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fam med

what are the 6 stages of behavior change precontemplation, contemplation, determination, action, maintenance, relapse
3 MC causes of dyspepsia GERD, PUD, fxnl dyspepsia (diagnose after upper endoscopy, etc are all nml)
alarm symptoms in dyspepsia age>55 w new onset of sympt, FMH of upper GI cancer, wgt loss, bleeding, worsening dysphagia, odynophagia, anemia, persistent vomitting
remember to ask abt NSAID use in dyspepsia
mgmt GERD PPI, if taking NSAID need to stop (I guess don't need PPI)
if dyspepsia but not GERD or NSAID, how manage? can do empiric PPI or H2 antagonist; **(best) H Pylori test/treat; endoscopy
lifestyle changes for GERD& dyspepsia just avoid trigger foods if only dyspepsia, if GERD: wgt loss, elevating head of bed, avoiding spicy and large meals and meals before bed
triple tx for H Pylori PPI, clarithromycin, amox (flagyl if allergic to PCN)
on female w UTI sympt be sure to ask abt gyne symptoms (discharge, pelvic pain) and even menstrual history; sympt suggestive of pyelo (F/C, N/V, back pain)
serious UTI type diseases want to consider/ r/o renal cell or bladder cancer, pyelo, PID, nephrolithiasis
ppl at risk for complicated UTI (ie pyelo) fxnl or anatomic abnlty of urinary tract incl polycystic kidney dz, nephrolithiasis, neurogenic bladder, preg, DM or immunosupp, recent urinary tract procedure or catheter
lifestyle changes for UTI liquids, urinate s/p sex, drink cranberry juice, wipe front to back s/p BM
MC bugs for UTI in female E Coli, then Staph Sapro
tx for uncomplicated UTI in women 3d Bactrim or Cipro sufficient, if recurrent may used 5-10d and ensure infxn clears
what cxns or serious URI don't want to miss meningitis, brain abscess, orbital cellulitis
imaging/w/u for URI/sinusitis none, could order sinus XR or CT, but not usu helpful, sinus cx could be considered if resistant to tx
tx URI/sinusitis if just viral use nasal saline spray, can give nasal decongestant (pseudoephed, oxymetazoline 3-5d), if sinusitis amox
if allergic component URI how tx loratadine (claritin), fexofenadine (allegra)
mild persistent asthma symptoms and use of inhaler daytime symptoms (using b2) >2x/wk, nighttime 3-4/mo, FEV1 >80% and FEV1/FVC nml (same as intermittent)
levels of asthma intermittent, mild persistent, moderate persistent, severe persistent
moderate persistent asthma symptoms and use of inhaler daytime symptoms (using b2) everyday, nighttime sympt >1x/wk, FEV1 60-80% and FEV1/FVC reduced by 5%
severe persistent asthma symptoms and use of inhaler daytime symptoms (using b2) throughout the day, nighttime sympt every night, FEV1 <60% and FEV1/FVC reduced by >5%
well controlled asthma sympt <2x/wk and nighttime <2x/mo, no interference nml activity, FEV1 >80% of best (can f/u 6mos)
not well controlled asthma sympt >2x/wk and nighttime >2x/mo, some limitation nml activity, FEV1 60-80% of best (add tx and f/u 2-6wks)
poor controlled asthma sympt throughout the day, nighttime sympt almost every night, using b2 mltpl times/day, FEV<60%, for tx consider short term oral steroids and f/u 2wks
SE of b2 tachycardia, tremor, hypoK, paradoxical bronchospasm
SE ipratropium antichol, ie dry mouth, nervous, can have anaphylactic rxn, angioedema
SE mast cell stabilizer (cromolyn) throat irritation/dry throat, bronchospasm, anaphylaxis
SE theophylline N/V, HA, insomnia, irritability. Serious SE: arrhythmias, sz
SE leukotriene modifiers various incl HA, flu like/URI, GI sympt. Serious SE incl angioedema, anaphylaxis
mech of action theophylline prevents breakdown of cAMP and cGMP for sm mscl relax and bronchodilation, also inhibits inflamm mediators
key adv/disadv theophylline cost is advantage; disadv incl SE and need to monitor levels
comorbidities/triggers asthma allergens, GERD, allergic rhinitis, smoke exposure, obesity and OSA
components to developing therapeutic relationship develop atmosphere of trust, connect on non-medical topic, learn abt family contextual things related to dz, offer to partner w pt, show empathy, etc
tx for mild persistent? Moderate? Severe? short acting b2 + low dose steroid. For moderate add long acting b2. for severe add medium dose steroid--if that doesn't control add oral steroid
cut offs for lipids tChol <200, >240 is high. TG <150, >200 high. HDL 40-60 (where 60 or higher is good!). LDL >160 high
LDL when start tx and goals: pt with BOTH DM and CAD start lifestyle and Rx at 70, goal <70
LDL when start tx and goals: pt with DM OR CAD OR 10yr risk >20% start lifestyle at 100 and Rx at 100 or 130, goal <100
LDL when start tx and goals: pt with 2 RF, 10yr risk 10-20% start lifestyle at 130 and Rx at 100 or 130, goal <130
LDL when start tx and goals: pt with 2 RF, 10yr risk <10% start lifestyle at 130 and Rx at 160, goal <130
LDL when start tx and goals: pt with <2 RF start lifestyle at 160 and Rx at 160 or 190, goal <160
RF used to calculate LDL smoking, HTN, FMH of premature CAD
LDL cutoff and goal for HTN, smoker w/o FMH premature CAD would need to calculate 10yr risk, but if >20%: start lifestyle at 130 and Rx at 100 or 130, goal <130
SE sulfonylureas hypoglycemia, wgt gain, rare: hepatitis, heme abnlties
name types of hypolgycemics used DM2 (8, incl 4 MC) **sulfonylureas (glyburide, glipizide), **biguanides (metformin), **thiazolidinediones (rosiglitazone, pioglitazone),**alpha glucosidase inhibitors (acarbose), meglinitinides, amylin analogs, incretin analogs, DPPV-IV inhibitors
key SE/cautions of metformin GILMAR=GI, lactic acidosis, metallic taste, renal (can't use if Cr 1.5 male, 1.4 female), wgt loss
which hypoglycemics can cause hepatitis/hepatotoxicity sulfonylureas, alpha glucosidase, thiazolidinediones
SE meglitinides hypolgycemia, anaphylactoid, heme
which oral hypoglycemics have risk of hypoglycemia (4) sulfonylureas, meglitinides, amylin analogs and incretin mimetics
SE thiazolidinediones (rosglitazone, pioglitazone) fluid retention, hepatotoxicity, CHF
SE alpha glucosidase inhibitors diarrhea, flatulence, bloating, rare: hypersensitivity, hepatitis
SE amylin analogs N/V, anorexia, HA, interferes w absorption oral meds, avoid in gastropoeresis, **severe hypoglycemia in DM1
SE incretin mimetics N/V, diarrhea, avoid in gastropoeresis or severe RF, **severe hypoglycemia in DM2 on sulfonylureas
which oral hypoglycemics have GI SE (4) **biguanides (metformin), **alpha glucosidase inhibitors (acarbose), amylin analogs, incretin analogs
SE DPPIV inhibitors runny nose, sore throat, HA, rare: hypersensitivity/anaphylactoid, S-J
MOA sulfonylureas (glyburide, glipizide) stimulate insulin sxn
adv/disadv sulfonylureas (glyburide, glipizide) cost, safety, low SE
MOA biguanide (metformin) incrs insulin sensitivity, decrs liver production of glu
adv/disadv metformin use in overwgt to decs wgt
MOA meglitinides pancreas incrsd sxn of insulin (Same as sulfonylureas but shorter acting)
adv/disadv meglitinides shorter acting than sulfonylureas (meal adjusted dosing), more effective than sulfonylureas and less likely hypoglycemia
MOA thiazolidinediones enhances insulin sensitivity in mscl
adv/disadv thiazolidinediones lowers insulin requirements (bc improves insulin sensitivity)
MOA alpha glucosidase inhibitors inhibits intestinal alpha glucosidase
adv/disadv alpha glucosidase inhib improves post-prandial hypergly, generally poorly tolerated
MOA amylin analogs, how given subQ before meal for ppl on insulin. Slows gastric emptying and decrses appetite
adv/disadv amylin analgos can only use in DM1 or 2 on insulin, improves postprandial hypergly, helps wgt loss, can't give gastropoeresis
MOA incretin mimetics subQ before meal for DM2. Slows gastric emptying and decrses appetite, stimulates glu dependent insulin secretion
adv/disadv incretin mimetics improves postprandial hypergly, helps wgt loss
MOA DPPIV inhibitors incrsd insulin sxn
agents for HLD (5) bile acid sequest, niacin, statins, fibric acid, ezetimibe
SE bile acid sequest (cholestyramine, colestipol) GI
SE niacin flushing, GI, hyperuric; hepatotoxic, PUD, severe hypergly
SE statins incrsd LFTs, myositis, rhabdo
SE fibric acid derivatives (gemfibrozil, fenofibrate) GI, incrsd LFTs, gallstones, myositis
SE ezetimibe upper respir sympt, HA, myalgia, rare hypersensitivity
MOA bile acid sequest interrupts bile absorb so more cholesterol turned into bile acids in liver
adv/disadv bile acid sequest usu add to statin bc SE
MOA niacin decrses TG synthesis in liver and increases lipases clearing vLDL
adv/disadv niacin good for incrsd TG and LDL, but SE limit use
MOA statin HMG CoA reductase leading to decrsd cholesterol synthesis in liver
adv/disadv statin effective and limited SE
MOA fibric acid binds PPAR
adv/disadv fibric acid use for high TG
MOA ezetimibe inhibits cholesterol absorption in small intestine
goals for DM for glu (fasting/postprandial), HbA1c, BP, LDL, TG fasting glu 130, postprandial 180, BP 130/75, LDL 100, TG 150, HbA1c 7
cut offs for impaired glu tolerance fasting 110-125 or 2hr postprandial 140-200
cut offs for dx of DM, incl HbA1c fasting >125 or 2hr postprandial >200, or random >200 w symptoms. Need 2 readings. Or HbA1c >6.5 x2.
ranges for HTN, preHTN preHTN 120-139/80-89; HTN I: 140-159/90-99; HTN II 160/100
8 meds for HTN diuretics, bb, ccb, ACEI, ARB, alpha1 antagonists, alpha2 agonists, direct vasodilators
SE BB FARSHILD: fatigue, asthma, reynauds/impaired peripheral circulation, sex dysfxn, halluc, insomnia, lipid…bradycardia, mask hypoglycemia
SE diuretics depends on specific, but hypoK, hypoMg, hyperuric, shortterm incrs cholesterol and glu
SE CCBs HA, flushing, peripheral edema, gingival hyperplasia, constipation, bardycardia/arrhythmias, CHF (ie verapamil ChOPPd Liver: constip, heart block, prolactin, potassium)
SE ACEI CAPTOPRIL: cough, angioedema, potassium, taste, preg, rash, liver toxicity
SE ARB angioedema (less than ACEI), hyperK
SE alpha1 blockers orthostatic hypotension
SE a2 agonist antichol, ie sedataion, dry mouth, bradycardia, rebound HTN
SE vasodilators HA, flushing, reflex tachycardia, lupus like
ex of direct vasodilators hydralazine, NG, nitroprusside, isosorbide nitrate
ex of central alpha 2 agonists methyldopa, clonidine
MOA alpha1 blocker blocks post syn alpha1, leads to less NE release
adv/disadv direct vasodilators difficult to control HTN, rapid control via IV, also pregnancy (hydralazine)
adv/disadv diuretics for HTN CHF
adv/disadv bb for HTN post MI, angina, SVT, CHF, diastolic dysfxn, migraine
adv/disadv ccb for HTN angina, SVT, reynauds, diastolic dysfxn, migraine
adv/disadv ACEI for HTN DM w albuminuria, CHF, postMI w systolic dysfxn, prevention progression CRF
adv/disadv alpha1 blockers for HTN BPH, HLD
adv/disadv alpha2 agonist for HTN clonidine can be used for rapid control HTN
what's BATHE model for psych visits Background (what's happening), affect (emotl state), trbl (what trbles you most), handling, empathy
in prevention and screening what are the 6 major areas CV, cancer, ID, injury/trauma, metabolic, emotl
screening DM starts, freq 45yo q3yrs or overwgt other RF
screening HLD starts, freq 35men, 45 women, q5
DEXA starts 65yo, 60 if high risk
mammography starts, freq 50-75 q2
colonoscopy starts, freq 50yo q10, or 10yrs before earliest/40yo high risk
ASA given to 45-79men and 55-79yo women for DM and hi risk CVD
pap smear starts, freq 21-30 q2; 30-65 q3
pelvic starts, freq 20-40 q3; annual >40
Created by: ehstephns
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