Case 2: Male Annual Exam Flashcards Preview

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Flashcards in Case 2: Male Annual Exam Deck (76):
1

RISE Mnemonic for annual visits

1. Risk factors: assess risk factors for serious medical conditions
2. Immunizations
3. Screening tests
4. Educate patients on healthy choices/living

2

Most frequent causes of death in 55 year old male

- malignant neoplasm
- heart disease
- accident
- diabetes
- chronic lung disease
- chronic liver disease
- cirrhosis

3

RFs for cardiovascular disease

- sedentary lifestyle
- stress
- premature family history
- excess alcohol use
- obesity
- poor diet
- low selenium
- high homocysteine

4

How often to assess major ASCVD risk factors in patients who are free from ASCVD?

Every 4 to 6 years in patients 20 to 79

5

Manifestations of atherosclerotic disease

Claudication
Angina pectoris

6

Claudication

Leg pain with activity [peripheral atherosclerotic disease]

7

Angina pectoris

Chest pain with activity [coronary artery atherosclerosis]

8

Effects of moderate alcohol intake (2)

1. Increases HDL
2. Decreases platelet adherence to one another

9

Things that increase HDL levels

1. Moderate alcohol intake
2. Exercise
3. Niacin

10

American Heart Association recommendations on alcohol

Do not start drinking for heart protective effects if you don't already drink

11

Flu vaccine

Annually

12

Tetanus vaccine

TDAP between 11-64
Td booster every ten years

13

Zoster

After age 60 (one time)

14

Vaccines to avoid in immunocompromised patients, close contacts, pregnant women (4)

Live vaccines
- MMR
- OPV
- zoster
- Varicella

15

Does prevalence affect sensitivity and specificity

Yes

Even if high specificity, if low prevalence, number of false positives will be high

16

USPSTF A

The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is substantial.

17

USPSTF B

The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is fair or fair certainty that the net benefit is moderate - substantial.

18

USPSTF C

The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved - net benefit is small. However there may be occasions that warrant provision of this service in a patient.

19

USPSTF D

The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits or harms outweigh benefits.

20

USPSTF I

There is insufficient evidence to recommend for or against the service.

21

Recommendations (7) for 55 year old asymptomatic man who smokes (USPSTF A/B)

Colorectal cancer
Obesity
Diabetes mellitus
Lipid disorders
Tobacco use
Hypertension
Alcohol misuse

22

Lung cancer screening

Annual screening with low dose CT in patients 55 to 80 with 30 pack year history who are currently smoking or have quit within past five years

23

Hep C virus screening

One time screening for patients born between 1945 to 1965

24

Depression (Grade B)

Screen adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up

25

Depression (Grade C)

Do not routinely screen adults for depression when staff assisted depression care supports are not in place

26

2 depression screening questions

1. Over the past 2 weeks have you felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things

27

USPSTF Grade D (not recommended) for asymptomatic 55 year old man who smokes

Bacteriuria
Bladder cancer
Pancreatic cancer
Testicular cancer
Spirometry for COPD
Genital herpes
Gonorrhea
Hemochromatosis
Hep B

28

USPSTF Grade I (insufficient evidence)

- prevention of MV injuries with seatbelt use and avoiding drinking under influence
- family violence
- intimate partner violence
- illicit drug use
- skin cancer
- glaucoma
- oral cancer
- thyroid disease

29

USPSTF Prostate recs

Grade D - risks outweigh the benefits - do not do it!

30

ACS and AUA prostate recs

men 55-69 should discuss with doctors the benefits and side effects of prostate cancer screening and treatment

31

Colon cancer screening options (3)

1. Colonoscopy q10 years
2. Sigmoidoscopy + FOBT q5 years
3. Double contrast enemas q5 years

*Rectal exam and test for occult blood are not adequate screening

32

Indications for exercise stress testing

Asymptomatic male pts > 45 yrs with at least one of following:
- hypercholesterolemia
- hypertension
- smoking
- family history of premature coronary artery disease

33

AHA diet recommendations for lowering heart disease risk

- eat fish 2x/week (more fatty fish high in omega3 fatty caids)
- eat oils in tofu, soybeans, conola, walnuts, flaxseeds

34

Do vitamin C, E, and folic acid reduce heart attacks or strokes?

NO

35

Three Cs of addiction

Compulsion to use
Lack of control
Continued use despite adverse consequences

36

Five A's of Counseling for Behavior Change

Ask/Address the behavior needing change
Assess for interest in behavior change
Advise on methods to change behavior
Assist with motivation to change behavior
Arrange for follow up

37

Stages of behavior change

Pre-contemplative
Contemplative
Active
Relapse

38

Pre-contemplative stage of behavior change

Not aware of need to change or not interested in changing behavior

39

Contemplative stage of behavior change

Currently interested in changing behavior

40

Active stage of behavior change

Currently making behavior change

41

Relapse stage of behavior change

attempted behavior but not longer making change

42

Screening for alcohol misuse

1. Quantify amount of alcohol drinking
2. CAGE questions

43

CAGE

Have you ever
- felt the need to cut down drinking
- felt annoyed by criticism of your drinking
- had guilty feelings about drinking
- taken a morning eye opener

44

Check fasting lipids how often?

Every 4-6 years after age 21

Draw these labs in fasting state at least 8 hrs after last food intake

45

What is affected by fasting?

What stays the same?

Affected: triglycerides
Same: LDL-C, HDL-C, total cholesterol

46

Individuals with clinical ASCVD (3)

1) acute coronary syndrome (MI or unstable angina)
2) Stroke or TIA atherosclerotic in origin
3) Peripheral vascular disease

47

Treatment for individuals with clinical ASCVD

High intensity statin

48

Individuals with diabetes 40-75 with diabetes

Moderate intensity statin
High intensity statin if ASCVD risk > 7.5%

49

Individuals > 21 with LDL > 190 (thought to have genetic hyperlipidemia and high ASCVD risk)

High intensity statin

50

Individuals 40-75 with 10 year ASCVD risk > 7.5%

Moderate or high intensity statin

51

Groups > 21 that qualify for statin (4)

- Individuals with clinical ASCVD
- 40 to 75 with diabetes
- > 21 and LDL > 190
- 40 to 75 with ASCVD risk > 7.5%

52

Low intensity statin (5)

Simvastatin 10 mg

Pravastatin 10-20 mg

Lovastatin 20 mg

Fluvastatin 20-40 mg

Pitavastatin 1 mg

53

Moderate intensity statin (7)

Atorvastatin 10-20 mg

Rosuvastatin 5-10 mg

Simvastatin 20-40 mg

Pravastatin 40-80 mg

Lovastatin 40 mg

Fluvastatin 40 mg bid

Pitavastatin 2-4 mg

54

High intensity statin (2)

Atorvastatin 40-80 mg

Rosuvastatin 20-40 mg

55

ASCVD risk factors (7)

- age
- gender
- hypertension
- systolic blood pressure
- total and HDL cholesterol
- diabetes
- smoking status

56

To reduce LDL cholesterol

- reduce calories from saturated fats (animal fats, coconut oil, palm oil) to 5%
- reduce trans fats (hydrogenated oils, vegetable shortenings, pre packaged baked goods and chips)

57

Exercise recommendation for low cholesterol

Moderate to vigorous intensity physical activity 3-4 times/week for 40 minutes/session

58

ECG changes that suggest coronary artery disease (3)

1. ST segment depression or downsloping ST segment (ischemia)
2. Convex ST segment elevation (acute injury)
3. Q waves > 25% of succeeding R wave and > 0.04 seconds (infarction)

59

U waves abnormal when

>1.5 mm in any lead

60

1.5 mm U wave associated with (9)

- bradycardia
- hypokalemia
- hypercalcemia
- hypomagnesemia
- drug effects: digitalis, quinidine, procainamide
- CNS disease
- hyperthyroidism
- left ventricular hypertrophy
- mitral valve prolapse

61

Annual quit rates for smokers without any medical interventions

2-3%

62

Interventions that help quit rates (6)

- group setting/with significant other
- oral medications
- one on one counseling
- practical problem solving skills practice
- social supports
- relaxation/breathing techniques

63

Meds for smoking cessation

1. Buproprion (first line)
2. Varenicline (if failed buproprion or pt specifically requests it)

64

How to take buproprion

Start one week before quit date
- one pill first three days
- two pills (one morning, one evening) for remainder
- at day7: stop smoking and continue pills
- gradually stop pills after 2 months on pill

65

JNC 8 Hypertension guidelines (3)

1. Age < 60 (general population): < 140/90
2. Age ≥ 60 (general population): < 150/90
3. All ages w CKD or DM: < 140/90

66

Anti HTN in general non black population (including those with diabetes)

First line: thiazide diuretic, CCB, ACEI, or ARB

67

Anti HTN in general black population (including those with diabetes)

First line: thiazide diuretic or CCB

68

If population > 18 with CKD

Initial (or add on): ACEI or ARB to help improve kidney outcomes
- this applies to all CKD patients regardless of race or diabetes status

69

If goal BP is not reached within a month of treatment

a) increase dose of initial drug or
b) add second agent: thiazide, CCB, ACEI, ARB
**If BP still not controlled, continue to titrate or add another agent (do not use ACEI or ARB in same patient)
**If BP still not controlled with 3 drugs use anti-HTN from other classes

70

Exercise recommended for patients with MSK problems (arthritis)

Swimming
Water jogging

71

CV fitness exercise

40 minutes 3 times a week

72

Weight loss exercise

20-40 minutes every day

73

Intensity guideline metrics

Target heart rate
Estimated rate of perceived exertion (RPE)

74

Target heart rate formula

THR = (220-age) x 0.8

75

Borg perceived level of exertion scale - patients should exercise at what level?

12-14 (somewhat hard: quite an effort, feel tired but can continue)

76

Managing high risk for ASCVD risk

1. Start aspirin
2. Begin moderate to high intensity statin
3. Consider exercise stress test
4. presence of high sensitivity CRP is a minor RF for ASCVD which might be helpful if there was clinical uncertainty