Card Set Information
Family med samp
Define primary insomnia:
Difficult initiating or maintaining sleep, or nonrestaurative sleep
≥3/wk for ≥1 month (ie chronic)
not occur in the presence of a mental or comorbid medical condition
causes next-day functional impairment
If insomnia is not >30d, what else is required to meet def'n?
Must have significant neurobiological or functional impairment
List 3 different patterns of insomnia:
Frequent awakenings during the night (sleep maintenance)
awakening in the small hours
Difficulting initiating sleep
2 medical conditions that can lead to insomnia:
Periodic limb movement disorder
Resltess leg syndrome
Nocturnal panic attacks
Two things you can ask patients to do when they present with acute insomnia?
Sleep diary (www.sleepfoundation.org - sleepiness diary)
Complete an Epworth Sleepiness Score (www.standford.edu/~dement/epworth.html)
3 kinds of functional impairment in insomnia?
*most ppl cope very well with little sleep
-fatigue or malaise
mood disturb or irritable
reduced motivation, energy
error-prone, accidents at work or driving
tension headaches or GERD 2/2 sleep loss
Interpersonal deficits - irritability, impatience
Additional questions on history important to include in a sleep Hx?
type of problem - nature, frequency, severity
AbN events during sleep - leg movements, snoring, etc
Daytime fxn - napping, drowsiness
beliefs about sleep
past sleep patterns
onset and worsening of problem
3 suggestions for stimulus control advice for insomnia?
Don't go to bed until you are sleepy
Use bed/bedroom only for sleep and intimacy
Get out of bed when you are unable to sleep after 15 minutes - do something relaxing
Get out of bed the same time every morning
Don't nap during the day
List 3 suggestions for improved sleep hygiene
Sleep only as much as you need to feel refreshed the next day
Bedroom comfortable, dark and quiet
Eat regular meals, don't go to bed hungry
Avoid drinking too many fluids in the evening
Reduce your caffeine intake
Avoid drinking alcohol - espy evening
Don't try too hard to fall asleep
Put the clock under the bed or face it away from you so you can't see it
Cancer Prevention - Ideal BMI to reduce risk?
18.5 to 24.9
Cancer prevention - ideal exercise?
Moderate-to-vigorous levels of physical activity
≥ 30 min/ day
≥ 5 days/wk
(shown to reduce CRC and BRCA)
Cancer prevention - 2 types of food to eat more of?
Eat less of processed and red meats - strong association with CRC
Fruits (3-4/d), vegetables (4-5/d), whole grains (6-8/d)
All fibre rich with nutrients and phytochemicals = anti-caricinogenic
Cancer prevention - how much alcohol to drink?
Increased cancer risk with >2/d males, >1/d females
So max 2/d Males and 1/d Females respectively
(*zero for head and neck Ca survivors)
DEMENTIA - 6 main steps for assessing
1) Pt Hx
2) Collateral family/caregiver Hx
4) Brief cognitive test
5) Basic labs
6) Structural imaging (if certain criteria met)
DEMENTIA - Specific items on Hx for each area in regard
Evolution of illness
: gradual/insidious (AD) vs. stepwise (Vascular)
Habits - EtOH abuse, smoking Hx
FHx - dementia, FHx CVA
PMHx - vascular events (CVA), renal failure, HTN, DM, lipid status or repetitive head trauma
(Vascular RF's - HTN, DM, Smoking, FH CVA, Lipid status)
DEMENTIA - Visual hallucinations and fluctuant course - what will you look for on PE?
Parkinsonian features - hyperreflexia, rigidity, extensor plantar responses, frontal gait apraxia
DEMENTIA - Name 2 other tests of cognitive fxn beside Folstein MMSE?
General Practitioner Assessment of Cognition
Behavioral Neurology Assessment
DEMENTIA - In addition to memory impairment, Dx requires at least 1 of 4 other cognitive domains be impaired. Name them.
LANGUAGE (expressive or receptive)
GNOSIS (ability to recognize objects, faces or other sensory info)
EXECUTIVE FXN (abstraction, reasoning, judgement)
PRAXIS (learned motor sequence)
DEMENTIA - What is the DDX for cognitive disorders, besides Alzheimer disease?
Dementia associated with Parkinson disease or with Lewy Bodies
DEMENTIA - Of the following, which tests are basic workup? Selectively applied? Insufficent evidence?
CBC, Lytes, FBG, Genetic testing - Apolipopr- E gene
HIV Ig, HomoCysteine levels
RBC folate, Serum B12, Serum calcium, Serum folic acid,
CBC - basic
Lytes - basic
FBG - basic
Genetic testing - insufficient evidence
HIV Ig - insufficient evidence
HomoCys - insufficient evidence
RBC folate - insufficient evidence
Serum B12 - selectively
Serum calcium - basic
Serum folic acid - insufficient evidence
Syphillis - selectively
HIV Ig - selectively
Basic for all patients
CBC, Serum Ca, Electrolytes, FBG
Selectively chosen based on PMHx, cognitive and PE
Insufficient evidence to recommend testing of:
Serum folic acid levels
Genetic testing - Apolipopr E gene
DEMENTIA - What are specific recommendations for neuroimaging - age?
Age < 60 yrs
DEMENTIA - neuroimaging recommendations for PMHx?
Recent and significant head trauma
History of Ca (esp'ly types that metastasize to brain)
DEMENTIA - neuroimaging recommendations for Meds?
Use of anticoagulations or Hx of bleeding d/o
DEMENTIA - neuroimaging criteria for HPI?
Rapid ( over 1 or 2 months) unexplained decline in cognition or fxn
Short duration of dementia (< 2 years)
Unexplained neurologic Sx (severe h/a, seizures)
Hx urinary incontinence or gait disorder (= NPH)
Unusual or atypical cognitive Sx or presentation (progressive aphasia)
DEMENTIA - neuroimaging criter on PE?
Any new localizing sign (hemiparesis, etc)
DEMENTIA - All Criterias for CT Head for dementia
Recent and signify head trauma
Hx of cancer
Anticoagulated or bleeding d/o
Rapid (< 2 mos) unexplained decline
Short duration of dementia (< 2 years)
Unexplained neuro Sx
Hx urinary incontinence and gait d/o (NPH)
Unusual or atypical cognitive Sx or presentation
Any new localizing sign
Clinical features suggesting presence of delirium?
Disturbed consciousness (sleepy)
Disturbed attention (rambling, agitated)
Disturbed cognition (disoriented, incoherent, shouting, hallucinaitons)
Altered sleep-wake cycle
Delerium - 2 categories of end-of-life delirium? Salient features of each.
Hypoactive - psychomotor retardation, lethargy, sedation, reduced awareness
hyperactive - agitated, hypervigilance, hallucinations, delusions
(3rd - mixed)
End of life delirium - 5 nonpharmacological and supportive strategies to reduce terminal delirium?
Minimize immobilizing catheters, IV lines and restraints
Avoid immobility, early mobilization
Provide visual and hearing aids
Monitor closely for dehydration
Monitor bladder and bowel fxn
Reorient communications with patient
Objects to reorient patient (clocks, familiar objects)
Cognitively stimulating activities
Sleep hygiene measures
Quiet at night
What is the most suitable medication for end-of-life delirium (none are approved, but certain have been shown to be safe and effective)
1st - Haloperidol most acceptable for delirium near end of life (+/- lorazepam for severe agitation)
2nd - chlorpromazine acceptable alternative
At which doses of haloperidol do EPS risks increase?
Increase EPS > 4.5 mg/d (vs. atypical anti-psychotics)
Decreased EPS < 3.5 mg/d (vs. atypicals)
30% of dying patients with delirium aren't well controlled with antipsychotics - what others meeds work?
Benzodiazepines - midaz, lorazepam
What is the evidence for meds for hypoactive delirium?
Very little - no recommended meds
Delerium - DSM-IV Criteria
Disturbance of consciousness, attention, cognition
related to medical causes
4 Causes of delirium?
Anticholinergic meds/ med interactions
Sepsis, organ failure
OBESITY - screening in adult?
BMI and waist circumference if BMI 25-35
OBESITY - mental health consequences of obesity?
depression, anxiety, personality d/o, self-esteem
OBESITY - mechanical health consequences of obesity?
OA, OSA, GERD, Urinary incontinence, intertrigo, falls and fractures
OBESITY - metabolic health consequences of obesity?
DM, DLP, fatty liver, HTN, Cancer, PCOS/Infertility, gallbladder disease
OBESITY - List 4 things of assessment on Hx?
Weight loss history
Motivation/readiness for change
barriers to weight loss/maintenance
OBESITY - List 4 meeds associated with weight gain
Psychiatric - antidepressants (TCA, MAOI, specific SSRIs), antipsychotics, lithium
Anticonvulsants - valproic acid, carbamazepine
Steroids - corticosteroids, estrogen and progesterone
Insulin and most oral hypoglycaemic agents
Highly active retroviral therapy
OBESITY - List 4 barriers to weight management
1) SES - can't afford equipment/gym/supplements, etc
2) Emotional - depression, OCD, addictions, psychosis, borderline PD
3) Comorbidities - a. ADHD, b. poor dentition, c. urinary incontinence, d. fecal incontinence, e. colitis f. CV and Resp disease - limits exercise. g. pain
4) Lack of time - most common
5) Saboteurs - esp. big wgt difference b/w partners.
6) Sleep disorder
7) Night eating, binge eating
OBESITY - Name 5 Stimulus Control Techniques to reduce hunger/overeating
do not allow yourself to become starving
3 meals/day, same time and place
eat while seated with full place setting
use small plates
focus on the food and the sensation of fullness
do not place cooking containers with food on the table
cook small amounts of food
eat slowly, take breaks, put down utensils
shop after eating
clean plate into garbage
avoid second serving
OBESITY - 3 medical/surgical treatments
1) Orlistat (Xenical)
2) Sibutramine (Meridia)
3) Bariatric surgery
OBESITY - Indications, dose, outcomes of Orlistat
BMI > 27 with complications from wgt OR BMI > 30
Orlistat 120mg TID ac meals
Inhibits pancreatic lipase - increases faecal excretion of fat
Wgt loss of 2-2.5kg, 30% reduction of DM type II
OBESITY - Contraindications/Not suitable for Orlistat
High calories from non-fat sources - CHOs or EtOH
OBESITY - Dose and MOA of Sibutramine (Meridia)
Meridia 10-20mg PO qD
Increased satiety, SNRI. Can't use with anti-depressants
?same indications as for orlistat
OBESITY - Indications for Bariatic surgery
>45kg over IBW
BMI > 40 x 5+ years
BMI > 35 with comorbidities for 5+ years
DRY EYES - Dx for dry, gritty eyes x 3/12, dry mouth, conjunctival injection, clouding cornea, fissures over mucous membranes?
DRY EYES - What labs would you order to confirm your diagnosis? List 3.
Antinuclear antibody (ANA)
DRY EYES - Name an eye test that could evaluate this patient's eye symptoms.
Schirmer test or rose bengal test
DRY EYES - List 3 treatment options for dry eyes.
1) Artificial tears ( non-preservative are better)
2) Pilocarpine (muscarinic)
3) Cevimeline (muscarinic)
DRY EYES - List 3 treatment options for dry mouth.
Daily fluoride use and sour lemon lozenges
OTC salivary substitutes
DRY EYES - Dose of Pilocarpine and Cevimeline
Pilocarpine 5mg PO BID
Cevimeline 30mg PO TID
DRY EYES - Dx Criteria for Sjogren's Syndrome
4/6 criteria, 1 of which is + minor salivary gland Bx or +ive antibody test:
1) Ocular Sx
2) Oral Sx
3) Ocular signs - +ive Schirmer or Rose bengal test
5) Salivary gland involvement (+ive salivary test)
6) Presence of Ig for anti-SSB or anti-SSA