Gen Med quiz 1

HIPAA

- Initially was designed for electronic transmission of information

- Includes Insurance Companies, Health Care Providers, Health Care Clearing Houses (billing companies, large health management companies, etc)

- In other words: You can disclose information for purposes of treatment of the patient, billing of the patient or for health care operations

what is protected health info?

Identifiable information: Name, DOB, Address, SS#

Health Information: Past or current medical history in the chart

FERPA

Protects Educational Information about the student-primarily educational records

What about Healthcare information housed within the school as a "school record"-school forms like immunizations, physicals, eye exams, medication records for those administered/allowed at school? These fall under FERPA

Federal Child Abuse Prevention and Tx Act (CAPTA)

You must report alleged or confirmed acts of abuse or neglect

Iowa rules of mandatory reporting

A reporter, in the scope of his or her professional practice or employment responsibilities, reasonably believes that a child has been abused.

A commercial film and photographic print processor has knowledge of or observes a visual depiction of a minor engaged in a prohibitedsexual act or in the simulation of a prohibited sexual act.

mandatory vs permissive reporting

Mandatory--you are in your job as a mandatory reporter

Permissive--not in your job--just in the community (not mandated, but recommended)

What must be on prescription

Name, DOB, Address of patient

Signed and dated by provider, provider information (DEA# if needed)

Name of medication, dosage, instructions for taking, # of refills, etc

Standard precautions of universal precautions

- Hand Hygiene-before and after patient care, moving from contaminated to non contaminated body part, after wearing gloves that have touched blood/dirty area, before touching any devices

- Gloves-if touching blood, mucous membranes, non intact skin, bodily fluids,secretions/excretions

- Mask, Goggles or Face Shield-During procedures that may spray/splash blood or bodily fluids on you

- Gown-To protect skin and clothing from bodily fluids

Transmission based precautions of airborne

- droplets of small particles that are in the air or dust

- Patient in a negative pressure isolation room with 6-12 air exchanges per hour

- Health care providers where N95, PAPR (powered air-purifying respirator) with HEPA (high-efficiency particular air) filter

Transmission based precautions of droplet

- Transmission usually within 3 to 6 feet

- Patient in private room

- Surgical Mask worn while within 6 ft from patient

- When transporting patient-patient wears a surgical mask

Transmission based precautions of contact

Spread with direct or indirect contact with surfaces (skin infection/wounds)

Wear gloves and gowns, good hand hygiene

OSHA mission

save lives, prevent injury, protect American workers

OPQRST

- Onset of Symptoms

- Occurrence of Symptoms

- Palliative-what improves symptoms

- Provocative-what makes symptoms worse

- Quality or Quantity of the Pain/Symptoms

- Region of the Body

- Radiation of symptoms

- Severity (0 to 10)

Symptoms-associated

- Time (duration)

- Temporal-what is going on when symptoms occur

pre convo w physician

Short (may even need to rehearse it), pertinent points, history, exam, concern for diagnosis(why did you send them in?)

post convo w physician

Listen & Take Notes-if questions, briefly ask them, when is follow up

Goals of PPE of High school

1. Determine general physical and psychological health

2. Evaluate for life-threatening or disabling conditions

3. Evaluate for conditions predisposing to injury or illness

4. Provide an opportunity for discussion of health and lifestyle issues

5. Serve as an entry point into a health care system for adolescents without a health care or medical home

PPE of college focus

Exam more musculoskeletal/orthopedic (most of the time they already know their medical issues)

Beware of promotion of health issues without work up from PCPs not in Sports Medicine!

Clearance categories

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for...

Not cleared-pending further evaluation

Not cleared-for any sports

Not cleared-for certain sports

sx of anxiety

- Difficulty Sleeping

- Shortness of Breath or Heart Palpitations

- Dizziness, Lightheadedness, Sweating

- Feeling of Choking

- Performance Impairment

- Worry, Fear, Nervousness

- Poor Appetite

- Paresthesias, Hot or Cold Flashes

- Irritability

Criteria for generalized anxiety DO

A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of eventsor activities (ex. School and work and sports, etc)

B. Person finds it difficult to control that worry

C. The anxiety and worry are associated with three or more of the 6 symptoms:• Restlessness or feeling keyed up or on edge, Being easily fatigued, Difficulty concentrating or mind going blank, Irritability, Muscle tension, Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep

D. Focus of anxiety or worry is not related to specific disorder such as panic attacks, separation anxiety,anorexia, hypochondriasis, PTSD, Body dysmorphic disorder, delusions like in schizophrenia, etc.

E. Anxiety or worry causes significant distress or impairment in social, occupational or other important areas of functioning

F. Not related to substance abuse or other medical conditioning like hyperthyroidism

Tx of Generalized anxiety DO

psychotherapy, CBT

Panic attack criteria

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time 4 or more of the following symptoms: Palpitations, sweating, shaking, shortness of breath, feeling of choking, chest pain,nausea/abd pain, dizzy/feeling faint, derealization (feelings of unreality) or depersonalization (being detached from onself, fear of losing control, fear of dying,paresthesias, chills or hot flashes

panic DO criteria

Both recurrent and unexpected panic attacks, greater than 1month or more of persistent concern about additional attacks and theirconsequences. A significant maladaptive change in behavior related to theattacks. These attacks are not related to any substances/medications or another mental disorder

Tx of panic DO and panic attacks

Psychotherapy-CBT with Systemic Desensitization

Medications-short vs long acting

If they have a phobia usually do not respond well to medications

PTSD criteria

- Exposure to a life threatening situation or event outside the normal range of human experience (war,sexual trauma, death, accident)-yourself, witness, close family or friend, repeated exposures like police or EMT

- Presence of 1 or more beginning after the event: Persistent avoidance of stimuli associated with the event, Negative alterations in cognition or mood associated with event, Marked alterations in arousal and reactivity associated with traumatic events-increased startle response, difficulty concentrating, reckless behavior, sleep disturbance, hypervigilance, irritable orangry outbursts.

- Duration of symptoms at least 1 month and they cause significant distress or impairment in social,occupational or other functioning.

Tx for PTSD

Psychotherapy-CBT with Systemic Desensitization

Medications-short vs long acting

If they have a phobia usually do not respond well to medications

OCD criteria

- Obsessions or recurrent and persistent thoughts, impulses or images that are not simply about life problems

- Attempts to suppress or neutralize such thoughts with other thoughts or actions while recognizing they are a product of the person's own mind

- Compulsive thoughts or actions engaged in accordance to rigid rules even though they may not be rationally connected to the intrusive thoughts

common pairs of OCD

- Contamination of infection---washing hands/excessive cleaning

- Doubts—Requesting or demanding reassurance

- Loss of order---Ritualized behaviors, certain order to getting dressed

- Personal safety—making sure doors are locked, appliances are off

- Sexuality—religious or psychological correction, defense

Tx of OCD

SSRI, effexor, anafranil, CBT (exposure and response prevention tx AKA ERP)

Pathophysiology of depression

decreased dopamine, serotonin, noriepi

Criteria for MDD

5 or more symptoms during the same 2-week period but lasting longer than 6 months and at least one of the symptoms should be either

(1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.

4. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).

5. Fatigue or loss of energy nearly every day.

6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specificplan for committing suicide

Adjustment SO w depressed mood

reaction to an event that occurred with 2 to 4 symptoms of depression that started within 3 months of the event but resolves by 6 months

Cyclothymia

ow level depressive symptoms cycling with hypomania-breaks cannot be present from either type of mood for more then 2 months-must have several episodes of depression and hypomania alternating for at least 2 years. (low level bipolar II)

Seasonal affective DO

A form of Major Depressive Disorder that is related to a particular season-most often winter and is present during this season, but stops once the season is gone

MDD Tx

medication and counseling combo the best

Functional hypothalamic amenorrhea Primary

something is going on in the hypothalamus/endocrine function (Low Estradiol & LH)

Functional hypothalamic amenorrhea secondary

weight loss related, stress-related, and exercise-related

Z score for bone density meanings

low b/ -1.0 and -2.5 = Osteopenia

Very low is <-2.5 = Osteoporosis

Energy availability (EA)

Dietary energy left over and available for optimum function of the bodysystems after accounting for exercise

Low Energy Availability (LEA)

Mismatch between dietary intake and energy expended--

- Adaptable LEA=do not cause adverse effects to the body

- Problematic LEA=greater and persistent disruption to the body systems

Color meaning for REDS

- Green means GO!

- Yellow mean mild REDS, Full training and competition, but treatment/monitoring/follow up

- Orange is the new color added, Likely some training modifications, treatment/CLOSE monitoring and follow up

- Red is very high risk, Significant training modifications and immediate treatment

energy availability equation

([Energy intake] - [dietary intake (calories in) - energy expended (calories out)] / fat-free mass

Physical manifestations of ED

- Stomach cramping/GI complaints

- Menstrual irregularities

- Difficulty Concentrating

- Abnormal Labs-Anemia, low thyroid/hormones, low potassium

- Slow Heart Rate, DIzziness, Fainting/Syncope

- Feeling cold all of the time (variation of Raynaudʼs)

- Sleep Problems

- Dry Skin, brittle nails, fine hair on body (lanugo)

- Muscle weakness

- Poor wound healing

- Impaired Immune Function

CV worsening manifestations

slow pulse, irregular heart beats, heart failure, Abnormal potassium, chloride

GI worsening manifestations

slowed digestion-gastroparesis, stomach pain/bloating, N/V, blood sugar fluctuations, blocked intestines, bacterial infections, early satiety (feeling full after only eating small amounts).

- Constipation

- Binge eating-to point of stomach rupture

- Vomiting-wear down esophagus leading to rupture, hoarseness, sore throats,enlargement of parotid (salivary) glands

- Pancreatitis

- Intestinal Obstruction

Neuro worsening manifestations

Brain consumes 1/5th of our calories

- Difficulty concentrating, difficulties with sleep, numbness/tingling,fainting/dizziness, Electrolyte imbalances-seizures or muscle cramping

Endocrine worsening manifestations

Low Sex hormones like estrogen and testosterone and thyroid hormone

- Abnormal Menses, reduced resting metabolic rate, osteopenia/osteoporosis,resistance to insulin-DM 2, hypothermia, high cholesterol from starvation

Orthorexia define and sx

- obsession with proper or "healthful" eating

- compulsive checking ingredient lists or nutritional labels, increased concern of health labels, cutting food groups-all sugar, carbs, dairy, etc), unusual interest in health and what others are eating, spending hours a day thinking about what food might be served at an event, high levels of distress when "safe" or "healthy" foods are not available

Other specified feeding or ED (OSFED) define

Catch-all classification for eating disorder that do not meet specific criteria for other eating disorders.

Avoidant Restrictive Food Intake DO (ARFID) define and sx

An eating or feeding disturbance as manifested by apparent lack of interest in eating food, avoidance based on sensory characteristic of food, concern about aversive consequences of eating-leading to persistent failure to meet appropriate nutritional and/or energy needs:

--Significant weight loss, nutritional deficiency, dependence on enteral or oral nutritional supplements, marked interference with psychosocial functioning

anorexia nervosa define

Weight loss or inappropriate weight gain in a child. Difficulty maintaining body weight. Usually from restriction of calories but people can also exercise compulsively, purging or binge eating

Dx of anorexia nervosa

1. Restriction of energy intake relative to requirements leading to significantly low body weight for the patientʼs normal

2. Intense fear of gaining weight or becoming fat, even though underweight.

3. Disturbance in the way in which oneʼs body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight.

- Restricting Type: During the last 3 months has not regularly engaged in binge or purging

- Binge-eating/Purging Type: During the last 3 months has engaged regularly in binge or purging episodes

Bulimia Nervosa criteria

- Recurrent episodes of binge eating: includes eating an amount of food that is definitely larger than normal in a discrete period of time, a sense of lack of control overeating during the episode

- Recurrent inappropriate compensatory behavior to prevent weight gain-such as vomiting, misuse of laxatives, medications, fasting, excessive exercise

- Behaviors occur about 1x/week for 3 months

- Self evaluation influenced by body shape and weight

physical findings of bulimia nervosa

- Swelling of salivary glands, cheeks or jaw

- Calluses on back of hand from self-induced vomiting

- Teeth discolored/stained

Binge eating DO Criteria

- Recurrent episodes of binge eating-eating in a discrete amount of time food that is larger amount than what most people would eat and a sense of lack of control over eating during the episode.

- +3 or more of the following: eating more rapidly than normal, eating until feeling uncomfortably full, eating large amount of food when not feeling physically hungry, eating alone because of feeling embarrassed, feeling disgusted/depressed/guilty afterward.

- Occurs once weekly for 3 months

- Not associated with purging

s/s binge eating DO

Hiding or hoarding food, not eating around others, frequent diets, withdrawal from friends, rituals with food or for binging sessions, fluctuations in weight, low self-esteem

Tx for eating DO

- Psychologist/Licensed Medical Social Worker-counselors specializing in eating disorder treatments

- Physician-Psychiatrist/Primary Care Provider Labwork, Vitals, Medications (SSRIs, atypicals that help with weight gain)

- Nutritionist-dietary planning for helping in food re-introduction

substance misuse

occasional use of an illegal substance or use of a legal substance to excess, resulting in impairment of one's ability to function

substance abuse

maladaptive pattern of substance use occurring within a 12 month period that causes impairment in social or occupational functioning--will continue this pattern of use despite its ongoing or increasingly negative consequences

substance dependence/addiction

maladaptive pattern of substance abuse occurring within a 12 month period that leads to significant impairment or distress and is characterized by tolerance or withdrawal

Rx Drug abuse

narcotics, sedative, stimulants

illicit drug abuse

marijuana, cocaine (stimulant), heroin (sedative)

cocaine acute sx, other sx, side effects

- Acute Sx-constricted blood vessels, dilated pupils, increased body temperature/heart rate/blood pressure.

Large amounts can lead to bizarre, erratic and violent behavior.

- Other Sx-restlessness, irritability, anxiety, panic and paranoia

- Side Effects-Heart arrhythmia and heart attack, headaches/seizures/strokes,abdominal pain/nausea, rarely-sudden death

heroin acute sx, repeated use, withdrawal

- Acute Sx-Heroin enters the brain-converts to Morphine-hits opioid receptors==>RUSH, Mental function cloudy, low heart rate, slow breathing

- Repeated use causes long term imbalances in neuronal and hormonal systems-may cause white matter changes

- Withdrawal-causes opposite-agitation, can take several months to completely detox

psychosis: delusion v hallucination

delusion: beliefs that aren't in line with your culture and don't make sense to others

hallucination: auditory, visual or tactile sensations that are not real

psychosis warning signs

drop in grades or job performance, trouble thinking clearly, suspiciousness around others, lack of self care/hygiene, spending more time alone, stronger emotions then the situation calls for OR no emotions at all

CAGE ?s about substance abuse

C-Cut Down- "Have you ever tried to cut down your (substance) use?"

A-Angry/Annoyed- "Have you ever felt angry or annoyed when someone asks orconfronts you about your substance use?"

G-Guilty- "Have you ever felt guilty about your substance use?"

E-Eye-Opener- "Have you ever used your (substance) in morning to get yourself going?"

Denial-COMMON

stages of readiness

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Follow up/relapse prevention

increased risk for crisis

- Inconsolable Emotions-rage/anger, sobbing, etc

- Drastic change in typical behvior

- Alcohol or drug use

- Suicidal/homicidal OR Hx of suicidal/homicidal ideation

- Isolation

- Unexplained Physical Symptoms

- Losing Touch with Reality

- Self Harm/Self Injury

QPR suicide prevention

- Question-Meet in a private place, ask open ended questions, think about supports-family member, friends, religious/cultural resources, Ask-"This situation seems very difficult, have you had any thoughts about committing suicide or harming yourself?"

- Persuade-them to get help"Can i go with you to the counselor's office", "I want you to live", "Who is someone I can help you talk to about with what you are feeling?"

- Refer-them to a care provider -> School Counselor, National Suicide Prevention Hotline, Mobile Crisis Response Team, ER,911

Bipolar type 1 criteria

- A distinct period of abnormally and persistently elevated,expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present most of the day, nearly every day.

- During the period of mood disturbance and increased energy oractivity, three (four if the mood is only irritable) of the symptoms of mania are present to a significant degree and represent a noticeable change from usual behavior

- The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or necessitate hospitalization to prevent harm to self or others, or there are psychotic features

- The episode is not attributable to the psychological effects of a substance (a drug of abuse, a medication, other treatment) or to another medical condition

sx of mania

Distractibility

Irresponsibility and erratic uninhibited behavior

Grandiosity

Flight of ideas

Activity increase (weight loss, increased libido and spending)

Sleep decrease

Talkativeness

is depression necessary for type i bipolar

No

2 multiple choice options

Bipolar 2 DO

Alternating episodes of:

- Severe depression

- Hypomanic episodes -> Mild mania marked by elation and increased productivity, but without marked disability

hypomania criteria

- A distinct period of abnormally and persistently elevated,expensive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day.

- During the period of mood disturbance and increased energy and activity, three or more of the symptoms of mania have persisted,represent a noticeable change from normal behavior, and have been present to a significant degree

- The episode is associated with an unequivocal change in functioning thatis a characteristic of the individual when not symptomatic.

- The disturbance in mood and the change in function are observable by others.

- The episode is not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization. If there are psychotic features, the episode is by definition, manic.

- The episode is not attributable to the psychological effects of a substance.

Cyclothymic DO

- For at least two years (at least one year in children) there have been numerous periods of hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

- During the two-year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without symptoms for more than 2 months at a time.

- Criteria for a major depressive, manic, or hypomanic episode have never been met.

- The symptoms are not better explained by another psychiatric disorder.• The symptoms are not attributable to the effects of a drug or medical condition.

- The symptoms cars clinically significant distress or impairment in social, occupational, orother functioning

Epidemiology of Bipolar DO

1:1 ratio male to female, 18-20 when onset happens, genetics play a factor, structure and function of brain play a factor, ACES plays a factor

Morbidity and Mortality of bipolar DO

- Suicide: 5% for women, 10% for men

- Acute Illness: Influenza or pneumonia 4x greater risk, Unintentional injuries ~10x greater risk

- Chronic Illness: Diabetes 3x, COPD 2.8x, Stroke ~2x, Cancer increased 40% among women with bipolar disorder, Heart disease

Tx of bipolar DO

lithium, anticonvulsants, antipsychotics, benzos, antidepressants, psychotherapy, lifestyle changes

ADHD criteria

- Symptoms must be present in more than one setting (academic, social, work,home management, etc.)

- Symptoms must persist for at least six months

- Symptoms must be present before twelve years of age

- Symptoms must be excessive for the developmental level of the patient

- Other mental disorders that could account for the symptoms must be excluded

Hyperactivity DC for ADHD

Patient must present at least six symptoms for six months:

- Often fidgets with hands or feet or squirms in seat

- Often leaves seat in classroom or in other situations in which remaining seated is expected

- Often runs about or climbs excessively in situations in which it is inappropriate

- Often has difficulty playing or engaging in leisure activities quietly

- Often is "on the go" or often acts as if "driven by a motor"

- Often talks excessively

- Often blurts out answers before questions have been completed

- Often has difficulty awaiting his or her turn

- Often interrupts or intrudes on others (eg, butts into conversations or games)

inattentiveness DC for ADHD

Patient must present at least six symptoms for six months:

- Often fails to pay close attention to details or makes careless mistakes in schoolwork or other activities

- Often has difficulty sustaining attention in tasks or play activities

- Often does not seem to listen when spoken to directly

- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties (not because of oppositional behavior or failure to understand instructions)

- Often has difficulty organizing tasks and activities

- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort(such as schoolwork or homework)

- Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils,books, or tools)

- Often is easily distracted by extraneous stimuli

- Often is forgetful in daily activities

Epidemiology of ADHD

boys>gilrs, 40-60% persist into adulthood, environmental influences

Tx of ADHD

- Pharmacotherapy: Nonstimulants, Stimulants

- Other Treatments: Cognitive-Behavioral Therapy, Adjunctive psychotherapy, Biofeedback

behavioral approach

Routine!!!!!

- Regular and adequate sleep on a schedule

- Regular and scheduled diet with good food

- Regular exercise

- Scheduled studying with frequent and regular breaks

- Limited or no alcohol use

- No drug use

RF of misuse and diversion among students

- Males

- Abuse of alcohol and other substances

- Residence in Greek system

- Worse academic standing

- Sensation seeking

- Comorbidities and worse symptoms of ADHD and depression

WBC: neutrophils

bacterial infection

WBC: lymphocytes

viral infection

WBC: monocytes

viral infection

WBC: eosinophils

allergy/parasite infection

MVC

mean corpuscular volume (avg size of RBC)

jobs of RBC

oxygen transporter, iron storage/use

platelet job

Clot Blood and Repair Wounds/Damaged Tissue

reticulocytes

Immature red blood cells; Elevation means making a lot of new RBCs-may be sign of acute bleeding

normochromic, normocytic anemia

- normal MCHC, normal MCV

- anemias of chronic disease

- hemolytic anemia (accel destruction of RBC)

- anemia of acute hemorrhage

- aplastic anemias (disappearance of RBC precursors from marrow)

hypochromic, microcytic anemia

- low MCHC, low MCV

- iron deficiency

- thalassemias

- anemia of chronic disease

normochromic, macrocytic anemia

- (normal MCHC, high MCV)

- vitamin B12 deficiency

- folate deficiency

pregnant and vegetarians

Sports (False) Anemia - Dilutional Anemia

Increased Plasma Volume; Increases our Stroke Volume to increase our Cardiac Output (total increase in an endurance runner can be 1L more than regular person); Cardiac Output = Heart Rate x Stroke Volume; This happens quickly in even novice runners

"Foot Strike" Anemia

occurs related to the trauma of superficial blood vessels, maybe muscle breakdown of RBCs with exercise, bladder friction, etc.; May be with or separate from iron deficiency anemia

iron deficiency anemia

Things that impair absorption or cause GI loss of iron: Use of NSAIDs, alcohol, coffee, decreased gut blood flow from exercise; Other things that can cause lower iron: sweating can lose up to 2.5mcg or iron/L sweat loss, heavy menses, other genetic anemias (thalassemias); Ferritin Can be falsely low when athletes start running, falsely high as an acute phase reactant-meaning is increases with inflammation in the body