failure
-
Definition: Heart failure with preserved ejection fraction
- impaired filling/relaxation
- thick ventricular walls (**Hypertrophied**)
- S4 gallop (Di-a-stol-ic)
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Etiology:
- HTN, aortic stenosis, restrictive & hypertrophic cardiomyopathy, fibrosis, amyloidosis, sarcoidosis, constrictive pericarditis, normal aging, CAD scarring
Tx of Heart Failure
- **initial management usually consists of an ACEI & (maybe a beta blocker) + diuretic (for sxs)**
-
Long Term Tx (Afterload reduction:
- ACE Inhibitors (Captopril, Enalapril, Lisinopril): reduce afterload by vasodilation & BP reduction, useful in pts with EF <35%,mainstay of tx, (adverse effects: hyperkalemia, cough, angioedema, & elevated creatinine)
- Angiotensin II Receptor Blockers (Losartan, Valsartan): blocks effects of angiotensin II, indicated in pts who cannot tolerate ACEI (cough)
- Angiotensin Receptor Neprilysin Inhibitor (Sacubitril/Valsartan): inhibits breakdown of BNP so BNP no longer becomes a reliable marker in pts taking this
- Beta-Blockers (Carvedilol, Metoprolol, Bisprolol): usually added after ACEI or AR
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Long Term Tx (Preload Reduction)
- Loop Diuretics (furosemide, bumetanide, torsemide): inhibit water transport across the Loop of Henle, effective for sx tx.
- potassium sparing diuretics (spironolactone, eplerenone): aldosterone antagonist, decreased mortality
- Thiazides (hydrochlorothiazide, Metolazone): inhibits DCT reabsorption of Na+
-
Long Term Tx (Positive Inotropes):
- Digoxin: positive inotrope; 2nd line for pts in CHF with sinus rhythm, 1st line for pts with afib + CHF
Primary Prevention of ASCVD in Age 40-75 and LDL-C ≥ 70 to <190 mg/dL without diabetes mellitus
10-year ASCVD risk percent begins risk discussion:
-
<5%: “low risk”
- emphasize lifestyle to reduce risk factors
-
5-<7.5%: “borderline risk”:
- If risk enhancers present then risk discussion regarding moderate-intensity statin therapy
-
≥7.5-<20%: “Intermediate Risk”
- Risk discussion:
- if risk estimate + risk enhancers favor statin, initiate moderate-intensity statin to reduce LDL-C by 30-49%
- if unsure, can use CAC score
- Risk discussion:
-
≥ 20%: “high risk”:
- initiate statin to reduce LDL-C ≥ 50%
At what LDL-C level do you initiate high intensity statin with no risk assessment?
LDL-C ≥ 190 mg/dL
Best meds to lower elevated LDL
-
Statins (Rosuvastatin, atorvastatin, etc) → inhibit HMG Co-A reductase
- impair production of cholesterol in the liver → upregulation of LDL receptors
-
Bile Acid Sequestrants (Cholestyramine, colesevelam, colestipol) & Cholesterol absorption inhibitors (Ezetimibe)
- impair enterohepatic recirculation and gut absorption → less hepatic cholesterol → upregulation of LDL receptors
Best Meds to Lower Triglycerides
- Fibrates (fenofibrate, gemfibrozil): inhibit triglyceride synthesis = Drug of Choice;gemfibrozil should NOT be given with statins
- Niacin
Best Meds to Increase HDL
- Niacin
- Fibrates (fenofibrate, gemfibrozil): inhibit triglyceride synthesis = Drug of Choice;gemfibrozil should NOT be given with statins
Abnormal Lipid Values
- Low HDL <40 mg/dL
- High LDL > 190 mg/dL
- high LDL in diabetic >70 mg/dL
- high total cholesterol >250 mg/dL
- high fasting triglyceride >150 mg/dL
Secondary HTN Definition and Causes
- Definition: SBP ≥130 and/or DBP ≥80 WITH identifiable cause
-
Causes:
- Primary aldosteronism = MOST COMMON
- renal vascular disease
- pheochromocytoma
- adrenal tumor that secretes catecholamines (ie norepi and epi)
- Cushing’s Syndrome
- activation of the renin-angiotensin system
- Congenital Adrenal Hyperplasia
- Hyperthyroidism
- Myxedema
- associated with hypothyroidism
- Coarctation of the Aorta
- Excessive alcohol intake
- Use of Oral Contraceptives
Secondary HTN Red Flags, Dx, & Tx
-
Red Flags:
- HTN at an early age <25 without a family hx
- HTN first develops >50 yo
- previously controlled now refractor
- Pt is refractory on antihypertensive medications or has severe BP
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Dx:
- when HTN is newly diagnosed consider ordering:
- urinalysis
- spot urine albumin: creatinine ratio → albuminuria ratio = >30mg/day
- indicative of CKD
-
Blood tests
- creatinine, K, Na, fasting glucose = BMP
- lipid panel
- TSH
- EKG
- when HTN is newly diagnosed consider ordering:
-
Tx:
- tx the underlying condition and aim for BP <130/80
Acute Bacterial Endocarditis Definition and organism
- Definition: infection of a normal valve with a virulent organism (usually S. Aureus).
- Rapidly destructive (fatal < 6 weeks if untreated)
Beck’s Triad
Associated with Cardiac Tamponade
- elevated JVP
- muffled heart sounds
- systemic hypotension
Mnemonic to Remember Medical Tx of STEMI
MOAN & BASH
Morphine, oxygen if O2 <90%, Aspirin 162 mg, Nitro q 5 min (don’t give to pts with systolic <90, or to inferior MI with R ventricular involvement → dependent on preload and nitro decreases preload)
Beta blockers (Decrease remodeling, decrease oxygen demand of heart, decreases HR, improve L ventricular hemodynamic funx, reduce incidence of ventricular arrhythmias; Contraindication in Heart block, high risk for cardiogenic shock) , ACE-I/ARB (more for long term use → improve L ventricular EF, mortality rate), Statin, Heparin (antithrombotic therapy → impede progression of thrombus in coronary artery)
TPA if pt cannot have reperfusion from cath lab in <90minutes from door to lab
Dressler’s Syndrome
Post-MI pericarditis
tx = aspirin or colchicine
Triad of R Ventricular Infarction
- JVD
- Clear Lungs
-
Positive Kussmaul Sign
- paradoxical rise of JVP with inspiration (blood backs up into vein during inspiration due to failure of R ventricle)
3 populations with atypical sxs for acute MI
elderly, women, diabetics