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Amb Care > Week 1 Lectures > Flashcards

Week 1 Lectures Flashcards

1
Q

USPSTF screening guidelines for osteoporosis

A

USPSTF screening guidelines for osteoporosis:

  • all women over 65
  • post-menopausal women under 65 w/ risk factors
  • no men!!
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2
Q

What is considered resistant hypertension?

A

Resistant HTN = when pt is failing 3 meds, one of which is max-dose thiazide (HCTZ or chlorthalidone 25 mg daily)

Basically if pt is on max oral meds: lisinopril (ACEi) 40 mg, amlodipine (CCB) 10 mg, and HCTZ 25 daily

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3
Q

Disadvantage of RAI ablation for Graves’ tx

A

Difficult to achieve euthyroid, usually pt becomes hypothyroid and requires levothyroxine afterwards

For a few days you can’t touch kids, pregnant women etc (surgery can’t be done on pregnant or breast feeding women) due to the long half life of the iodine

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4
Q

Average number of mutations in a colorectal cancer

A

Average colorectal cancer has 15+ mutations- showing that it’s not just one hit but tons of cumulative hits

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5
Q

Average-risk 50 yo F

(a) Preventative services
(b) Vaccines

A

Average risk 50 yo F

(a) The usual: alcohol, tobacco, depression, HTN, HIV, lipids
+ mammography (at age 50)
+ colonoscopy (at age 50)
+ cervical cancer screen

(b) Vaccines: annual influenza

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6
Q

Medications that you should be very careful before giving to elderly

A
  • Diphenhydramine (Benadryl): very sedating and anti-cholinergic
  • Amitriptyline (TCA)
  • Anticholinergics
  • Benzos: very sedating, can cause altered mental status
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7
Q

Give 3 examples of chemoprophylaxis

A

Chemoprophylaxis = giving drugs for prevention

  1. Folic acid to women of child bearing age
  2. Tamoxifen or Raloxifene daily for 5 years in women over 35 at an increased risk for breast cancer
  3. Baby aspirin for high risk CAD pts
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8
Q

Chromosomal vs. microsatellite instability

(a) Type of change
(b) Prototypical CRC syndrome

A

Chromosomal instability- causes 85% of sporadic CRC

(a) change in the amount of genetic material
(b) Prototypical syndrome caused by chromosomal instability = FAP

Microsatellite instability

(a) change in genetic sequence
(b) Lynch syndrome

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9
Q

65 yo F w/ no risk factors

(a) Preventative services
(b) Vaccines

A

65 yo w/ no risk factors

(a) The usual: tobacco, alcohol, Hep C, depression, HTN, lipids
+ osteoporosis (DEXA test)
+ breast cancer screen
+ cervical cancer (last Pap test if persistently normal)
+ colonoscopy (depending on date and result of last)
-no aspirin

(b) Vaccines
- Pneumoncoccal- starts at age 65
- Zoster- starts at 60 yoa
- Influenza
- Td booster every 10 yrs

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10
Q

Graves’ disease

(a) TFT results
(b) Antibody
(c) RAIU results

A

Graves’ disease

(a) TFT: low TSH w/ high T4
(b) Positive TSI = antibody that is an agonist of the TSH receptor
- constantly stimulating the TSH-receptor
(c) RAIU shows homogenous increased uptake

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11
Q

Physical exam features of hyperthyroidism by system

(a) Endo
(b) Neuro
(c) Optho
(d) Cardio
(e) Skin

A

Features of hyperthyroidism

(a) Endo- thyroid enlargement, nodules
(b) Neuro- fine tremor, brisk DTRs
(c) Optho- lid retraction, lid lag
(d) Cardio- palpitations, tachycardia, ST, aFib, wide PP
(e) Skin- palmar erythema, alopecia, thyroid dermopathy, acropachy (clubbing)

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12
Q

Drug notorious for causing edema

A

Amlodipine (CCB) 10 mg

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13
Q

Indications for aspirin prophylaxis

A

CAD primary prevention w/ aspirin in M 45-79 and W 55-79 w/ risk high enough that cardiovascular benefit outweighs the risk of GI bleed

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14
Q

Why is EKG sometimes indicated in HTN pts?

A

EKG in HTN pts to assess for voltages indicating LVH

-heart muscle as a target end organ for HTN

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15
Q

Maximum dose medication regimen for HTN

A

ACEi: Lisinopril (ACEi) 40 mg
CCB: Amlodipine 10 mg
Thiazide: HCTZ or chlorthalidone 25 mg

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16
Q

Exercise recommendation

A

At least 30 min/day at 5 days/week to attain BMI of 25 or less

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17
Q

What is subclinical hypothyroidism?

(a) Next step

A

Subclinical hypothyroidism- high TSH w/ normal free T4 and T3

(a) Repeat in 6 weeks- if remains present then can decide to treat based on symptoms and/or values
And check TPO
- if positive, more likely to progress to overt hypothyroidism
-check family history of thyroid d/o

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18
Q

DEXA: t-score vs. z-score

A

DEXA: t-score is just on a bell curve for all, z-score is matched for age, race, and sex

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19
Q

Presenting symptoms of hypothyroidism

A

Hypothyroidism presents w/ weight gain, depression, constipation, cold intolerance

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20
Q

Differentiate Graves’ disease from toxic multinodular goiter/adenoma

A

RAIU- patchy (multinodular) or single (adenoma) increase in uptake, as opposed to homogenous increased uptake (Graves’)

Graves’ = (+) TSI
MNG and Adenoma = (-) TSI

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21
Q

How to differentiate if pt is actually hyperthyroid vs. pt taking exogenous thyroid hormone

A

Check amount of thyroglobulin = precursor that gets iodized by TPO in follicular cells to make T4

  • TG will be low if exogenously taking thyroid hormone
  • TG will be high if endogenously overproducing T4
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22
Q

Best anti-anginal

(a) long acting
(b) short acting

A

Anti-anginal

(a) Beta-blocker = best longer term anti-anginal for prophylaxis
(b) Nitroglycerin

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23
Q

Lynch Syndrome

(a) Mode of inheritance
(b) Mutation
(c) Physiology
(d) Age to start CRC screening
(e) Management

A

Lynch Syndrome

(a) Aut dom
(b) Mutation in microsatellite repair gene (most cases due to mutation in MSH2)
(c) Mutation in DNA repair gene => build up of mutations of the genome => increased risk of cancers in epithelium w/ high turnover rate (colon, ovarian, endometrial)
(d) Start CRC screening around age 25
(e) Tx = remove colon

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24
Q

What are the two most common types of genomic instability that cause CRC?

(a) Which is more common?

A

Chromosomal instability- responsible for 85% of sporadic CRCs

Microsatellite instability- responsible for 15% of sporadic CRCs

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25
Q

What is the futility of CEA (carcinoembryonic antigen)

A

CEA isn’t good for diagnosing colon cancer, but can be good to track progress/effect of treatment/relapse

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26
Q

Name the vaccines you’d give to a previously up to date 24 yo F

A

24 yo F

  • influenza (given annually)
  • TDap: one dose then Td booster every 10 years
  • HPV: 3 dose series
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27
Q

What are the dosing step-up regimens for the 3 standard hypertension drugs?

A

Hypertension drugs: 8 notches before at max regimen

  • HCTZ (thiazide diuretic): 12.5 mg –> 25 mg
  • Lisinopril (ACEi): 10 –> 20 –> 40 mg daily
  • Amlodipine (CCB): 2.5 –> 5 –> 10 mg daily
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28
Q

CRC on which side are more likely to cause symptoms

A

Change in bowel habits only really seen if CRC is very distal (on the left side)
-majority of right sided CRCs are clinically silent

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29
Q

Tx HTN in a pregnant women

(a) Avoid which drugs
(b) Use which drugs

A

Treating HTN during pregnancy

(a) Avoid ACEi and ARB (statins also contraindicated in pregnancy)
(b) Use labetaolol (alpha/beta blocker) and Nifedipine (CCB)

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30
Q

Daily sodium recommendations for pts w/ HTN

A

Under 2.3 g/day for adults w/o HTN

About 1.5 g/day for adults w/ HTN (bummer)

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31
Q

Describe how APC mutation is involved in CRC

A

APC wild type acts as a break on the Wnt signaling pathway by ubiquinating Beta-catenin to cause it’s degradation

W/o APC (or w/ mutated APC) beta-catenin doesn’t get broken down and goes on to be a transcription factor for growth pathways

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32
Q

Effect on risk of colorectal cancer of having an affected first degree relative

A

Risk increases 2x

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33
Q

Indication for lasix over HCTZ in HTN pt

A

GFR under 30 ml/min- can’t give thiazide diuretic => can give lasix (furosemide)

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34
Q

Pathology of Multinodular goiter and thyroid adenoma

A

Mutation in the TSH receptor that causes autonomous function => d/o is lifelong

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35
Q

How do you make the diagnosis of hypothyroidism (what labs do you need?)

A

Dx hypothyroidism can be based on just TFTs: High TSH (over 5) and low T4
-send TSH w/ reflex to T4- aka lab will measure TSH and then if TSH is abnormal it will also measure T4

Don’t need to get anti-TPO antibodies (but would expect them to be positive)

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36
Q

Differentiate ADLs from IADLs

A

IADLs = instrumental activities of daily living
-require higher cognitive/physical functioning than just ADLs

ex: manage own finances, take medications, laundry, cooking, shopping

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37
Q

Lipid disorder screening

(a) Indicated in which population
(b) Mode of testing and frequency

A

Lipid d/o screen

(a) Men beginning at 35, W at 45
- start at 20 if at increased risk for CAD

(b) Fasting lipid panel every 5 yrs until abnormal

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38
Q

Describe the general production of thyroid hormone

(0) Stimulating hormone
(a) Precursor
(b) Enzyme for conversion
(c) T3 vs. T4
(d) Binding protein

A

TRH from hypothalamus stimulates anterior pituitary to release TSH

TSH binds to it’s receptor on the thyroid gland and stimulants T3 production from precursor thyroglobulin

TPO (thyropyroxidase) converts thyroglobulin to T3

(c) T3 is made initially, then converted to T4 in the thyroid cell. More T4 is made and transported out of cell, then more T3 floats around in blood attached to TBG (thyroid binding globulin)

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39
Q

What percent of colorectal cancers are

(a) Genetic
(b) Hereditary
(c) Familial
(d) Sporadic

A

Percent of colorectal cancers that are

(a) Genetic- UM 100%…duh all cancers involve mutations
(b) Hereditary- 5%
Syndromes such as Lynch and FAP where specific gene found as responsible
(c) Familial- 10-30%, no specific gene possible
(d) Sporadic- other 70-85%

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40
Q

Why types of CRC are picked up by

(a) Barium enema
(b) FIT

A

CRC picked up by

(a) Barium enema only catches larger lesions
(b) FIT = fecal immunohistochemical test looks for human blood in the stool
- picks up large polyps and cancers, but not the small stuff

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41
Q

Mechanism by which ACEi may cause acute renal injury in HF pts

(a) Is it reversible?

A

ACEi can cause dilation of efferent arteriole => reduction in intraglomerular pressure => initial loss of GFR
-most often in CHF pts on over-diuresis (volume depletion)

(a) Yes, reversible

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42
Q

Preferred first 3 agents for HTN tx in a diabetic pt

A

ACE (or ARB), CCB, thiazides

-same as pt w/o diabetes

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43
Q

Describe the staging system for CRC

A

Colorectal cancer

-stage 0 =

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44
Q

Physical exam of a hypothyroid pt

(a) Skin findings
(b) Neuro

A

Physical exam in a hypothyroid pt

(a) Skin: cool skin, puffiness (myxedema), alopecia, bradycardia
Myxedema = swelling w/o pitting

(b) Neuro: decreased DTRs, carpal tunnel

45
Q

Which cancers are screened for?

A

4 cancers are screened for

  1. breast
  2. cervical
  3. lung- in heavy smokers (30 pack years)
  4. colon
46
Q

Levothyroxine

(a) What is it?
(b) How often does it need to be taken?
(c) How to start dosing
(d) How to track response

A

Levothyroxine

(a) exogenous T4 for hypothyroid pts
(b) Levothyroxine has a really long half life (like a week), can be taken once daily- and if you miss a dose not a huge deal
(c) Start at dose btwn 25-100 mg initially, then recheck TSH in 6-8 weeks
(d) Check TSH, not T4 to track tx response
- check TSH to see if the T4 is working to suppress the feedback loop (aka if the entire system is working properly)

47
Q

HCTZ vs. chorthalidone

Which is

(a) Stronger
(b) More likely to cause hypokalemia

A

HCTZ vs. chorthalidone (both thiazide diuretics that inhibit NaCl reabsorption from DCT)

(a) Chorthalidone is 1.8 times stronger, but is
(b) More likely to cause hypokalemia (chorthalidone)

48
Q

1 cause of hypothyroidism

(a) Worldwide
(b) In the US

A

1 cause of hypothyroidism

(a) Worldwide = iodine deficiency
(b) in the US = autoimmune
- almost always Hashimoto’s

49
Q

Disadvantages of surgery for Graves’ disease

A

Subtotal or near total thyroid resection: hypoPTH (b/c cant spare parathyroid glands), risk of recurrent laryngeal nerve damage, often then permanently hypothyroid

50
Q

At what time of day should BP meds be taken?

A

Improved outcome when at least one pill is taken at night- b/c allows for ‘dipping’ (10+ drop in systolic BP) during sleep- which is associated w/ better CV outcomes

51
Q

Describe where colorectal mets are most likely to go?

A

(well obv first regional lymph nodes)
Liver (thru portal vein which drains most of the gut)

Rectal –> lungs thru the inferior mesenteric vein

52
Q

Follow up requirements for diabetes stage

(a) 1
(b) 2

A

Follow up in

(a) 2 months for stage 1 HTN: > 140, >90
(b) 1 month follow up for stage 2 HTN: >160, >100

53
Q

Differentiate the 2 types of subacute destructive thyroiditises:

subacute granulomatous vs. subacute lymphocytic

A

Subacute granulomatos = post-viral, very painful, elevated ESR
-stage of hyper (T4 all oozes out due to destruction) then stage of hypo (compensatory change in TSH) then return to euthyroid

Subacute lymphocytic = autoimmune (so +TPO), painless/silent, can come in phases of hyper/hypo/eu

  • can have transient or permanent hypothyroid (10-20% stay hypothyroid)
  • associated post-partum
54
Q

Methimazole vs. propylthiouracil

A

Methimazole and propylthiouracil (PTU) are both anti-thyroid drugs to treat Graves’ disease: block synthesis of T4 and T4
-both take 6-8 until euthyroid, then goal is to taper pt off and hope they remain euthyroid (remission w/o relapse)

Methimazole- daily but can’t be used during prengnacy

PTO- TID but can use during pregnancy

55
Q

Lung cancer screening

(a) Indicated in which population
(b) Mode of testing and frequency

A

Lung cancer screen

(a) Adults 55-80 w/ 30+ pack years and quit less than 15 yrs ago
(b) Annual low dose, non-contrast chest CT

56
Q

Describe the normal mucosa of the GI tract

A

GI tract = simple columnar epithelium

  • long thin cells w/ nuclei on the bottom
  • N:C ratio less than 1
57
Q

Name the antibody that is present in most thyroid autoimmune processes

A

Anti-TPO (thyropyroxidase) antibody

TPO = enzyme that couples iodine to Tg (thyroglobulin) in follicular cells to make T3

58
Q

When is chorthalidone used over HCTZ?

A

When BP is really bad (chorthalidone is 1.8x stronger than HCTZ) and K+ is solid (b/c chorthalidone is more likely to cause hypokalemia)

59
Q

Differentiate hyperthyroidism and thyrotoxicosis

A

Hyperthyroidism = general term for when thyroid gland is overproducing

vs.

Thyrotoxicosis = when thyroid gland has overproduced to the point where the amount of thyroid hormone in the blood is toxic (too much thyroid hormone in the blood)

60
Q

Describe the physiology of colorectal cancer

A

As GI mucosa rapidly turns over and divides mutations accumulate that let cells evade normal halts in cell cycle (endow growth advantage) => polyps (neoplastic clones) form that continue to divide and accumulate mutations that eventually cause cells to no longer respond to physiology controls

Vogelgram shows ideas of stepwise accumulation of mutations

61
Q

Mechanism of thiazide diuretics

A

Work at DCT by blocking thiazide sensitive NaCl symporter => inhibits Na and Cl reabsorption => decreases water reabsorption

-also increases Ca2+ reabsorption

62
Q

What is the target BP reading for adults?

A

Target:
-under 140/90 for adults under 60 yo
-under 150/90 for adults over 60 without DM, CAD, CKD
^^b/c systolic increases more than diastolic w/ age

-if have diabetes, coronary artery disease, or chronic kidney disease: lifetime goal is under 140/90

63
Q

Mechanism of aldosterone activity

A

Aldosterone works at distal tubules and collecting ducts to cause increased reabsorption of Na+ (and therefore water)
-as a result of increased Na+ absorption = increased K+ excretion

Hence why decreased aldo secretion (ex: pt on ACEi) may suffer from hyperkalemia

64
Q

Preventative services for everyone

A

Everyone (all ages and gender) get these basic 7 screens

  1. alcohol abuse
  2. tobacco use
  3. depression
  4. HTN
  5. HIV (until age 65)
  6. Hep C: if born btwn 1945-1965
  7. Lipids
65
Q

Purpose of aspirin prophylaxis in M vs. W

A

Aspirin helps prevent

  • stroke (CVA) in F
  • heart attack (CAD) in M
66
Q

What percent of sporadic colorectal cancers are due to MSI?

(a) How does the gene differ from that seen in Lynch Syndrome

A

15% of sporadic colorectal cancers are due to MSI

(a) Sporadic cancers caused by MSI are usually due to MLH1 mutation while most Lynch syndromes are due to mutation in MSH2

67
Q

How does having a family member w/ adenoma vs. colorectal cancer affect risk of CRC?

A

Adenoma (benign polyp, before becomes neoplastic) in a family member also increases risk of CRC

68
Q

Average-risk monogamous 21-yo F

(a) Preventative services
(b) Vaccines

A

Average-risk 21-yo F

(a) The usual: alcohol, tobacco, depression, HTN, HIV, lipids
(not Hep C b/c not born btwn 1945-1965)

+ cervical cancer screen (pap smear)
+ chlamydia infection screen
+ folic acid 0.4-0.8 mg daily to prevent neural tube defects

Vaccines: TDap, MMR, Varicella if not previously vaccinated

  • HPV: 3 dose series
  • Influenza: annually
69
Q

Contraindications to thiazide therapy

A
  • hypokalemia (since thiazides decrease potassium reabsorption)
  • urinary incontinence (you don’t wanna explode your bladder!!)
  • gout (thiazides increase uric acid level)
  • GFR under 30 ml/min (need to be perfusing kidneys for them to work, and don’t want to further decrease GFR by decreasing volume)
70
Q

Recommendations for vitamin D supplementation in ppl w/

(a) Normal DEXA
(b) Abnormal DEXA

A

Vitamin D supplementation

(a) Don’t give it to pts w/ normal DEXA
(b) Abnormal DEXA: recommend 800-1000 IU/d if Vit D under 30

71
Q

Describe the cervical cancer screening guidelines

(a) Women 21-65
(b) Women 30-65

A

Cervical cancer screening

(a) Women 21-65 w/ cervix: pap testing every 3 years or
(b) Women 30-65 w/ cervix: pap + HPV testing every 5 years

-changes if have irregular pap

72
Q

Vaccines contraindicated during pregnancy

A

3 contraindicated vaccines during pregnancy

  • varicella
  • zoster
  • MMR
73
Q

Most common cause of thyrotoxicosis

A

60-80% of thyrotoxicosis is due to Graves’ disease

74
Q

Workup for subacute thyroiditis

A

Subacute thyroiditis = weeks to months of non-euthyroid due to damage to thyroid gland

Workup: RAIU, ESR, TPO, (duh history and physical)

Subacute granulomatous:
-painful, + ESR, -TPO, post-viral

Subacute lymphocytic:
-painless, -ESR, +TPO, may be post-partum

75
Q

When would you need to increase the dose of levothyroxine?

A

Increase dose of levothyroxine w/ anything that increases estrogen: pregnancy, OCPs, Tamoxifen, endogenous estrogen for menopause

-estrogen increases TBG => need higher dose of levothyroxine to fill more of the binding sites

76
Q

Describe the staging system for CRC and how each stage is treated

A

Colorectal cancer

Stage 0 = doesn’t go beyond the mucosa, can be removed during endoscopy

Stage 1 = beyond mucosa but not into muscularis propria, removed surgically and by some adventurous endoscopists

Stage 2 = beyond muscularis but thru the serosa, surgically remove

Stage 3 = spread to lymph nodes, surgically resect then chemo

Stage 4 = distant mets, tx depends on the degree of meds

77
Q

What drug can’t be used w/ amlodipine?

A

Amlodipine (CCB) can cause myositis => can’t use a high dose of another drug (aka statins) that can cause myositis as well

=> Max simvastatin dose:

  • 20 mg w/ amlodipine
  • 10 mg w/ verapamil or diltiazem
78
Q

Backbone medical therapy for HTN

A

Backbone of HTN medicines:

  1. ACEi (or ARB)
  2. Thiazide diuretic
  3. CCB
79
Q

Effect on HTN reading of using the wrong size cuff

A

If you use a cuff that is too small for the pt, the BP reading can be falsely elevated

80
Q

65 yo M smoker w/ HTN

(a) Preventative services
(b) Vaccines

A

65 yo M smoker w/ HTN

(a) The usual: tobacco, alcohol, depression, Hep C, HTN, lipids
+ colonoscopy (depending on date and result of last)
+ lung cancer screen (b/c smoker)
+ abdominal aortic aneurysm
+ diabetes screen
+ dietary counseling (b/c HTN => lose weight and low sodium diet)
+ aspirin

(b) Vaccines
- Pneumococcal infection: one time dose
- Zoster: one time dose
- Influenza: annually
- Td every 10 years

81
Q

CKD (GFR under 60 or UACR over 30)

(a) Which BP meds should be avoided
(b) Which BP meds are preferable

A

Chronic kidney disease

a) Avoid thiazides and spironolactone (b/c can cause hyperkalemia
(b) Use ACE (or ARB)

82
Q

FAP- familial adenomatous polyposis

(a) Mode of inheritance
(b) Mutation
(c) Physiology
(d) Age to start CRC screening
(e) Management

A

FAP

(a) Autosomal dominant- all but one (MUTYH) genetic CRC syndrome is aut dom
(b) mutation in APC gene (controls Wnt/beta-catenin signal transduction pathway)
(c) No halt on cell growth => every cell has massively increased risk of becoming a polyp => thousands of adenomatous polyps that each have the potential to become cancer
(d) Start CRC screening at age 12, almost 100% lifetime risk of CRC
(e) Remove colon

83
Q

2 most common presenting features of CRC

A

Most CRC are clinically silent (hence why screening is key), but of the ppl that have symptoms:
44% have abdominal pain
40% hematochezia

84
Q

Sexually active women should be screened for which 2 thigns

A

Chlamydia and gonorrhea

-done in gyn clinic

85
Q

ACEi vs. ARBs

(a) Advantages of ACEi
(b) Advantages of ARBs

Which has more

(c) hypotension
(d) hyperkalemia

A

ACEi vs. ARBs

(a) ACEis: in diabetic pts ACEi reduced all cause mortality, CV deaths, and CV events. ARBs did not!

(b) ARBs- less angioedema and cough
(c) ARBs cause more hypotension
(d) Similar rates of hyperkalemia

86
Q

2 most common SEs of CCBs

A

Calcium channel blocker side effects:

  • edema (especially amlodipine 10 mg)
  • myositis (hence why can’t use high dose statin w/ CCB)
87
Q

Modification in HTN tx regimen if the pt has comorbid

(a) Asthma
(b) BPH
(c) Calcium kidney stones
(d) Osteoporosis
(e) Hx of MI

A

Modifications in HTN regimen w/ comorbid

(a) Asthma = avoid beta-blockers
- side effect of bronchoconstriction
(b) BPH = use alpha-blocker = Flomax
(c) Calcium kidney stones- use thiazide which will increase renal Ca2+ reabsorption to decrease amount in urine
(d) Osteoporosis- thiazide diuretic increases Ca2+ reabsorption
(e) Hx of MI- beta-blocker

88
Q

3 groups of pts that qualify for bisphosphonate treatment

A

Bisphosphonate tx

  • osteoporosis
  • anyone w/ hx of fracture
  • high risk osteopenic (FRAX score)
89
Q

Diabetes screening

(a) Indicated in which population
(b) Mode of testing and frequency

A

Diabetes screen

(a) Overweight adults 40-70 yoa
(b) Hgb A1C every 3 years

90
Q

What is destructive thyroiditis?

Describe findings on labs and RAIU

A

Transient state of thyrotoxicity due to damage to the thyroid gland

High T4, low TSH, no hot or cold nodules on RAIU- but can see suppression of iodine uptake

91
Q

ONTARGET trial: simultaneous use of ACEi and ARBs

A

ONTARGET trial: ACEi and ARBs should NOT be used together

-increased incidence of hypotension, syncope, and kidney dysfunction

92
Q

Theory behind bisphosphonate holiday

A

Side effects of bisphosphonate

  • esophagitis (GI distress)
  • rare jaw necrosis
  • atypical femoral fracutre
93
Q

Name a rare endocrine causes of secondary hypertension

A
  1. Cushing’s syndrome = hypercortisolism
    - cortisol secreting adenoma in the adrenal cortex
  2. Pheochromocytoma = neuroendocrine hormone secreting tumor of the adrenal medulla
    - secretes tons of NE
94
Q

Give some etiologies of

(a) Acute
(b) Subacute
(c) Chronic

Destructive thyroiditis

A

Destructive thyroiditis etiology

(a) Acute: bacterial, hemorrhage, post TAI
(b) Subacute: granulomatous and lymphocytic
(c) Chronic: Hashimoto’s and Riedel’s

95
Q

TSH

(a) Normal range
(b) Target level when treating a hypothyroid pt

A

TSH

(a) Normal range: 0.5 - 5
(b) When treating a hypothyroid pt (TSH will be super elevated), treat the TSH to 1-2.5
- don’t target T4, target the TSH

96
Q

Graves’ disease tx

(a) First things first
(b) 3 second line options

A

Treating Graves’ disease

(a) Give beta-blocker (propranolol or atenolol) for symptoms
(b) Second: have a few options
- Antithyroid drugs: goal of remission w/o relapse
- RAI ablation: usually makes pt hypothyroid => will take levothyroxine afterwards
- surgery: subtotal or near-total resection => permanent hypothyroidism

97
Q

Age at which we stop screening for the 4 screenable cancers

A

Stop screening for

  • cervical cancer at age 65
  • breast and colon cancer at 75
  • lung cancer (in smokers) at age 80
98
Q

Vogelgram

(a) Early mutations
(b) Middle mutations
(c) Late mutations

A

Vogelgram = diagram of step wise accumulation of mutations in CRC

(a) Early mutations = APC, thought to be associated in many/most initial polyp formation
(b) Mutations in the middle
- PI3K
- SMAD4
- MSI
- KRAS
- B-RAF
(c) Late mutation = p53- evade cell cycle check points

99
Q

Recommendations for calcium supplementation in ppl w/

(a) Normal DEXA
(b) Abnormal DEXA

A

Calcium supplementation

(a) Pts w/ normal DEXA- insufficient evidence for or against, basically ppl w/ normal bones don’t need it
(b) Abnormal dexa, ensure > 1200 IU/d- ideally through diet
- only supplement if can’t get thru diet

100
Q

Describe the link btwn IBD and CRC

A

Not genetic factors, not due to increased sporadic mutation risk. Due to oxidative stress and inflammation of the bowel

101
Q

RIsk of anti-thyroid drugs

A

Both methimazole and propylthiouracil (block T3/T4 production) carry a risk of agranulocytosis

102
Q

Difference in screening recommendations for men once they hit 65

A

Men 65-75 who have smoked over 100 cigarettes lifetime: one time ultrasound for abdominal aortic aneurysm (AAA)

103
Q

How would the pt being black influence your management of HTN?

A

African Americans are more likely to respond to thiazides and CCBs and NOT ACEi/ARB
-only use ACEi/ARB if kidney disease is also present

104
Q

Lid lag vs. proptosis

A

Features of Graves’ disease (autoimmune hyperthyroid due to antibody that constantly stimulates TSH receptor)

Lid lag = see white of the eye above the iris when pt looks down

Proptosis = how far out of the orbit the globe is sitting
-can be suggested by seeing white of the eye above the iris when pt is NOT looking down

105
Q

Name the 6 ADLs

A

6 Activities of daily living

  1. Transfer
  2. Continence
  3. Toileting
  4. Bathing
  5. Dressing
  6. Eating
106
Q

What electrolyte abnormality is associated w/ ACEi

(a) Mechanism

A

ACEi can cause hyperkalemia

(a) Due to decreased aldosterone secretion
- less aldo => less Na+ reabsorption => less K+ excretion by exchange

107
Q

Potassium recommendation for ppl w/ HTN

A

Potassium > 4.7 g/day
-fruits and vegetables

High K+ intake recommended in ppl w/ significant HTN, doesn’t improve BP in normotensive pts

108
Q

(a) So after the 3 drug-backbone of HTN treatment, what is drug #4?

Good in

(b) CKD pts
(c) diabetics

A

(a) Drug 4
- beta-blocker: atenolol and metoprolol
- K-sparing diuretics: spironolactone

(b) a1b blocker: labetalol: good in CKD pts
(c) a1b blocker: carvedilol: better than metoprolol in diabetes pts

Amb Care (13 decks)

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