Thieme Review for the USMLE®: A WIN for Step 2 and 3 CK (eBook)
756 Seiten
Georg Thieme Verlag KG
978-1-63853-585-0 (ISBN)
1. Preventive Medicine
“Treatment without prevention is simply unsustainable.”
—Bill Gates
1.1 Types of Prevention
1.2 General Screening Recommendations in Adults
In a nutshell
●Patient’s age is very important for screening purposes.
○Is chlamydia screening recommended for a 27-year-old sexually active female patient with no risk factors? The answer is no.
○What if the patient’s age was 24? The answer is yes.
●Generally, preventive screening is stopped at the age of 70 to 80 years, or if life expectancy is less than 10 years.
●Do not screen a patient just because he/she requests it. Know the indications above.
Additional screening
All adults should be screened for depression, alcohol misuse, hypertension, obesity, and smoking at regular intervals.
Smoking cessation: patients who want to quit smoking, nicotine replacement therapy is recommended; use combination of nicotine patch plus gum, inhaler, or lozenges. Bupropion or varenicline (which decreases the urge to smoke) can also be considered.1
1 Varenicline is associated with higher rates of cardiovascular events. Avoid this in patients with cardiac conditions. Also, both varenicline and bupropion comes with black-box warning of increased risk of suicide. Consider this risk in patients with psychiatric conditions.
1.3 Preventive Management of Dyslipidemia
Start screening for dyslipidemia from 20 years of age, if patient has any of the following risk factor:
●Diabetes mellitus.
●Family history of dyslipidemia.
●Multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) (e.g., smoking and hypertension).
●Family history of coronary artery disease (CAD) in a male relative < 50 years or female relative < 60 years—termed as premature CAD.
●Obese patient.
If none of the above is present, begin screening for dyslipidemia at the age of 35 years in male and 45 years in females.
When to initiate statin therapy ?
aIf patient has any of following medical history, it is defined as Clinical ASCVD
•Cerebrovascular disease—history of ischemic stroke or transient ischemic attack.
•Peripheral vascular disease—history of claudication or vascular procedure.
•CAD—history of stable angina, acute coronary syndrome, or cardiovascular procedures.
bThe boards will not ask you what is high- or moderate-intensity dose for each statin (Just FYI- high intensity dose of atorvastatin is 40–80 mg).
cBenefits of statin therapy may be less clear in the following patients: age < 45 or > 75, or with low-density lipoprotein (LDL) levels of < 70 mg/dL.
dASCVD score is a composite number calculated using following risk factors: age, gender, hypertension (controlled or uncontrolled), diabetes mellitus, race, cigarette smoking, and high-density lipoprotein. A 10-year risk score is used for dyslipidemia management. (The boards will not ask you to calculate ASCVD score, or what conditions are factored in 10-year ASCVD risk-score will be provided in the question itself).
MRS
The magic number is 75. Age cutoffis 75 and ASCVD score cutoffis 7.5.
Clinical Case Scenarios
Let us try some clinical case scenarios (CCS) using the above-mentioned guidelines: what is the next step in management (NSIM) regarding statin therapy in each of the following CCS?
1.A 60-year-old male has history of intermittent claudication. Total LDL is 100 mg/dL. What intensity of statin therapy is recommended?
2.What if the patient’s age was 76?
3.A 65-year-old male is diagnosed with type 2 diabetes mellitus. Total LDL is 90 mg/dL. ASCVD score is 7.5.
4.What if the patient in question 3 had an ASCVD of 6.5?
5.A 39-year-old male with no history of clinical ASCVD and no history of diabetes has an LDL of 140 mg/dL.
1.4 Statin Therapy
Mechanism of action: statins (atorvastatin, simvastatin, pravastatin, etc.) are very good drugs to lower the LDL levels. They work by inhibiting HMG-CoA (hydroxymethylglutaryl-coenzyme A) reductase enzyme, the rate-limiting enzyme for biosynthesis of cholesterol. They have also been shown to stabilize atherosclerotic plaques.
Side effects
| Presentation | Management |
| Myopathyb | Generalized muscle pain ± increase in serum creatine kinase level | Discontinue statin and check thyroid-stimulating hormone (TSH)a |
| Hepatotoxicityb | ↑ ALT/AST (alanine aminotransferase/aspartate aminotransferase) ± jaundice | If patient develops ALT elevation > 3 times the upper limit of normal, NSIM is to lower the statin dose or change medication |
| aThere’s increased incidence of myopathy with associated conditions like hypothyroidism and coadministration of fibrates. bCheck TSH and LFTs (liver function tests) prior to initiating statins |
1.5 Adult Vaccination2
2 Vaccination is one of the greatest achievements of modern medicine. All patients should receive specific vaccination in a timely fashion.
| Vaccine | Indications |
| Infl uenza | All patients ≥ 6 months of age should receive yearly fl u vaccine |
| Tetanus diphtheria (TD) | Every 10 years |
| Tetanus diphtheria and acellular pertussis (TDaP) | •All adults ≥ 19 years of age should receive TDaP vaccine once •TDaP must be given during each pregnancy •Health care workers and adults who have close contact with infants (<12 months of age) should receive one-time booster of TDaP regardless of the timing of the last booster •When TDaP is given, it becomes a substitute for TD |
| Vaccine | Indications |
| Human papilloma virus (9-valent) | All male patients 11–21 years of age All female patients 11–26 years of age In males who have sex with males, vaccination can be given up until 26 years of age Two to three doses are given |
| Measles, mumps, rubella (MMR) | All adults without documented vaccination or immunity; once is enough Booster dose is recommended in health care workers, college students and after exposure |
| Meningococcal | Adolescents, persons living in dormitories, HIV, and asplenia |
| Varicella | See pneumococcal vaccine section for further details. |
| Recombinant zoster for prevention of shinglesa | Adults aged ≥ 50 (given twice) |
| Pneumococcal vaccine | All healthy adults aged ≥ 65. (See pneumococcal vaccine section for further details.) |
| Hepatitis A | Chronic liver disease and risk factors for STD |
| Hepatitis B | Chronic liver disease and risk factors for STD Additional indications would include health care workers, household contacts of a patient with hepatitis B, patients with end-stage renal disease, diabetics who are <60 years old, and anyone who requests this vaccination |
| aThis is a new recombinant zoster vaccine. Unlike varicella vaccine, there is no need to determine the history of chicken pox, shingles, or to check antibodies. |
MRS
There is 11 in papilloma.
1.5.1 Influenza Vaccine
In the United States, flu vaccine is administered annually from October to May, which is the flu season.
There are two common forms of flu vaccine—intramuscular inactivated vaccine (IIV) and live-attenuated intranasal vaccine (LAIV). There is no specific preference between the two, but know that LAIV is not recommended in the following...
| Erscheint lt. Verlag | 7.7.2021 |
|---|---|
| Verlagsort | Stuttgart |
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Allgemeines / Lexika |
| Medizin / Pharmazie ► Medizinische Fachgebiete | |
| Medizin / Pharmazie ► Studium | |
| Schlagworte | board prep • COMLEX • Exams • Medical • Step 2 • Step 3 • Test Prep • USMLE |
| ISBN-10 | 1-63853-585-X / 163853585X |
| ISBN-13 | 978-1-63853-585-0 / 9781638535850 |
| Haben Sie eine Frage zum Produkt? |
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