Prevention Health Promotion Immunization Study Guide

PREVENTION/HEALTH PROMOTION/IMMUNIZATION LEVEL OF PREVENTION ➢ PRIMARY o Goal: preventing the health problem, the most cost-effective form of healthcare o Example: immunizations, counseling about safety, injury and disease prevention ➢ SECONDARY o Goal: detecting disease in early, asymptomatic, or preclinical state to minimize its impact o Example: screening tests, such as BP check, mammography, colonoscopy, ASA in hx MI ➢ TERTIARY o Goal: minimizing negative disease induced outcomes o Example: in established disease, adjusting therapy to avoid further target organ damage. Potentially viewed as a failure of primary prevention, support groups IMMUNIZATION PRINCIPLES ➢ Community (herd immunity) o Immunize those who can be to protect those who cannot be immunized ➢ Active immunity o Resistance developed in response to an antigen (either infection or vaccine) ➢ Passive immunity o Immunity conferred by an antibody produced in another host (infant of mother or immune globulin Immunize unless sending to the hospital in an ambulance SMOKING - PACK YEAR HX HX of Anaphylactic reaction Neomycin Streptomycin, polymyxin B, neomycin Baker’s yeast Gelatin, neomycin Gelatin Immunization to avoid IPV, MMR, varicella IPV, smallpox Hepatitis B Varicella zoster MMR Previously unvaccinated adults age 19-59 with diabetes should be vaccinated against Hepatitis B Number of packs-per-day (PPD) Multiplied by # of years smoked 5 A’S OF SMOKING CESSATION 1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to make a quit attempt 4. Assist in quit attempt 5. Arrange follow-up o MMR ▪ Patients born before 1957 have likelihood of immunity due to natural infection ▪ Two doses 1 month apart for those never immunized o Varicella o Zostavax o Intranasal Flu Mist ➢ Avoid these with Pregnancy, immune suppression and with HIV (CD4 count < 200) – case by case situation ➢ Rotavirus o Avoid with SCID (severe combined immunodeficiency) HEPATITIS B ➢ Chronic Hep B can lead to hepatocellular carcinoma, cirrhosis and continuedinfectivity ➢ Childhood Hep B vaccines began in 1982 ➢ 3 dose series 0, 1, 6 months ➢ If not vaccinated and exposed – HBIG and series ➢ If vaccinated and exposed –single dose vaccine PNEUMOCOCCAL IMMUNIZATION ➢ PCV13 associated with greater immunogenicity ➢ PPSV23 not licensed for children under 2 ➢ Indications: chronic lung disease, chronic cardiovascular disease, diabetes, chronic liver disease, chronic alcohol abuse, smokers, malignancy, chronic renal failure, asplenia, sickle cell, immunocompromised, HIV. ➢ PCV13 followed by PPSV23 one year later and then again at 65 o Exception: HIV (8 weeks later) ➢ If PPSV23 before age 65, repeat in 5 years PREVENTION/HEALTH PROMOTION/IMMUNIZATION SMALLPOX ➢ Caused by variola virus ➢ Infective droplets – contagious during fever, but most contagious during rash o Contagious until last scab falls off ➢ Stopped vaccinating in 1972 ➢ Incubation period 7-17 days ➢ Prodromal stage – fever, malaise, headaches, body aches ➢ Rash starts on face > arms/legs > hands/feet o All lesions within same phase and spreads within 24 hours ➢ Vaccination within 3 days of exposure reduces severity ➢ Vaccinia – unique immunization method o 2-pronged needle dipped into vaccine and then pricks skin POLIOVIRUS ➢ Transmission is fecal-oral SENSITIVITY AND SPECIFICITY ➢ Sensitivity –ability of a test to detect a person who has disease (SEN rule in) ➢ Specificity –ability of a test to detect a person who is healthy (SPOUT – rule out) ➢ Live virus; 2 dose series starting > 1 year of age ➢ Although highly protective, mild cases of chicken pox have been associated with the disease ➢ Varicella antibody titers should be ordered on a healthcare worker who had chicken pox as a child ➢ Varicella Zoster Immune Globulin (VZIG) is made of pooled blood product with excellent safety rating (given if contraindications for vaccine) ➢ Pregnant women without immunity should be vaccinated with two doses after giving birth ➢ Varicella is transmitted via droplet ➢ Vaccination within 3-5 days of exposure has shown benefits to reduce disease ➢ PRECONTEMPLATION o Not interested or minimalizes ➢ CONTEMPLATION o Considering change, looks at positive and negative, feels 10% ASCVD ➢ Breast Cancer o Mammography age 50-74 (every 2 years) o Risk factors (start age 40 or BRCA1/2) ▪ Previous hx of breast cancer ▪ >2 first-degree relatives ▪ Early menarche, late menopause, nulliparity ▪ obesity ➢ Cervical Cancer o Age 21 – screen every 3 years o Age 30 – screen with HPV every 5 years o Hysterectomy with removal of cervix – only need screening if hysterectomy due to cervical cancer o Stop screening at age 65 o Risk factors: ▪ Multiple sex partners ▪ Younger age at onset of sex ▪ Immunosuppression and smoker ➢ Colorectal Cancer o Start age 50-75 ▪ Colonoscopy every 10 years ▪ Flex sigmoidoscopy or CT colonography every 5 years ▪ FOBT (3 consecutive stool samples) annually ▪ New Cologuard o Risk Factors ▪ Familial polyposis ▪ First degree relative w/ colon CA ▪ Crohn’s (ulcerativecolitis) ➢ Prostate Cancer o Benefits of PSA screening do not outweigh the disadvantages o Risk factors: ▪ Age > 50 ▪ African ancestry ▪ First degree relative ➢ Ovarian Cancer o Routine screening not recommended o BRCA1/BRCA2 mutations – refer to specialist ➢ Skin Cancer Counseling o Recommend for those with fair skin ➢ Abdominal Aortic Aneurysm o Men age 65-75 who have smoked o One-time ultrasound ➢ Lipid Disorders o Start low – moderate statin when all: ▪ Age 40-74 ▪ CVD risk factor ▪ ASCVD > 10% ➢ Lung Cancer o Smoke 30 pack-years or quit in last 15 years o Age 55-80 (annual screening with CT) OVARIAN CANCER ➢ No recommendation for routine screening ➢ In postmenopausal women with palpable ovary o Intravaginal ultrasound and CA-125 ➢ Strongest risk factor is BRCA1 or BRCA2 ➢ Other risk factors include age, obesity, Clomid use or endometriosis ➢ Prostate/testicular cancer screening not recommended CANCER PREVALENCE ➢ Skin cancer is most common cancer o Basal cell carcinoma o Melanoma highest mortality ➢ Men – prostate cancer ➢ Women – breast cancer ➢ Gynecological o Uterine/endometrial o Ovarian ➢ Children – acute lymphoblastic leukemia (ALL) MORTALITY ➢ Leading cause of death (all ages) o Heart disease o Cancer ▪ Men (lung, prostate, colorectal) ▪ Women (lung, breast, colorectal) o Chronic respiratory ADOLESCENTS ➢ Death rate for teen males is higher than females o Accidents (MVC most common) o Suicide o Homicide PHARMACOLOGY DRUG -DRUG INTERACTION http://medicine.iupui.edu/clinpharm/ddis/clinical -table/ Substrates: drugs that are metabolized as substrates by the enzyme o CYP450 3A4 substrates: Sildenafil, Atorvastatin, simvastatin, venlafaxine, alprazolam o CYP450 ³ by 30% after age 70 Inhibitors: drugs that prevent the enzyme from concentration) metabolizing the substrates (± drug o Macrolides (Clarithromycin, Erythromycin) – can lead to substrate induced toxicity (Ex: atorvastatin 20mg may be like 300mg) o Antifungals (ketoconazole, fluconazole) o Cisapride (propulsid – no longer in US) o Cimetidine (Tagamet) o Citalopram (Celexa) o Grapefruit (statins, erythromycin, calcium channel blocker, antivirals, amiodarone, benzodiazepines, Cisapride, carbamazepine, buspirone) Activators: drugs that increase the enzyme's ability to metabolize the substrates (³ drug) o St John’s wort - antiretrovirals, contraceptives and cyclosporine; Also lead to Serotonin syndrome when combined with SSRI, SSNI FIRST-PASS EFFECT ➢ Drug is swallowed and absorbed into small intestine where it enters portal circulation o Once in liver the CYP450 is responsible for biotransformation ➢ Drugs with extensive first-pass metabolism cannot be taken orally. o Insulin ➢ CYP450 can be induced (increase drug metabolism) or inhibited (slow down drug metabolism) o Biotransformation also includes kidneys, GI tract and lungs SAFETY ISSUES ➢ Avoid in heart failure, GI bleeding, kidney disease o Inhibit prostaglandin synthesis – we need prostaglandins to keep things running smoothly o Long term use – document informed consent such as ± risk of MI, stroke, emboli, GI bleed, acute renal failure o Consider PPI, H2RA, Misoprostol PHARM FACTS ➢ Pharmacokinetics – absorption, distribution, metabolism, elimination of a drug ➢ Pharmacodynamics – biochemical and physiological effects of drugs on the body or disease (this does not change as a personages) NARROW THERAPEUTIC INDEX DRUGS ➢ Warfarin – monitor INR o Sulfa drugs elevate INR o Interacts with 65 ➢ Antibiotic use within the last month o 3 months for pneumonia ➢ Hospitalization within 5 days ➢ Comorbidities ➢ Immunocompromised CEPHALOSPORIN ➢ 1st generation: Gram +; Beta-lactam; Cephalexin, Cefadroxil Group A Strep, S. aureus – not MRSA – Keflex (pregnancy UTI, cellulitis, impetigo) ➢ 2nd generation: Gram +/- Broad spectrum – Ceftin, Cefzil –otitis media, rhinosinusitis, CAP, chronic bronchitis ➢ 3rd generation: Gram – with weak Gram +; Betalactam; Cefixime ➢ Extended 3rd generation: Gram +/-; Beta-lactam; Rocephin, Cefdinir – gonorrhea, PID, pyelonephritis, otitis media Cross reactivity between PCN and cephalosporin usually occurs with 1st generation PENICILLIN ➢ Diarrhea, C. Diff, Vaginitis, StevensJohnson syndrome ➢ Avoid amoxicillin for patients with mono (generalized rash) ➢ Dicloxacillin – mastitis & impetigo ➢ Anaphylaxis and angioedema are type 1 IgE ➢ PCN allergic: macrolides AUGMENTIN Gram +/-, beta-lactamase. NO MRSA High-dose 3-4g/day amoxicillin needed for drug-resistant Strep pneumoniae (DRSP) Clavulanate as beta-lactamase inhibitor so amoxicillin can work on H. influenzae, M. catarrhalis FLUOROQUINOLONES Cipro: Gram -; atypical pathogens Levaquin: Gram +/-; Atypical, DRSP Achilles Tendon rupture (esp. with steroid use ➢ Contraindicated – less than 18, pregnancy, breast feeding, myasthenia gravis QT prolongation, hypoglycemia ANTIBIOTIC THERAPY/PHARMACOLOGY SULFONAMIDE Gram -; MRSA; NO STREP, NO E COLI Contraindications o G6PD anemia causes hemolysis o Newborns and infants < 2 months HIV patients are high risk for Stevens-Johnson MEDICATIONS THAT REQUIRE EYE EXAM ➢ Digoxin (yellow to green, blurred vision, halos if blood level too high) ➢ Ethambutol and linezolid (optic neuropathy) ➢ Corticosteroids (cataracts, glaucoma, optic neuritis) ➢ Fluoroquinolones (retinal detachment) ➢ Viagra, Cialis, Levitra (cataracts, blurredvision, ischemic optic neuropathy, others) ➢ Accutane (cataracts, decreased night vision) ➢ Topamax (acute angle-closure glaucoma, increased intracranial pressure, mydriasis) ➢ Plaquenil (neuropathy and permanent loss of vision) SOUTHEAST ASIAN CULTURE ➢ Vietnamese, Hmong, Filipinos ➢ Pt may have difficulty verbalizing questions about treatment ➢ May consult family about major health decisions ➢ Will not tell provider if not compliant ➢ Would never verbalize disagreement in loud voice – have high regard for physicians ➢ Imbalance of hot and cold (yin/yang) ➢ Male is head of house ➢ Alpha thalassemia is common in Asians, Filipino ➢ View surgery as last resort ➢ Infants and small children may wear amulet RANDOM HERB FACTS BETA-LACTAMS ➢ Penicillin – Penicillin, Amoxicillin, dicloxacillin, ampicillin and others ➢ Cephalosporin – ceph- or cef- prefix ➢ Carbapenem – imipenem usually given with cilastatin ➢ Monobactam – aztreonam ➢ High rate of allergic reactions NITROFURANTOIN ➢ Urinary pathogens ➢ Echinacea – immunological effects ➢ Black cohosh, roasted soy beans –acts similar to estrogen for some people ➢ Kava Kava - anxiety ➢ St John’swort– depression o interacts with oral contraceptives, cyclosporine and select antiretrovirals ➢ Saw Palmetto – BPH ➢ Fish oil and ginseng can cause bleeding ➢ Milk thistle – lower cholesterol, liver problems and diabetes VITAMIN D DEFICIENCY METRONIDAZOLE (FLAGYL) ➢ ➢ Anaerobes ➢ FOOD FACTS ➢ Tetracycline and dairy interact ➢ Avoid MAOI and high tyramine containing foods (fermented foods) ➢ Eat salmon and omega-3 for heart disease; plant sterols and stanols reduce cholesterol ➢ Collard greens are high in vitamin K ➢ Magnesium - decreases BP and dilates blood vessels (nuts, beans, wheat, laxatives) ➢ Potassium – decreases BP – most fruits, leafy greens and nuts ➢ Non-dairy calcium includes: tofu, spinach and sardines ➢ Celiac Disease - Avoid gluten, wheat, rye, barley, oats. Gluten free foods: corn, rice, potato, quinoa, tapioca, soybeans ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ Vitamin D inhibits abnormal cellular growth; encourages reabsorption and metabolism of calcium and phosphorus; reduces inflammation Skin exposure to sun produces greatest values Someone taking phenytoin needs 2-5x vitamin D Symptoms of vitamin d deficiency o Rickets, osteomalacia, antigravity muscle weakness 25-hydroxyvitamin D is lab measurement A child must drink 32 oz of milk daily to receive recommended 400 IU (infants) of daily vitamin D 600 IU for those age 1-70 including pregnant; 800 IU > 70 Darker skin tones synthesize less vitamin D Sunscreen increase risk of vitamin d deficiency Vitamin d deficiency is common in hepatic, renal and after gastric bypass. Vitamin D3 is preferred form o 50,000 IU per week x 8 weeks o 1000-2000 daily HEENT - EYES 1. ➢ Macula – responsible for central vision ➢ Optic Disc – shaped like saucer with indentation where cup goes (balance between intraocular and intracranial pressure) – should be sharp with cup to disc ratio < 0.5 ➢ Veins pulsate and are prominent ➢ Papilledema – optic disc swollen withblurred edges due to ± ICP; absent vein pulsations 2. 3. 4. ➢ ➢ ➢ ➢ ➢ ➢ ➢ Angle closure glaucoma -deeply cupped disc –b/c too much intraocular pressure (cup ratio > 0.5) ➢ Hypertensive Retinopathy o o o Copper and silver wire arterioles (hard) AV nicking – artery crosses over vein (atherosclerosis in eye) Flame hemorrhages Visual Acuity - with any eye complaint o OU (both) OD (right) OS (left) o Two-line difference between each eye o Can miss up to 2 letters on each line o 20/200 is considered legally blind o By age 6 child can see 20/20 Slit-lamp or binocular loupe - evaluation of anterior eye, including cornea, conjunctiva, sclera and iris o Penlight and do 180 Fluorescein staining Lid Eversion Near vision – ask patient to read small print Triad of ophthalmologic emergency o Red eye, painful eye, new-onset vision change Presbyopia – gradual, age-related loss of eyes’ ability to accommodate stiffening of the lens; unable focus actively on nearby objects; starts around age 40 Amsler grid test – early detection of macular degeneration Tonometry – measures IOP, glaucoma screening test If a protruding object is found – it should not be removed ➢ Diabetic Retinopathy o Microaneurysms o Cotton wool spools (nerve reels dying) o Flame hemorrhages ➢ Chronic steroids, trauma, aging, sunlight, tobacco ➢ Opacity of lens of eye which can be central or on the sides ➢ Difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision ➢ Absent red reflex ➢ Retinoblastoma – leukocoria – white reflex TERMINOLOGY ➢ Palpebral conjunctiva – mucosal lining inside eyelids ➢ Bulbar conjunctiva – mucosal lining covering eyes ➢ Hyperopia – farsighted – distance vision intact, but near vision is blurry ➢ Myopia – nearsighted – near vision is intact, but distance vision is blurry ➢ Xanthelasmas – yellow plaque on the inner canthus – 50% of people have elevated lipids ➢ Uveitis – occasionally dull painful red eye with vision changes, pupil is constricted, nonreactive and irregularly shaped. Tx with pupil dilation, corticosteroids, evaluate underlying cause (autoimmune) HEENT CHEILOSIS LYMPH NODES ➢ ➢ Cancerous nodes are non-tender Tender nodes indicate infection ➢ Gums may be red and swollen due to gingivitis or taking Dilantin ➢ Salivary glands – parotid, submandibular and sublingual ➢ Painful skin fissures and maceration at corner of mouth o Over salivation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma o Remove underlying cause o If yeast – treat with azole ointment BID o If staph – treat with mupirocin ointment BID o When infection clear, use barrier cream at night ▪ Zinc ▪ Petroleum jelly ORAL CANCER ➢ ➢ ➢ ➢ Ulcerated lesion with indurated margins Relatively fixed submandibular nodes Squamous cell cancer is most common form Risk factors include male gender, advanced age, tobacco and alcohol abuse, HPV type 16 ➢ Screening is recommended at every dental visit ➢ Sialadenitis – swelling to side of face (mumps) ➢ Sialolithiasis – calculi or stone – painful lump under tongue - ± fluids, moist heat, NSAIDs, antibiotics if infected, surgery to remove stone ➢ Torus palatinus – painless bony protuberance midline on hard palate RED EYE COMPLAINTS ➢ Send to ophthalmology o Change in vision o FB sensation with inability to keep eye open o Photophobic ➢ Keep FB sensation, scratchy, gritty o Pink eye DACROCYSTITIS ➢ Infection of lacrimal sac/tear duct usually caused by blockage ➢ Common in infants, adults > 40 ➢ Thick eye discharge, pain, redness, swelling, warmth of lower eyelid, watery eye, excess tears ➢ Treatment: lacrimal sac massage (downward towards mouth) 2-3 times daily, antibiotics 7-10 days NOSE ➢ Small-sized red papules white centers inside cheeks ➢ Only inferior nasal turbinates are seen ➢ Pale, boggy, bluish nasal turbinates are seen in allergic rhinitis ➢ Sinus cavities – frontal appear by age 5 and sphenoid by age 12 ➢ Rhinitis Medicamentosa - Prolonged use (> 3 days) of topical nasal constrictor/decongestants HEENT EAR Location Cause Weber Result – tuning fork on forehead Rinne Result – mastoid then front of ear Treatment Conductive Outer or middle ear Sound is being blocked (earwax, foreign objective, damaged eardrum, serous otitis media, bone abnormality – cholesteatoma) Sound lateralizes to affected ear (buzzing sound heard louder in affected ear) – otitis media, ceruminosis, perforation of TM Negative (BC > AC) Sensorineural Inner ear Inner ear or nerve becomes damaged (advanced age, ototoxic medications, immune disorders, trauma) Sound lateralizes to unaffected ear (buzzing sound not at all in affected ear- numbness) – Presbycusis Meniere’s disease Normal (AC > BC) or positive **can hear longer in front of ear than on mastoid bone Hearing aids or cochlear implants possible options with expert communication Often self-resolves post cerumen impaction removal, post URI or AOM resolution. Rarely, further pharmacologic or surgical intervention is needed **Temporary **Permanent ➢ Acoustic nerve or CN VIII Vestibulocochlear – Auditory ➢ Presbycusis – age related hearing loss; difficulty appreciating content in noisy environment ➢ S. pneumoniae –usually causes most significant symptoms and is least likely to resolve without antibiotics o Resistance to low dose amoxicillin, certain cephalosporins and macrolides o Mechanism of resistance is alteration of intracellular protein-binding sites ▪ Use high dose amoxicillin and select cephalosporins o Risk factor is recent antibiotic use ➢ H. influenza and M. catarrhalis o Gram negative capable of producing beta lactam ring o High rate of spontaneous resolution o H. influenza is most common found in mucoid and serous middle ear infection ➢ Treatment o No recent antibiotics ▪ Amoxicillin high dose TID ▪ Augmentin BID ▪ Cefdinir o Recent antibiotic use ▪ Augmentin BID ▪ Levofloxacin or Moxifloxacin ➢ Otitis Media with Effusion o Symptomatic treatment o Can last 8 weeks ➢ Bones – Malleus, incus and stapes ➢ Tympanogram –test for presence of fluid inside middle ear (straight line vs peaked shape) ➢ Pinna injuries – refer to plastics ➢ Tragus – small cartilage flap of tissue in front of ear ➢ Ceruminosis – carbamide peroxide HEENT EMERGENCIES Name Herpes Keratitis Cause Herpes simplex (Herpes Simplex Keratitis) or herpes varicella zoster (Herpes Zoster Ophthalmicus) Signs/Symptoms Acute onset of severe eye pain, photophobia, tearing and blurred vision in one eye Herpes Zoster Ophthalmicus – acute crusty rashes that follow ophthalmic branch (CN V) of trigeminal nerve (one side forehead, eyelids and tip of nose) can result in blindness Elderly patient with acute onset of severe eye pain with redness and vision changes. Accompanied by headache, N/V, halos around lights and decreased vision. Acute AngleClosure Glaucoma Diagnostics Fluorescein dye Fern like lines in corneal surface (corneal abrasions are round or irregularly shaped) Treatments Refer to ED Infection permanently damages corneal epithelium – corneal blindness Refer to ED Ophthalmological emergency 2 nd leading cause of blindness Risk factors: Asian ethnicity, female gender, far-sightedness Mid-dilated pupil oval shaped. Cornea appears cloudy. Funduscopic exam reveals mid-dilated cupping of optic nerve Angle (door) closing in eye – pain Young adult female with new or intermittent loss of vision of one eye alone or accompanied by nystagmus or other abnormal eye movements. (aphasia, paresthesia, abnormal gait, spasticity). Daily fatigue upon awakening that worsens as day goes on. Heat exacerbates symptoms. Has recurrent episodes. Acute onset of erythematous swollen eyelid with proptosis (bulging of eyeball) and eye pain on affected side. Unable to perform ROM of eyes. Abnormal EOM with pain on eye movement. Hx of recent rhinosinusitis or URI Optic Neuritis Multiple Sclerosis Orbital Cellulitis Acute bacterial infection of orbital contents Retinal Detachment Risk factors: myopia, cataract surgery, diabetic retinopathy, hx of retinal detachment, older age, trauma Sudden onset of shower of floaters associated with looking through a curtain sensation with sudden flashes of light (photopsia). Associated symptoms include unilateral photophobia, wavy distortion of an object. Keratinizing squamous epithelium Cauliflower like growth accompanied by foulsmelling ear discharge. Hearing loss on affected ear. No tympanic membrane or ossicles are visible because of destruction by tumor. Hx of chronic otitis media infection. Mass is not cancerous but can erode into bones of face and damage facial nerve (CN VII) Cholesteatoma Concerns Refer to neurologist Refer to ED Refer to ED Refer to otolaryngologist. Treated with antibiotics and surgical debridement More common in young children