SAMPs.txt

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dohertys
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159574
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SAMPs.txt
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2012-06-21 14:50:37
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Family med samp
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Family Med
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  1. SAMPS
  2. 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
  3. If insomnia is not >30d, what else is required to meet def'n?
    Must have significant neurobiological or functional impairment
  4. List 3 different patterns of insomnia:
    • Frequent awakenings during the night (sleep maintenance)
    • awakening in the small hours
    • Nonrestorative sleep
    • Daytime impairment
    • Difficulting initiating sleep
  5. 2 medical conditions that can lead to insomnia:
    • Periodic limb movement disorder
    • Resltess leg syndrome
    • Nocturnal panic attacks
    • Pain
    • Headaches
    • GERD
  6. 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)
  7. 3 kinds of functional impairment in insomnia?
    • *most ppl cope very well with little sleep
    • -fatigue or malaise
    • attention/conc/memory
    • social/vocational/school impairment
    • mood disturb or irritable
    • daytime sleepiness
    • reduced motivation, energy
    • error-prone, accidents at work or driving
    • tension headaches or GERD 2/2 sleep loss
    • sleep concerns
    • Interpersonal deficits - irritability, impatience
    • decreased creativity
    • procrastination
  8. 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
    • Sleep hygiene
    • beliefs about sleep
    • past sleep patterns
    • onset and worsening of problem
  9. 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
  10. List 3 suggestions for improved sleep hygiene
    • Sleep only as much as you need to feel refreshed the next day
    • Exercise regularly
    • 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
    • Avoid cigarettes
    • 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
  11. Cancer Prevention - Ideal BMI to reduce risk?
    18.5 to 24.9
  12. Cancer prevention - ideal exercise?
    • Moderate-to-vigorous levels of physical activity
    • ≥ 30 min/ day
    • ≥ 5 days/wk
    • (shown to reduce CRC and BRCA)
  13. Cancer prevention - 2 types of food to eat more of?
    • Eat less of processed and red meats - strong association with CRC
    • Eat more:
    • Fruits (3-4/d), vegetables (4-5/d), whole grains (6-8/d)
    • All fibre rich with nutrients and phytochemicals = anti-caricinogenic
  14. 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)
  15. DEMENTIA - 6 main steps for assessing
    • 1) Pt Hx
    • 2) Collateral family/caregiver Hx
    • 3) PE
    • 4) Brief cognitive test
    • 5) Basic labs
    • 6) Structural imaging (if certain criteria met)
  16. 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)
  17. DEMENTIA - Visual hallucinations and fluctuant course - what will you look for on PE?
    Parkinsonian features - hyperreflexia, rigidity, extensor plantar responses, frontal gait apraxia
  18. DEMENTIA - Name 2 other tests of cognitive fxn beside Folstein MMSE?
    • MOCA
    • DemTect
    • 7-minute screen
    • General Practitioner Assessment of Cognition
    • Behavioral Neurology Assessment
  19. 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)
  20. DEMENTIA - What is the DDX for cognitive disorders, besides Alzheimer disease?
    • Depression
    • Delerium
    • Vascular Dementia
    • Frontotemporal dementia
    • Dementia associated with Parkinson disease or with Lewy Bodies
  21. 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,
    • Syphillis, TSH
    • 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
  22. Basic for all patients
    CBC, Serum Ca, Electrolytes, FBG
  23. Selectively chosen based on PMHx, cognitive and PE
    • Syphillis screening
    • HIV Ig
    • Serum B12
  24. Insufficient evidence to recommend testing of:
    • RBC folate
    • Serum folic acid levels
    • HomoCysteine levels
    • Genetic testing - Apolipopr E gene
  25. DEMENTIA - What are specific recommendations for neuroimaging - age?
    Age < 60 yrs
  26. DEMENTIA - neuroimaging recommendations for PMHx?
    • Recent and significant head trauma
    • History of Ca (esp'ly types that metastasize to brain)
  27. DEMENTIA - neuroimaging recommendations for Meds?
    Use of anticoagulations or Hx of bleeding d/o
  28. 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)
  29. DEMENTIA - neuroimaging criter on PE?
    • Any new localizing sign (hemiparesis, etc)
    • Gait disturbance
  30. DEMENTIA - All Criterias for CT Head for dementia
    • <60 yrs
    • 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
    • Gait disturbance
  31. END-OF-LIFE DELERIUM
  32. Clinical features suggesting presence of delirium?
    • Disturbed consciousness (sleepy)
    • Disturbed attention (rambling, agitated)
    • Disturbed cognition (disoriented, incoherent, shouting, hallucinaitons)
    • Altered sleep-wake cycle
    • Acute onset
    • fluctuating coarse
    • end-stage illness
  33. 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)
  34. End of life delirium - 5 nonpharmacological and supportive strategies to reduce terminal delirium?
    • Minimize immobilizing catheters, IV lines and restraints
    • Avoid immobility, early mobilization
    • Monitor nutrition
    • Provide visual and hearing aids
    • Monitor closely for dehydration
    • Control pain
    • Review medications
    • 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
  35. 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
  36. 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)
  37. 30% of dying patients with delirium aren't well controlled with antipsychotics - what others meeds work?
    • Benzodiazepines - midaz, lorazepam
    • Propofol
    • Opioids
  38. What is the evidence for meds for hypoactive delirium?
    Very little - no recommended meds
  39. Delerium - DSM-IV Criteria
    • Disturbance of consciousness, attention, cognition
    • abrupt onset
    • fluctuating course
    • related to medical causes
  40. 4 Causes of delirium?
    • Fecal impaction
    • Bladder retention
    • Dehydration
    • Anticholinergic meds/ med interactions
    • Sepsis, organ failure
  41. OBESITY - screening in adult?
    BMI and waist circumference if BMI 25-35
  42. OBESITY - mental health consequences of obesity?
    depression, anxiety, personality d/o, self-esteem
  43. OBESITY - mechanical health consequences of obesity?
    OA, OSA, GERD, Urinary incontinence, intertrigo, falls and fractures
  44. OBESITY - metabolic health consequences of obesity?
    DM, DLP, fatty liver, HTN, Cancer, PCOS/Infertility, gallbladder disease
  45. OBESITY - List 4 things of assessment on Hx?
    • Weight history
    • Weight loss history
    • Lifestyle
    • Medications
    • Psychiatric assessment
    • Motivation/readiness for change
    • barriers to weight loss/maintenance
    • social history
    • workplace/disability/insurance/support systems
  46. 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
    • Tamoxifen
    • Highly active retroviral therapy
    • B-blockers
  47. 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
  48. 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
    • eliminate distractions
    • 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
  49. OBESITY - 3 medical/surgical treatments
    • 1) Orlistat (Xenical)
    • 2) Sibutramine (Meridia)
    • 3) Bariatric surgery
  50. 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
  51. OBESITY - Contraindications/Not suitable for Orlistat
    • Non-responders
    • High calories from non-fat sources - CHOs or EtOH
    • snackers/grazers
    • dietary inconsistencies
    • non-compliance
  52. 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
  53. OBESITY - Indications for Bariatic surgery
    • >45kg over IBW
    • BMI > 40 x 5+ years
    • BMI > 35 with comorbidities for 5+ years
  54. DRY EYES - Dx for dry, gritty eyes x 3/12, dry mouth, conjunctival injection, clouding cornea, fissures over mucous membranes?
    Sjogren's syndrome
  55. DRY EYES - What labs would you order to confirm your diagnosis? List 3.
    • Antinuclear antibody (ANA)
    • Anti-SSA (Ro)
    • Anti-SSB (La)
    • Rheumatoid factor
  56. DRY EYES - Name an eye test that could evaluate this patient's eye symptoms.
    Schirmer test or rose bengal test
  57. DRY EYES - List 3 treatment options for dry eyes.
    • 1) Artificial tears ( non-preservative are better)
    • 2) Pilocarpine (muscarinic)
    • 3) Cevimeline (muscarinic)
  58. DRY EYES - List 3 treatment options for dry mouth.
    • Daily fluoride use and sour lemon lozenges
    • OTC salivary substitutes
    • Pilocarpine
    • Cevimeline
    • Interferon alpha
  59. DRY EYES - Dose of Pilocarpine and Cevimeline
    • Pilocarpine 5mg PO BID
    • Cevimeline 30mg PO TID
  60. 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
    • 4) Histopathology
    • 5) Salivary gland involvement (+ive salivary test)
    • 6) Presence of Ig for anti-SSB or anti-SSA

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