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!!
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
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
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
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
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
7
Q
Give 3 examples of chemoprophylaxis
A
Chemoprophylaxis = giving drugs for prevention
- Folic acid to women of child bearing age
- Tamoxifen or Raloxifene daily for 5 years in women over 35 at an increased risk for breast cancer
- Baby aspirin for high risk CAD pts
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
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
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
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)
12
Q
Drug notorious for causing edema
A
Amlodipine (CCB) 10 mg
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
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
15
Q
Maximum dose medication regimen for HTN
A
ACEi: Lisinopril (ACEi) 40 mg
CCB: Amlodipine 10 mg
Thiazide: HCTZ or chlorthalidone 25 mg
16
Q
Exercise recommendation
A
At least 30 min/day at 5 days/week to attain BMI of 25 or less
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
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
19
Q
Presenting symptoms of hypothyroidism
A
Hypothyroidism presents w/ weight gain, depression, constipation, cold intolerance
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
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
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
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
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
25
What is the futility of CEA (carcinoembryonic antigen)
CEA isn't good for diagnosing colon cancer, but can be good to track progress/effect of treatment/relapse
26
Name the vaccines you'd give to a previously up to date 24 yo F
24 yo F
- influenza (given annually)
- TDap: one dose then Td booster every 10 years
- HPV: 3 dose series
27
What are the dosing step-up regimens for the 3 standard hypertension drugs?
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
28
CRC on which side are more likely to cause symptoms
Change in bowel habits only really seen if CRC is very distal (on the left side)
-majority of right sided CRCs are clinically silent
29
Tx HTN in a pregnant women
(a) Avoid which drugs
(b) Use which drugs
Treating HTN during pregnancy
(a) Avoid ACEi and ARB (statins also contraindicated in pregnancy)
(b) Use labetaolol (alpha/beta blocker) and Nifedipine (CCB)
30
Daily sodium recommendations for pts w/ HTN
Under 2.3 g/day for adults w/o HTN
About 1.5 g/day for adults w/ HTN (bummer)
31
Describe how APC mutation is involved in CRC
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
32
Effect on risk of colorectal cancer of having an affected first degree relative
Risk increases 2x
33
Indication for lasix over HCTZ in HTN pt
GFR under 30 ml/min- can't give thiazide diuretic => can give lasix (furosemide)
34
Pathology of Multinodular goiter and thyroid adenoma
Mutation in the TSH receptor that causes autonomous function => d/o is lifelong
35
How do you make the diagnosis of hypothyroidism (what labs do you need?)
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)
36
Differentiate ADLs from IADLs
IADLs = instrumental activities of daily living
-require higher cognitive/physical functioning than just ADLs
ex: manage own finances, take medications, laundry, cooking, shopping
37
Lipid disorder screening
(a) Indicated in which population
(b) Mode of testing and frequency
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
38
Describe the general production of thyroid hormone
(0) Stimulating hormone
(a) Precursor
(b) Enzyme for conversion
(c) T3 vs. T4
(d) Binding protein
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)
39
What percent of colorectal cancers are
(a) Genetic
(b) Hereditary
(c) Familial
(d) Sporadic
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%
40
Why types of CRC are picked up by
(a) Barium enema
(b) FIT
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
41
Mechanism by which ACEi may cause acute renal injury in HF pts
(a) Is it reversible?
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
42
Preferred first 3 agents for HTN tx in a diabetic pt
ACE (or ARB), CCB, thiazides
| -same as pt w/o diabetes
43
Describe the staging system for CRC
Colorectal cancer
-stage 0 =
44
Physical exam of a hypothyroid pt
(a) Skin findings
(b) Neuro
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
Which cancers are screened for?
4 cancers are screened for
1. breast
2. cervical
3. lung- in heavy smokers (30 pack years)
4. colon
46
Levothyroxine
(a) What is it?
(b) How often does it need to be taken?
(c) How to start dosing
(d) How to track response
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
HCTZ vs. chorthalidone
Which is
(a) Stronger
(b) More likely to cause hypokalemia
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
#1 cause of hypothyroidism
(a) Worldwide
(b) In the US
#1 cause of hypothyroidism
(a) Worldwide = iodine deficiency
(b) in the US = autoimmune
- almost always Hashimoto's
49
Disadvantages of surgery for Graves' disease
Subtotal or near total thyroid resection: hypoPTH (b/c cant spare parathyroid glands), risk of recurrent laryngeal nerve damage, often then permanently hypothyroid
50
At what time of day should BP meds be taken?
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
Describe where colorectal mets are most likely to go?
(well obv first regional lymph nodes)
Liver (thru portal vein which drains most of the gut)
Rectal --> lungs thru the inferior mesenteric vein
52
Follow up requirements for diabetes stage
(a) 1
(b) 2
Follow up in
(a) 2 months for stage 1 HTN: > 140, >90
(b) 1 month follow up for stage 2 HTN: >160, >100
53
Differentiate the 2 types of subacute destructive thyroiditises:
subacute granulomatous vs. subacute lymphocytic
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
Methimazole vs. propylthiouracil
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
Lung cancer screening
(a) Indicated in which population
(b) Mode of testing and frequency
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
Describe the normal mucosa of the GI tract
GI tract = simple columnar epithelium
- long thin cells w/ nuclei on the bottom
- N:C ratio less than 1
57
Name the antibody that is present in most thyroid autoimmune processes
Anti-TPO (thyropyroxidase) antibody
TPO = enzyme that couples iodine to Tg (thyroglobulin) in follicular cells to make T3
58
When is chorthalidone used over HCTZ?
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
Differentiate hyperthyroidism and thyrotoxicosis
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
Describe the physiology of colorectal cancer
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
Mechanism of thiazide diuretics
Work at DCT by blocking thiazide sensitive NaCl symporter => inhibits Na and Cl reabsorption => decreases water reabsorption
-also increases Ca2+ reabsorption
62
What is the target BP reading for adults?
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
Mechanism of aldosterone activity
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
Preventative services for everyone
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
Purpose of aspirin prophylaxis in M vs. W
Aspirin helps prevent
- stroke (CVA) in F
- heart attack (CAD) in M
66
What percent of sporadic colorectal cancers are due to MSI?
(a) How does the gene differ from that seen in Lynch Syndrome
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
How does having a family member w/ adenoma vs. colorectal cancer affect risk of CRC?
Adenoma (benign polyp, before becomes neoplastic) in a family member also increases risk of CRC
68
Average-risk monogamous 21-yo F
(a) Preventative services
(b) Vaccines
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
Contraindications to thiazide therapy
- 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
Recommendations for vitamin D supplementation in ppl w/
(a) Normal DEXA
(b) Abnormal DEXA
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
Describe the cervical cancer screening guidelines
(a) Women 21-65
(b) Women 30-65
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
Vaccines contraindicated during pregnancy
3 contraindicated vaccines during pregnancy
- varicella
- zoster
- MMR
73
Most common cause of thyrotoxicosis
60-80% of thyrotoxicosis is due to Graves' disease
74
Workup for subacute thyroiditis
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
When would you need to increase the dose of levothyroxine?
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
Describe the staging system for CRC and how each stage is treated
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
What drug can't be used w/ amlodipine?
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
Backbone medical therapy for HTN
Backbone of HTN medicines:
1. ACEi (or ARB)
2. Thiazide diuretic
3. CCB
79
Effect on HTN reading of using the wrong size cuff
If you use a cuff that is too small for the pt, the BP reading can be falsely elevated
80
65 yo M smoker w/ HTN
(a) Preventative services
(b) Vaccines
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
CKD (GFR under 60 or UACR over 30)
(a) Which BP meds should be avoided
(b) Which BP meds are preferable
Chronic kidney disease
| a) Avoid thiazides and spironolactone (b/c can cause hyperkalemia
(b) Use ACE (or ARB)
82
FAP- familial adenomatous polyposis
(a) Mode of inheritance
(b) Mutation
(c) Physiology
(d) Age to start CRC screening
(e) Management
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
2 most common presenting features of CRC
Most CRC are clinically silent (hence why screening is key), but of the ppl that have symptoms:
44% have abdominal pain
40% hematochezia
84
Sexually active women should be screened for which 2 thigns
Chlamydia and gonorrhea
| -done in gyn clinic
85
ACEi vs. ARBs
(a) Advantages of ACEi
(b) Advantages of ARBs
Which has more
(c) hypotension
(d) hyperkalemia
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
2 most common SEs of CCBs
Calcium channel blocker side effects:
- edema (especially amlodipine 10 mg)
- myositis (hence why can't use high dose statin w/ CCB)
87
Modification in HTN tx regimen if the pt has comorbid
(a) Asthma
(b) BPH
(c) Calcium kidney stones
(d) Osteoporosis
(e) Hx of MI
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
3 groups of pts that qualify for bisphosphonate treatment
Bisphosphonate tx
- osteoporosis
- anyone w/ hx of fracture
- high risk osteopenic (FRAX score)
89
Diabetes screening
(a) Indicated in which population
(b) Mode of testing and frequency
Diabetes screen
(a) Overweight adults 40-70 yoa
(b) Hgb A1C every 3 years
90
What is destructive thyroiditis?
Describe findings on labs and RAIU
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
ONTARGET trial: simultaneous use of ACEi and ARBs
ONTARGET trial: ACEi and ARBs should NOT be used together
| -increased incidence of hypotension, syncope, and kidney dysfunction
92
Theory behind bisphosphonate holiday
Side effects of bisphosphonate
- esophagitis (GI distress)
- rare jaw necrosis
- atypical femoral fracutre
93
Name a rare endocrine causes of secondary hypertension
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
Give some etiologies of
(a) Acute
(b) Subacute
(c) Chronic
Destructive thyroiditis
Destructive thyroiditis etiology
(a) Acute: bacterial, hemorrhage, post TAI
(b) Subacute: granulomatous and lymphocytic
(c) Chronic: Hashimoto's and Riedel's
95
TSH
(a) Normal range
(b) Target level when treating a hypothyroid pt
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
Graves' disease tx
(a) First things first
(b) 3 second line options
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
Age at which we stop screening for the 4 screenable cancers
Stop screening for
- cervical cancer at age 65
- breast and colon cancer at 75
- lung cancer (in smokers) at age 80
98
Vogelgram
(a) Early mutations
(b) Middle mutations
(c) Late mutations
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
Recommendations for calcium supplementation in ppl w/
(a) Normal DEXA
(b) Abnormal DEXA
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
Describe the link btwn IBD and CRC
Not genetic factors, not due to increased sporadic mutation risk. Due to oxidative stress and inflammation of the bowel
101
RIsk of anti-thyroid drugs
Both methimazole and propylthiouracil (block T3/T4 production) carry a risk of agranulocytosis
102
Difference in screening recommendations for men once they hit 65
Men 65-75 who have smoked over 100 cigarettes lifetime: one time ultrasound for abdominal aortic aneurysm (AAA)
103
How would the pt being black influence your management of HTN?
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
Lid lag vs. proptosis
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
Name the 6 ADLs
6 Activities of daily living
1. Transfer
2. Continence
3. Toileting
4. Bathing
5. Dressing
6. Eating
106
What electrolyte abnormality is associated w/ ACEi
(a) Mechanism
ACEi can cause hyperkalemia
(a) Due to decreased aldosterone secretion
- less aldo => less Na+ reabsorption => less K+ excretion by exchange
107
Potassium recommendation for ppl w/ HTN
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
(a) So after the 3 drug-backbone of HTN treatment, what is drug #4?
Good in
(b) CKD pts
(c) diabetics
(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
