6502 Exam 3

Description of sensory hypersensitivity pain

- General hypersensitivity to sensory input bright lights, loud noises, smells - Hyperalgesia and allodynia found in neuropathic pain and sensory hypersensitivity, seen less often nociceptive pain

When would you switch a patient from oral medication to insulin for the treatment of type 2, DM?

- If the patient is not at goal in 3mo and has been on triple therapy - OR if the entry A1C is >9.0%

Examples of Nociceptive pain conditions

1. OA 2. RA 3.Neck 4. Back pain with structural pathology 5. Chronic tendonitis or bursitis

Sensory hypersensitivity pain / Central sensitization

1. altered pain sensory processing and impaired central pain modulation; CNS develops reduced ability to diminish responses to peripheral stimuli. 2. Exists without an identifiable nerve or tissue damage - Diffuse pain in multiple body regions - Dysfunction of the neurons throughout the CNS leading to lowering the pain threshold and amplification of sensory signals - Associated with mood disorders - Cognitive dysfunction

Causes of neuropathic pain

1. diabetic neuropathy, nerve trauma, stroke, phantom limb pain 2. Central - Spinal cord injury - Post CVA 3. Peripheral - Diabetic peripheral neuropathy - Post herpetic neuropathy - Lumbar or cervical radiculopathy - Stenosis - Tumor related neuropathy -Chemotherapy induced neuropathy - Small fiber neuropathy - Persistent post-operative pain

Medications to treat nociceptive pain

1.Acetaminophen 2. NSAIDS - Ibuprofen - Naproxen • Consider Age • Contraindicated - Asthma - CKD - Increased risk of bleeding 3.Used in combination with corticosteroids 4. Disease modifying agents • Biologics due to tissue damage or inflammation 5. Topical therapy options -Nonselective NSAIDs • Patches and gels

Medications to treat sensory hypersensitivity pain

1.Antiepileptic medications - Gabapentin -Serotonin-norepinephrine reuptake inhibitors • duloxetine 2. NSAIDs are not recommended • Not shown efficacy 3.Consider a trial of an Opioid pain medication

Medications for neuropathic pain

1.Antiepileptic medications - Gabapentin -Serotonin-norepinephrine reuptake inhibitors • duloxetine 2. NSAIDs are not recommended • Not shown efficacy 3.Consider a trial of an Opioid pain medication 4. Topical therapy options: - Lidocaine - Capsaicin

Neuropathic pain

1.results from a maladaptive response to damage or pathology of the nervous system; central and/or peripheral disorder of pain modulation 2. Pain associated with damage to the nervous system (nerve injury)

What are possible symptoms or other signs that a patient may be experiencing a schizophrenic episode?

50 or more weeks before the psychotic presentation the patient may have: Changes in sleep Changes in mood Reduced concentration, attention, drive, and motivation Anergia Positive Symptoms: Symptoms "added" to the usual human experience Visual hallucinations: Vivid and clear perceptions occurring without external stimuli Auditory hallucinations Delusions: Fixed beliefs not amenable to change in light of conflicting evidence Disorganized thinking: Inferred from speech that is disorganized, or incomprehensible Grossly disorganized or abnormal motor behavior: Repetitive odd movements or catatonia Negative symptoms Decrease or loss of normal function and predict long term disability Alogia Blunted affect Asocial Avolition anhedonia Cognitive symptoms: Problems with focusing, memory, attention Problem solving Problems with serial learning Impaired verbal fluency

What is the American Diabetes Association criteria to diagnosis type 2, Diabetes Mellitus

A1C: 5.7-6.4 (pre diabetes) 6.5 or higher on two separate tests = diabetes Random blood test >200 FBS >126 OGGT commonly done during pregnancy

Clinical presentation of IBS

Abdominal pain → often nonradiating, intermittent, crampy, can occur anywhere but most common in LLQ Symptoms occur after food or alcohol intake Diarrhea and constipation, often in alternating pattern Chronic onset Mucus in the stool Abdominal distention, bloating, nausea, lethargy, and backache Bleeding can be due to anal fissure or hemorrhoids - careful diagnoses should occur if bleeding is reported ALARM FINDINGS: More than minimal rectal bleeding, Weight loss, Unexplained iron deficiency anemia, Nocturnal symptoms, Fam Hx colorectal CA, IBD, celiac disease

ABCs in the diagnosis of IBS

Abdominal pain, bloating, constipation (or diarrhea)

typical symptoms of Panic disorder

Abrupt surge of intense fear or intense discomfort that reaches a peak within 10 minutes Includes 4 or more symptoms: Palpitations, pounding heart, accelerated HR' Sweating Trembling or shaking Feeling of choking Chest pain or discomfort Chills or hot flashes Nasuea or abdominal stress Dizzy, unsteady, lightheaded, or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying Numbness or tingling sensation

Prescription Drug Monitoring Program

Always check Prescription Drug Monitoring Program (PDMPs) for patients prior to prescribing and at least every 3 months while prescribing a statewide electronic database that tracks all controlled substance prescriptions. PDMPs can help identify patients who may be misusing prescription opioids or other prescription drugs and who may be at risk for overdose. PDMPs improve patient safety by allowing clinicians to: • Identify patients who are obtaining opioids from multiple providers. • Calculate the total amount of opioids prescribed per day (in MME/day). • Identify patients who are being prescribed other substances that may increase risk of opioids—such as benzodiazepines.

6 A's of chronic pain management

Analgesia Affect Activities Adjuncts Adverse reactions Aberrant behaviors

What is the assessment for OCD?

Assess for these Characteristics: presence of obsessions, compulsions, or both; obsessions are defined as recurrent thoughts or urges or images that are intrusive and unwanted; compulsions are repetitive behaviors or acts that the individual feels driven to perform and are aimed at reducing anxiety or dreaded situation impairment is related to severity of symptoms and can affect interpersonal relationships, occupational, academic, physical health

common side effects of SSRI medications

BLACK BOX warning: suicide ideation in early treatment Drowsiness, fatigue, sedation Insomnia Excitement Confusion Headache Dry mouth Constipation Sweating Tremor Orthostatic hypotension Nausea diarrhea Weight gain Sexual dysfunction occur in early treatment and are usually transient and dose dependent

How frequently should patients be tested for DM

Begin testing at age 45 for all, and at age 40 through 74 those who are overweight and have risk factors listed in question 1 or hx of A1c >5.7%. If screening is negative, repeat every 3 years or earlier with a change in risk

What are the common risk factors for chronic pain?

Biologic: severity and extent of surgery or trauma, disease condition, genetic factors such as sickle cell disease, autoimmune inflammatory disease, metabolic disorders (diabetes), advanced age, frailty. Psychological: mental health issues such as depression, anxiety, PTSD, catastrophizing Substance use or abuse: tobacco, alcohol, sedatives, opioids Social issues: disability, unstable housing, social disconnection, poverty, low health literacy, poor access to medical care Repeated surgeries of same condition (multiple spine procedures) Prolonged exposure to opioids Pre Existing wide-spread pain (such as fibromyalgia)

clinical presentation of colorectal cancer

Clinical presentation: fatigue, SOB, angina (usually causes by anemia), melenic stools → all indicative of right sided colon cancer Obstructive symptoms → indicative of left sided cancer Cramps, gas pain, and decrease in caliber of stool Colicky abdominal pain after meals and change in bowel habits Hematochezia Anorexia Weight loss

adverse effects of opioid pain medications.

Cognitive impairment Increased irritability Depressed mood Disturbed sleep Fatigue Sedation Respiratory depression Constipation Dependence Itching N/V

tenesmus

Cramping rectal pain, spasm of the rectum, the feeling of needing to poop but nothing is there

Common issues seen in patients diagnosed with dysphagia

Dehydration Choking Pneumonia Aspiration Death Malnutrition

clinical presentation for Inflammatory bowel disease

Diffuse Abdominal pain may be lower right or left, pain is cramping and can be intermittent or constant Diarrhea - loose and watery, can be bloody Tenesmus Spasms in the rectum Urgency Fecal incontinence Rectal bleeding Fatigue Weight loss Anorexia Fever Chills Nausea Vomiting Joint pain Mouth sores

What are common issues with prescribing SSRI's in primary care; under/over dosing, etc.?

Disadvantages Delayed onset of action Early anxiogenic effects Sexual side-effects Dose titration (often) Discontinuation Syndrome Advantages: Effective Safety Tolerability No dependence Once-daily dosing Primary care providers tend to underdose antidepressants and prescribe them for an insufficient length of time Length of pharmacological intervention in depression In acute phase treatment, 4-8 weeks of treatment is needed before concluding that a patient is partially responsive or unresponsive to a specific treatment Patients successfully treated during acute phase should continue the same course of treatment for 4-9 months, preferably for a minimum of 6 months Relapse highest in first 2 months after discontinuation of therapy With >2 major depressive disorder episodes, 81 % relapse in 1 year without treatment

treatment recommendations for diverticulosis

Diverticulosis: description of many outpouchings located in the colon Fiber, 27-40g per day recommended by the WHO Antispasmodics or anticholinergics have been used without substantiated evidence Surgical resection for pain relief Diverticulitis: inflammation of one or more of the diverticula Mild cases: clear liquids for 2-3 days, limit physical activity, PO antibiotics (trimethoprim-sulfamethoxazole 160mg/800mg BID PLUS metronidazole 500mg TID, Amoxicillin-clavulanate potassium 875/125, OR ciprofloxacin 500mg BID PLUS metronidazole 500mg TID Immediately after the attack a short term low fiber diet of 15g or less per day can reduce the volume of fecal matter and prevent irritation Colonoscopy after symptoms resolve Diverticular Bleed: 70-90% of cases stop spontaneously Hemodynamic stability and resuscitation

When would a provider refer a patient to a psychiatrist with bipolar disorder?

During acute phases of manic or depressive episodes High risk of suicide during the episodes

typical clinical presentation of cirrhosis

Earliest symptoms reported include: weight loss, fatigue, pruritis Nonspecific symptoms: weakness, malaise, dark urine, pale stools Anorexia Nausea/Vomiting Hematemesis: secondary to esophageal varices Abdominal pain: related to ascites and stretching of muscles Menstrual abnormalities, impotence, sterility Neuropsychiatric symptoms: difficulty focusing, irritability, confusion Late stage: jaundice Identification of high risk behaviors Thorough review of medications, OTC products, allergies, family history, blood transfusions, or risk for hepatitis

6 essential elements for chronic pain management

Educate patient and family to promote the self-efficacy and shared decision making Train all team members to their discipline specific competencies Develop and integrate non-pharmacological modalities into care plans Institute evidence-based medication prescribing Establish metrics to monitor chronic pain care and outcomes

pathophysiology of fibromyalgia

Fibromyalgia is currently understood to be a disorder of central pain processing or a syndrome of central sensitivity.

DSM-5 associated with depression, what symptoms need to be included to make the diagnosis of depression

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. depressed mood most of day, nearly every day 2. diminished interest/pleasure 3. weight change, change in appetites 4. insomia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue or loss of energy 7. feelings of worthlessness 8. diminished ability to think or concentrate 9. recurrent thoughts of death

typical symptoms of GAD

GAD → excessive anxiety and worry about a number of events or activities Associated with 3 or more of the following 6 symptoms (persisting >6 months): Restlessness Easy fatigability Difficulty concentrating Irritability Muscle tension Sleep disturbances Physical complaints: tachycardia, shortness of breath, muscle aches, trembling, twitching, sweating, dizziness, nausea, diarrhea

What are the common adverse effects of GLP-1 agonists?

GFR<30 (in Byetta and Bydureon) Nausea and GI upset - most common due to slowed digestion, but this is dose dependent Hypoglycemia Gastroparesis Pancreatitis, pancreatic cancer BLACK BOX WARNING: thyroid C-cell tumors in mice so it is contraindicated in patients with history of thyroid carcinoma

What are the common side effects of an alpha-glucosidase inhibitor?

GI (flatulence, diarrhea, abdominal distention) Increases liver transaminases Decreased iron absorption leading to anemia Contraindicated in IBS or cirrhosis

laboratory findings for colorectal cancer

Gastric Cytology: - Endoscopic scraping or gastric lavage - Sensitivity 97-98% w/ experienced pathologists - False positive possible w/ healing gastric ulcer Endoscopy: - Less sensitive for early cancers Multiple biopsies of all lesions increases sensitivity to 90% Fecal Occult Blood - Appropriate screening for all GI malignancies Metastatic evaluation → LFTs, CT scan, Chest Xray

Signs/Symp of Hypothyroid

General: Fatigue Weight gain Decreased or change in appetite Sleepy Endocrine: Cold intolerance Decreased perspiration Skin: Dry Hair loss EENT: Blurred vision Decreased hearing Fullness in throat Mental: Depression Emotional lability Forgetful Low concentration GI: Constipation GU: Menstrual irregularities Neuro: Paresthesia MSK: Muscle pain, joint pain weakness

Signs/Sym of hyperthyroid

General: Weight loss Fatigue Increased appetite Endo: Heat hypersensitivity Increased sweating Skin: Warm, moist skin EENT: Stare Lid lag Eyelid retraction Mild conjunctival injection Exophthalmos Mental/Emo: Nervousness Hyperactivity Insomnia CV: Palpitations Tachycardia Wide pulse pressure Atrial fibrillation GI: Frequent bowel movements May have diarrhea GU: Hypomenorrhea Neuro: Weakness tremor

Describe celiac disease and common treatment

Gluten Free Diet Vitamin supplementation: fiber iron calcium magnesium zinc folate niacin Riboflavin vitamin B12 → supplementation of B12 and folate may help individuals with celiac disease recover from anxiety and depression caused by vitamin deficiencies vitamin D

List of conventional antipsychotics

Haloperidol Perphenazine Prochlorperazine

What is the benefit to a patient of an appropriate or usual anxiety response to a life event?

Helps a person focus on the issue at hand Can be protective Heightens senses when an individual encounters a dangerous situation

Description of neuropathic pain

Hot • Burning • Electric shock • Stabbing • Painful • Cold • Tingling • Pins and needles

common signs and symptoms of Grave's disease

Hyperthyroid and one of the following: Goiter Exophthalmos Infiltrative dermopathy

AACE/ACE guidelines to treat DM2

If <7.5 start with monotherapy If >7.5 the dual therapy, step up to triple therapy after 3 months If >9.0 and symptomatic then start insulin with other agents If not symptomatic then treat with dual or triple therapy

goals of treatment for chronic pain

Improve function Maintain a therapeutic relationship with the patient Manage expectations

Define fibromyalgia

It is a disorder of chronic, widespread pain and tenderness. It typically presents in young or middleaged women but can affect patients of either sex and at any age. >3 months of persistent widespread musculoskeletal pain (WPI score >7 and SS score >5 or WPI score 3-6 & SS score >9) above and below waist bilaterally, associated with palpation of tender points and no other pain source identified & usually accompanied by profound chronic fatigue and sleep disturbance; 8-9x more in women, onset 40-50 but rarely after 55.

List contraindications to the use of Biguanides (Metformin)

Kidney disease (Cr>1.4 in females and >1.5 in males) or reduced CrCl, acute MI, septicemia, acidosis Hold for 48h post exam on any exam that uses contrast dye Elevated lactate

List factors that may cause depression in older adults.

Living in long term care Physical illness/poor health status Cognitive decline Hospitalization Death of a partner/friends

advantages of topical pain medications

Lower total systemic daily dose Site-specific drug delivery Potential to avoid first-pass metabolism Fewer major drug interaction and systemic side effects

What are treatment recommendations for ADHD in adults?

Medications, including stimulants, non stimulants and antidepressants Behavioral therapy Self-management, education programs and assistance through schools or work or alternative treatment approaches

ADA initial pharmacologic agent

Metformin Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. Monitor Vitamin B12 deficiencies

PHQ-9 screening tool and how to score the tool

Minimal depression 0-4 → The score suggests the patient may not need depression treatment Mild depression 5-9 → Physician uses clinical judgment about treatment, based on patient's duration of symptoms and functional impairment Moderate depression 10-14 → Physician uses clinical judgment about treatment, based on patient's duration of symptoms and functional impairment Moderately severe depression 15-19 → Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment. Severe depression 20-27 → Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment.

SGLT-2 Inhibitors: Sodium glucose cotransporter 2 inhibitors

MoA: By inhibiting SGLT2 these meds reduce reabsorption of filtered glucose, lower the renal threshold for glucose and increase urinary glucose excretion Brand Name: "-flozin", Jardiance

Glinides: Meglitinide/Phenylalanine Derivatives

MoA: Increases insulin secretion Brand Names:prandin, starlix

Alpha glucosidase inhibitors:

MoA: block enzymes that digest starches and absorption of glucose in the small intestine Brand Names: Acarbose (Precose)

Biguanides

MoA: decrease hepatic glucose production and increase insulin mediated peripheral glucose uptake to lower fasting sugars Brand Names: metformin (glucophage)

Sulfonylureas

MoA: increase endogenous insulin secretion Brand Names: glipizide, glyburide, glimepiride

GLP-1 (Glucagon Like Peptide) Agonist

MoA: incretin mimetic agent that enhances the glucose-dependent insulin secretion, inhibits glucagon secretion and delays gastric emptying GLP-1 increases insulin levels when needed and reduces the amount of glucose produced by the liver and reduces the rate of digestion Brand Names: "-glutides", Victoza, Trulicity, Ozempic

Dipeptidyl Peptidase IV (DPP-IV)

MoA: inhibits enzyme that inactivates GLP-1 in the gut therefore increases insulin secretion and suppresses glucagon secretion Brand Names: Januvia, "-gliptins", Trajdenta

Thiazolidinediones

MoA: insulin sensitizers, decrease insulin resistance by making muscle, fat, and liver cells more sensitive to insulin, and suppresses hepatic glucose production Brand Names: Pioglitazone, Actos, Avandia

Extraintestinal Symptoms of IBD

Ocular: Conjunctival inflammation, Episcleritis, Uveitis, corneal ulcers Musculoskeletal: Arthralgias of 1 or more peripheral joints, spondylitis or sacroiliitis, osteoporosis, septic necrosis Skin and Mouth: Erythema Nodosum, pyoderma gangrenosum, Sweet's syndrome, apthous ulcers, vasculitis Hepatobiliary: Sclerosing Cholangitis, autoimmune hepatitis, gallstones

clinical presentation of diverticulosis

Often asymptomatic Irregular defecation Abdominal pain Bloating Excessive flatulence Flattened or ribbon like stool Urine disfunction, anorexia, nausea, vomiting, and heartburn Abdominal distention that is relieved by passing stool Elderly often show symptoms of IBS whereas younger patients show symptoms of appendicitis

List of atypical antipsychotics

Olanzapine Clozapine Quetiapine Risperidone

recommended goal for HA1C control in elderly patients

Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.5% while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less-stringent glycemic goals (such as A1C <8.0-8.5%)

risk factors for type 2, Diabetes Mellitus (DM)

Overweight or obese according to BMI Age >45 Family hx African american, alaska native, american indian, asian american, hispanic/latineo, native hawaiian, or pacific islander High BP High TG or low HDL History of gestational DM or baby>9lbs Not physically active History of heart disease or stroke Depression PCOS Acanthosis nigricans

Allodynia

Pain due to a stimulus that does not normally provoke pain; such as touch

Hep C transmission

Parenteral (blood), sexual contact, perinatal

Hep B transmission

Parenteral (blood). maternal - fetal, sexual contact

guidelines for an opioid taper

Patient requests Lack of significant improvement in pain or function Occurrence of an overdose or adverse effect Changes in patient's comorbidities Noncompliance with treatment plan High dose opioid therapy ( is on dosages ≥ 50 MME*/day without benefit or opioids are combined with benzodiazepines ) Signs of misuse or abuse Go Slow: 10% per moth as a starting point; shorter term patients can taper 10% per week coordinate with specialists make sure patient has support adjust the rate and duration according to patient's response but don't reverse the taper

How do you differentiate bipolar disorder from other mental health conditions

People with a bipolar I disorder diagnosis will have had at least one manic episode, but they might not ever have an episode of major depressive disorder. People with a diagnosis of bipolar II disorder will have had at least one hypomanic episode, which preceded or followed a major depressive episode. People with major depressive disorder do not experience any extreme, elevated feelings that would classify as mania or hypomania.

Signs and Symptoms of hyperparathyroidism

Primary hyperparathyroidism • Elevated serum calcium ○ May be masked by hypoalbuminemia or vitamin D deficiency • Fasting hypophosphatemia • Neurocognitive symptoms: ○ Weakness ○ Fatigability ○ Depression ○ Intellectual weariness ○ Cognitive impairment ○ Loss of initiative ○ Anxiety ○ Irritability ○ Insomnia • Cardiovascular symptoms: ○ Hypertension ○ Coronary artery disease ○ Left ventricular hypertrophy ○ Valvular calcifications • Kidney stones Secondary hyperparathyroidism • Seen with CKD stage III-V and vitamin D deficiency • Bone pain or pathologic fracture • Hypocalcemia • Hyperphosphatemia

Typical symptoms of Nociceptive pain

Prolonged nociceptive pain can lead to peripheral sensitization - Hyperalgesia (greater levels of perceived pain in response to painful stimuli) Allodynia (pain in response to stimuli such as touch which normally do not evoke pain) Sore Throbbing Dull Tender Aching Cramping

Rome IV criteria for IBS

Recurrent abdominal pain, on average at least 1 day/week last 3 months, plus two or more of the following: Related to defecation Assoc w/ change in frequency of stool (< 3 BMs per week or > 3 BMs per day) Assoc w/ change in stool consistency (lumpy/hard or loose/watery) Criteria fulfilled past 3 months with symptom onset at least 6 months prior to diagnosis

Preferred DM2 treatment for patient with ASCVD at high risk of heart failure per ADA

SGLT2 inhibitors

First line therapy for OCD

SSRIs or CBT, exposure and response therapy

screening tools used in chronic pain management.

STaRT back - Chronic back pain tool COMM - Current Opioid Misuse Measure SOAPP - Screener and Opioid Assessment for Patients with Pain - Opioid Risk Tool IDPain - 6 item tool - distinguish between nociceptive and neuropathic pain PainDETECT - Neuropathic pain Fibromyalgia Survey Brief Psychosocial Screening: ACT-UP - A-activity - C-cope - T-think - U-upsets their mood - P-people, how their pain affects interactions with people PEG tool: Pain intensity, pain interference with Enjoyment of life and General activity; validated tool, 3 questions scored from 0-10. Helpful for both initial and ongoing evaluation; useful tool to determine effectiveness of treatment plan PHQ-4 tool: anxiety and depression, 4 item validated tool. If score greater than 5 then more detailed screening tools should be completed such as PHQ-9 and GAD-7. Body Diagram: useful for all patients, good visual tool

potential and some dangerous adverse events or side effects from antipsychotic medications

Side effects from conventional antipsychotics: Dry mouth Blurred vision Constipation Drowsiness Weight gain Orthostatic hypotension EPS: Tardive dyskinesia/parkinsonism/dystonia Prolonged QT interval Hyperprolactinemia Side effects of atypical antipsychotics: Agranulocytosis (clozapine) Accelerated cardiovascular disease (weight gain, hyperlipidemia) Metabolic syndrome

typical laboratory findings for a patient with Crohn's disease

Stool testing to r/o other causes: C. diff, culture, O/P Fecal leukocytes indicate inflammation Fecal calprotectin indicates inflammation CBC, ferritin levels, anemia work-up → determines the presence of anemia, iron deficiency anemia is the most common Low Hgb, Hct, MCV, and MCH Increased RDW Ferritin levels low when iron stores are depleted (<33, range 33-220) B12 deficiency ESR, CRP → elevated, but are nonspecific, these are markers of inflammation CMP - look at LFTS, renal function, electrolytes, glucose Genetic testing Endoscopy: crohns will have skip areas or patchy sections of normal mucosa mixed with inflamed mucosa this causes a cobblestone appearance

Which class of medications become less effective in controlling blood glucose (BG) and DM as time goes by?

Sulfonylureas (due to few beta cells being left that actually produce insulin; since the goal of the medication is to increase insulin production by beta cells, it is less effective due to few beta cells that are actually left late in the disease)

Hyperthyroid Labs

TSH low, Increase in T3 and T4 - Increased secretion of T3 and increased conversion of T4 - If only T3 is elevated its called T3 toxicosis TSH low and T4 is normal then order a T3

hypothyroid labs

TSH with reflex to T4 High TSH, low T4 Subclinical (high TSH, normal T4) Free T4 index Common to order in pregnant women

goals of treatment for GAD

To reduce symptoms To improve function To treat comorbid conditions Achieve long term remission

Which therapies are typically part of a successful treatment for depressive disorders

Treatment with medication, first line is SSRI and SNRI Dosing is done in 1-2 weeks increments titrating up slowly Takes 4-8 weeks to see effectiveness and medication should be continued for at least 6-9 months to prevent relapse Psychotherapy Proper nutrition and vitamin and electrolyte balance

What diagnostic test would you order if you found a thyroid mass during the PE on one of your patients?

Ultrasound of thyroid Anti thyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies Determines etiology (such as hashimoto)

extra precautions that are important to use when prescribing opioid medications for elderly patients

Use cautiously with elderly due to: Increased risk of CV; Renal adverse events; Hematological adverse events Look for drug interactions Use the lowest effective dose for the shortest length of time Consider topical NSAIDs Increased monitoring for adverse events

Nociceptive pain

caused by stimuli that threaten or result from bodily tissue damage; expected after surgery or trauma; can be musculoskeletal or visceral; underlying cause can be degenerative, inflammatory or neoplastic. 2. Tissue damage due to trauma, inflammation, or non-healing injury (somatic or visceral tissue injury)

Hep D transmission

co-infects w/ Hep B parenteral

For patients with type 2 diabetes and CKD

consider use of an SGLT2 inhibitor or GLP-1 receptor agonist shown to reduce risk of DKD progression, cardiovascular events, or both

MOA of Glucophage (metformin)

decrease hepatic glucose production and increase insulin mediated peripheral glucose uptake to lower fasting glucose

Per ADA when is early introduction of insulin

evidence of ongoing catabolism (weight loss) symptoms of hyperglycemia are present when A1C>10%or blood glucose levels≥300 mg/dL

Hep A transmission

fecal-oral

Hep E transmission

fecal-oral often in contaminated water

MOA of DPP-4 inhibitors (gliptins)

increase incretins (or GLP-1) by inhibiting dipeptidly peptidase-4 (the enzyme inactivative GLP-1) -increases insulin release from pancreas -decreases glucagon secretion (decreases glycogen= less glucose in liver) lowers post meal glucose

MOA of sulfonylureas

increase insulin secretion lowers post meal and fasting glucose Ex: glipizide, glyburide, glimepiride

Per ADA when do you consider dual therapy

newly diagnosed type 2 diabetes who have A1C ≥1.5% above their glycemic target (at roughly A1C of 7.5)

Preferred treatment for patients with type 2 diabetes who have established ASCVD per ADA

sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists with demonstrated CVD benefit

Acanthosis nigricans

thickening and darkening of skin near axillary region, A/w Diabetes Type II Neck, armpit, skin folds

conditions associated with hypersensitivity pain

• Fibromyalgia • Irritable bowel syndrome • Tension type HA • Interstitial cystitis • TMJ • Chronic fatigue syndrome - chronic pancreatitis - chronic pelvic pain - sickle cell disease

Treatment of hyperparathyroidism

• Surgery ○ Resection of parathyroid adenoma or 3 3/4 of parathyroid glands • Medical management to see if surgical criteria are met ○ Monitor serum calcium and creatinine at least annually ○ DEXA scan every 1-2 years ○ Maintain weight bearing activities and adequate fluid intake ○ Adequate calcium and vitamin D intake Cinacalcet-normalize calcium and PTH levels in primary hyperparathyroidism