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AAFP Board Review
A 52 yo man presents with 45 minutes of squeezing substernal chest pressure radiating to his left arm. EKG from a physical two months ago was normal. This is his current EKG: His history and EKG are most consistent with which one of the following? - Answers -C. Non-ST segment elevation - Acute Coronary Syndrome
EKG: ST segment depression (not elevation) in inferior and lateral precordial leads (NSTE-ACS or NSTEMI)
A 72 yo man with NSTE-ACS (NSTEMI) presents to your rural emergency room with onset of pain two hours ago. What is an appropriate immediate intervention? - Answers -Oral Chewable aspirin (162-325 mg)
Ischemia-guided strategy: (lower risk patients, preference for low intervention)
- Aspirin (non-enteric coated, chewable) 2. P2Y12 inhibitor (clopidogrel, ticagrelor) 3. Anticoagulation (heparin) Early invasive strategy: (higher risk patients) Aspirin (non-enteric coated, chewable) P2Y12 inhibitor (clopidogrel, ticagrelor) Anticoagulation (heparin) Consider Glycoprotein IIb/IIIa receptor blockers [Tirofiban (Aggrastat), Eptifibatide (Integrilin), Abciximab (ReoPro)] before invasive treatment
A 55 yo male is a former smoker with type 2 diabetes mellitus, hypertension, and hyperlipidemia. He had an ST-elevation myocardial infarction 2 years ago treated with a drug-eluting stent. He is currently asymptomatic with unremarkable physical exam, Hgb A1c of 6.8%, blood pressure 130/78 mm Hg and heart rate 65 beats/min. His medications include metformin 2000 mg daily; metoprolol succinate 25 mg daily; losartan/hydrochlorothiazide 50 mg/12.5 mg daily; rosuvastatin 20 mg daily; clopidogrel 75 mg daily; and aspirin 81 mg daily. He would like to reduce the number of medications he is taking. You agree and explain that guidelines recommend that he may stop taking which of the following? - Answers - Clopidogrel
A 52 yo man has an acute myocardial infarction for which he had cardiac catheterization and percutaneous coronary intervention with placement of two drug-eluting stents. Echo shows an EF of 35%. He is started on numerous medications at discharge. Which one of the following medications is more useful for symptom control than for improving mortality for this patient? - Answers -Nitroglycerin
ACE-inhibitors, ß-blockers, statins, and ASA improve survival post MI. Dual anti-platelet therapy for at least a year if stents or grafts placed.
Nitrates, calcium-channel blockers, and digoxin may improve symptoms but do not affect survival.
A 45 yo man complains of acute, sharp chest pain relieved by leaning forward. On examination, you hear a pericardial friction rub. The EKG shows diffuse ST elevation. Which of the following is the most appropriate treatment - Answers -NSAIDs Pericarditis Common cause of chest pain in young adults, usually viral or idiopathic cause. Relieved is typically by sitting forward. Pain is due to inflammation. Treatment is NSAIDs (such as indomethacin or high-dose aspirin (2-4 g/day)
Selecting Statin Intensity
Individuals with clinical ASCVD High-intensity or maximally tolerated statin. Goal: lower LDL by ≥50%
Primary elevations of LDL >190 mg/dL (usually familial) High-intensity statin
40-75 yrs with diabetes and LDL ≥70 mg/dl Moderate or high-intensity statin. Goal: lower LDL by ≥50%
40-75 yrs without clinical ASCVD or diabetes and LDL ≥70, and estimated 10-year ASCVD risk of ≥7.5%Moderate intensity statin if a discussion of options favors statins - Answers -High-intensity Statins (>50% LDL-C reduction) Atorvastatin 40-80 mg Rosuvastatin 20 mg
Moderate-intensity Statins (30% to <50% LDL-C reduction) Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40- mg Lovastatin 40 mg Fluvastatin 40 mg bid
An 86 yo woman presents with shortness of breath and a nonproductive cough. She is slightly tachypneic and tachycardic but temperature and BP are normal. Normal cardiac exam but bilateral crackles on lung exam and bilateral fluffy infiltrates on CXR. A CBC, metabolic panel, and troponin are normal. Her EKG shows sinus tachycardia. Which of the following tests would be best to determine whether she should be treated for pneumonia, heart failure, or both? - Answers -BNP and procalcitonin levels
•BNP (brain natriuretic peptide) is secreted from the ventricles in response to ventricular volume expansion and pressure overload. •Release is directly proportional to ventricular dysfunction and correlates with end- diastolic pressure. •BNP undergoes partial renal excretion; levels are inversely proportional to creatinine clearance.
Current American Heart Association guidelines recommend which of the following to further reduce morbidity and mortality? - Answers -Stop enalapril and start sacubitril/valsartan (Entresto) 49/51 mg twice daily
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality. (Class I)
A 70 yo man has a history of a myocardial infarction and now has heart failure with an EF of 30%. EKG with sinus rhythm. Which one of the following medications that he is currently taking is potentially harmful and should be discontinued? - Answers -Diltiazem (Cardizem)
Drugs to Avoid in HFrEF •Calcium channel blockers−Verapamil, diltiazem have potent negative inotropic effect and are associated with worsening heart failure and increased risk of adverse cardiovascular events. −May use amlodipine for BP lowering, but can cause leg edema
•Most antiarrhythmic drugs
•NSAIDs
•Thiazolidinediones (cause water retention) −Pioglitazone (Actos) −Rosiglitazone (Avandia)
Advanced Heart Failure Care - Answers -•Implantable cardioverter defibrillator (ICD) to reduce risk of sudden death due to ventricular tachyarrhythmias −For patients with LVEF ≤35%, NYHA class II or III symptoms on meds, and life expectancy > one year
•Cardiac resynchronization therapy (CRT) (Biventricular pacing) −For patients with LVEF ≤35%, NYHA class II, III, or IV symptoms on meds, QRS duration ≥150 ms, and life expectancy > one year
•Left ventricular assist devices (LVAD) as a "bridge" to recovery or transplant or other decisions −For patients with anticipated 1-year survival of <50%
•Heart transplantation
HFpEF Treatment In appropriately selected patients with HFpEF
- EF ≥45%
- elevated BNP levels or HF admission within 1 year
- estimated glomerular filtration rate >30 mL/min
- creatinine <2.5 mg/dL
- potassium <5.0 mEq/L) - Answers -aldosterone receptor antagonists might be considered to decrease hospitalizations. . A 42 yo woman has a BP 162/98 in both arms; BMI 24;CV exam unremarkable. She reports adherence to her daily regimen of hydrochlorothiazide 25 mg, lisinopril 40 mg, and amlodipine 10 mg. Blood tests: Na 144 mEq/L, K 3.3 mEq/L, Cr 0.68 mg/dL. Which one of the following tests is most likely to reveal the cause of her refractory hypertension? - Answers -Plasma aldosterone/renin ratio
Primary hyperaldosteronism is present in 5-10% of hypertensive patients and 7-20% of those with resistant HTN
A clue is hypokalemia
Diagnosis is based on the aldosterone:renin ratio
Sleep apnea is now the leading secondary cause of HTN, present in 30-40% of hypertensive patients and 60- 70% of those with resistant hypertension.
A 54 yo Hispanic woman has home BP of 155/95 mm Hg, confirmed by multiple similar readings and office BP of 154/94. She exercises, follows a low-salt diet, and rarely drinks alcohol. Which one of the following medications would be most appropriate for this patient? - Answers -Chlorthalidone
In the general non-black population, including those with diabetes, initial treatment should include: ̅U A thiazide-type diuretic or Calcium Channel Blocker (CCB) or Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin II Receptor Blocker (ARB)
In the general black population, including those with diabetes, initial treatment should include: ̅U A thiazide-type diuretic or CCB
- Thiazide diuretics more effective than ACEI for improving heart failure and cardiovascular outcomes in African Americans (ALLHAT)
- CCBs more effective than ACEI for reducing strokes in African Americans. • ACEI/ARB still recommended in CKD, heart failure
54 yo man presents for follow-up of HTN. Despite adherence to his daily regimen of chlorthalidone, carvedilol, amlodipine, and lisinopril, his BP averages 152/92 mm Hg.Recent labs are normal, including CBC, BMP, UA.
Which one of the following medication adjustments would be most appropriate to bring his blood pressure to goal? - Answers -Add spironolactone
Cyanide - Answers -Sinus Bradycardia, First Degree AV Block (Rate <60 bpm, PR interval >0.20 secs)
- Associated with higher degrees of physical conditioning.
- Neither is a contraindication to the use of β-blockers, CCBs, or any other antihypertensives.
A 52 yo man with COPD and hypertension has worsening fatigue. He denies chest pain or shortness of breath. Exam is notable for a slow, irregular pulse; his lungs are clear. His medications are lisinopril, chlorthalidone, tiotropium, and ASA. Based on history and this rhythm strip, what is the diagnosis? - Answers -Mobitz type I second degree AV block (Wenckebach) The PR interval progressively lengthens until a P wave fails to conduct and a beat is "dropped."
- Usually disease of the AV node.• Normal in some athletes, especially during sleep.
- If acute, inferior wall ischemia is likely.• Inferior wall supplied by RCA, which also supplies the AV node.
- The rhythm itself does not require treatment; the underlying cause may.
Mobitz Type II Second Degree Block - Answers -Intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening
Usually disease of the distal conduction system, below the AV node (His-Purkinje system)
May progress to third-degree AV block
Treatment: permanent pacemaker.
Third Degree AV Block (complete heart block) - Answers -Buried P wave
Impulses from SA node do not propagate to the ventricles creating two regular but completely dissociated and independent rhythms.
Can cause syncope
If the cause is inferior MI, AV node may recover
- Escape rhythm originates at or near the AV junction, and is narrow-complex
If the cause is anterior MI, distal conduction system is typically permanently damaged
- Escape rhythm originates in the ventricles, and is wide-complex
Treatment: permanent pacemaker
Conduction System and Coronary Arteries - Answers -Anterior MI (LAD) may affect distal conducting system Inferior MI (RCA) may affect AV node
SVT: Narrow Complex, Fast - Answers -•Originate above ventricles (atrium or AV node) •Usually structurally normal hearts •Paroxysmal = sudden onset, sudden resolution •Palpitations, light-headedness, anxiety, SOB
. A 24 yo woman who has been treated for panic attacks presents to the ED with heart rate of 180 beats/min without clear atrial activity. Her blood pressure is 130/80 and she reports feeling anxious but does not have dizziness or chest pain. You diagnose SVT based on her EKG. You try vagal (Valsalva) maneuvers without successful change in the rhythm or rate. Which of the following is the next best step in treatment? - Answers - Intravenous adenosine (Adenocard)
SVT acute treatment - Answers -Vagal maneuvers: Valsalva, unilateral carotid massageIf unsuccessful, next step is Adenosine: 6 mg IV bolus; repeat with 12 mg prn
If still not successful, several next options to slow AV conduction: ß-blocker: metoprolol 5 mg IV; repeat twice if needed
Diltiazem: 5-20 mg IV; repeat in 15 min if needed
Verapamil: 2.5-5 mg IV; repeat q 15 min up to 20-30 mg
Digoxin requires loading over hours so is not quickly effective.
SVT: Long-term Therapy If merited by frequency and severity of episodes - Answers -"Pill in the pocket" for prn useDiltiazem 120 mg + propranolol 80 mg or flecainide 3 mg per kg
Typically use the medication that converted the rhythm
- Diltiazem 240-360 mg daily
- Verapamil 240-480 mg daily
- Metoprolol 25-200 mg daily
- Flecainide 50-300 mg daily
Catheter Ablation (radiofrequency or cryoablation) 95% effective, expensive Inadvertent heart block risk <5%
A 76 yo man is in your office with new atrial fibrillation with a rate of 130 bpm with BP 130/80 mm Hg. He also has COPD from smoking and uses an albuterol inhaler and inhaled corticosteroids. Lung exam reveals scattered wheezes and rhonchi. Which one
Pharmacologic cardioversion
- IV dofetilide, flecainide, propafenone, amiodarone, ibutilide
- Amiodarone can cause bronchiolitis obliterans organizing pneumonia (BOOP), interstitial pneumonitis, and hypothyroidism
Catheter ablation For patients with refractory fibrillation who are symptomatic Younger patients Targeted destruction of foci near pulmonary vein ostia in left atrium Best predictor of long-term success is size of left atrium Needs to be repeated in ~20% of patients
A 32 yo woman presents with dyspnea, palpitations and near-syncope. Her EKG shows rapid atrial fibrillation (150 bpm) with delta waves. Which of the following treatments is a Class I recommendation for acute treatment? - Answers -Intravenous Procainamide
Wolff-Parkinson-White Syndrome Treatments Acute treatment when the tachyarrhythmia is... •AVRT: follow usual approach for SVT, with cardioversion available if needed
- Atrial fibrillation/flutter: Ibutilide or procainamide - do NOT use AV nodal blockers such as Amiodarone, Digoxin, Beta blockers, Adenosine, Verapamil, diltiazem***
Long term treatment: catheter ablation vs watchful waiting - EP study can risk stratify. Patient preference or patient occupation may influence treatment decision. The incidence of sudden cardiac death (SCD) is low.
Sinus Node Disease ("Sick Sinus Syndrome") - Answers -•Sinus node disease can cause tachy-brady syndrome, bradycardia, episodic sinus arrest •Junctional escape beats may be seen (AV nodal origin; narrow complex; no preceding P wave). •Causes: Aging, superimposed drug effect, right or circumflex coronary artery disease, severe hypothyroidism •Pacemaker therapy is indicated in symptomatic patients.
Ventricular Tachycardia (VT) - Answers ->3 beats in a row originating from ventricle at rate >100 bpm Non-sustained: Self-termination within 30 seconds Sustained: Duration >30 seconds, even if ultimately self-terminates)
Causes: ischemia, heart failure, hypoxemia, prolonged QT interval, electrolyte abnormalities, drug toxicity
If pulseless→defibrillation
If hemodynamically stable → Lidocaine, Amiodarone
Torsades de Pointes "Twisting of the Points" - Answers -• Polymorphic VT with cyclical progressive change in cardiac axis.
- Usually non-sustained; may evolve into ventricular fibrillation.
- Associated with hypomagnesemia, hypokalemia and medications or conditions that prolong the QT interval.
- Treatment = IV magnesium
Long QT syndrome - Answers -Genetic (~1 in 7000 people) •If resting QTc is greater than 470 msec, a beta blocker is advised •QTc >500 msec is high-risk for torsades de pointes and sudden death, may need Implantable Cardioverter Defibrillator (ICD) •Avoid QT-prolonging medications
Acquired
- Due to low potassium, magnesium, or calcium, or QT-prolonging medications
Because of the prevalence and its lethality, the USPSTF recommends that ultrasound screening be performed in which patients? - Answers -One-time screening for men ages 65-75, who have ever smoked
Medicare Part B Covers One-time AAA Screening for: Men aged 65-75 years who have ever smoked (+) Family Hx AAA (1st degree relative)
You identified an abdominal aortic aneurysm (AAA) in your patient. At what size (in centimeters) should you refer your patient for surgical intervention? - Answers -5-5.5 cm
Diameter, cm
Surveillance recommendation
3.0-3.9; 4.0-4.9; 5.0-5. 36 months; 12 months; 6 months
A 68 yo male presents with complaints of an aching pain in both thighs when he walks about one block. The pain subsides within about 1-2 minutes after he stops ambulating.
A 76 yo male with a Hx of HTN, hyperlipidemia, and smoking presents with a painful toe. He denies trauma. No Hx of atrial fibrillation. The toes are dusky blue in color. He has 2+ posterior tibial and 1+ dorsalis pedis pulses. The most likely diagnosis is: - Answers -Blue toe syndrome
Arterioarterial emboli: TheBlueToeSyndrome ̅U Cholesterol or atherothrombotic emboli
̅U Occludes small vessels
̅U Don't be fooled:
- Pulses remain present
- Often confused with bruising
̅U Can involve multiple organs - especially kidneys
̅U Can confirm diagnosis with
- Skin or muscle biopsy• Cholesterol crystals on funduscopic exam
SORT Strength of Recommendation Taxonomy - Answers -• Category A: Recommendation based on consistent and good quality patient-oriented evidence.
•Category B: Recommendation based on inconsistent or limited quality patient-oriented evidence.
•Category C: Recommendation based on consensus, usual practice, opinion, disease- oriented evidence-based series for studies of diagnosis, treatment, prevention, or screening.
What the U.S. Preventive Services Task Force Grades Mean - Answers -A. The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B. The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C. The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Relative risk - Answers -- Calculated: Cohort Study or Randomized Controlled Trial
- Indicates the increased (or decreased) risk of an outcome (disease) associated with exposure to the "factor" of interest
- The ratio of the incidence of the outcome among exposed persons to the incidence among unexposed
Absolute risk - Answers -Event RATE in control group - Event RATE in experimental group
The results of a given study are reported as achieving significance at a p-value of <0. (the 5% level). True statements about this finding include which one of the following? - Answers -.There is a 5% likelihood of the results having occurred by chance alone
You are considering how useful a new treatment might be in preventing stroke. A well designed study is reported with 200 patients in the treated group and 200 patients in the untreated group. The study finds a 5-year risk of stroke of 3% in the treated group versus 5% in the untreated group. Assuming this study is valid and applicable to your patient population, how many patients would you have to treat for 5 years to prevent one stroke (number needed to treat, or NNT)? - Answers -
1/(0.05-0.03) ARR = Incidence of disease in control group minus incidence of disease in treatment group
NNT = 1/ARR
Results of a clinical study show a relative risk reduction(RR = 0.67) of 33% and an absolute risk reduction (AR = 0.2) of 20%. There are 1000 patients each in the treatment and control groups. To help determine the potential benefit of the treatment, it is necessary to identify the number needed to treat (NNT).Which one of the following is the NNT for this clinical study? - Answers -
1/0.02 = 5
does not have the disease
NPV = TN/FN +TN
Sensitivity/Specificity PPV/NPV - Answers -• As the prevalence of the disease in a population increases
- PPV increases
- NPV decreases
- As the prevalence of the disease in the population decreases
- PPV decreases
- NPV increases
The No. 1 cause of preventable morbidity in the United States today is: - Answers - Tobacco
Which one of the follow ing statements is TRUE regarding the use of antidepressants for smoking cessation? - Answers -Bupropion is contraindicated in a patient with an eating disorder Contraindicated
✓Seizure disorders
✓ Medications that lower the seizure threshold ✓History of significant head injury
✓Anorexia nervosa or Bulimia (eating disorder)
Bupropion and nortriptyline are effective
Which of the following statements is true regarding alcohol abuse counseling? - Answers -The USPSTF recommends screening and counseling adults on the risks of alcohol misuse.
Prevention Primary - Answers -• Avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
Which immunization would be considered safe to administer during pregnancy? - Answers -Tdap
Safe: Tdap, influenza IV, hep A and B (if at risk), meningococcal if indicated, pneumococcal if indicated
Wait until after pregnancy: MMR, varicella, HPV, influenza LAV
HPV Vaccine - Answers -9-11 yo = 2 dose series at 0 and 6-12 months
15 yo or IMC = 3 dose series at 0, 1-2 months, 6 months
27-25 yo use shared decision making
Prevention Secondary - Answers -• Activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms. −Breast cancer
Breast cancer screening - Answers -The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
The American Cancer Society recommends screening breast MRI (impact on breast cancer mortality is uncertain): - Answers -Women with BRCA1 or BRCA2 gene mutations
Women with a first-degree relative with BRCA1 or BRCA2 gene mutations who have not as yet had genetic testing
Women with a lifetime risk of more than 25% as defined by risk assessment tools largely dependent on family history
Women who underwent radiation to the chest between ages 10-30 for Hodgkins disease
Women known to have a hereditary breast cancer syndrome, ie, Li Fraumeni, Cowden, and Bannayan-Riley-Ruvalcaba, and their first- degree relatives
Prevention Tertiary - Answers -Reduces the negative impact of an already established disease by restoring function and reducing disease- related complications.
e.g. Heart Failure ➢The definition of HF has now expanded to: ▪ HF with reduced ejection fraction (HFrEF, EF ≤40%) ▪ HF failure with preserved ejection fraction (HFpEF, EF ≥50%) ▪ HFpEF, borderline (EF 41-49%) ▪ HFpEF, improved (EF >40%)
A 74 yo female with New York Heart Association class II heart failure and a left ventricular ejection fraction of 34% is on optimal dosages of an ACE inhibitor, a β- blocker, and rosuvastatin (Crestor). Her past medical history is notable only for a long history of hypertension. She is a nonsmoker and reports that she has a small glass of blush wine with dinner each evening. On examination she has a blood pressure of 126/72 mm Hg and a BMI of 28.2 kg/m2. Her chest is clear and her cardiac examination
Which one of the following statements is true? - Answers -Wound irrigation with tap water has been shown to have comparable (if not lower) rates of wound infection than sterile saline.
Child abuse should be suspected in all of the following EXCEPT:
7-month-old with diffuse cerebral and retinal hemorrhages 2-year-old with 3 rib fractures after a fall 6-month-old with multiple lower ext bruises from falls 20-month-old with spiral fracture of distal tibia - Answers -20-month-old with spiral fracture of distal tibia
Toddler's fx MC fx in age 9 mos - 3 yrs BK walking cast x 3 weeks
Which of the following bites has the highest risk of infection?
A. Cat bite to the handB. Human bite to the face C. Dog bite to the thigh D. Spider bite to the arm - Answers -Cat Bite
53-80% with Pasteurella multocida RX: Amoxicillin-clavulanate
Human bite - Answers -RX: Amoxicillin-clavulanate x 5 days irrigate and avoid closure
Dog bite - Answers -• Primary closure - OK • +/- Amoxicillin-clavulanate
A 24 yo male presents with a 3-day history of a rash thatis increasing in size.- It is not (-) painful or tender.- It is flat, oval, 14 cm x 7 cm in size, has central clearing and has no fluctuance.
- No associated fever/chills or systemic symptoms.- No new medications. No recall of any insect bite.- He recently vacationed on Martha's Vineyard, MA. In this case, you would: - Answers -Prescribe doxycycline 100 mg BID x 10 days
A 64 yo male presents to the ED with diffuse pruritus and erythema along with facial and oral swelling.This occurred 15 minutes after eating peanuts.His blood pressure is 65/35 mm Hg, pulse is 120 bpm. The first medication this patient should receive is: - Answers -Epinephrine
A 21 yo college student presents to the ED with friends who report the student swallowed "a whole bottle" of acetaminophen 45 minutes before arrival. They also note the patient has been drinking alcohol. The patient is awake but appears intoxicated. Which of the following would be the best course of action: - Answers -Administer activated charcoal
charcoal for gastric decontaminaione for acute acetaminophen toxicity, N-acetylcysteine is the antidote after measuring the levels at 4 hours after ingestion if >150 mg/kg in system
A 62 yo obese male with diabetes and anemia presents to your office. Which of the following anemias could falsely elevate his A1c? - Answers -Iron deficiency anemia
−Falsely elevate: hypertriglyceridemia, hyperbilirubinemia, splenectomy, renal failure, iron deficiency anemia, aplastic anemia* (decrease erythrocytosis and increase lifespan of erythrocytes)−Falsely lower: HIV meds, liver disease, blood loss, hemolytic anemia, hemoglobin variants (decrease lifespan of erythrocytes - use fructosamine levels*)
DM diagnosis - Answers -•Hgb A1c ≥ 6.5% •Fasting plasma glucose ≥126 mg/dL (still the standard) •2-hr plasma glucose ≥200 mg/dL (75 g glucose load) •Random plasma glucose ≥ mg/dL with classic symptoms of hyperglycemia (polyuria, polydipsia)
Which of the following medications affects B12 levels, necessitating monitoring? - Answers -Metformin
•Check creatinine prior to use*
- Stop if GFR <30 mL/min; do not start if GFR <45 mL/min (theoretical risk of lactic acidosis) •Stop prior to IV contrast** and 48 hours after** (angiography/pyelography)
- Increased all-cause mortality if used in Stage 5 kidney disease •Check for B12 deficiency** (no defined interval)
55 yo with newly diagnosed DM and HTN with chronic renal failure and a creatinine of 2.4. Which medication would be the safest with regard to renal function? - Answers - Glipizide (Glucotrol)
A 43 yo Hispanic male with type 2 diabetes and a BMI of 45 is on metformin 1000 mg bid. His fasting sugars average 150 and his postprandial 220. A1c is 9%. Which of the following would improve his postprandial sugar and help with weight loss? - Answers - Exenatide (Byetta)
Which of the following medications would be outside the recommendations for a 15- year-old with type 2 diabetes, hypertension, and hyperlipidemia? - Answers -Sitagliptin (Januvia)
- 3 choices: metformin (type 2); liraglutide (type 2 to age 10); insulin* (type 1 or 2)
- Screening for complications in Type 1
