Ask - ask about smoking
Advise - quit now
Assess - assess willingness to quit
Assist - help patient make a plan, give advice, prescribe drugs, give supplemental materials
Arrange - arrange follow-up
Based on the AHCP clinical practice guidelines, what are the 5 A's of counseling on smoking cessation?
- Help patient make a plan with a definite quit date
- Prescribe pharmacologic assistance
- Advise re: likely symptoms and avoiding dangerous situations
- Provide with supplemental materials
What are things you can do to ASSIST a patient in smoking cessation?
Nicotine replacement: Not harmful, including in pregnancy
Bupropion (Zyban, Wellbutrin): Lower doses than antidepressant dosing
Varenicline: Very effective, no increased risk of suicide or depression, no contraindications
Pharmacologic treatments for smoking cessation
Insomnia, dry mouth
Bupropion side effects
Mouth sores (since it's gum), dyspepsia (you can't digest gum)
Nicotine replacement side effects
Bupropion: start 1-2 weeks prior to quitting, 150 mg BID
Nicotine patch: 21 mg for 4 weeks, 14 mg for 2 weeks, 7 mg for 2 weeks (i.e. wean off of it)
Nicotine gum: for breakthrough cravings, 1-2 chews then store in cheek
Treatment regimen for pharmacologic smoking cessation aids
Mechanism: inhibit HMG-CoA reductase (decreasing hepatic production of cholesterol)
Lipid effects: LDL decrease 20-60% (intermediate effect on Tg, slight increase in HDL)
Side effects: Myositis/myalgias, hepatotoxicity
Statins: mechanism, lipid effects, side effects
Mechanism: downregulates VLDL production, inhibits lipolysis
Lipid effects: LDL decrease 15-20%, HDL increase 20-25%, Tg decrease 20-30%
Side effects: Flushing, hepatotoxicity, myalgias, gout (hyperuricemia), DM (hyperglycemia)
Niacin: mechanism, lipid effects, side effects
Mechanism: PPAR-gamma activation -> inhibit lipolysis, decreases extraction of FFAs by liver, increases clearance and decreases production of ApoB
Lipid effects: LDL decrease up to 20%, HDL increase up to 10%, Tg decrease 30-40%
Side effects: Myopathy, gallstones (think the "6 Fs"), dyspepsia
Fibrates: mechanism, lipid effects, side effects
Mechanism: blocks receptors, preventing absorption of cholesterol at brush border, forcing creation of new bile salts and depletion of systemic cholesterol
Lipid effects: LDL decrease up to 20%
Side effects: hepatotoxicity
Ezetimibe (Zetia): mechanism, lipid effects, side effects
Mechanism: binds cholesterol in gut, blocking absorption and forcing synthesis of new bile salts and depletion of systemic cholesterol
Lipid effects: LDL decrease up to 20%, no effect on HDL, mild INCREASE Tg
Side effects: bad taste, GI upset (constipation, diarrhea), decreased absorption of some meds (e.g. warfarin)
Bile resins: mechanism, lipid effects, side effects
Main effect of statins
Increase HDL (lower Tg)
Main effect of niacin
Main effect of bile resins
Lower Tg (raise HDL, lower LDL)
Main effect of fibrates
Lower LDL only
Main effect of ezetimibe (Zetia)
All people older than 20 years, every 5 years (or if screening total cholesterol >200, or HDL <40)
In terms of age, what is the indication to get a fasting lipid profile?
<200: Desirable, screen every 5 years
200-239 (no CHD, <2 CHD risks): borderline high, recheck annually
200-239 (CHD or >2 CHD risks): lipoprotein analysis, treat based on LDL levels
>240: lipoprotein analysis, treat based on LDL
Total cholesterol screenings: levels and subsequent actions
LDL = total - (HDL + Tg/5)
How do you calculate LDL?
(Note: average of 3 measurements at different times)
HTn stage 1: 140-159/90-99
HTn stage 2: 160+/100+
EMERGENCY: diastolic >120
Criteria to diagnose hypertension
(Lower blood pressure!)
Side effects of ACE-inhibitors
Side effects of ARBs
- May mask hypoglycemia
- Worsen CHF
- Bronchospasm (contraindicated in asthmatics)
- Bradycardia (can -> MI if suddenly discontinued)
- Dyslipidemia (increases Tg, decreases HDL)
Cardioselective beta-blockers, side effects
"Werewolf with an ACE in one hand, next to a CART with a PIN and a PEN"
- Drug-induced lupus
Symptathomimetic beta-blockers, side effects
"LAB beaker and Knife going into the liver"
- Orthostatic hypotension
Beta/alpha blockers, side effects
HCTZ, Chlorthalidone, Metolazone, Indapimide
- Pancreatitis, gout
- HIGH: urate, glucose, Tg, cholesterol, calcium
- LOW: Mg, Na, K
Thiazide diuretics, side effects
- Metabolic alkalosis
- HIGH: urate, glucose, Tg, cholesterol
- LOW: Mg, Na, K
Loop diuretics, side effects
Amiloride, Spironolactone, Triamterine
- GI upset
Potassium-sparing diuretics, side effects
Non-DHP: Verapamil, diltiazem
- Increased risk of MI, CAD, CHF in diabetics
- AV block, bradycardia, dizziness
- Lupus, constipation
- Gingival hyperplasia, flushing, tachycardia (DHP)
Non-DHP and DHP CCBs, side effects
- First-dose syncope
- Vertigo, dizziness
Alpha blockers, side effects
ACE-I (reduces kidney damage)
- Also use in CHF, LV dysfunction, and HLD
What hypertensive med should be given to diabetics?
- Also in angina, migraine, CHF (depending on the scenario), systolic HTn (+thiazide, DHP CCB)
Antihypertensive agent for a patient with a history of MI
- Decreases mortality, esp. in African-Americans
When should thiazides be used?
Antihypertensive agent for patients with chronic renal insufficiency
Drug regimen for patients with CHF
Drug regimen for patients with hyperlipidemia
Drug regimen for elderly patient with systolic HTn
Drug for patient with prostatism
Elevated blood pressure with new-onset organ damage (neuro, papilledema, CP, ECG findings, CHF, AKI, UA sediment)
Malignant hypertension definition
Dx: malignant hypertension
Tx: IV nitroglycerin/nitroprusside, labetolol (hydralazine in pregnancy)
Patient comes in with BP 200/110 with ECG changes, CP, and papilledema. Dx and Tx?
Dx: migraine headaches
Tx: triptans, ergots, NSAIDs, antiemetics
PPx: TCAs, topamax/depakote, beta blocker
Patient comes in with aura, photophobia, sonophobia, nausea/vomiting, weakness, ataxia. Pain is unilateral and throbbing for hours. Dx, Tx, PPx?
Dx: tension headache
Tx: NSAIDs/acetaminophen, narcotics
PPx: amytriptyline/doxepin (TCAs)
Patient comes in with a bilateral bandlike pain around the head and neck, worsening as the day progresses, and associated with neck stiffness. Dx, Tx, PPx?
Dx: cluster headaches
Tx: 100% oxygen, intranasal lidocaine, DHE (ergots)
PPx: verapamil, lithium, ergot (2 hours before), steroid taper (second line)
Patient comes in with unrelenting unilateral pain associated with conjunctival injection, tearing, rhinorrhea, ptosis, miosis, eyelid edema. Always happens at a certain time. Occurs in periods of days and weeks. Dx, Tx, PPx?
- nitrates (preserved meats)
What are three examples of triggers for cluster headaches?
1) reduce weight:
- 500-1000 kcal reduction
- <30% calories from fat, >15% calories from protein
2) lower cholesterol
- reduce saturated fats and cholesterol intake (sat fats < 7% total calories, dietary cholesterol < 200 mg, total fat < 30%)
- increase soluble fiber to 10-25 g/day
- plant stanols/sterols 2 g/day
3) control hypertension: DASH diet
- <2 g salt per day
- 8 grains, 5 veggies/fruits, 3 dairy, <2 meat, 3 fats
- 5 sweets/week, 3 nuts/week
In an overweight person, what are specific dietary measures to reduce weight, lower cholesterol, control hypertension?
Sciatica (95% due to disc herniation)
- pain/numbess/paresthesias of calf/thigh/lateral ankle/foot
- calf atrophy
- decreased reflexes
- great toe extensor weakness, plantar flexion weakness
- paraspinal muscle spasm
- positive straight leg raise test
Patient comes in with sharp and burning pain radiating down the posterior and lateral aspect of their ankle and foot. Worse with cough and Valsalva, endorses paresthesias, numbness, and weakness. What would you expect to find on physical exam?
- local swelling
- marked tenderness to palpation
Patient comes in with lower back pain. Onset of pain was immediate and associated with twisting, lifting, and bending. Radiates across the low back and no radiation into leg. What would you expect to find on physical exam?
- continue ordinary activity
- heat pad, warm baths
- mild analgesics or anti-inflammatories
Treatment for lumbosacral strain?
- suspect malignancy (>50 yo, focal/persistent bone pain)
- compression fracture (steroids, postmenopausal woman, focal tenderness)
- ankylosing spondylitis (sacroiliac pain, morning pain relieved with activity, young male, limited spinal motion)
- chronic osteomyelitis (fever, high ESR, focal tenderness)
- major trauma
- major neurologic deficits
- back pain in thoracic or high lumbar
When would you get a plain film in a patient with low back pain?
YES - hx of malignancy, mets
Patient comes in with focal back pain. Hx of malignancy. Plain film?
YES - steroids, compression fracture
Patient comes in with focal back pain. Hx of lupus controlled with steroids. Plain film?
YES - postmenopausal, compression fracture (osteoporosis)
Patient comes in with focal back pain. She is postmenopausal. Plain film?
YES - morning pain, sacroiliac, ankylosing spondylitis
Patient comes in with sacroiliac pain, worse in morning but gets better with activity. Limited motion. Plain film?
YES - fever and ESR, chronic osteomyelitis
Patient comes in with focal back pain, fever. Labs show elevated ESR. Plain film?
YES - neurologic deficits suggest injury or more insidious process
Patient comes in with back pain. Decreased reflexes and motor strength in both extremities. Plain film?
YES - thoracic pain (MI, AA, etc.)
Patient comes in with focal back pain in the thoracic region. Plain film?
- random plasma glucose > 200 + symptoms
- two fasting plasma glucose > 126
- two hour OGTT > 200
What are the criteria to diagnose diabetes mellitus?
How much do oral hypoglycemic agents lower HbA1c?
"-amides" (1st gen, acetohexamide, chlorpropamide, tolbutamide, tolazamide), glyburide/glipizide (2nd gen)
increase postprandial insulin secretion, decrease insulin resistance
- (1st gen) may displace meds from plasma proteins
What are the sulfonylureas? Mechanism and side effects?
Which generation of sulfonylurea should be used in patients with CRI?
sensitize muscle to insulin, inhibit liver gluconeogenesis
- GI side effects: bloating, diarrhea, cramping
- lactic acidosis
- lowers lipids
What are the biguanides? Mechanism and side effects?
it is renally excreted, so...
- if creatinine > 1.5 (CRI)
- if contrast just given
- if CHF
When should metformin NOT be given?
reduce insulin resistance
- hepatotoxicity ("glittery liver")
What are the thiazolidinediones? Mechanism and side effects?
inhibits mono- and oligosaccharide hydrolysis in
- GI side effects: abd pain, n/v/d
- can potentiate hypoglycemia
What are the alpha-glucosidase inhibitors? Mechanism and side effects?
repaglinide (Prandin), nateglinide
stimulates insulin release (similar to sulfonylurea, but different site), increases insulin sensitivity
- Stevens-Johnson syndrome
- liver dysfunction
What are the meglitinides? Mechanism and side effects?
Onset: 15 min
Peak: 30-90 min
Duration: 2-4 h
Onset, peak, duration of rapid-acting insulin (Lispro)?
Onset: 30-60 min
Peak: 2-4 hr
Duration: 6-8 hr
Onset, peak, duration of regular insulin?
Onset: 1-3 hr
Peak: 6-12 hr
Duration: 18-26 hr
Onset, peak, duration of intermediate insulin (NPH, Lente)?
Onset: 4-8 hr
Peak: 14-24 hr
Duration: 28-36 hr
Onset, peak, duration of long-acting insulin (Ultralente, Glargine/Lantus)?
give total daily dose as 2/3 breakfast, 1/3 dinner
How do you divide and start insulin?
- inspect feet daily
- wash feet daily in lukewarm water
- keep feet clean and dry
- apply moisturizing cream to prevent skin breaks
- clip toenails straight across
- wear cotton socks
- break shoes in carefully and slowly
- alternate shoes
- consult doctor
What are preventative foot care measures for a diabetic?
Which immunizations should the diabetic patient receive?
(and intensive glycemic control)
What medication should be started to prevent diabetic nephropathy?
- intensive glycemic control
- yearly eye exams by ophthalmologist
- laser surgery as needed
What precautions should be taken to prevent diabetic retinopathy?
- intensive glycemic control
What precautions should be taken to prevent diabetic neuropathy?
- abnormal ECG, loss of physiologic splitting, S3/S4
Patient comes in with chest pain, squeezing and pressure-like. Sudden onset with exertion, stress, or eating. Relieves with rest (or nitro). Radiates to jaw, neck, shoulder, arm. Endorses diaphoresis and nausea. What would you expect on physical exam?
Patient comes in with chest pain, dull and aching. Worse when supine and after large meals. Reports some difficulty swallowing. Also reports a chronic cough. Dx?
musculoskeletal chest pain
- tenderness to palpation
- evidence of trauma/rash
- localized swelling, erythema, warmth
Patient comes in with chest pain, pinpointed in one location. Sharp and aching in nature. Worse with deep inspiration, cough, movement, and palpation. What would you expect on physical exam?
12 (men) or 14 (women) symptoms of 60 [DSM III]
2 GI, 1 GU, 1 neuro symptom [DSM IV]
- agree there is a problem, willingness to identify it
- emphasize function, not symptoms
- schedule regular appointments
- reinforce non-illness behavior and communication
- limit diagnostic tests - focus on signs rather than symptoms
How is somatization disorder diagnosed? What are some approaches to the care of a patient with somatization disorder?
- variable in duration, nonorganic variations
- floridly positive ROS
- description of symptoms are qualitative and emotional
- nonverbal cues: poor eye contact, sighing
- insistent fear of a specific disease even after ruled out
- verbal complaints contrast with nonverbal presentation
- many prior surgeries or workups, multiple prior doctors
List 7 clues that make somatization more likely.
Patient comes in with double sickening (a cold, which became significantly worse 7 days later). Think of Dx?
Dx: acute sinusitis (maxillary pain referred to teeth)
- S. pneumoniae, H. influenzae, Moraxella, anaerobes (like otitis media in kids)
Tx: amoxicillin or bactrim, doxycycline or azithro, decongestants
Patient comes in with acute sinus pain, purulent nasal discharge. Reports increased facial pain when bending forward. Positive ROS for fever, fatigue, teeth pain. Recent history of cold one week ago. Dx (organisms) and Tx?
Dx: chronic sinusitis
- S. aureus, anaerobes
Tx: amoxicillin-clavulanate (Augmentin) x 10 days, decongestant, ENT for surgical drainage or sinus irrigation
Patient comes in with nasal congestion, purulent nasal discharge. Denies fevers, headaches, or pain. Has been going on for several months now. Dx (organisms) and Tx?
Dx: irritable bowel syndrome (IBS)
- one of constipation or diarrhea can predominate
Tx: reassurance, high fiber/low fat diet, anxiolytics (SSRI, bupropion), loperamide, cholestyramine
("reassure, diet, psych, GI")
Patient comes in with achy LLQ and lower abdominal pain. Reports having multiple episodes of diarrhea that alternate with constipation. Some anorectal discomfort that is relieved with bowel movements. Dx and Tx?
diagnostic algorithm for IBS
1) onset of pain linked to more frequent BM
2) onset of pain associated with looser stools
3) pain relieved with passage of stools
4) noticeable abdominal bloating
5) >25% of time, sensation of incomplete evacuation
6) >25% of time, diarrhea with mucus
What are the Manning Criteria?
Tx: rest, oral fluids, salt-water gargling (soothing effect)
Patient comes in with cough, rhinorrhea, and reports having a fever. Most likely diagnosis?
tender anterior cervical LAD*
* are most common symptoms
What are the four physical exam criteria when looking for Streptococcus pharyngitis (i.e., the "Strep Criteria")?
Score 0: Streptococcus probability 1% (3% in ER)
Score 1: Streptococcus probability 4% (8% in ER)
Score 2: Streptococcus probability 9% (18% in ER)
Score 3: Streptococcus probability 21% (38% in ER)
Score 4: Streptococcus probability 43% (63% in ER)
What did the Strep Criteria mean?
- penicillin or cephalosporin if PEN allergic
Patient comes in with acute onset of dysphagia. They report having a fever. Denies cough. On physical exam, tonsillar exudates are seen and anterior cervical LAD is felt. Most likely diagnosis and treatment?
- TEST if 1-2 symptoms, treat based on results
- TREAT (no test) if the three * symptoms (exudates, LAD, fever) or hx of rheumatic fever
- DON'T TEST if no hx/exam suggestive of strep, or if typical viral URI symptoms
What are the indications for doing a rapid Strep test?
fever, back pain
("an elderly male catheterized patient with fever and back pain")
What symptoms or characteristics make a simple UTI into a complicated UTI?
fluoroquinolone (-floxacins) x 10-14 days
Treatment for a complicated UTI?
high fever, rigors, flank pain, nausea, vomiting
When should a patient presenting with a complicated UTI be hospitalized?
typical dysuria and frequency → check UA/dipstick
no PEX of pyelonephritis, vaginitis, STD
- 3 days of bactrim, ciprofloxacin, nitrofurantoin (if allergic to sulfa)
What is a cost-effective approach in diagnosing (uncomplicated) UTI?
Dx: bacterial conjunctivitis
- Pneumococcus, Neisseria/Chlamydia (corneal scars), Staph (chronic with ulcers)
- Chlamydia will have LAD
Tx: erythromycin ointment OR polymyxin/TMX drops
Patient comes in complaining of eye discharge, conjunctival injection, lids stuck together in AM, with no pain or photophobia. Only one eye is affected, there is a little itching but no foreign body sensation. Discharge is mucopurulent. No preauricular LAD. Dx (organisms) and Tx?
Dx: viral conjunctivitis
Tx: self-limited for 2-3 weeks, contagious up to 2 weeks
Patient comes in complaining of eye discharge, conjunctival injection, lids stuck together in AM, with no pain or photophobia. Patient reports that initially only one eye was affected, but is now bilateral. Sensation is feels like a foreign body with lots of tearing. Discharge is watery and mucoid. Preauricular adenopathy is present. Patient reports recent fever and pharyngitis. Dx (organisms) and Tx?
Dx: allergic conjuncitivtis
Tx: cool compresses, decongestant-antihistamine drops, oral decongestants
Patient comes in complaining of eye discharge, conjunctival injection, lids stuck together in AM, with no pain or photophobia. Both eyes are affected. There is a little itching and some foreign body sensation. Discharge is clear. No preauricular LAD. Patient endorses a history of season allergies and some atopic dermatitis (eczema). Dx (organisms) and Tx?
98. Patient comes in with nervousness, irritability, heat intolerance with warm moist skin, pruritis, hair loss, weight loss, increased appetite, lid lag, stare, palpitations, systolic hypertension, tachycardia, DOE, increased BM, diarrhea, muscle weakness, and hyperreflexia. Dx?
- methimazole (MMI) or propylthiouracil (PTU) - MMI better except in pregnancy
- radioactive iodone (except pregnancy/breastfeeding)
- subtotal thyroidectomy
- iodides, beta-blockers
Treatment for hyperthyroidism?
Graves' disease (60-80%)
- toxic multinodular goiter (elderly)
- toxic adenoma
- DeQuervain's (painful subacute granulomatous thyroiditis)
- ectopic hyperthyroidism (struma ovarii)
- medications (amiodarone, lithium, excess iodide, excess thyroid hormone)
What is the most common etiology of hyperthyroidism?
DeQuervain's subacute granulomatous thyroiditis
Patient comes in with symptoms of hyperthyroidism, fever, malaise, recent URI, and a painful and tender goiter. Dx?
free T4: high
thyroglob (colloid): high in thyroiditis, low in exogenous
antibodies: TSI in Grave's
What would be expected of the thyroid panel studies (TSH, free T4, thyroglobulins, antibodies) for hyperthyroidism?
- thyroid ultrasound
- thyroid scan (scintigraphy) - "hot/cold nodule"
- 24 hour thyroid iodine uptake - "Geiger counter if present"
In a patient with hyperthyroidism, what kind of studies should be ordered?
Patient comes in complaining of fatigue and inability to exercise. Endorses cold intolerance, weight gain, puffy facies, hoarseness, and constipation. Physical exam shows coarse hair and skin, brittle nails, alopecia, bradycardia, delayed relaxation of DTRs, and myxedema. Dx?
Synthroid or levothyroxine
- check thyroid panel and adjust dose every 6 weeks until TSH and T4 normalized
- pregnancy/weight gain/meds can increase T4 requirements
- for elderly or CAD, start low to avoid myocardial ischemia
Treatment for hypothyroidism?
- thyroidectomy, radioiodine therapy, neck irradiation
- iodide deficiency OR excess
- infiltrative disease: TB, sarcoid, amyloid, cancer ("T-SAC" a "thyroid sack")
- congenital hypothyroidism
- central hypothyroidism (low TSH or TRH)
What is the most common etiology of hypothyroidism?
free T4: low
antibodies: anti-thyroglobulin, antimicrosomal
What would be the expected thyroid panel studies in hypothyroidism (TSH, T4, antibodies)?
MRI of the brain to evaluate central hypothyroidism
If a patient with clinical hypothyroidism comes in with low TSH and low free T4, what is the next study to get?
labs: TSH/T4 to evaluate for hyperfunctioning nodule
studies: thyroid U/S, FNA, scintigraphy
Patient comes in with a thyroid nodule. What labs should be done? Which studies?
excise, give radioiodine and T4 suppression
Thyroid FNA reveals a nodule to be cystic. Plan of action?
excise, give radioiodine and T4 suppression
Thyroid FNA reveals a nodule to be malignant. Plan of action?
scintigraphy (to determine hot or cold nodule; hot nodules are rarely malignant, but 5-8% of cold nodules are)
Thyroid FNA reveals a nodule to be of indeterminate cytology. Plan of action?
repeat FNA in 6-9 months to confirm benign cytology
Thyroid FNA reveals a nodule to be macrofollicular (benign). Plan of action?
systemic skeletal disease with low bone mass, microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
What is osteoporosis?
- fragility fracture from minimal trauma (fall from standing height or less) - vertebral, hip (femur), Colle's (wrist)
- via bone mineral density, DEXA (proximal femur, lumbar spine, forearm, total body) showing:
T < 2.5 = osteoporosis (30% postmenopausal women)
T between -1.0 and -2.5 = osteopenia
How is osteoporosis diagnosed?
primary: menopause or aging
secondary: low bone mass due to any other factors
What is the difference between primary and secondary osteoporosis?
- demographic: female, Caucasian or Asian, older age
- history: hx of fracture > 50 yo, early menopause < 45 yo, tobacco/alcohol, sedentary, low-calcium diet, low sunlight, family history (genetics)
- physical: thin, low bone mass
- medications: steroids, AEDs, excess thyroid replacement, anticoags, antacids with aluminum, cholestyramine
- GI: malabsorption (bile, celiac, pancreatitis), chronic liver disease
- endocrine: hyperthyroidism, hyperparathyroidism, Cushing's
- immune: rheumatoid arthritis
- neoplasia: multiple myeloma, leukemia/lymphoma, pernicious anemia
What are the risk factors for developing osteoporosis? Demographic, history, physical, meds, GI, endocrine, immune, neoplasia.
USPSTF: all women > 65 yo, risk factor women > 60 yo
NOF: all women > 65 yo, postmenopausal women < 65 with 1 risk factor, postmenopausal women presenting with fracture, women on HRT for long periods
What are the screening guidelines for osteoporosis, USPSTF vs. NOF?
- calcium and vit D 500 mg BID or TID (best absorbed in doses of 500 mg or less)
- exercise via walking (weight bearing) or lifting (resistance)
- lifestyle: avoid ETOH and smoking, fall prevention
How is osteoporosis treated non-pharmacologically?
for T < 2.5 or fragility fracture (i.e. osteoporosis)
- bisphosphonates (alendronate, risedronate) - first line
- raloxifene (SERM)
- estrogen (prevention)
- nasal calcitonin
- PTH (teriparatide)
How is osteoporosis treated pharmacologically?
yearly for 2 years, then every 2 years afterward
Once treatment for osteoporosis is initiated, how often should the patient be screened?
microscopy: "clue cells" and "fishy smell" on KOH whiff test; HIGH PH (4.5-4.9)
Dx: bacterial vaginosis
Tx: metronidazole 500 mg BID, 7 day course
Patient comes in vaginal discharge and itching. It is thin and grayish-white and has been occurring for several weeks. She describes smelling an odor after urination and intercourse. Physical exam shows minimal vaginal erythema and no cervical discharge. Lab findings on microscopy, Dx, and Tx?
microscopy: hyphae/pseudohyphae on KOH mount; NORMAL PH (4.0-4.5)
Dx: candida vaginitis
Tx: fluconazole 150 mg or monistat OTC 1 week
Patient comes in with vaginal discharge, itching, and burning pain. It is thick, white, and "cottage-cheese" like in nature. It has been occurring for several days. Physical exam shows marked vaginal erythema and edema, but no cervical discharge. Lab findings on microscopy, Dx, and Tx?
antibiotic use, douching
Candida vaginitis is associated with what conditions?
microscopy: flagellated motile protozoa, HIGH PH (4.5-7.0)
Dx: trichomonas vaginitis
Tx: metronidazole 2 g one dose, TREAT PARTNER ALSO
Patient comes in with vaginal discharge, itching, and complaints of dysparunia. It is frothy, foul-smelling, and greenish. It has been occurring for several days. Physical exam shows erythematous and edematous vulva with excoriations (scratch marks) and a cervix that is erythematous with scattered petechiae (strawberry). Lab findings on microscopy, Dx, and Tx?
STD, hot tubs, swimming pools
What is trichomonas vaginitis associated with?
What vaccines are given at birth?
HepB, rota, DTaP, Hib, PCV, IPV
("HepB + RoaD, HiPpIe")
What vaccines are given at 2 months?
rota, DTaP, Hib, PCV, IPV
What vaccines are given at 4 months?
HepB, rota, DTaP, Hib, PCV, IPV
("HepB + RoaD, HiPpIe")
- YEARLY FLU SHOT STARTS NOW
What vaccine are given at 6 months?
HiB, PCV, IPV, MMR, VZV, HAV
("HiPpIes HAV MMR and Chickenpox")
What vaccines are given at 12 months?
Which vaccines are given at 18 months?
DTaP, IPV, MMR, VZV
("I DMV" at 4!)
Which vaccines are given at 4-6 years?
MCV, HPV, TDaP
("the adult vaccines [meningitis, papilloma] and tetanus booster")
Immunizations at 11-12 years?
- > 50 yo
- CV: "chronic CV conditions"
- resp: asthma, COPD
- GU: renal dysfunction, pregnancy (2nd/3rd trimester)
- endocrine: diabetes
- heme: hemoglobinopathies
- immune: immune suppression
- healthcare workers
- nursing home residents
- high risk contacts
What are the indications for the influenza vaccine?
- > 65 yo
- CV: "chronic CV conditions"
- resp: COPD
- GI: liver disease
- GU: renal failure, nephritic syndrome
- endo: diabetes
- heme: asplenia
- immune: immune suppression
- nursing home residents
What are the indications for the pneumovax vaccine?
- GU: hemodialysis
- heme: anyone receiving clotting factor concentrates
- healthcare workers
- public safety workers
- medical, dental, nursing, lab tech students
- IV drug users
- people with > 1 sexual partner in 6 months
- people with STDs
- household/sexual contacts with chronic HBV individuals
- international travelers
- inmates/workers at correctional facilities
What are the indications for the HBV vaccine?
every 10 years
How often should the tetanus/diphtheria (Td) vaccine be given?
2 doses for susceptible ages >18 yo
How often should the VZV vaccine be given if not in childhood?
for women of childbearing age after 18 yo
When is the MMR vaccine given after age 18?
mammography Q 1-2 years at 40 yo
- 50-70 yo, gain 1 month
- 40-50 yo, gain 0-5 days
What is the USPSTF guideline for screening breast cancer? Benefits?
data inconclusive; PSA still more sensitive than DRE but both will miss cancers; no benefit of annual vs. biennial screening
- 50-70 yo average risk, gain some benefit (up to 2 weeks increased survival)
- 45 yo increased risk (AA or FHx), gain some benefit
What is the USPSTF guideline for screening prostate cancer? Benefits?
within 3 years of first sexual activity or 21 yo, Q 1-3 years until age 65 yo
- ACOG: Q1-3 years after age 21 until age 30, then Q3 years until age 65
- gain in life expectancy = 3 months
What is the USPSTF guideline for screening cervical cancer? Benefits?
starting age 50 yo, FOBT + flex sigmoidoscopy Q 5 years or colonoscopy Q 10 years
- gain in life expectancy = 3 months
- FOBT decreases death 15-30%
- flex sigmoidoscopy decreases death 60%
What is the USPSTF guideline for screening colon cancer? Benefits?
start 10 years earlier than age of when first degree relative was diagnosed
For a patient with a family history of colon cancer, when should they be screened?
sensitivity: the probability that a test is positive, given subject has disease - TP/(TP+FN)
specificity: the probability that a test is negative, given subject does not have disease - TN/(TN+FP)
PPV: given a positive test, probability that subject truly has disease - TP/(TP+FP)
NPV: given a negative test, probability that subject truly does not have disease - TN/(TN+FN)
Define sensitivity, specificity, PPV, and NPV.
- free samples
- giving "information about a new drug"
- assessment of physician personalities and life details
- prescribing habits via database
List at least 5 tactics used by pharmaceutical companies to influence physician prescribing habits.
- evidence of effectiveness
- must include all risk information and contraindications
- label correctly
- provide website, number, or other source for more information
Describe what limitations the FDA has over controlling direct marketing to patients.
3-5 years? (Vioxx pulled after 5 years from FDA approval, Rezulin troglitazone pulled after 3 years)
Describe the typical time course for rare, serious side effects to surface after a drug is released on the market.
most common infectious illness in the general population
nasopharyngitis: kids 3-8 per year, adults 2-4, >60 have 1/yr
acute pharyngitis: 1% of all visits
What is the prevalence of URI presenting to primary care?
inappropriate use of antibiotics when not indicated
- acute sinusitis: only narrow range antibiotics for S. pneumoniae or H. influenzae if severe symptoms (regardless of duration)
- pharyngitis: only fever, LAD, exudates (or positive Strep test)
- acute bronchitis (cough/sputum 3 weeks): usually viral; only if suspect pneumonia with fever, cough, tachypnea, tachycardia, consolidation
main mechanisms of antibiotic resistance are:
1) enzymatic inactivation
2) decreased uptake
3) increased removal
4) alteration of target sites.
What is the mechanism of antibiotic resistance in URIs? Its impact on primary care?
if < 2 weeks, think TRAUMA (fracture, dislocation, sprain), otherwise...
- instability: subluxation of GH joint
- instability: subluxation/dislocation of AC joint
- VERY RARE to have rotator cuff tears
- impingement (AC joint space narrows from OA spurs)
- frozen shoulder
- complete rotator cuff tear (#1)
- DJD (OA)
- frozen shoulder
List the common diagnoses presenting as shoulder pain in the primary care office. Which diseases are associated with which populations?
- meniscal injury (locking)
- ligamentous injury (giving out, instability)
- extensor mechanism (sudden weakness, collapse)
- tumors (osteo/chondrosarcoma)
- bursitis (painters, housekeepers)
- overuse syndrome (exercise)
- referred from hip (esp. internal rotation)
MEDIAL PAIN (most common)
- MCL or medial meniscus (most vulnerable meniscus)
- anserine bursitis
ANTERIOR PAIN (2nd most common)
- quad tendonitis / partial tear
- bilateral-patellofemoral syndrome (women, can't walk down stairs)
- prepatellar bursitis
- inflammatory arthritis
- IT band friction syndrome (runners)
- LCL or lateral meniscus
- medial meniscus (at joint line)
- baker's cyst
- popliteal aneurysm
- effusion causing joint capsule distention
List the common diagnoses presenting as knee pain in the primary care office. Which diseases are associated with which populations?
- neers/hawkins: impingment
- empty can: supraspinatus
- (external rotation = infraspinatus)
- apprehension sign: instability
- lachman: ACL
- anterior/posterior drawer: ACL/PCL
- varus/valgus: LCL/MCL
- mcmurrays: medial/lateral meniscus
What are the shoulder and knee physical exam maneuvers and what are they used for?
shoulder instability: subluxation/dislocation of AC joint
25 yo patient comes in after falling off a bike and landing directly onto his shoulder. Dx?
complete rotator cuff tear
What is the number one cause of shoulder pain in adults >50 years old?
impingement of the acromion, coracoacromial ligament, AC joint, and coracoid process ON THE underlying bursa, biceps tendon, and rotator cuff
What is the number one cause of rotator cuff tears in older adults?
proximal humerus (adults), clavicle (childhood)
Where do shoulder fractures tend to occur in older osteoporotic adults vs. childhood? i.e., patient comes in with shoulder pain < 2 weeks...
anterior GH instability dislocation (>90% of dislocations, 2% are posterior)
- shoulder slips out in throwing position = apprehension sign
Patient comes in with shoulder pain < 2 weeks. Positive apprehension sign. Dx?
Tx: NSAIDS and exercises to stretch posterior capsule
Patient comes in with gradual onset of anterior and lateral shoulder pain. Positive nighttime pain. Painful arc from 60-100 degrees with positive Neers/Hawkins. Most likely Dx and Tx?
AC joint common, GH joint only if pitchers and laborers
What shoulder joint is most commonly arthritic?
- loss of passive ROM is classic
Female diabetic age 40-65 comes in complaining of progressive loss of shoulder motion. Denies trauma or injury. Physical exam shows reduction in both active AND PASSIVE ROM. Rotator cuff is tender. Dx?
Dx: iliotibial band friction syndrome
Runner comes in with lateral knee pain, especially over lateral femoral condyle with an audible snap. Dx and Tx?
CVD equivalents: DM, CAD, PVD, CVA, AAA
- LDL goal <100 (70)
- TLC immediately
- start drugs if LDL>100 (70)
What constitutes someone who is at "high risk" for cholesterol levels? In these patients, what is the LDL goal, when to do lifestyle changes, when to start drugs?
- >65 yo
- family history
What are the CHD risk factors?
>2 risk factors
- LDL goal <130
- TLC if LDL >130 (100)
- Drugs if LDL>130 (160 if low risk)
What constitutes someone who is at "moderate risk" for cholesterol levels? LDL goal, when to do lifestyle changes, when to start drugs?
0-1 risk factors
- LDL goal <160
- TLC if LDL >160 (130)
- Drugs if LDL >190
What constitutes someone who is at "low risk" for cholesterol levels? LDL goal, when to do lifestyle changes, when to start drugs?
20-30% in trials (10% in community)
How much does TLC (therapeutic lifestyle changes) reduce cholesterol?
fibrates (can lower Tg by 45%, and prevent pancreatitis!)
Which cholesterol medication is best given to those with hereditary hypertriglyceridemias?
double the risk of vascular disease
What happens with every increase in 20/10 mm Hg of blood pressure?
- weight loss: 5-20 mmHg
- DASH: 8-11 mmHg
- exercise: 4-9 mmHg
- sodium reduction: 4-8 mmHg
- EtOH restriction: 2-4 mmHg
How much does weight loss, DASH diet, exercise, sodium reduction, and EtOH restriction decrease blood pressure?
- renal failure, RA stenosis
- sleep apnea
- Cushing's, pheochromocytoma
What are some causes of secondary hypertension?
Why is hypertension poorly controlled in the United States?
Beta-blockers should definitely not be used in which population?
ACE-inhibitors should definitely not be used in which population?
arrhythmias (AFib), osteoporosis
In a 65 yo who is hypothyroid, what is the risk associated with "running a little high" on Synthroid?
exophthalmos, pretibial myxedema, goiter
What would you expect to find in a hyperthyroid patient with Graves' disease vs. exogenous thyroid hormone?