GENERAL HEALTH

Case 1 Health Maintenance:

- Health maintenance approach is employed to prevent future disease. In general, the approach is immunizations,
cancer screening, & screening for common diseases.
o Colon cancer should be initiated at 50 yrs & beyond.
o Influenza annually.
o Tetanus every 10 yrs.
- Purposes of the health-maintenance visit are to identify the individual patients health concerns, manage the
patients current medical conditions, identify the patients risks for future health problems, perform rational & cost-
effective health screening tests, & promote a healthy lifestyle.
- Primary prevention = intervention designed to prevent a disease before it occurs. [Statin reduce LDL, Remove
Colon Polps]
Q Normal: LDL range:

Q Remove Colon Polps = to prevent Colon Cancer development

- Secondary prevention = intervention intended to reduce the recurrence or exacerbation of a disease. [Ex: Statin
AFTER Pt has MIto reduce risk of 2nd MI]
- Effective screening for diseases or health conditions should meet several established criteria.
o Disease should be of high enough prevalence in the population.
o Time frame during which patient is asymptomatic, but disease/risk factor can be identified.
o Test needs to be available that has sufficient sensitivity & specificity, is cost-effective & acceptable to
patients.
o Intervention must be available do prevent disease or reduce mortality.
- USPSTF grades:
o A: strong evidence for intervention & strongly recommended.
o B: fair evidence for intervention and recommended.
o C: balance of benefits & potential harms are too close to justify making a recommendation.
o D: fair evidence that service is ineffective or harm outweighs benefits & service is not recommended.
o E: insufficient evidence.

Case 7 Tobacco Cessation:

- Tobacco use is the single greatest cause of preventable death. It is responsible for increased death rates from cancer,
cardiac, cerebrovascular, & chronic pulmonary disease.
- Smoking in pregnancy is associated w/ prematurity, intrauterine growth restriction, stillbirth, spontaneous abortion,
& infant death.
- The process of discussing tobacco use & cessation involves several steps; one useful framework is the five As:
o Ask about tobacco use.
o Advise to quite through clear personalized messages.
o Assess willingness to quit.
o Assist to quit.
o Arrange follow-up & support.
- A strategy to enhance motivation includes discussing the specific relevance to the patient of smoking cessation, risks
of ongoing tobacco use, rewards to quitting (financial, health, social), roadblocks to quitting (withdrawal,
discouragement b/c of failed past attempts, enjoyment of smoking), & repetition.
- Bupropion is a nonnicotine treatment for smoking cessation that works by blocking uptake of norepinephrine &/or
dopamine. It is contraindicated in patients w/ eating disorders, MAO inhibitor use in the last 2 weeks, or history of
seizure disorder.
- Varenicline is another nonnicotine treatment for smoking cessation. It is a nicotinic receptor partial agonist that may
reduce cravings for nicotine, reduce nicotine withdrawal symptoms, & block some of the binding of nicotine from
cigarettes.
o Side effects include neuropsychiatric symptoms, including changes in behavior, agitation, depression, &
suicidal behaviors.

Case 8 Medical Ethics:

- Ethical considerations when treating adolescent patients can be complex & one should use the moral principles of
ethics, which include autonomy, beneficence, nonmaleficence, & justice to guide clinical decisions to maintain
confidentiality.
- Respect for autonomy should involve respect for the patients wishes, choices, & beliefs when deciding what is best for
 the patient.
- Nonmaleficence implies that the physician will do nothing to harm the patient, which includes emotional &
psychological harm.
- The principle of beneficence requires action to further a patients welfare.
- Justice implies the fair & nonbiased treatment of the patient regardless of age, sex, or ethnicity.
- There are instances when it would be in the best interest of the patient to disclose medical information.
- It is mandatory that STI information be disclosed to partners. Partner notification can occur in either of 2 ways: by
patient referral or by the department of health staff.

Case 11 Health Maintenance in Adult Female:

- CVD are the #1 killer of women in the U.S. CVD risk factors are: HTN, high LDL, tobacco use, DM, family hx of CVD.
o All women > 18 yrs old should be screened for HTN.
o All women > 45 yrs old should be screened for lipid disorders.
- There are increased rates of adverse cardiovascular outcomes in women taking either estrogen alone or combined
estrogen & progesterone. These risks include an increased risk of coronary heart disease, stroke & venous
thromboembolic disease.
o Any use of hormone replacement should be of the lowest effective dose for the shortest effective time period.
- Mammography screening every 12-33 months has been shown to reduce mortality from breast cancer. The benefits
of routine mammographic screening increase w/ age, as the incidence of breast cancer is higher in older women.
o Most abnormalities found on mammography are not breast cancer but require further eval to make that
determination.
o USPSTF advises screening w/ mammography, beginning at the age of 40 for the general population w/ a
recommended interval of every 1-2 yrs.
- The incidence of cervical cancer has fallen dramatically since the introduction of the Pap smear as part of routine
screening.
o Most cases of cervical cancer occur in women who either have not been screened in over 5 yrs or did not have
follow-up after an abnormal Pap smear.
o USPSTF recommends against Pap smears for women who have had a hysterectomy.
- The purpose of the Pap smear is to detect precancerous cervical changes or possible cases of cervical cancer early, in
order to improve the odds of survival.
- Osteoporosis is a condition of decreased bone mineral density associated w/ an increased risk of fracture. Half of all
postmenopausal women will have an osteoporosis related fracture in their lifetime.
o Risk factors include: tobacco use, low body weight, Caucasian or Asian ancestry, family history of
osteoporosis, low calcium intake, & sedentary lifestyle.
- Screening for osteoporosis is done by measurement of bone density. Measurement of the hip bone density by DEXA is
the best predictor of hip fracture.
o Osteoporosis is present if the patients T-score is at or below -2.5; osteopenia is present if the T-score is
between -1.0 & -2.5.
o USPSTF recommends screening for osteoporosis via DEXA in women after the age of 65 & considering
screening in women aged more than 60 if at risk.
- It is recommended to ingest at least 1200 mg of Ca++ & 400-800 IU of vitamin D per day for all women over the age of
50. Weight-bearing & muscle strengthening exercise is also recommended both for its direct effects on increasing
bone density & for its benefits in strength, agility, & balance, which may reduce the risk of falls.
- Multiple factors are associated w/ intimate partner violence & include young age, low income status, pregnancy,
mental illness, alcohol or substance use by victims or partner, separated or divorced status, & a history of childhood
sexual/physical abuse.

Case 29 Adolescent Health Maintenance:

- The hallmark phys. Exam finding in HCM is a systolic murmur that decreases in intensity w/ the athlete in the supine
position (increased ventricular filling, decreased obstruction). This contrasts w/ functional outflow murmurs
common in athletes that increase in intensity upon lying down.
- HCM murmur increases w/ Valsalva maneuver (decreased ventricular filling, increased obstruction).
- Physicians who treat adolescent patients should have policies in place to ensure doctor-patient confidentiality while
balancing the parents right to be involved w/ the childs care.
- GAPS recommend counseling for both parents & adolescents.
o Parents should be guided on normal physical, sexual, & emotional development, signs of physical & emotional
problems, parenting behaviors to promote health, & methods to help their child avoid harmful behaviors.
o The adolescent patient should receive counseling annually on their growth & development, injury prevention,
healthy diet, exercise, & avoidance of harmful substances.
 o All adolescents should be screened annually for HTN, w/ further eval & treatment for those whose BP is
above the 90th percentile.
o Sexually active females should be screened for gonorrhea & Chlamydia by cervical sampling.
o Sexually active males should be screened for presumptive gonorrhea & Chlamydia infections by urine test for
leukocyte esterase.
- A preparticipation examination allows the physician to provide the comprehensive health maintenance, including
counseling, anticipatory guidance, screening & vaccinations, recommended in the GAPS guideline.
- The history is the most important tool in screening for congenital cardiac anomalies.
o The murmur of hypertrophic cardiomyopathy, while not always present, is best heard along the left sternal border
& accentuates w/ activities that decrease cardiac preload & end diastolic volume of the left ventricle.
o Any adolescent w/ stigmata of Marfan syndrome, a murmur suggestive of hypertrophic cardiomyopathy, w/ a
grade 3/6 or louder systolic murmur, or any diastolic murmur should be evaluated by a cardiologist prior to
clearance for athletic participation.
- Any patient w/ a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of hypertrophic
cardiomyopathy, or signs of Marfan syndrome should be evaluated by a cardiologist prior to clearance participate in
athletics.

Case 33 Obesity:
- Metabolic syndrome: a state of insulin resistance characterized by abdominal obesity, dyslipidemia, elevated BP, &
impaired fasting glucose.
- Obesity: an excessive amt of body fat, which increases the risk of medical illness & premature death.
- Satiation: level of fullness during a meal.
- Satiety: level of hunger after a meal.
- Recent data show that 33.3% of adult men, 35.3% of adult women, & 16% of 2- to 19-year-olds were obese.
- BMI is not an accurate measure of overweight/obesity in patients w/ heart failure, pregnant women, body builders, &
certain ethnic groups.
- Obesity is caused by ingesting more energy than is expended over a period of time. Energy balance is affected by both
genetic & environmental factors.
o Its estimated that genetic background can explain 40% or more of the variance in body mass in humans.
o An increase in energy consumption w/ a decrease in physical activity is thought to be the main contributor to the
current obesity epidemic.
- Treatment of obesity should begin in patients w/ a BMI greater than 25 or who have visceral obesity, documented by
increased waist circumference or a waist-to-hip ratio greater than 0.9 in men & greater than 0.85 in women.
o Developing a treatment plan for obesity is complex & should use a combination of dietary restrictions,
increased physical activity, & behavior therapy as a gold standard.
o A calorie deficit of 500 to 1000 cal/d produces a weight loss of 1 to 2 lb/week.
o Physical activity alone is not an effective method for achieving weight loss. Although increasing physical
activity is not effective for initial weight loss, physical activity is very important for long-term weight
management.
- The purpose of behavior modification therapy is to help patients identify & modify eating & physical activity habits that
contribute to obesity.
- Anorexieant medications increase satiation, satiety, or both, by affecting the monoamine system in the hypothalamus.
Increasing satiation results in a reduction in the amount of food eaten, whereas increasing satiety reduces the frequency of
eating.
- Only orlistat & sibutramine are indicated for long-term treatment of obesity.
- Patients w/ a BMI greater than 40, or greater than 35 w/ comorbid conditions, are potential candidates for surgical
treatment of obesity.
- Metabolic syndrome:
o Abdominal obesity, defined as a waist circumference in men greater than 40 in & in women greater than 35 in.
o Serum TGL greater than or equal to 150 mg/dL.
o Serum high-density lipoprotein cholesterol less than 40 mg/dL in men & less than 50 mg/dL in women. o
BP greater than or equal to 130/85 mm Hg.
o Fasting plasma glucose greater than or equal to 110 mg/dL.
Case 34 Migraine Headache:
- Characteristic classic migraine w/out aura symptoms are unilateral, throbbing in nature, & have been progressively
worse.
o Migraine headaches are the most common headaches of vascular origin. They typically cause recurrent
episodes of headache, nausea, & vomiting.
- Red Flag symptoms & signs in the eval of headache:
o Sudden-onset headache.
o Headaches increasing in severity & frequency. o
Headache beginning after age of 50 yrs.
o New-onset headache in pt w/ risk factors for HIV infection or cancer. o
Headache w/ signs of systemic illness (fever, stiff neck, rash).
o Focal neurologic signs or symptoms of disease (other than typical aura). o
Papilledema
o Headache subsequent to head trauma.
- Symptoms diagnostic of migraine headache include moderate to severe headache w/ a pulsating quality; unilateral
location; nausea &/or vomiting; photophobia; phonophobia; worsening w/ activity; multiple attacks lasting for 4 hrs
to 3 days; & the absence of history of physical exam findings that would make it likely that the headache is the result
of another cause.
- Migraine headaches: vascular headaches typically throbbing unilateral in character, & may be present w/ or w/out
aura. There is a high female predominance.
- Tension headache: typically presenting w/ pericranial muscle tenderness & a description of a bilateral bandlike
distribution of the pain.
- Cluster headache: unilateral headaches that may have a high male predominance, can be located in the orbital,
supraorbital, or temporal region. It is generally described as a deep, excruciating pain lasting from 15 min to 3 hrs.
These headaches are usually episodic; however a small subset may have chronic headaches.
- The role of the practitioner is to attempt to accurately diagnose the cause of the headache, rule out secondary causes
of headaches (red flags) that may signify a serious underlying pathology, provide appropriate acute management, &
assist w/ headache prevention when needed.
o The quality & characteristics of the headache & its specific location & radiation should be identified.
o The age at which the pt first developed the headaches, the frequency & duration of the headaches, & the amt
of disability & distress that is caused to the patient should be explored.
o It is also important to note what the patient has done to try to treat the headaches in the past.
- Identifying a focal neurologic deficit increases the likelihood of finding a significant CNS pathology as the cause of the
headache.
- The presence of rapidly increasing headache frequency or a history of either lack of coordination, focal neurologic
symptom, or headache awakening the patient from sleep, raises the likelihood of finding an abnormality on an
imaging test.
- The goal of therapy in migraine prophylaxis is a reduction in the severity & frequency of headache by 50% or more.
- Tension headache is the most prevalent form of primary headache disorder, typically presenting w/ a pericranial
muscle tenderness & a description of a bilateral bandlike distribution of pain.
o Initial medical therapy of episodic tension-type headache includes aspirin, acetaminophen, & NSAIDs.
- Cluster headache is strictly unilateral in location & can be located in the orbital, supraorbital, or temporal region.
Deep, excruciating pain lasting form 15 min to 3 hrs.
o Acute treatment of cluster headache involves 100% oxygen at 6 L/min, dihydroergotamine, & the triptans.

Case 36 Family Violence:

- Family violence includes child abuse, intimate partner violence, & elder abuse. The abuse that occurs can be physical,
sexual, emotional, psychological, or economic.
- Neglect: failure to provide the needs required for functioning or for the avoidance of harm.
- Physical abuse (battery): intentional physical actions that can cause injury or pain to another person.
- Family violence is an abuse of power, in which a more-powerful person exerts control over a less-powerful person or
persons.
- It is estimated that 1 to 4 million women are abused annually in the U.S. & that approximately 1 in 3 women are
abused at some time in their lives.
 - Certain situations increase the likelihood, or escalate the occurrences, of abuse. These situations include changes in
family life (i.e., pregnancy, illnesses, deaths), economic stresses, & substance abuse.
- The USPSTF recommends that all clinicians should be alert to physical & behavioral signs & symptoms associated w/
abuse & neglect, &t that direct questions about abuse are justifiable, due to high levels of undetected abuse in women
& the potential value of helping these patients.
- Victims of abuse may present to doctors frequently for health complaints or have physical symptoms that cannot
otherwise be explained. Delays in treatment for physical injuries may be a sign of IPV.
- When abuse is identified, an initial priority is to assess the safety of the home situation. Direct questioning regarding
increasing levels of violence, the presence of weapons in the home, as well as the need for a plan for safety for the
victim & others at home are critical.
- The laws regarding a clinician reporting of partner violence vary from state to state.
- Certain history & phys exam findings raise the suspicion for child abuse. Injuries that are inconsistent w/ the stated
history or a history that repeatedly changes w/ questioning should raise the suspicion of abuse. Children who are
taken to numerous different physicians or ERs, or who are brought in repeatedly w/ traumatic injuries, may be
victims. Delay in seeking medical care for an injury may also be a clue to abuse.
o Neglect is also a form of child abuse. Failure to provide for basic nutritional, healthcare, or safety needs may
be other forms of neglect.
- All 50 states require reporting of suspected child abuse to the appropriate authorities. Any health-care provider who
makes a good-faith report of suspected abuse or neglect is immune form any legal action, even if the investigation
reveals that no abuse occurred.
- Persons who are older, more cognitively & physically debilitated, & have less access to resources are more likely to be
abused or exploited. If feasible, it is helpful to interview the patient w/out the presence of the caregiver.

Case 9 Geriatric Anemia:

- The presence of epigastric & LUQ pain, along w/ long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs),
should also raise a flag for testing to rule out a bleeding ulcer.
- Anemia is a hemoglobin level < 12 g/dL in women & < 13 g/dL in men.
- There is wide variation in the rates of anemia in different ethnic & racial groups. The highest rates are in non-
Hispanic blacks & lowest in non-Hispanic whites.
- Fatigue, weakness, & dyspnea are symptoms that are commonly reported by elderly persons w/ anemia.
o Conjunctival pallor is recommended as a reliable sign of anemia in the elderly.
o Glossitis, decreased vibratory & positional senses, ataxia, paresthesia, confusion, dementia, & pearly gray hair
at an early age are signs suggestive of vitamin B12-deficiency anemia.
o Profound iron defiency may produce koilonychias.
o Jaundice & splenomegaly may be present.
- Initial workup of anemia should include a CBC w/ measurement of red blood cell (RBC) indices, a peripheral blood
smear, & a reticulocyte count.
- Most common cause of anemia w/ a low mean corpuscular volume (MCV), microcytic anemia, is iron deficiency.
o Iron deficiency should be confirmed by low serum iron, low ferritin, & high total iron-binding capacity (TIBC).
- Folate defiency anemia is usually seen in alcoholics, whereas B12-deficiency anemia usually occurs in people w/
pernicious anemia, a history of gastrectomy, diseases associated w/ malabsorption.
- In the elderly, anemia of chronic inflammation is the most common cause of normocytic anemia. In anemia of chronic
inflammation, the bodys iron stores are normal, but the capability of using the stored iron in the reticuloendothelial
system becomes decreased.
o Lack of improvement of symptoms & iron levels w/ iron supplementation are important clues indicating that
the cause is chronic disease & not iron depletion.
- The treatment of anemia is determined based on the type & cause of the anemia. Any cause of anemia that creates a
hemodynamic instability can be treated w/ a red blood cell transfusion. A Hb < 7 g/dL is a common threshold for
transfusion.
o A typical treatment is ferrous sulfate 325 mg 3 times a day.

Case 18 Geriatric Health Maintenance:

- Presbycusis: an age-related sensorineural hearing loss typically associated w/ both selective high frequency loss &
difficulty w/ speech discrimination.
- Preventative services for the elderly include as goals the optimization of quality of life, satisfaction w/ life, &
maintenance of independence & productivity.
- As estimated 25% of patients older than age 65 yrs have impairements in their instrumental activities of daily living
(IADL) or activities of daily living (ADL).
 o IADL: transportation, shopping, cooking, using the telephone, managing money, taking mediciations,
housecleaning, laundry.
o ADL: bathing, dressing, eating, transferring from bed to chair, continence, toileting.
- The incidence of presbyopia increases w/ age.
- Age-related macular degeneration (AMD) is the leading cause of severe vision loss in the elders. AMD is characterized
by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in loss of central vision.
- Cataract disease is the most common cause of blindness worldwide.
- Common causes of geriatric hearing impairments are presbycusis, noise-induced hearing loss, cerumen impaction,
otosclerosis, & central auditory processing disorder.
- Falls are the leading cause of nonfatal injuries in the elderly. Hip fractures are common precursors to functional
impairment & nursing home placement.
o Approximately 30% of the noninstitutionalized elderly fall each year.
- The combination of the clock draw & the three-item recall is a rapid & fairly reliable office-based screening for
dementia.
- Dementia is usually treatable & depressive symptoms are more common in the elderly. Have you felt
down/depressed/hopeless in the last 2 weeks? & Have you felt little interest or pleasure in doing things? shows
high sensitivity.
- A combination of serial weight measurements obtained in the office & inquiry about changing appetite are likely the
most useful methods of assessing nutritional status in the elderly.
- The incidence of stroke in older adults roughly doubles w/ each 10 years of age. The greatest risk factor is HTN
followed by atrial fibrillation.
- Osteoporosis risk factors: older age, female gender, white or Asian race, low calcium intake, smoking, excessive
alcohol use & chronic glucocorticoid use.
- Well-informed, competent adults have a right to refuse medical intervention, even if refusal is likely to result in death.
- Advanced directives are oral or written statements made by patients when they are competent that are intended to
guide care should they become incompetent.
- A durable power of attorney allows the patient to designate a surrogate decision maker. The responsibility of the
surrogate is to provide substituted judgment to decide as the patient would.
- Only approximately 15% of all patients who undergo CPR in the hospital survive to hospital discharge.

Case 43 Sting & Bite Injuries:

- Rapidly removing the stinger is preferable to taking the time to locate a scraping implement.
- Hymenoptera: order of insects which includes wasps, yellow jackets, hornets, honeybees, bumblebees, & fire ants, &
make up the majority of insect stings.
- Large local allergic reactions: redness or warmth of the skin at the area of insect sting, mediated by immunoglobulin
(Ig) E reactive to the hymenoptera venom.
o Large areas of redness & warmth develop over 24 to 48 hrs. These rxns are not infectious & will not respond
to antibiotic.
o These rxns are best treated w/ oral steroids initiated early after the sting.
- Almost all Hymenoptera stings will result in a local reaction, which includes redness, swelling, pain, & itching at the
site of the injury. These reactions tend to occur almost immediately & last for a few hrs.
 7

- Systematic rxns can vary from milder symptoms of nausea, generalized urticarial, or angioedema to
severe & life-threatening hypotension, shock & airway edema. Severe immediate hypersensitivity
rxns usually occur w/in minutes of the sting.
o ABCs, w/ intubation, IV access, & fluid resuscitation to 10 to 20 mg/kg as soon as possible.
o Subcutaneous or intramuscular injection of 0.3 to 0.5 mL of 1:1000 solution of epinephrine
should be given as quickly as possible.
- Local cleaning of the animal bite wound w/ soap & water, irrigation w/ saline, & debridement of
devitalized tissue should take place as soon as possible.
o Hand wounds tend to have an increased risk of infection.
o The primary closure of bite wounds is controversial & should be limited to lacerations less
than 24 hrs old. Deep puncture & wounds w/ signs of infection should not be primarily
closed.
- Although clear evidence of efficacy is lacking for dog & cat bites, current recommendations are
for antibiotic prophylaxis for 5 7 dys for patients w/ moderate to severe wounds from dog, cat,
or human bites.