Ambulatory Exam

Asthma

:-)

On an asthma action plan green is ____%, yellow is ___-___% and red is ___%.

What is the math?

>80 ; 79-50 ; <50

Current peak flow/personal best x100%

TRACK 1: >12 yrs with asthma

Step 1 & 2 → Symptoms ___ - ___ days/week with ____/____ ____ lung function. It’s treated with _____

3-5 days/week ; normal/mildly reduced ; AIR (as needed low dose ics-formoterol)

TRACK 1: >12 yrs with asthma

Step 3 → Symptoms ______ days/week or waking up _____ time/week or ____ lung function. It’s treated with _____

Most days/week ; >1 ; low ; MART (low-dose maintenance ICS-formoterol)

TRACK 1: >12 yrs with asthma

Step 4 → Symptoms ______ or waking up _____ time/week and ____ lung function.  It’s treated with _____

Daily ; >1 and low ; MART (medium dose ics-formoterol)

TRACK 1: >12 yrs with asthma

Step 5 → Refer to an expert. Can

(1) ____ _____

(2) Consider ___-____ month of ____-dose ____ ____-____ therapy

(3) Add on biologic

(1) Add LAMA

(2) 3-6 months of high-dose maintenance ICS-formoterol therapy 

TRACK 2: >12 yrs with asthma

Step 1 → Symptoms _____ . Treat with ___-dose ___ whenever ____ is taken.

Infrequently ; low-dose ICS whenever SABA is taken

TRACK 2: >12 yrs with asthma

Step 2 → Symptoms ___ - ___ days/week with ____/____ ____ lung function. It’s treated with ____-dose ____ _____

3-5 days/week ; normal/mildly lower ; low-dose maintainence ICS

TRACK 2: >12 yrs with asthma

Step 3 → Symptoms ______ days/week or waking up _____ time/week or ____ lung function. It’s treated with ____-dose ____ _____-____

Most ; >1 ; low ; low-dose maintainence ICS-LABA

TRACK 1: >12 yrs with asthma

Step 4 → Symptoms ______ or waking up _____ time/week and ____ lung function.  It’s treated with _____-dose _____ ___-____

Daily ; >1 WITH low lung function ; medium-dose maintenance ICS-LABA

TRACK 1: >12 yrs with asthma

Step 5 → Refer to an expert. Can

(1) ____ _____

(2) Consider ___-____ month of ____-dose ____ ____-____ therapy

(3) Add on biologic

Add LAMA

3-6 ; high-dose ; maintenence ICS-LABA

Children 6-11

Step 1 → Symptoms ______ days/week. Treat with ___-dose ____ whenever ____ is taken.

<2 ; low-dose ICS ; SABA

Children 6-11

Step 2 → Symptoms ___-___ days/week. Treat with ___-dose ____.

2-5 ; low-dose ICS

Children 6-11

Step 3 → Symptoms _____ days/week or waking up _____ time/week. Treat with:

1. ___- dose ____-___ 

2. __- dose ____

3. ____-___-dose ___-___

most ; >1

low-dose ICS-LABA

medium-dose ICS

very low dose ICS-formoterol

Children 6-11

Step 4 → Symptoms _____ days/week and waking up _____ time/week and ____ lung function. Treat with:

1. ___- dose ____-___ 

2. ___-dose ___-___

daily & >1 & low lung

medium-dose ICS-LABA

low dose ICS-formoterol

Children 6-11

Step 5 → Consider:

(1) ___-dose ____-___ 

(2) Add on therapy (___ or ___)

higher doses ICS-LABA

LAMA or biologics

Children <5 (Not enough evidence for doing anything for step one)

Step 2 → Symptoms _____ days/week or waking up _____ time/week or SABA deliver needed ___ times/week or ____ ____ or ____ severe ____. Treat with: ____ ___-dose ____

>2 ; >1 ; >3 ; activity limited ; 1 severe exacerbation

Children <5

Step 3 → If still not controlled then ____ current ____-dose ____

double current low -dose ICS

Counseling steps for MDI without spacer:

1. ____ _____

2. ____ fully

3. _____ while ____ _____

4. Hold breath for ____ seconds

1. Shake inhaler

2. Exhale fully

3. Breath while pushing down

4. 10

Counseling steps for MDI with spacer:

1. insert the inhaler into spacer

2. ____ ____ ____

3. Can do up to ____ times

1. Breathe slowly

2. 6

Counseling steps for DPI:

1. Open device

2. ____ _____

3. ____ ____ (away from device)

4. Inhale _____ through mouthpiece

5. Hold breath for ___ secs

1. Load dose

2. Fully exhale

3. Forcefully

4. 10

Albuterol HFA Treatment for Exacerbation

• Dose: ___ puffs every ____ ___ for up to___ doses in the ___ hour (s)

• After that, ___ puffs every ____ ___ as needed

• pred ___-___mg for ____ days if did not respond to SABA / recent corticosteroid use

2-4 puffs q 20 minutes 3 in one hour

2-4 puffs q4-6h PRN

40-60mg for 5-10 days

Mild exacerbation: Can often be managed __ ____ with increased ____ use and ___-__  ____.

At home ; reliever ; follow-up with provider

Moderate exacerbation: Requires ____ or ____ with possible ____ ____.

Pred ___-____mg for ___-___ days

ER or urgent care ; systemic corticosteroids 

40-60mg for 5-10 days

Severe exacerbation: ____ may be needed, possibly requiring ____, continuous ____, or even mechanical ventilation. ADD ____.

WARD VS ICU

Hospitalization ; O2 ; nebulization ; SAMA

WARD → oral corticosteroids & SABA

ICU → IV corticosteroids & SABA continuous

Biostatistics

: D

NNT/NNH calculation 

 

1. Calculate ARR = [(A / A+C) – (B / B+D)]

   • (6/50) - (18/50) = -0.24

2. NNT/NNH = 1 / ARR

   • 4.166 (NNT = 5 and NNH = 4)

Calculate the Relative Risk Reduction (RRR)

RRR = 1 - [(A / A+C) ÷ (B / B+D)]

• (6/50) ÷ (18/50) = 0.33

COPD

: O

Presentation: COPD typically presents with ___ , ___ ___ , and/or ___ ___ . Symptoms are ___ and often under-recognized until significant lung function is lost.

• dyspnea that is ___ , ___ , and ___ with exercise

• recurrent ___ , recurrent ___

dyspnea, chronic cough, and/or sputum production ; progressive.

• recurrent, progressive, worsened

• Wheezing ; LRIs

If your ____/____ is < ___ after a bronchodilator you have COPD

FEV1/FVC is <70

Based on FEV1 predicted

GOLD 1 → ___

GOLD 2 → ___

GOLD 3 → ___

GOLD 4 → ___

GOLD 1 → > 80

GOLD 2 → 79-50

GOLD 3 → 49-30

GOLD 4 → <30

GROUP A: Low symptoms, low exacerbation risk: (mMRC ___ and CAT ____.)

Start with a ___-___ ____

0-1 ; <10

long-acting bronchodilator (LAMA or LABA).

GROUP B: High symptoms or exacerbation risk: (mMRC ___ and CAT ____.)

Use: ____

>2 ; >10

LAMA+LABA combo

GROUP E: (____ moderate exacerbation or __ ____)

Eosinophils ≥300 cells/μL or history of asthma → ______

• Do not use ____ if Hx of ____, ___/____ infections

>2 moderate exacerbations or >1 hospitalization

Consider LABA+LAMA+ICS.

• ICS ; Pneumonia, TB/mycobacterial infections

New in 2025: ______ (PDE3/4 inhibitor) and ____ (anti-IL-4/13 biologic) are now options for select patients with frequent exacerbations despite optimized therapy.

Ensifentrine (PDE3/4 inhibitor) and dupilumab (anti-IL-4/13 biologic)

Exacerbation definition: ___ ____ of respiratory symptoms requiring additional therapy.

Acute worsening

Treatment for COPD exacerbation includes:

1. ___-___ ____

2. ____ ______

3. ______ if >2 of 3 cardinal symptoms

1. Short-acting bronchodilator (SAMAs take a few minutes. SABAS instant.)

2. Systemic corticosteroids

3. Antibiotics

Treatment for COPD exacerbation includes: Dose of ____ is _____mg ___ for ___ days.

Prednisone 40mg daily x5 days

Treatment for COPD exacerbation includes: Antibiotics are needed if >2 of 3 cardinal symptoms are present. The cardinal symptoms are:

1. ___ ___

2. ___ ___

3. ___ ___

1. Increased dyspnea

2. Increased sputum volume

3. Sputum purulence

DIABETES MELLITUS

U - U

1. A1C Target:

2. Fingerstick Blood Sugar Testing: Preprandial glucose target ____, peak postprandial glucose_____.

3. Continuous Glucose Monitoring (CGM): Time in range (TIR) ____ for at least ____ of the day is recommended.

1. Generally <7% but if a patient is very old and sic,k then <8% is fine.

2. Preprandial glucose target 80–130 mg/dL, peak postprandial glucose <180 mg/dL.

3. 70-180 mg/dL for 70% of the day

Fill this out

(maybe liraglutde also has CKD benefit? unclear) 

Metformin Dosing:

eGFR >60 ml/min/1.73m³ →

eGFR 60-45 ml/min/1.73m³ →

eGFR 45-30 ml/min/1.73m³ →

eGFR <30 ml/min/1.73m³ →

1. 1000mg BID

2. 1000mg BID but monitor renal function every 3-6 months

3. Don’t initiate therapy… but if you must 500mg QD → 500mg BID (NMT 500BID if continued)

4. Use is contraindicated

Ozempic dose & titration

0.25mg → 0.5mg → 1mg → 2mg

Dulaglutide dose & titration

0.75mg → 1.5mg → 3mg → 4.5mg

Mounjaro dose & titration

2.5mg → 5mg → increase by 2.5mg q4weeks until NMT 15

Insulin dose of basal insulin: Start ___ units/day or ____-___ per day. Increase in increments of ___ units every ____ days. If they get hypoglycemia reduce units by ___-___.

Start 10 units ; 0.1-0.2/kg/units ; increase 2 units every 3 days ; 10-20%

Insulin dose of prandial insulin: Start ___ units/day or ____ of basal insulin dose. Increase in increments of ___ units or ___-___ twice weekly . If they get hypoglycemia reduce units by ___-___. Start with the ___ ___. 

4 units ; 10% ; 1-2 units ; 10-15% ; biggest meal

Given a patient’s insulin dosage, calculate the number of pens needed for a 30- or 90-day prescription. The concentration and volume of the specific pen will be provided. Standard insulin pen: 300 units per pen. 

If a patient takes 40 units/day and needs a 30-day supply then how many pens?

(Total daily dose × Days supply) ÷ 300 = Number of pens needed.

If a patient takes 40 units/day and needs a 30-day supply, they require (40 × 30) ÷ 300 = 4 pens.

Dyslipidemia

:-0

LDL goals: Primary prevention WITHOUT DM

1. LDL >190 →

2. Without DM 40-75 years + 7.5-20% ASVCD risk →

3. Without DM 40-75 years + 20+% ASVCD risk →

1. >50% reduction and LDL <100mg/dL

2. >30-49% reduction and LDL <100mg/dL

3. >50% reduction and LDL <70mg/dL

LDL goals: Primary prevention WITH DM

1. With DM 40-75 years + >7.5% ASVCD risk →

2. With DM 40-75 years + <7.5% ASVCD risk →

3. With DM 40-75 years + >20% ASVCD risk →

1. >30-49% reduction and LDL <100mg/dL

2. >50% reduction and LDL <70mg/dL

LDL goals: WITH ASVD/Secondary prevention

1. ASCVD not at very high risk →

2. Very high risk →

3. Baseline LDL >190 mg/dL WITH Familial hypercholesterolemia (FH) →

1. >50% reduction and LDL <70mg/dL

2. >50% reduction and LDL <55mg/dL

3. >50% reduction and LDL <70mg/dL

Low vs High intensity statins

LOW= Some People Love Flowers (Simvastatin 10mg, Pravastatin 10-20mg, Lovastatin 20mg, Fluvastatin 20-40mg)

HIGH= AR 40-20 (AR “420” a gun that shoots weed? lol idk)

Calculate the LDL via the Friedewald equation, given the patient’s total cholesterol, HDL, and triglyceride results

What are the limitations of this?

LDL-C = Total Cholesterol - HDL-C - (Triglycerides / 5)

This is not valid if the TGs of the patient are >400 mg/dL. 

HEART FAILURE

: (

Categorize the difference

1. HFrEF → 

2. HFpEF →

1. LVEF <40%

2. LVEF >50%

HF symptoms/staging (not same as NYHA class)

You ____ go back in stage

Stage A →

Stage B →

Stage C →

Stage D →

Cannot

Stage A → No structural heart disease or HF sx. Just other high risk conditions (like HTN, DM, obesity)

Stage B → Structural heart disease (previous MI, LV hypertrophy, low EF) but no current or prior symptoms

Stage C → Structural heart disease (previous MI, LV hypertrophy, low EF) with no current or prior symptoms

Stage D → Marked symptoms at rest despite optimal medical therapy; patients may require specialized interventions (e.g., inotropes, LVAD, transplant, palliative care).

NYHA class

You ____ go back in stage

Class I:

Class II:

Class III:

Class IV:

Can

Class I: No limitation

Class II: Slight limitation during ordinary activity

Class III: Marked limitation with less than ordinary activity

Class IV: Symptoms at rest

Identify medications that are considered potentially harmful when used in patients with HFrEF

1. ___-___ ____

2. _____

3. ______

4. _____-___ ____

5. ____, _____

6. ______

7. ______

8. ______

1. non-DHP CCBs

2. TZDs

3. NSAIDS

4. COX-2 inhibitors

5. Saxagliptan, alogliptan 

6. Antiarrythmics (Flecainide, dronedarone, disopyramide, sotalol)

7. Dozasozin

8. PDD4is

HFrEF mortality benefit: 

1. What are the four pillars

2. What deceases mortality in AA patients w/ NYHA-3 to 4 receiving optimal therapy

1. ACEs/ARNis/entresto, BBs (nebivolol, carvedilol, metoprolol succ, bisoprolol), MRAs, SGLT2is

2. Hydralazine/isosorbide dinitrate

What benefits HFpEF for mortality?

We learned nothing but the 2022 guidelines said this: … but I’m still not sure because the wording in the guideline was so ambiguous? To be discussed! 

I’m not gonna re-do the dosing because we prob have other resources. Use prac 5.

I’m not gonna re-do the dosing because we prob have other resources. Use prac 5.

HIV/PrEP

—

1. Who should receive Pneumocystis jirovecii pneumonia prophylaxis?

Treatment?

1. CD4 count 100-200 cells/mm3 AND plasma HIV RNA levels are above detection limits

or

2. CD4 count <100 cells/mm3 (regardless of detection limits)

Treatment: Bacrim DS or SS once daily

1. Who should receive Mycobacterium avium complex prophylaxis?

1. CD4 count <50 cells/mm3 AND not receiving ART

2. Remains viremic on ART

3. Has no options for fully suppressive ART regimen

Treatment:

Azithromycin 1,200 mg PO once weekly (AI)

Clarithromycin 500 mg PO twice daily (AI)

Azithromycin 600 mg PO twice weekly (BIII)

NRTIs → Nucleotide reverse transcription inhibitors

____, _____/____, ____/____, _____

Class ADE:

1. _____ _____ (____ _____)

Lab monitoring:

1. ___, ____, ___, ____/____

Abacavir, Emtricitabine/Lamivudine, TAF/TDF, zidovudine

Mitochondrial toxicity (lactic acidosis)

LDLs, Renals, CBC, CD4/Viral load

NNRTIs → Non-nucleotide reverse transcription inhibitors

(-___)

Class ADE:

1. _____

2. _____ ____

-Virine (Doravirine, Rilpivirine, Etravirine, Efavirenz)

Rash

Sleep disturbances (with Doravirine & Efavirenz and slightly Rilpivirine)

INSTIs→ Integrase strand transfer inhibitors (-___)

Class ADE:

1. _____ _____ ____

Lab monitoring:

1. ___, ____/____

-Gravir

Class well tolerated (but bitegravir and dolutegravir cause false SCr elevations)

renal function, CD4/Viral load

Protease inhibitor→ (-___)

Class ADE:

1. __/__/__

Lab monitoring:

1. ___, ____/____

-Navir

N/V/D

Liver, CD4/Viral load

PKN Booster 

1. Cobicistat ADE →

2. Ritonovir ADE →

monitoring:

1. False SCr increase

2. GI, dyslimidemia

Monitor DDI (And remember this is not antiretroviral)

What are the 3 regimens recommended for PrEP?

1. ____ (___/___) ; classes ___ _____

2. ____ (___/___) ; classes ___ _____

3. ____ (___) ; class ___

1. Descovy (Emtricitabine/TAF) → 2 NRTIs

2. Truvada (Emtricitabine/TDF) → 2 NRTIs

3. Apretide (Cabotegravir) → INTSI

Descovy (Emtricitabine/TAF) is taken _____ ____.

Monitoring

At baseline monitor ____ and ___.

• Documented negative HIV test (≤1 week before initiating or reinitiating PrEP, at least every 3 months while taking PrEP, and following discontinuation of PrEP)

once daily ; lipids and Hep B test

1. Apretide (Cabotegravir) _____ ____.

Monitoring

At baseline monitor ____

• assess symptoms & test acute HIV infection (prior to initiation of PrEP at 1 month post-initiation, then every 2 months while taking while taking PrEP)… AKA test before every shot bc if they have HIV u could make them resistant to this

every 2 months; liver (no renal or Hep b testing needed)

Immunizations

: )

Tetanus, diphtheria, pertussis (Tdap)

Doses:

Population:

1. ____

2. ____

Inactivated

Doses: 1 every 10 years

Population:

1. Pregnant women (gestational age

2. Dirty wounds (if >5 yrs after lost shot)

Measles, mumps and rubella (MMR) 𖤒 𖤫

Dose: ___ dose (___ doses if _____, ____ or _____)

Population:

1. ______

2. ______

Live

Dose: 1 dose (2 doses if healthcare, international travelers, post-secondary school)

Population:

1. Born after 1957

Varicella (VAR) 𖤒 𖤫

Dose: ____ dose _____ ____ ____

Population:

1. ______

2. ______

It is CI in ______ _____ and ______ ______ _______ ______

Live

Dose: 2 doses 4-8 weeks apart

Population:

1. Born after 1980

2. Born before 1980, and in healthcare

Pregnant people ; after pregnancy before discharge

Zoster (RZV)

Dose: _____ dose ____ _____

Population:

1. ______

2. ______

Dose: 2 ; 2-6 months apart (at least 4 weeks apart)

Population:

1. 50+ and older

2. Immunocompromised

Human papillomavirus (HPV)

Dose: ____ dose _____ ____ ____

Population:

1. ______

Inactivated

Dose: 0, 1–2 and 6 months

Population:

1. Everyone until 26

Pneumococcal

Dose: ____ dose of _____ or _____ _____ of ____ ____ and then ______, ____ weeks after

Population:

1. ______

2. ______

Dose: 1 dose of PCV 20 or 1 doses of PCV15, then PPSV23 8 weeks after

Population:

1. 50+

2. Immuno disease (CV, or lung)

Hepatitis A 𖤖 𖠘 𖠶

Dose: ____ dose _____ ____ ____

Population:

1. ______

2. ______

Inactivated

Dose: 2 doses 6 months apart

Population:

1. Anybody who requests it

2. Hep A risk (HIV, men having sex w/ men, inject drugs)

Hepatitis B

Dose: ____ dose _____ ____ ____

Population:

1. ______

2. ______

Dose: 2, 3 or 4 dose series

Population:

1. 19-59

2. 60+ w/ risk factors or if requested

Meningococcal B

Dose: ____ . dose _____ ____ ____ Then ________

Population:

1. ______

2. ______

Inactivated

Dose: 2 doses 6 months apart. Then dose 3 at least 4 months after

Population:

1. 16-23 years not at increased risk

2. Anatomical or functional asplenia

Influenza

Dose: ____ dose _____ ____ ____

Inactivated

Dose: Once every year

COVID-19

Dose: ____ dose of the ____ or _____ of the ______

Population:

1. ______

2. ______

Dose: 1 dose of the 2024-2025 Moderna/Pfizer or 2 doses of the novavax 3-8 weeks apart

Population:

1. Everyone

2. If over 65 then 2 doses 6 mo apart

Respiratory syncytial virus (RSV)

Dose: ____ dose

Population:

1. ______

2. ______

Dose: 1 dose

Population:

1. Pregnant women of any age as 32-36 weeks

2. 75+

Thromboembolic

o-(-(

(Assuming you already know how to calculate CHA₂DS₂VASc)

1. What is a CHA₂DS₂VASc score do you need in men or women to initiate oral anticoagulation?

2. What HAASBLED score tells you they are a high bleed risk?

1. 2 in men 3 in women

2. 3

When is Warfarin preffered over DOACS?:

1. ____ _____

2. _____

3. ____ _____

1. Valve disorders

2. Obesity

3. Adherence issues

Warfarin INR goals for non-valvular is _____ and for valvular/mitral valve it’s _____ because of the higher bleed risk.

2-3 ; 2-2.5