Family Medicine

Which of the following are major risk factors for atherosclerotic cardiovascular disease (ASCVD)? *Case 31, Q1* *Explanation*

*Important modifiable risk factors include:* *- diabetes* *- hypertension, whether controlled or uncontrolled* *- current tobacco use* *- abnormal lipid levels, particularly high LDL-c and low HDL-c* *Key non-modifiable risk factors include:* *- older age (men over 45, women over 55)* *- family history* Changes in vision (A) and history of dizziness (F) are symptoms that may be secondary to CAD, but are not risk factors. The history and differential diagnosis for these symptoms must be considered. Elevated HDL cholesterol (C) is protective against development of CAD. An HDL-c level below 40 is considered an independent risk factor. Myocardial infarction in a 72-year-old first-degree relative (D) does not confer increased risk. Myocardial infarction (MI) at a young age (male <55; female <65) in a first-degree relative does increase an individual's risk for CAD. Female sex (E) is not a risk factor although CAD is the leading cause of death among women in America. The rise in incidence of cardiovascular disease happens about 10 years later for women than for men.

Ways to gather more information about dietary habits

-24-hour Dietary Recalls -Daily Dietary Intake Record (or Food Diaries) -Food Frequency Questionnaire -Usual Diet History

Dr. Nayar asks you which of the following you recommend for Mr. Reynolds now. Select all that apply. -A. Low dose aspirin (81 mg daily) -B. Moderate- to high-intensity statin -C. High sensitivity C-reactive protein (HS CRP) -D. Electron-beam computerized tomography scan for coronary calcium (EBCT) -E. Carotid ultrasound -F. Abdominal ultrasound of aorta

-A. Low dose aspirin (81 mg daily) -B. Moderate- to high-intensity statin

Which of the following are characteristics of a good screening test? Select all that apply. -A. There should be a treatment for the condition being screened for. -B. There should be a latent (asymptomatic) stage of the disease. -C. The test should have low sensitivity and high specificity. -D. The test should be acceptable to the population. -E. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.

-A. There should be a treatment for the condition being screened for. -B. There should be a latent (asymptomatic) stage of the disease. -D. The test should be acceptable to the population. -E. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole

Hormone risk factors of breast cancer

-Advanced age at first pregnancy -Exposure to diethylstilbestrol -Estrogen therapy

What are the five A's when discussing smoking cessation

-Ask -Advise -Assess -Assist -Arrange

One the way out of the door a male patient ask for a sample of Viagra what is a good response?

-Asking about the problem attaining a erection directly -Reassure patient that this can be addressed on another visit --Access if issue requires early return or is an emergency

ABCDE of Suspicious Skin Lesions

-Asymmetry -Border irregularity -Color non-uniform -Diameter >6mm -Evolution or change

Which of the following medical conditions is associated with depression? Select all that apply. A. Asthma B. Dementia C. Hypertension D. Hypothyroidism E. Parkinson disease

-B. Dementia -D. Hypothyroidism -E. Parkinson Disease

What are the United States Preventive Services Task Force Screening Recommendations for this patient? Select all that apply. -A. Lung cancer screening -B. High blood pressure screening -C. Pancreatic cancer screening -D. Testicular cancer screening -E. Alcohol misuse screening and counseling -F. Hepatitis C screening -G. Depression screening

-B. High blood pressure screening (all 18 or older) -E. Alcohol misuse screening and counseling (all 18 or older) -F. Hepatitis C screening (screen once for those born b/w 1945-1965) -G. Depression screening (general population)

A 55-year-old male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? -A. Borders -B. Color -C. Diameter -D. Location -E. Symmetry

-C. Diameter

Three Cs of addiction

-Compulsion to use -Lack of Control -Continued use despite adverse Consequences

Which treatments are recommended in the elderly? Select all that apply. The best option is indicated below. -A. Antidepressants -B. Antihistamines -C. Benzodiazepines -D. Cognitive behavioral therapy -E. Zolpidem

-D. Cognitive Behavior Therapy Explanation: sleep restriction/sleep compression therapy

Which of the following are risk factors for osteoporosis? Select all that apply. A. African American heritage B. BMI > 30 C. Early menopause D. History of previous fracture as an adult E. Sedentary lifestyle

-Early Menopause -History of previous fracture as an adult -Sedentary lifestyle -Explanation why not A and B: higher BMI seem to be protective by increasing estrogen levels. African Americans adults are at a lower risk of osteoporotic facture compared to Caucasian adults (high bond mineral density)

Common Causes of Insomnia in elderly

-Environmental problems -Drugs/alcohol/caffeine -Sleep apnea -Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder -Disturbances in the sleep-wake cycle -Psychiatric disorders, primarily depression and anxiety -Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure) -Pain or pruritus -Gastroesophageal reflux disease (GERD) -Hyperthyroidism -Advanced sleep phase syndrome (ASPS)

What history related to risk of cardiovascular disease do you want to obtain from a patient? -A. Exercise -B. Tobacco use -C. Stress -D. Travel history -E. Family history -F. History of leg pain with exercise -G. History of chest pain with exercise -H. Excess alcohol use

-Everything except travel history

Ways to raise HDL cholesterol

-Niacin (B3) -exercise -moderate alcohol intake

Stages of behavior change

-Pre-contemplative: Not aware of need to change or not interested in changing behavior. -Contemplative: Currently interested in changing behavior. -Active: Currently making a behavior change. -Relapse: Attempted behavior change but no longer making the change

Factors associated with decreased breast cancer rates include:

-Pregnancy at an early age -Late menarche -Early menopause -High parity -Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin.

RISE Mnemonic for Preventive Visits

-Risk Factors (for serious medical conditions) -Immunizations (immunizations/chemoprophylaxis) -Screening tests -Education (ways to live healthier while reducing risk for disease)

A 63-year old cisgendered female comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago; both were normal. She has never had an abnormal Pap test. At the age of 45 she had a total hysterectomy for fibroids. Of the details provided about this patient, which is an appropriate reason to explain why she does not need a Pap test today? -A. She experienced menopause more than 10 years ago -B. She had a total hysterectomy for fibroids -C. She has never had an abnormal Pap test -D. She is 63 years old -E. She is not sexually active

-She had a total hysterectomy for fibroids (removal of cervix and uterus w/ or w/o oophorectomy) Explanation: USPSTF guidelines recommends against continued cervical cancer screenings in patients whose uterus removed for benign reasons. Cervical cancer screening should begin at the age of 21. Females between the ages of 65 and 70 who have had three or more normal Pap tests or two negative co-tests (Pap and HPV) in the past 10 years may choose to stop cervical cancer screening.

WAVE Mnemonic

-Weight -Activity -Variety (food types) -Excess (food: sugar, salt, fat, calories)

How many drinks a day are allowed for women? How many for men?

-Women: 1 -Men: 2

What is the mechanism of action of Varenicline?

-alpha 2 beta2 nicotinic cholinergic receptor partial agonist (mimics the action of nicotine). This reduces the rewarding aspect of nicotine and prevents the withdrawl symptoms

The USPSTF recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years using:

-fecal occult blood testing -sigmoidoscopy -colonoscopy -Fecal Immunochemical -----Testing (FIT Test) -Fecal DNA Testing -CT Colography

Mechanism of action of Bupropion

-inhibitor of dopamine and NE reuptake -reduces craving and withdrawl symptoms

What are the withdrawl symptoms of nicotine?

-intense craving -dysphoria (dissatisfaction) -anxiety -poor concentration -increased appetite -weight gain -restlessness -insomnia

Most frequent causes of death for 55 year old male in US

-malignant neoplasm -heart disease -unintentional injury (accident) -chronic lower respiratory disease -diabetes mellitus -chronic liver disease and cirrhosis -CVA

BMI normal

18.5-24.9

BMI overweight

25.0-29.9

BMI obese

30.0 and above

BMI underweight

<18.5

Which of the following is correct regarding breast self-examination? Choose the single best answer. -A. Breast self-examination increases the number of biopsies performed. -B. It is recommended to teach females breast self-examination -C. Most females should regularly perform breast self-examination. -D. The practice of regular breast self-examination by trained female patients

A. Breast self-exam increases the number of biopsies performed Explanation: -Females performing self exams were almost twice as likely to undergo a breast biopsy. -According to ACS in 2015 There is also a low sensitivity rate and high false-positive rate for clinical breast exams for screening purposes

A 55-year-old male with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. He is a lifelong non-smoker, and he doesn't drink alcohol or use recreational drugs. Which of the following screening tests is given either a USPSTF A or B recommendation in favor of its routine use for patients such as this one? -A. Colon cancer screening -B. ECG screening for coronary artery disease -C. Lung cancer screening -D. Pancreatic cancer screening -E. Prostate specific antigen (PSA) testing

A. Colon cancer screening

He asks, "Which of the following do you want to order for Mr. Reynolds?" Select only those that are strongly recommended by evidence-based guidelines. Select all that apply. A. Glucose B. Lipid panel C. TSH D. Ferritin E. Liver test panel F. Electrolyte panel: Na, K, Cl, CO2, BUN, Creatinine

A. Glucose B. Lipid F. Electrolyte panel: Na, K, Cl, CO2, BUN, Creatinine

Dr. Nayar asks you, "What ECG changes would suggest that Mr. Reynolds has existing coronary artery disease?" Select all that apply. A. ST segment depression or downsloping ST segment B. Q waves C. U waves D. Convex ST segment elevation E. Short PR interval

A. ST segment depression or downsloping ST segment (ischemia to myocardium) B. Q waves (infarction if greater than succeeding R wave and greater than 0.04 seconds) D. Convex ST segment elevation (acute injury to myocardium)

At what age does the CDC recommend the recombinant zoster vaccine (Shingrix) be given to every adult?

Age 50 -Its a two-vaccine series given 2-6 month apart

A 64-year-old cisgendered female who is overweight with well-controlled hypertension comes to your office with concerns of a lump in her breast that she noticed while showering. She reports having no pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 31 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer? -A. Age -B. Age at first birth -C. Age at menarche -D. Age at menopause -E. Weight

Age of Menopause Explanation: The patient was not 20 or younger her first pregnancy, her period started earlier than 12, her BMI is over 30, no medications such as NSAIDs or selective estrogen recpetor modulators

What are the risk factors for developing breast cancer in the general population? Select all that apply. -A. Age -B. Excessive alcohol intake -C. Family history of breast cancer in first-degree relative -D. Genetic factors -E. Postmenopausal obesity -F. Prolonged exposure to estrogen

All of the above

What are the risk factors for developing cervical cancer?(Select all that apply) -A. Cigarette smoking. -B. Early onset of sexual intercourse. -C. Immunosuppressed patient. -D. Multiple sexual partners.

All of the above Explanation: Early age of sexual intercourse and multiple partners increase risk of HPV, which causes cervical cancer. Smoking exposes to more cancer causing chemicals.

Lung Cancer Screening Recommendations

As of 2013, the USPSTF recommends annual screening with a low-dose computed tomography (LDCT) scan to screen for lung cancer in patients aged 55 to 80 who have smoked for 30-plus years. To be considered, the patient should also be currently smoking or have quit within the prior 15 years.

Which of the following are major risk factors for atherosclerotic cardiovascular disease (ASCVD)? Select all that apply. *Case 31, Q1* A. Changes in vision B. Diabetes C. Elevated HDL cholesterol levels D. Father had a myocardial infarction at age 72 E. Female sex F. History of dizziness G. Hypertension H. Older age (men over 45, women over 55) I. Tobacco use

B. Diabetes G. Hypertension H. Older age (men over 45, women over 55) I. Tobacco use

A 48-year-old male with a past medical history that includes hypertension, chronic obstructive pulmonary disease (COPD), and hyperlipidemia presents to clinic as a new patient in October for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently nonadherent with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient? -A. Influenza, meningococcal, and zoster -B. Influenza, pneumococcal, and Tdap -C. Influenza, zoster, and Tdap -D. Meningococcal, pneumococcal, and Tdap -E. Meningococcal, pneumococcal, and zoster

B. Influenza, pneumococcal, and Tdap

How effective are oral medications, such as bupropion (Wellbutrin, Zyban, Budeprion) or varenicline (Chantix), in helping smokers quit? Choose the single best answer. -A. Not effective (Quit rate at 12 months is no higher than placebo quit rate.) -B. Somewhat effective (Quit rate at 12 months is 1.5 to 3 times the placebo quit rate.) -C. Moderately effective (Quit rate at 12 months is 3 to 5 times the placebo quit rate.) -D. Very effective (Quit rate at 12 months is 5 to 10 times the placebo quit rate.)

B. Somewhat effective (Quit rate at 12 months is 1.5 to 3 times the placebo quit rate.)

Potential benefits of PSA? Potential harm of PSA?

Benefit: prolonged life from early detection and txmnt, psychological reassurance that don't have prostate cancer or that it is was caught early Harm: serious complications (ED, incontinence, bowel dysfunction) or even death from txmnt of cancer that would not have caused symptoms if undected; pain and discomfort associated w/ prostate biopsy and psychological effects of false positive

Which medication is usually prescribed 1st for a patient trying to quit smoking bupropion or varenicline?

Bupropion

A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? -A. Ideal -B. Morbidly (very severely) obese -C. Obese -D. Overweight -E. Underweight

C. Obese

Changes associated with dyslipidemia

Corneal arcus, xanthelasmas, acanthosis

Other risk factor of cervical cancer

DES (diethylstilbestrol) exposure in utero

American Cancer Society screening for Breast Cancer

Females aged 45 to 54: mammograms every year. Females aged 55 and older: switch to mammograms every two years, or have the choice to continue yearly screening. Females aged 40 to 44:should have the choice to start annual breast cancer screening with mammograms as desired (consider risk/benefits)

A 25-year-old patient presents to the office for follow-up on anxiety and tobacco dependence. She reports she is doing well on her new medication to help with both her mood and smoking, though she continues to smoke. She recently started her first sexual relationship with a new female partner. She received a tetanus vaccine at the age of 18, and she received her flu vaccine this year. Her blood pressure is 122/70, and her physical exam is within normal limits. You review her recent Pap test, which was negative. Which of the following indicates the vaccines she should receive today? Choose the single best answer. -A. HPV vaccine alone -B. HPV vaccine and pneumococcal conjugate vaccine (PCV13) -C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23) -D. HPV vaccine and Zoster vaccine -E. No vaccines are needed

HPV vaccine and pneumococcal conjugate vaccine (PCV13) -The pneumococcal polysaccharide vaccine (PPSV23) is recommended for adults who smoke (like this patient); have chronic heart, lung, or liver illness; have alcohol use disorder; and have diabetes. The pneumococcal conjugate vaccine (PCV13) is not routinely recommended for adults, though it can be given to some patients at the age of 65

What diseases are individuals with elevated BMI at greater risk of developing?

High blood pressure Coronary artery disease Stroke Osteoarthritis Some cancers Type 2 diabetes

Vaccines not to give to immunocompromised patients, their close contacts, or pregnant women

MMR, Varicella, OPV (poli) -all are live vaccines

A 55-year-old male with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35-pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" Which stage of change best describes this patient at this time? -A. Action -B. Contemplation -C. Maintenance -D. Precontemplation -E. Preparation

Precontemplation

Ovarian Cancer Screening Recommendations

The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians all recommend against routine screening for ovarian cancer in asymptomatic patients

Colon Cancer Screening

USPSTF gives colon cancer screening an A recommendation 50-75 yo

A 34-year-old cisgendered female who has no past medical problems and is not currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has a maternal aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children, aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago, and her other vital signs are stable. On breast exam, you note a mobile rubbery mass approximately 1 x 1cm that has regular borders and is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following puts this patient at increased risk for breast cancer? -A. Age -B. Age of menarche -C. Family history of cancer -D. Parity history -E. Weight

Weight Explanation: for excess estrogen: exposure menarche must be before age 12, menopause after 45, advance age of first pregnancy

Changes associated with atherosclerosis

decreased peripheral pulses and carotid bruit

A 47-year-old cisgendered female comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34, and the remainder of her physical exam is within normal limits. Her vaccinations are up to date, and she has a Pap test today and will have labs drawn. According to USPSTF, which of the following is the best recommendation to give her concerning mammography? The best option is indicated below. Your selections are indicated by the shaded boxes. -A. Should have started at age 40 and every year thereafter -B. Should have started at age 40 and every two years thereafter -C. Should have started at age 45 and every year thereafter -D. Start at age 50 and every year thereafter -E. Start at age 50 and every two years thereafter

start at age 50 and every two years thereafter -mammograms have sensitivity of 60-90% for detecting breast cancer -test 50-74yo on this schedule

Skin Cancer Screening Recommendations

the USPSTF currently reports that there is insufficient evidence to recommend for or against skin cancer screening

Calculate BMI

weight in kg/height in m2