sensitivity
percentage of pts with disease who have a positive screening test
- a / a+c
specificity
- percentage of normal pts with a negative screening test
- d / d+b
What happens to PPV and NPV as the prevalence of a disease decreases?
as prevalence decreases, PPV decreases and NPV increases
- opposite is true if disease prevalence increases
positive predictive value
TP/ TP + FP
- probability that a person actually has disease given a positive test result
positive likelihood ratios of 2,5 and 10 increase the probability of disease by….
15%, 30% and 45% respectively
screening for abdominal aortic aneurysm
men aged 65-75 who smoked, should undergo one time screening with USG
screening for osteoporosis
women 65 yo or older or women over 60 yo w/ significant fracture risk factors
men only with certain RFs - long term steroid use, androgen deprivation
pneumococcal vaccine
all pts > 65 yo
- if over 65, should get second dose in 5 years
- second dose after 5 yrs also for pts with CKD, asplenia, cancer or IC pts
influenza vaccine in COPD pts
annually - trivalent killed vaccine
- its actually recommended for everyone over 6 months of age
who is the intranasal trivalent live attenuate influenza virus vaccine indicated for?
pts ages 5 to 49 who are NOT pregnant, IC or living with an immunosuppressed pt
what is the best end-point for measuring the effect of cancer screening on patient outcomes?
cancer-specific mortality
length bias
preferential detection of asymptomatic, more indolent cancers by any screening test
- this influences the case fatality ratio
lead time bias
patient survival after cancer diagnosis is artificially prolonged by screening
indications for herpes zoster vaccine
immunocompetent patients age 60 or older
- live attenuated zoster vaccine, single subcutaneous dose
- reduces incidence of herpes zoster and postherpetic neuralgia
contraindications to herpes zoster vaccine
live vaccine, therefore:
- people with active, untreated TB
- pregnant women
- immunocompromised pts
- pts receiving chemo, radio or immunosuppressants
- living in same house as IC pt
in whom is tetanus immune globulin indicated?
pts who have not completed the primary series of tetanus immunizations or in pts who have an unclear immunization history
recommendations for HPV vaccine
all females between ages 9 and 26, regardless of sexual activity
acceptable CRC screening methods
screening should begin at age 50
- annual FOBT
- colonscopy every 10 years
- flexible sigmoidoscopy every 5 years + FOBT every 3 years
pt with syncope with prodromal symptoms of nausea, lightheadedness and diaphoresis lasting > 10 secs
vasovagal (neurocardiogenic) syncope
- may also have brief myoclonic jerks after LOC
in pt with suspected vasovagal syncope, but otherwise healthy - what do you do next?
no further testing required
syncope with sudden LOC and lack of preceding symptoms resulting in pt falling and injuring themself
cardiogenic syncope - ex. heart block
tx. of trifascicular heart block
if asymptomatic - nothing
if symptomatic - pacemaker
indications for permanent pacemaker implantation
intermittent 3rd degree block
type 2- 2nd degree block
alternating BBB
implantable loop recorder
continously records the ECG and allowes pt to save the previous 30 sec and 2 mins (Adjustable) after they have an episode
causes of obstructed cardiac output that lead to syncope
severe aortic stenosis
hypertrophic obstructive cardiomyopathy
cardiac ischemia
best test to evaluate recurrent syncope
implantable loop recorder
- records pt activated events and automatically records bradycardic and tachycardic events
what do you do with depressed pt who does not respond to full-dose therapy within 6 weeks?
should receive another medication (can be within same class) OR referral to psychotherapy
when can you add methylphenidate to depression tx?
no benefit of methylphenidate augmentation in treatment-resistant depression
indications for ECT therapy in depression?
profound suicidal ideations
psychotic features present
pt fails to respond to multiple antidepressants
best predictor of completed suicide
previous suicide attempts
when does a greiving person become a candidate for anti-depressant therapy?
symptoms of major depression for at least 2 weeks, 8 or more weeks after their loved one’s death
- essentially, when sx. persist for more than 2 months
which anti-depressant also causes sedation and weight gain?
mirtazipine
what drug is used to prevent alcohol-withdrawl induced seizures?
lorazepam
- prophylactic, on fixed schedule, even if asymptomatic
pts scoring > 10 points on clinical institute withdrawl assessement scale for alcohol withdrawl
need additional medication for withdrawl symptoms - usually benzos
pts scoring > 15 on clinical institute withdrawl assessement scale for alcohol withdrawl
require hospitalization
initial tx. of cocaine intoxication
sedation with lorazepam, IV or IM
drug of choice for drug induced seizures
benzodiazepines
which drugs are not recommended during acute cocaine intoxication?
B-blockers - worsen vasoconstriction due to unopposed alpha blocking effects
what drug is useful in alcohol dependence and in decreasing frequency of relapses?
naltrexone
management of hypoventilation caused by opioid overdose
naloxone - if inadequate, endotracheal intubation needed
IV fomepizole is used for…
ethylene alcohol or methyl alcohol poisoning
tx of cyanide poisoning
inhalation of amyl nitrate followed by IV sodium nitrate/sodium thiosulfate
CAGE questionnaire
best choice screening test for alcohol problems
C - do you feel you should cut down?
A - have people annoyed you by criticizing your drinking?
G - have you ever felt bad or guilty about it?
E - have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Tx. of lumbar spinal stenosis unresponsive to conservative tx
surgery - minimum of 3 months of failed nonsurgical interventions
pt with back pain gradually worsening over weeks/months, fever and elevated ESR > 100 mm/hr with tenderness over palpated portion of spine
vertebral osteomyelitis
preferred imaging modality in evaluating vertebral osteomyelitis or spinal epidural abscess
MRI of spine
Tx. of vertebral osteomyelitis/epidural abscess
IV antibiotics - guided by blood cultures
when should you order an MRI for back pain?
pt has evidence of motor impairment, has not responded to therapy or symptoms are increasing; or if fever is present
first line tx of acute, nonspecific lower back pain
acetaminophen or NSAIDs
- most pts improve w/in 1 month
triad of back pain, muscle weakness and loss of bowel/bladder control suggests?
spinal cord compression
cough variant asthma
presence of airway hyperresponsiveness; confirmed when cough resolves with asthma-therapy - do a trial of albuterol
MCC of chronic cough
asthma
post-nasal drip (chronic sinusitis)
GERD
what do you do in pts with chronic cough > 8 weeks who does not smoke, does not take an ACEi and has a normal CXR?
trial of first gen. antihistamine-decongestant medication
what should you consider in pts who fail to respond to tx. directed at UACS, GERD and asthma?
non-asthmatic eosinophillic bronchitis
- confirmation with bronchial biopsy OR respond to inhaled corticosteroids
all pts with hemoptysis should have?
chest XRAY
- if high risk for malignancy, do CT scan even if normal CXR
are B-agonists useful in acute bronchitis?
help decrease cough severity and duration in adults when there is also WHEEZING
which drugs can be used for smoking cessation?
nortriptyline and buproprion - similar efficacy to nicotine replacement therapy
varenicline - most effective
what should varenicline not be combined with?
nicotine replacement therapy - increases risk of adverse effects
what is the black box warning on varenicline and bupropion?
both pose risk of serious neuropsychiatric changes including behavioral changes, hostility, agitation, depressed mood, suicidal thoughts and behaviors and attempted suicide
indications for bariatric surgery
- BMI > 35 and serious medical comorbidities
- BMI > 40 and failed attempts at weight loss
- progressive obesity (> 5kg/yr before age 30)
pt has persistent N and V occuring within the first few months after gastric bypass surgery - what could this be and what test should you order?
stomal stenosis (stricture at anastomosis of gastric pouch and jejunum) - get upper endoscopy to further assess
most appropriate management of heavy menstrual bleeding due to a known cause, ie. large fibroid
oral medroxyprogesterone acetate
- if pt is dizzy or orthostatic from blood loss, consider IV estrogen
next step in evaluation of secondary amenorrhea in a patient who just stopped OCP
progestin withdrawl challenge
- menses after challenge excludes anatomic defects and chronic anovulation w/o estrogen (in other words, indicated relatively normal estrogen production and patent outflow tract)
what are the initial lab tests that should be done in evaluating secondary amenorrhea
FSH, TSH and PRL levels
CAGE questionnaire
best choice screening test for alcohol problems
C - do you feel you should cut down?
A - have people annoyed you by criticizing your drinking?
G - have you ever felt bad or guilty about it?
E - have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
what do you do in pts with chronic cough > 8 weeks who does not smoke, does not take an ACEi and has a normal CXR?
trial of first gen. antihistamine-decongestant medication
all pts with hemoptysis should have?
chest XRAY
- if high risk for malignancy, do CT scan even if normal CXR
what is the most worrisome side effect of bupropion?
1 in 1000 risk of seizures
next step in pts over 35 with abnormal uterine bleeding
endometrial biopsy to R/O endometrial cancer or hyperplasia
