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ACC GERI

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banannie's version from 2016-06-23 11:47

geriatrics

Question Answer
DEEP INDementia
Eyes
Ears
Physical
Performance
Incontinence
Nutrition
DementiaMini-COG, MIS
DepressionPHQ-2 and if positive PHQ-9
Drugsantis
Eyessingle question and if positive snellen
Earswhisper test
Fallsfall last year
Performancechair rise
rapid out and back gait
timed get up and go
animal namingless than 12 is abnormal
i-ADLSmedication
money
transportation
telephone
shop
ADLSDress
Eat
Ambulate
Transfer/Toilet
Hygiene
Falls risk factors4+ medications
gait disorder
postural hypotension
vision impairment
foot pain
spinal stenosis painrelieved by sitting down and bending forward
disc herniation painmade worse with
- coughing
- sneezing
- leaning forward
- sitting
straight leg testsciatica test
T score of osteopenia1- to -2.5
T score for osteoporosis-2.5
1st line treatment for osteoporosisbisphosphonates
Buckman's 6 step guide to bad newsSPIKES
- Setting
- Perception
- Invite
- Knowledge transmission
- Explore
- Summarize
NURSEName
Understand
Respect
Support
Explore
fundamental skillsask-tell-ask
tell me more
i wish statements
animal naming test abnormalless than 12/min
can't do chair rise40% lose 1 ADL (bathing and dressing are most complex) in a year
can't do chair rise in 10 sec35% chance to lose ADL
can do chair rise in 10 seconds4% chance of losing ADL in a year
PSA values high likelihood of BPHbetween 0 and 4
PSA values high likelihood of prostate cancervalue of 10 or higher
timed get up and go19+ seconds: moderate to high falls risk
higher scores are more likely to lose ADL in next year
functional reach<8 inches indicates limited functional balance
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Preventative Medicine

Question Answer
top causes of deathheart disease
cancer
chronic lower respiratory disease
top preventable causes of deathtobacco smoking
obesity
alcohol
breast cancer screeningmammo every 2 years women 50-74
screening for cervical cancer21 to 65. 21 to 30 every 3 years of after 30 every 5 years with cytololgy and HPV testing
when to stop cervical cancer screening?stop at 65 if 3 consecutive negative and most recent within past 5 gears
colorectal cancerstarting at 50.
- fecal occult annual
- sigmoidoscopy (every 5 years)
- colonoscopy (every 10 years)
HTNevery 2 years
hyperlipidemiaevery 5 years
DEXA65 q2-4 years
CMPnot indicated in asymptomatic persons
colorectal screening stops75
hyperlipidemia men35 every 5 years
hyperlipidemia womenover 45 if increased risk every 5 years
lung canceradults age 55 to 80 annual screening if
- 30 pack-year history
- smoke or quit within past 15 years
aspirin menmen 45 to 79
aspirin womencould consider starting at 55
screening for DMII USPSTFeveryone over 45
ADA screening for DMIIall adults with BMI over 25
one or more risk factors
chlamydia and gonorrhea screeningall sexually-active non-pregnant woman 24 and younger
older women at increased risk
pap smear- 21 to 65 every 3 years
- 30 to 65 can do HPV + cytology every 5 years
AAA screeningmale active or former smoker aged 65-75 w/one time abdominal ultrasound
HIV screeningadolescents and adults age 15 to 65
testicular cancershould not screen
annual screening for adults over 65height
weight
BMI
BP
lipid profile
vision
depression
if patient's life expectancy is less than 5 yearssurvival benefit from cancer screening not documented
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screening for patients at average risk

Question Answer
breast cancer age50-75
breast cancer test and intervalmammogram every 2 years
cervical cancer agewomen 21-65
cervical cancer test and intervalpap smear every 3 years
colon cancer age50-75
colon cancer test and itnervalfecal occult blood test yearly or colonoscopy every 10 years
HIV age15-65
HIV test and intervalHIV antibody screen 1 time
hyperlipidemia agemen 35 q5
women 45 q5
screen younger if have increased risk
hyperlipidemia test and intervallipid panel every 5 years
hypertension age18 and up
test and panel hypertensionblood pressure every 2 years
osteoporosis agewomen 65 and up
test and interval osteoporosisDEXA
aspirin45 to 79 in men
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vaccines

Question Answer
HPV vaccinationrecommended 11-12.
- Max age 26 for woman
- Max age 21 for men
TdapAge 11 + Td q10 years thereafter
- give Tdap during each pregnancy
Tdap vaccineq10 after primary series booster dose
19+ and older should recieve 1 booster dose of Tdap in replacement of Td
meningococcal if high riskgiven every 5 years
PPSV23relatively T-cell independent B-cell response
pneumococcal vaccine: HIVPCV13 first
PPSV23, 8 weeks later
PPSV23, q5 years
pneumococcal vaccine: adults >65PCV13
PPSV23, 6-12 months later
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pneumococcal vaccine: adults <65 : PPSV23 for chronic conditions (eg. chronic heart, lung disease, DM, cirrhosis)

BP rules JNC-8

Question Answer
target BP for less than 60, CKD, diabetesless than 140/90
target BP for older than 70less than 150/90
initial treatment for african americans for HTNthiazide or CCB
all ethnicites with CKD or diabetes should be onACEI or ARB
antihypertensive medications contraindicated in pregnancythiazides, ACEi, CCB and ARBS.
hydralazine, methyldopa, labetalol, nifedipine are safe
diagnose HTN over2 BP readings over span of 4 weeks
side effects of thiazidesOtotoxic
Hypokalemia
Diabetes
Allergy to sulfa
Nephrotoxic
Gout
ace-i, side effectshyperkalemia
dry cough
angioedema
skin rash
CCB, side effectsamlodipine, peripheral edema.
verampamil: heart block
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Cholesterol Treatment

Question Answer
clinical ASCVDhigh intensity statin
LDL greater than 190high intensity statin
diabetic pateints 40-75 with LDL 70-189statin
nondiabetic patients 40-75 with LDL 70-189 and ASCVD risk greater than 7.5statin
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Smoking Cessation

Question Answer
5A'sask
advise
assess
assist
arrange
NRT (nicotine replacement rx) contraindicatedrecent MI (2 weeks)
serious cardiac issues
long standing NRTnicotine-patch
contraindications for nicotine inhalerCOPD/asthma, sinus, allergies, allergy to menthol
contraindications for buproprionpatients with uncontrolled depression, anxiety or psychosis, bulimia/anorexia, seizure disorder
moa of varenclinepartial antagonist and agonist at the nicotinic acetylcholine receptor
side effects of vareniclinesuicide risk, nausea, insomnia, CV events
pack yearnumber of cigarettes smoker per day X number of years smoked
what do you want to ask before starting bupropionhistory of seizures, alcohol intake, eating disorder, pregnancy-category C
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DM medications

Question Answer
meformin side effectsmc GI side effects
rare lactic acidosis
sulfonyureas side effectshypoglycemia
weight gain
TZDS (ploglitazone) side effectsweight gain
edema/HF
bone fractures
DPP-4 inhibitors (liptins) advantagesno hypoglycemia
DPP-4 inhibitors (liptins) side effectsangioedema
acute pancreatitis
cost DPP-4 inhibitorshigh
SGLT-2 inhibitors (flozins) - side effectsGU infections
polyuria
volume depletion
cost SGLT 2 inhibitorshigh
GLP-1 receptor agonists (Tide) side effectsWeight loss
Acute pancreatitis
rapid acting insulinslispro, aspart, glulsiline
short acting insulinshuman regular
intermediate acting insulinsNPH
long acting insulinglargine, determir
weight lossGLP-1 receptor agonist (exenatide)
SGLT-2 inhibitors (flozins)
amylin mimetics
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Question Answer
goal BP in DMless than 140/90
fasting plasma glucoseDM > 125
Pre-DM >100
random plasma glucoseDM > 200 + symptoms
2 hour post-prandial glucoseDM > 200 after administration of 75g glucose load
pre-DM >140
Hemoglobin A1CDM > 6.5%
screen for microalbuminuriaevery year
BUN and creatinineevery year
eye screeningevery year
feetevery visit
give statins in diabeticsLDL >100
give ACE or ARB in diabetics if BPgreater than 130/80
aspirindaily in all diabetics over age 30
pneumococcal vaccineall diabetics
spot-urine albumin creatinine ratio when in DM1 vs. DM2annual testing
- type 1 within 5 years
- type 2 at time of diagnosis
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Osteoporosis

Question Answer
T-scorepatient's bone density vs. mean peak bone density of healthy adult
Z-scorepatient bone density to mean age-matched bone density
osteoportic t-score-2.5
estrogen deficiencylose trabecular bone (spine)
disorders of calciumlose cortical bone (forearm)
bisphosphonate, side effectsrenal
GI
Jaw Osteonecrosis
raloxifene moaSERM
agonist at bone
antagonist at endometrium
side effects of raloxifenincreases risk of DVT
hot flashes
normal t-score-1.0 or above
low z-score-1.5 or below
best site for screening for bone loss peri-menopausal womanspine
best site for screening for bone loss in the elderlyhip
total spine densitymeasures primarily trabecular bone (lose bone from here first)
forearmcortical bone loss
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Asthma/COPD

Question Answer
FEV mortality cut off.75
- 95% of the people will die within 10 years
intermittent asthmaday time < 2/week
night < 2/mo
treatment intermittent asthmaSABA
mild persistent asthmaday: > 2/week
night: > 2/month
treatment mild persistent asthmashort acing beta agonist plus low dose corticosteroid inhaled
moderate persistent asthmaDay: every day
night: >1/week
FEVI 60-80% if predicted
treatment moderate persistent asthmabeta agonist, low dose corticosteroid
+long acting beta agonist
severe persistent asthmaday: frequent, continuous
night: frequently
FEV1 less than 60%
treatment severe persistent asthmashort acting beta, long acting beta
+high dose inhaled or oral steroid
mainstay of treatment for COPDbeta agonist plus anti-cholinergic like ipratropium
if mainstay not enough addlong acting anticholinergic (tiotropium)
if long acting antichol not enoughadd inhaled steroids
memorize

ACC Nutrition and MI

Question Answer
modifiable risk factors for CVDobesity and unhealthy diet
obese BMIgreater than or equal to 30
overweight BMI25-29.9
healthy weight BMI18.5-24.9
DASH Dietfruits, vegetables, whole grains, low-fat or fat free milk
sodium in DASH diet2,300mg
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Urinary Incontinence

Question Answer
normal PVR0-50 cc normal
0-100 in old
urge incontinence typeoveractive: bladder moving
HX urge incontinenceurge // pee constantly // not much comes out
PVR urge incontinencelow
non-pharm mgt for urge incontinencebladder training
pharm mgt for urge incontinenceoxybutynin (anti-cholinergic) and TCA (impramine)
{aka overactive bladder}
overflow (neurogenic bladder) typebladder doesn't contract
Hx overflow (neurogenic bladder)rarely pee // all comes out at once
PRV for neurogenic bladderhigh
non pharm mgt neurogenic bladderself-catheter
stress incontinence hxconstant dribble (cough, laugh, sneeze etc)
non-pharm mgmt stresskegel
kegel60-80 times daily.
- should see result in 6 to 8 weeks, max ben 3 months
type overflow 2nd to obstructionsphincter closed
pharm mgmt overflow 2nd to obstructionalpha blocker
innervation of detrusor muscleparasympathetic (cholinergic)
innervation of sphinctersympathetic (alpha)
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Eyes

Question Answer
blepharitisinflammation of the eyelid staph aureus
episcleritisinflammation of vessels lining the episclera.
scleritisinflammation of the sclera.
associated with RA
exam of scleritissignificant eye pain on palpation
acute anterior uveitis clinical findingsciliary flush
blurred vision
pain
photophobia
herpes simplex keratitislook for classic dendritic ulcer on the cornea.
irreversible vision loss if not treated
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GI disease

Question Answer
test of choice for dyspepsiaendoscopy
GERD plus dysphagiapeptic stricture
endoscopy with biopsy in GERD ifheartburn refractory to treatment
alarm symptoms: dysphagia, odynophagia, bleeding, wt loss
gold standard for GERD24 hour pH monitoring
mc electrolyte abnormality w/severe diarrheametabolic acidosis and hypokalemia
vomitting electrolyte abnromailtyhypokalemia with metabolic alkalosis
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MSK

Question Answer
neurogenic claudicationspinal stenosis manifests as pain, cramping, numbness or paresthesia worst with walking and relieved with sitting
patellofemoral paincommon cause anterior knee pain. worst with climbing and descending stiars.
rotator cuff tenditismcc shoulder pain. lidocaine injection will reduce pain opposed to tear
lateral epicondylitistennis elbow.
hip OAgroin pain
De Quervain's tenosenovitispain at radial aspect of the wrist
radiographic findings in OAjoint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts
pharm management OA1st line acetampinophen
tenderness over lateral area of hiptochanteric bursitis
1st line treatment for osteoporosisbisphosphonates
lidocaine injection w/rotator cuff tearrelief of pain but persistent weakness
lidocaine injection w/rotator cuff tendinopathyrelief of pain and normal strength
lidocaine injection w/adhesive capsulitisno improve in pain or ROM
whenever an elderly patient is beginning to rely more on assistive devicesconsider cervical stenosis and order an MRI
patellofemoral paincommon cause of anterior knee pain. worst with climbing and descending stairs
treatment for ankle sprainsRICE (rest, ice, compression, elevation)
weakness on shoulder abductionrotator cuff tear should be suspected
tinel signtap over median nerve at wrist crease: causes paresthesias in median nerve distribution'
phalen testpalmar flexion of the wrist for 1 minutes; causes paresthesias in median nerve distribution
OA findings on X-rayjoint space narrowing, osteophytes, sclerosis, subchondral cysts
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MSK disease treatment

Question Answer
RA pain controlNSAIDS
DMARDS for RAmethotrexate
Felty syndromeRA
anemia, neutropenia, thrombocytopenia
splenomegaly
acute goutNSAIDS or colchicine
prophlactyic goutallopurinol
pseudogout acuteNSAIDS
OA pharm treatmentacetaminophen first line
can also use NSAIDS
osteoporosis pharm therapybisphosphonates (1st line) or PTH therapy
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Hearing

Question Answer
conductive hearing loss, causesotitis externa
cerumen impaction
tympanic membrane perforation
otosclerosis
sensorineural hearing loss, causespresbycusis
drug induced
meniere
acoustic neuroma
conductive hearing losscan hear loud noises well
sensorineural hearing lossdifficulty hearing loud noises
pathology of senorineural hearing lossdegneration of sensory cells and nerve fibers at the base of the cochlea
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