Periodic Health Exam

Question 1

What is primary prevention

Answer 1

identify risk factors for common diseases; counsel patients to promote healthy
behaviour

Question 2

What is secondary prevention

Answer 2

presymptomatic detection of disease to allow early treatment and to prevent
disease progression

Question 3

What is strength of recommendation vs quality of evidence?

Answer 3

Strength of recommendation - ex. strong is when there is a high level of confidence that the desirable effects outweigh the undesirable effects (or vice versa for evidence against)

Quality of evidence - high means there is a high level of confidence that the true effect lies close to the estimate of the effect

Question 4

What are the recommendations for folic acid supplementation in pregnancy?

Answer 4

• To prevent neural tube defects in all women
capable of becoming pregnant

• Low risk women (no personal health risks,
planned pregnancy):
0.4-1.0 mg daily folic acid supplementation for at least 2-3 mo before conception and throughout
pregnancy and postpartum period

• High risk women (health risks including
epilepsy, insulin dependent diabetes, BMI
>35, family history of NTD, high risk ethnic
group):
at least 3 mo prior to conception until 10-12 wk post conception: daily supplementation with multivitamins with 5 mg folic acid
• From wk 12 post-conception until
postpartum period (4-6 wks or as long as
breastfeeding continues):
0.4-1.0 mg of folic acid supplementation is sufficient

• Women with additional lifestyle issues (poor compliance with medications, no consistent birth control, taking possible teratogenic substances): higher folic acid dose of 5 mg and counselling about
prevention of birth defects

Question 5

Periodic health exam therapy provided for general population

Answer 5

Folic acid supplementation to women of child-bearing
age

Pharmacologic treatment of HTN (Refer to CHEP Guidelines)

Varicella vaccine for children age 1-12 and susceptible
adolescents/adults

Rubella vaccine for all non-pregnant women of child-bearing age unless there is proof of immunity via immunization records or serology

Tetanus vaccine: routine booster q10yr if had 1° series

Pertussis vaccine: adults <65 should receive one booster
given as Tdap– Adacel® or Boostrix®

Herpes zoster vaccine for adults ≥60

Question 6

PHE therapy provided for pediatric population

Answer 6

Routine immunizations, Hepatitis B, HPV and Meningococcal immunizations are offered in schools in
most Canadian provinces

Question 7

PHE therapy provided for high risk TB population

Answer 7

INH prophylaxis for household contacts or skin test converters

INH prophylaxis for high risk sub-groups

Question 8

PHE therapy provided for Immunocompromised, Age≥65, COPD, Asthma, CHF, Asplenia, Liver Disease, Renal Failure or DM

Answer 8

Pneumococcal vaccine (Pneumovax)

Question 9

PHE investigations that should be done for pediatric patients

Answer 9

Routine hemoglobin for high risk infants

Blood lead screening of high risk infants

Question 10

What are the Canadian Task Force guidelines for breast cancer screening for average risk women

Answer 10

Mammography
• age 40-49: none
• age 50-74: routine screening q2-3yr
• age 75+: screen on a case by case basis

MRI
• no routine

Clinical Breast Examination
• no routine

Breast Self-Examination
• no routine

Question 11

What does the Canadian Task Force consider average risk women for breast cancer screening

Answer 11

Women age 40-74 with no personal history of breast cancer, history of breast cancer in 1st degree relatives, known mutations of the BRCA1/BRCA2 genes or previous exposures of the chest wall to radiation

Question 12

Canadian Task Force lung cancer screening guidelines

Answer 12

• apply to adults aged 18 and older who are not suspected of having lung cancer

• annual screening with low dose CT for adults aged 55-74 with at least a 30 pack-year smoking history
who currently smoke or quit less than 15 years ago, up to three consecutive times

Question 13

Colorectal screening guidelines

Answer 13

• recommendations for average risk individuals (asymptomatic, no family history of UC, polyps, or CRC)

• average risk testing should begin at age 50, but assessment for risk factors should begin earlier to
identify high-risk individuals

◆ FIT q2yr OR flexible sigmoidoscopy q10yr
◆ no colonoscopy as a screening test
◆ no screening after age 75 is recommended for average risk patients, but it may be assessed on an
individual basis for ages 76-85

Question 14

What is the approach to higher risk screening for colorectal cancer

Answer 14

See FM 4

Question 15

Cervical screening tests that can be used

Answer 15

either conventional Papanicolaou (Pap) smear or liquid based cytology testing

Question 16

What types of cells are sampled in cervical cancer screening

Answer 16

endocervical and exocervical cell sampling (aim is to sample the transitional zone)

Question 17

What type of abnormalities is cervical cancer screening best at identifying

Answer 17

best identifies squamous cell abnormalities, less reliable for glandular abnormalities

Question 18

What is the false positive and false negative rate for cervical cancer screening for a single test

Answer 18

■ false positives 5-10%
■ false negatives 10-40% (for single test)
■ false negative rate 50% for existing cervical cancer

Question 19

What is the effect of PSA screening for prostate cancer on mortality

Answer 19

PSA-based screening significantly reduced

prostate cancer-related mortality but did not affect all-cause mortality.

Question 20

What are the Ontario guidelines for cervical cancer screening

Answer 20

■ screen all women age ≥21 who are or have ever been sexually active (includes intercourse or digital/
oral activity with partner of either sex)

■ if cytology is normal, can screen every 3 yr

■ women age ≥70: if 3 successive negative Pap tests in last 10 yr, can discontinue screening

■ women who are not sexually active by age 21 should delay cervical cancer screening until sexually
active

■ pregnant women and women who have sex with women should follow the routine cervical screening
regimen

• women who have had a hysterectomy
■ total: discontinue screening if hysterectomy was for benign disease and no history of cervical dysplasia or HPV infection, continue to swab vaginal vault if history of uterine malignancy/dysplasia
■ subtotal: continue screening according to guidelines

• exceptions to guidelines
■ immunocompromised (transplant, steroids, diethylstilbestrol exposure, HIV)
■ previously unscreened patients

Question 21

Decision making chart on next steps for cervical cancer screening

Answer 21

FM5

Question 22

Canadian Task Force prostate cancer screening guidelines

Answer 22

No routine

Question 23

What are the stages of change

Answer 23

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Relapse

Question 24

Recommendations for Vitamin D intake in Canada

Answer 24

• 800-1,000 IU for individuals age <50 yr
• 800-2,000 IU for individuals ≥50 yr

• Adults living in Canada should consider taking Vitamin D supplementation of 1,000 IU a day during the fall and winter

• Adults at higher risk of having lower Vitamin D levels should consider taking Vitamin D supplementation of 1,000 IU/d all year round.
This includes people: who are older, with dark skin, who do not go outside often, and who wear clothing that covers most of their skin

• Babies who are exclusively breast-fed:
400 IU/d

Question 25

Recommendations for calcium intake in Canada

Answer 25

• 1,000 mg daily from all sources for individuals 19-50 yr and pregnant/lactating women • 1,200 mg daily for individuals >50 yr (recommended to obtain calcium from nutrition whenever possible vs. supplementation)

Question 26

Alcohol consumption recommendations

Answer 26

≤3 drinks/d for men, max 15/wk | ≤2 drink/d for women, max 10/wk

Question 27

Salt consumption recommendations

Answer 27

≤2,400 mg/d

Question 28

What are normal waist circumference cut offs

Answer 28

Men >102 cm (40 in) | Women >88 cm (35 in)

Question 29

What is the MOA of Orlistat

Answer 29

Orlistat: gastrointestinal lipase inhibitor, reduces fat absorption by 30% by inhibition of pancreatic lipase

Question 30

What is a practice recommendation for the use of Orlistat that is important to keep in mind when prescribing

Answer 30

• Orlistat is associated with several adverse effects and not approved for clinical use longer than 2 yr

Question 31

In what populations should Orlistat be avoided

Answer 31

• Orlistat should be avoided in people with | inflammatory or chronic bowel disease

Question 32

Indications for pharmacotherapy in weight loss

Answer 32

BMI ≥27 kg/m2 + risk factors or BMI ≥30 kg/m2

Question 33

Indications for bariatric surgery in weight loss

Answer 33

BMI ≥35 kg/m2 + risk factors or BMI ≥40 kg/m2

Question 34

What are signs of hyperlipidemia that can be seen on physical exam?

Answer 34

• Atheromata: plaques in blood vessel walls • Xanthelasmata: a sharply demarcated yellowish deposit of cholesterol underneath the skin, usually on or around the eyelid • Tendinous xanthoma: lipid deposit in tendon (especially Achilles) • Eruptive xanthoma: hypertriglyceridemia induced reddish yellow, pruritic, and painful papular or nodular rash • Lipemia retinalis: thin atheromata seen in the retinal blood vessels • Corneal arcus (arcus senilis): lipid deposit in cornea

Question 35

When can LDL not be calculated

Answer 35

LDL cannot be calculated when | TG ≥4.5 mmol/L

Question 36

In what population and how often should lipid screening be completed

Answer 36

q1-3yr males >40 yr females >50 yr or who are menopausal any age for adults with additional dyslipidemia risk factors

Question 37

What is a factor that doubles the risk calculated by the Framingham Risk Score

Answer 37

family history of CVD <55 male relative or <65 in female relative

Question 38

What treatment decision thresholds should be used for a moderate risk patient with LDL-C <3.5

Answer 38

Shifted to apo B >1.2 g/L or nonHDL C >4.3 mmol/L

Question 39

What is a risk of prescribing fibrates and statins

Answer 39

Use with caution when prescribing combined statin and fibrate therapy as there has been concern regarding the safety of certain combinations (potential increased risk of myopathy and rhabdomyolysis)

Question 40

What is a risk of using statins and what weight does it hold in prescribing decisions

Answer 40

Trials have shown that statin therapy slightly increases the incidence of diabetes; however the absolute risk is small. Relative to the reduction in coronary events, the clinical significance is not great enough to recommend against their use.

Question 41

What is the meaning of the Framingham Risk Score

Answer 41

gender-specific algorithm used to estimate the 10-year cardiovascular risk (coronary heart disease) of an individual

Question 42

In what population and how often should the Framingham Risk Score be calculated

Answer 42

Repeat screening every 5 years for FRS <5% or every year for FRS ≥5% to be completed for men age 40-75, and women age 50-75 q3-5yr

Question 43

What is the Framingham risk score calculation based off of

Answer 43

gender age HDL-C total cholesterol sBP smoking DM

Question 44

What patients require no pharmacotherapy for dyslipidemia?

Answer 44

Low risk (FRS <10%)

Question 45

What patients require primary prevention methods to manage dyslipidemia?

Answer 45

``` Intermediate Risk: FRS 10-19% and LDL-C ≥3.5 mmol/L or Non-HDL ≥4.3 mmol/L or ApoB ≥1.2 g/L or Men≥50 and women ≥60 with 1 additional risk factor: low HDL-C, impaired fasting glucose, high waist circumference, smoker, hypertension ``` High Risk: FRS ≥20% or alternative method

Question 46

What are statin indicated conditions in dyslipidemia

Answer 46

Clinical atherosclerosis Abdominal aortic aneurysm Most diabetes including: Age ≥40 yr Age ≥30 yr and 25 yr duration (type 1 DM) Microvascular disease Chronic kidney disease LDL-C ≥5 mmol/L genetic dyslipidemia

Question 47

What is the LDL target for patients with an LDL 5+?

Answer 47

LDL-C >50% reduction

Question 48

What is the LDL target for patients with an LDL <5?

Answer 48

LDL-C <2.0 mmol/L or >50% reduction or apoB <0.8 g/L or non-HDL-C <2.6 mmol/L

Question 49

What is your approach to management for patients with dyslipidemia?

Answer 49

1. Discuss behavioural management - Smoking cessation - Diet: adopt a health dietary pattern - Exercise: for adults 150 min/wk of moderate-vigorous aerobics 2. Initiate Statin Treatment: Treat to Target Approach (confirm adherence and barriers to use) 3. If target achieved monitor response to tx and health behaviours 4. If target not achieved with maximally tolerated dose discuss add-on therapy with patient (evaluate reduction in CVD risk vs. additional cost & side effects) 1st line: Ezetimibe (BAS as alternative) 2nd line: PCSK9 inhibitors (add-on to other drugs)

Question 50

What is the extent of improvement that can be seen with health behaviours in LDL level

Answer 50

Can decrease LDL-C by up to 10%

Question 51

When should pharmacotherapy (timeline wise) in patients with dyslipidemia

Answer 51

Employ consistent lifestyle modifications for at least 3 mo before considering drug therapy High risk patients should start treatment immediately with concurrent health behaviour interventions

Question 52

What is the extent of improvement that can be seen with pharmacological therapy in LDL level

Answer 52

can decrease LDL-C by up to 40%

Question 53

What is the clinical definition of metabolic syndrome

Answer 53

1. Central obesity Men – waist circumference ≥94 cm Women – waist circumference ≥80 cm 2. Plus any TWO of the following four factors TG level ≥1.7 mmol/L (150 mg/dL) HDL-C level: Men <1.0 mmol/L (40 mg/dL) Women <1.3 mmol/L (50 mg/dL) Blood pressure ≥130/85 mmHg Fasting glucose level ≥5.6 mmol/L (100 mg/dL)

Question 54

What is the mechanism of action of a statin

Answer 54

HMG-CoA reductase inhibitors

Question 55

What are the potential adverse effects of statins

Answer 55

myopathy and hepatotoxicity

Question 56

What is the MOA of ezetimibe

Answer 56

cholesterol absorption inhibitor

Question 57

What effect on LDL is usually seen with ezetimibe

Answer 57

19% reduction in LDL-C

Question 58

What medications should be used in individuals with dyslipidemia post acute coronary syndrome

Answer 58

Cholesterol absorption inhibitors (e.g. ezetimibe) in addition to simvastatin reduced mortality, attained lipid targets <1.8, and improved outcomes in high risk individuals

Question 59

What monitoring should take place when a patient is placed on a statin

Answer 59

◆ ALT, CK, creatinine at baseline then 6 wk later for signs of transaminitis or myositis tolerate rise in CK up to 10 times upper limit of normal vs 2-3 times if symptomatic, or serum creatinine rise of ≤25% ◆ no routine repeated measures of ALT and CK necessary in asymptomatic patients using statin therapy ◆ if adequate response is achieved, evaluate fasting lipids q6-12mo

Question 60

What is the effect of isolated hypertriglyceridemia on cardiovascular risk

Answer 60

does not increase cardiovascular risk

Question 61

What are the management strategies of hypertriglyceridemia

Answer 61

• principal therapy is lifestyle modification • drug therapy ■ nicotinic acid ■ fibrates

Question 62

What is severe hypertriglyceridemia (>10 mmol/L) associated with

Answer 62

■ severe hypertriglyceridemia (typically >10 mmol/L) is associated with an increased risk of acute pancreatitis

Question 63

What is the purpose of drug therapy in hypertriglyceridemia

Answer 63

Used to prevent pancreatitis, NOT cardiovascular disease!

Question 64

What is the single most preventable cause of premature illness and death

Answer 64

smoking

Question 65

What are the 5 A's for patients willing to quite smoking

Answer 65

``` Ask if the patient smokes Advise patients to quit Assess willingness to quit Assist in quit attempt Arrange follow up ```

Question 66

What are the symptoms of nicotine withdrawal

Answer 66

``` low mood, irritability, anxiety insomnia, restlessness difficulty concentrating decreased heart rate increased appetite ```

Question 67

What is the 2-3 pattern of smoking cessation

Answer 67

* Onset of withdrawal is 2-3 h after last cigarette * Peak withdrawal is at 2-3 d * Expect improvement of withdrawal symptoms at 2-3 wk * Resolution of withdrawal at 2-3 mo * Highest relapse rate within 2-3 mo

Question 68

How can you help patients develop a quit plan

Answer 68

``` STAR Set quit date Tell family and friends (for support) Anticipate challenges (e.g. withdrawal) Remove tobacco-related products (e.g. ashtrays/lighters) ```

Question 69

When should NRT be used with caution

Answer 69

Immediately post-MI serious/worsening angina Serious arrhythmia

Question 70

What should be advised for patients using NRT

Answer 70

NO smoking while using NRT

Question 71

What is the MOA of Varenicline

Answer 71

Partial nicotinic receptor agonist (to reduce cravings) and partial competitive nicotinic receptor antagonist (to reduce the response to smoked nicotine)

Question 72

What is the most effective type of NRT available

Answer 72

All commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the rate of quitting by 50-70% regardless of setting and independent on the level of additional support provided to the smoker. Compared to a single form of NRT, combining a nicotine patch with a rapid delivery form of NRT may be more effective.

Question 73

Nicotine gum dosing

Answer 73

2 mg if <25 cig/d 4 mg if >25 cig/d 1 piece q1-2h for 1-3 mo (max 24 pieces/d)

Question 74

Nicotine gum instructions

Answer 74

Chew until “peppery” taste then “park” between gum and cheek to facilitate absorption Continue to chew-park intermittently for 30 min

Question 75

Nicotine gum side effects

Answer 75

``` Mouth soreness Hiccups Dyspepsia Jaw ache Most are transient ```

Question 76

Nicotine patch dosing

Answer 76

Use for 8 wk 21 mg/d x 4 wk 14 mg/d x 2 wk 7 mg/d x 2 wk Start with lower dose if <10 cig/d

Question 77

Nicotine patch instructions

Answer 77

Change patch q24h and alternate sides

Question 78

Nicotine patch side effects

Answer 78

Skin irritation Insomnia Palpitations Anxiety

Question 79

Nicotine inhaler dose

Answer 79

6-16 cartridges/d up to 12 wk

Question 80

Where is product of nicotine inhaler absorbed

Answer 80

Nicotine inhaled through mouth, absorbed in mouth | and throat not in lungs

Question 81

Nicotine inhaler and nasal spray side effects

Answer 81

Local irritation | Coughing

Question 82

Buproprion MOA, side effects, dosage, prescribing and contraindications

Answer 82

Inhibits re-uptake of dopamine and/or norepinephrine Side effects: insomnia, dry mouth 1. 150 mg qAM x 3 d 2. Then 150 mg bid x 7-12 wk 3. For maintenance consider 150 mg bid for up to 6 mo 1. Decide on a quit date 2. Continue to smoke for first 1-2 wk of treatment and then completely stop (therapeutic levels reached in 1 wk) Seizure disorder, eating disorder MAOI use in past 14 d Simultaneous use of bupropion (Wellbutrin®) for depression

Question 83

Varenicline MOA, side effects, dosage, prescribing and contraindications

Answer 83

Partial nicotinic receptor agonist, and partial nicotinic receptor competitive antagonist Side effects: nausea, vomiting, constipation, headache, dream disorder, insomnia, increased risk of psychosis, depression, suicidal ideation 1. 0.5 mg qAM x 3 d 2. Then 0.5 mg bid x 4 d 3. Continue 1 mg bid x 12 wk ± additional 12 wk as maintenance 1. Decide on a quit date 2. Continue to smoke for first wk of treatment and then completely stop Caution with pre-existing psychiatric condition (stable depression is not a contraindication)

Question 84

What are standard drink equivalents

Answer 84

``` One standard drink = 14 g of pure alcohol • Beer (5% alcohol) = 12 oz • Wine (12-17% alcohol) = 5 oz • Fortified wine = 3 oz • Hard liquor (40%) = 1.5 oz ```

Question 85

What laboratory investigations are important to monitor in a patient with alcohol abuse history

Answer 85

* AST, ALT (usually AST:ALT approaches 2:1 in an alcoholic) * CBC (anemia, thrombocytopenia) * INR (decreased clotting factor production by liver)

Question 86

What is the MOA of disulfiram (Antabuse)

Answer 86

impairs metabolism of alcohol by blocking conversion of acetaldehyde to acetic acid, leading to flushing, headache, N/V, hypotension if alcohol is ingested (available in U.S., but no longer available in Canada)

Question 87

What is the MOA of naltrexone

Answer 87

competitive opioid antagonist that reduces cravings and pleasurable effects of drinking may trigger withdrawal in opioid-dependent patients

Question 88

What is the MOA of acamprosate

Answer 88

glutamate receptor modulator that also reduces craving

Question 89

What are pharmacological measures that can be used for patients with alcohol abuse issues

Answer 89

Diazepam for withdrawal Disulfiram Naltrexone Acamprosate

Question 90

Outline the continuum of alcohol use

Answer 90

1. Abstinence 2. Low Risk Drinking <2 drinks/d <10 drinks/wk for women <15 drinks/wk for men 3. At Risk Drinking Consumption above low-risk level but no alcohol-related physical or social problems ``` 4. Alcohol Use Disorder Physical or social problems Continued use despite consequences Inability to fulfill life roles Legal problems No evidence of dependence ``` 5. Alcohol Use Disorder