N314 Midterm 1 study guide

What is included in the term clinical preventive services? 4 parts

screening tests, behavior change counseling, preventitive medications, information/education

determinants of health

1.Biology and Genetics

2.Individual Behavior

3.Health Services

4.Social factors

5.Policymaking

6.Physical Environment

social determinants of health

1- Housing & Transportation

2- Racism & Discrimination

3- Education & Financial Stability

4- Access to Food & Physical Activity

5- Environmental Pollution

(non-medical factors that contribute to health outcomes)

Primary Prevention

approaches to prevent disease/health conditions from developing (e.g. health promotion/protection, community class, immunization, lifestyle change)

secondary prevention

identify health condition as early as possible/slow progression -- early diagnosis/adequate treatment (e.g. screenings, contact tracing)

medication: statin

tertiary prevention

decreases negative impact of already established health condition/prevent complication -- promote recovery (e.g. diabetes management, rehabilitation, harm reduction)

USPTF

United States Preventive Services Task Force -- evaluate benefits and harms of preventitive services in healthy population, makes recommendatins about which should be incorporated into routine primary care practice

what does USPTF assess in recommendations

quality of evidence supporting a specific service, magnitude of net benefit in providing service

USPTF A grade

high certainty that net benefit is substantial (suggestion: offer/provide service)

USPTF B grade

high certainty that net benefit is moderate OR moderate certainty that net benefit is moderate-substantial (suggestion: offer/provide service)

USPTF C grade

at least moderate certainty that net benefit is small, use professional judgment/patient preferences (suggestion: offer/provide for selected patients depending on individual circumstances)

USPTF D grade

moderate or high certainty that service has no benefit or harms outweigh benefit (suggestion: discourage use of service)

USPTF I grade

current evidence is insufficient to assess balance of benefits to harms. Patients should understand uncertainty

examples of top Ranked Clinical Preventive Services for the U.S. Population

colorectal screening, tobacco cessation, BP screening, cervical cancer screening, HIV screening

Data entry points in ASCVD risk estimator

age, sex, race, cholestrol levels (total, HDL, LDL), systolic BP; personal history (diabetes, smoker, on beds (HTN, HLD, aspirin))

should be calculated routinely for adults 40-75

top 4 CVD risk factors (and compared to 12 risk markers)

HTN, HLD, DM, and smoking

12 risk markers are not necessarily direct treatment targets, they are just associated with risk

estimating LDL

3/4(TC-HDL)

ASCVD lifestyle risk factors

nutrition/diet, exercise/physicial activity

non-lifestyle ASCVD risk factors

overweight/obesity, type 2 diabetes, high cholestrol, high BP, tobacco use, aspirin use

what does the risk estimator estimate?

10-year risk of developing CVD in age 40-79; OR lifetime risk in age 20-59

classification of CVD risk

low: less than 5%

borderline: 5-7.4%

intermediate: 7.5-19.9%

high: 20+%

recommended diet for CVD prevention

mediterranean/DASH, fruits/veggies/nuts/whole grain, lean protiein, sodium reduction

elimintating trans/saturated fats, eliminating sweetened drinks

exercise recommendations for ASCVD prevention

150 min/week of moderate-intensity aerobic activity// 75 min/week of vigorous

overweight/obesity BMI

overweight: 25+

obese: 30+

at-risk obesity numbers (waist circumfrence)

men: greater than 40 in

women: greater than 35

Normal BP

less than 120 AND less than 80

elevated BP

120-129 AND

stage 1 hypertension BP

130-139 OR 80-89

stage 2 hypertension BP

140+ OR 90+

severe hypertension BP

180+ AND/OR 120+

hypertensive emergency BP

180+ AND/OR 120+

Total cholestrol desirable vs high

desirable: less than 200

high: 240+

LDL optimal, high, very high

optimal: less than 100

near optimal: 100-129

borderline high: 130-159

high: 160-189

very high: 190+

HDL optimal, low

optimal: 60+ mg/dl

low: less than 40

factors that affect cholestrol level

diet, weight, exercise, age, sex, genetics, chronic conditions

Statin benefit groups

- ASCVD

- LDL-C >/= 190, Age 21+

- primary prevention

Goal for Statin primary prevention

-For intermediate risk >7.5% to

when to use statin for primary prevention

adults 40-75 with 1+ CVD risk factors and estimated 10-year CVD risk of 10%+, AND one more (diabetes, hypertension, smoking, dyslipidemia)

Proper BP technique

no smoking, caffeinated bevs, alcohol, or exercise in 30 min

proper position: upright, feet flat on floor

proper cuff and directly on skin

no talking

anti-hypertensive drug classes

diuretics, vasodilators, output

anti-hypertensive diuretics

thiazide-type, furosemide, aldosterone antagonist

thiazide-type

work on volume! Decreases Na --> decreases H2O --> lower BP (HCTZ)

furosemide

Lasix

Loop Diuretic

aldosteron antagonists

K-sparing diuretic

aldosterone --> sodium and water retention

antagonist blocks aldosterone --> prevent volume increase (spironolactone)

Vasodilators

ACE inhibitors, Angiotensin II receptor blockers, Calcium channel blocker

ACEI

ACE inhibitors block conversion of angio1 to angio2 (potent vasoconstrictor) --> VASODILATION also decreases aldosterone production. Ex. Lisinopril, captopril (-PRIL suffix).

ARB

Angiotensin II receptor blockers (ARB), or antagonists: it's in the name, blocking or competing with Angiotensin II . Work similarly to ACEI. EX. Losartan, Telmistartan (-Sartan suffix)

CCB

Calcium channel blocker (CCB): block calcium from entering --> lowers BP. Causing vessel relaxation and may decrease/slow HR (may be beneficial for angina or certain arrythmias). Ex. Amlodipine (e.g. verapamil)

Output drugs

beta blocker!

beta blocker

decrease cardiac output by blocking effects of epinephrine. Decreases HR and force. Work on both b1 and b2 receptors. EX. Metoprolol, propranolol (-LOL suffix)

treatment for elevated BP

nonpharmacological therapy, reasses in 3-6 mo

stage 1 hypertension treatment

if ASCVD risk < 10, nonpharmacological therapy

if > 10, nonpharmacological therapy + 1 BP lowering medication

Stage 2 HTN treatment

nonpharmacological therapy + 2 BP lowering medication of different class regardless of 10-year risk

nonpharmacological interventions for high BP

weight loss, heart-healthy diet, sodium reduction, dietary potassium supplementation, increased physical activity, and limited alcohol use.

when to use low-dose aspirin

Weak data: Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.

diabetes

vascular/vessel disease

- micro vs macrovascular damage

- long term impact on heart, kidneys, eyes, feet

signs and symptoms of diabetes

Frequent urination, excessive thirst, unexplained wt loss, extreme hunger, blurred vision, sensory changes (tingling/numbness in feet/hands), fatigue, unhealed wounds

Type 1 vs type 2 vs gestational

type 1: Cellular-mediated autoimmune destruction of pancreatic beta cells, complete insulin dependency (diagnosed young)

type 2: Progressive loss of b-cell insulin secretion, Insulin may be insufficient or insulin resistance

GDM: Glucose intolerance with onset of pregnancy, Insulin resistance or inadequate insulin production, Increased lifetime risk for type 2 DM

Microvascular diabetes complications

eye: retinopathy/cataracts/glaucoma

kidney: nephropathy

neuropathy

macrovascular diabetes complications

brain: stroke, cognitive impairment

heart: coronary heart disease

extremities: lack of blood flow to legs --> gangrene

risk factors for diabetes

- overweight/obesity/high abdominal fat

- physical inactivity

- smoking

- CVD risk factors (hyperlipidemia, hypertension)

uncontrollable: GDM history, race/ethnicity, age over 45, family history

fasting blood glucose test

fast 8 hrs

normal:

OGTT

fast 8 hrs, consume 75 g glucose drink, wait 2 hours, measure

- used for GDM screening

normal:

HBA1C test

no fasting required, avg sugar level of 3 mo, measures sugars attached to hemoglobin (on rbcs), avg lifespan of rbc is 3 mo

normal: < 5.7%

pre-diabetes: 5.7-6.4%

diabetes: 6.5+%

random glucose test

diabetes: 200+ WITH symptoms

what are the complications of diabetes and how does lowering glucose/A1c affect these? How else may these complications be reduced?

How can pre-diabetes be managed to prevent or delay the onset of Type 2 Diabetes?

1.Weight loss and physical activity (lose 5 % to 10% of weight, 30 minutes of moderate activity at least 5 days per week, reduced calories, etc.)

2.Medication: metformin IF unable to lose 7 percent of their weight, women with a history of GDM

C.Age/ younger (aged 25 to 44 years)

D.Person of Size (BMI ≥35 kg/m2)

3.Cardiovascular disease risk management

Blood glucose management goals for people with diabetes

A1C

cholestrol management for people with diabetes

statin regardless of lipid level for people with over CVD; consider for those 40-75 without overt CVD, primary prevention for those

when to use low-dose aspirin for diabetes

adults with diabetes and ASCVD history; consider for primary prevention for those with multiple ASCVD risk factors in context of shared decision making

diabetic foot assessment

- history of previous ulceration/amputation

- footwear

- visual inspection

- skin (dryness, sweating, infection)

- nails

- pulses

- capillary refill time

- sensory assessment (touch/vibration)

- 10ga monofilament testing

- ankle reflex

diabetes treatment

lifestyle mods, medication (metformin, pharmacoligical therapy, insulin therapy)

pharmacological therapy for type 1 diabetes

multi-dose insulin injections or continuous subcut insulin infusion, insulin analogs to reduce hypoglycemia risk

types of meds for type 2 diabetes

biguanide, DPP-4 inhibitors, GLP-1 Agonist, SGLT2 Inhibitors

biguanides

metformin

-Mechanism of Action: decreases liver's glucose production. Increases insulin sensitivity of muscle tissue which increases glucose uptake

-1st line oral treatment for type 2 DM

-Also used for patients who are in the pre-diabetes range, PCOS, metabolic syndrome

-Common side effects: GI symptoms (upset stomach, diarrhea)

-Usually taken Daily/BID with meals PO

May help with weight loss

DPP-4 inhibitors

-Examples: Sitagliptin (Januvia) , Saxagliptin (onglyza)

-Mechanism of Action : increases glucose utilization, stimulates insulin secretion, decreases glucagon secretion, reduces blood glucose

-Common side effects: headaches, dry mouth

-Taken once daily PO

GLP-1 Agonist

-Examples: Semaglutide (Ozempic, Rybelsus)

-Mechanism of Action: lower blood glucose, slows gastric emptying, reduces appetite

-Common side effects: nausea, vomiting, stomach upset

-Most formulations are a once-a-week injection, except for Rybelsus which is taken PO

-Also been shown to have cardioprotective factors

Precautions and contraindications

SGLT2 Inhibitors

-Examples: Empaglifozin ( Jardiance) Canagliflozin (Invokana)

-Mechanism of Action: excretes excess glucose through the urine

-Common side effects: Urinary tract infections, fungal infections

-Has extra benefit for patients with heart disease, kidney disease and heart failure (reduces hospitalizations)

Taken Daily PO

rapid acting insulin

taken with meals

aspart, glulisine, lyspro

short-acting insulin

◦Regular human insulin --> Delayed onset; inject...wait...eat . Risk for hypoglycemia

intermediate acting insulin

◦NPH --> covers in between meals (cloudy) can be mixed with regular insulin

long acting insulin

◦No peak. Take at same time daily

◦Insulin detemir (Levemir®)

Breast cancer screening USPSTF recs (population, strategy, frequency)

Mammogram

- every 2 years

- women age 40-74

- grade B

ALSO braca-genetic testing

- grade B

- risk-assessment, genetic counseling/testing

women with personal/family history of breast, ovarian, tubal, or peritoneal cancer

cervical cancer screening USPSTF recs (population, strategy, frequency)

PAP test

population: women 21-65!

every 3-5 years

- for 21-29: every 3 years with cervical cytology

- for 30-65: every 3 years with cervical cytology alone, every 5 years with HPV alone, every 5 years with cytology + HPV

- grade A

colorectal cancer screening USPSTF recs (population, grade)

population: 50-75!

Grade A

(45-49 grade b, 76-85 grade c)

colorectal screening types + intervals

- FIT/cologuard every year (at home)

- colonoscopy screening every 10 years

lung cancer screening USPSTF recs (population, strategy, frequency)

low-dose computed tomography (LDCT)!!!

- population: adults 50-80 who have 20 pack-year history and currently smoke OR quit in past 15 years

- frequency: annually

- grade B

(smoking cessation is grade A)

prostate screening grade

C/D

one pack-year

smoking 1 pack per day for a year on avg

risk factors for falls in elderly

physical: age, chronic disorders, gait instability/balance problems, deconditioning, vision impairment, orthostatic BP, urinary urgency

behavioral: alcohol use, drug use, poor judgment, non-adherennce to assistive devices, risky routines, sedentary lifestyle

environmental: clutter, rugs, poor lighting, bed/chair height, slippery surfaces, lack of assistive devices in br, weather, stairs

medications: polypharmacy

drugs especially linked to falls

benzos, hypnotics/sedatives BP meds, psychotropics

TUG

tests gait

timed up and go. Must stand up, walk 10 ft, walk back, and sit down in 10 seconds (other sources say 12 seconds)

30 second chair stand test

tests strength

can't use arms, sit and stand up for 30 seconds

4 stage balance test

stand in 4 positions for 10 secondds each

tests balance

if can't hold for 10 sec, fall risk

measuring orthostatic BP

- patient lies down for 5 min, check bp

- patient stands 1-3 min, check bp

a drop of 20+ systolic or 10+ diastolic, or experiencing dizziness is abnormal

what vision acuity is considered a fall risk

20/40 or worse

2 perameters of hearing test and what they measure

decibel's measure volume

Hertz measure tone/frequency

conductive hearing loss

problem in outer/middle ear interfering with transmission to inner ear

- usually easier to treat

- sounds may be faint, distorted, or both

- hearing loss in lower frequency ranges

sensorineural loss

impairment of inner ear nerves that transmit sound to brain (soubnds may be garbled no matter how loud)

- hearing loss in higher frequency ranges

interview questions to assess functional vision loss in elderly

do you wear glasses?

can you read medication bottles/labels?

can you read street signs?