PRESENTACIÓN DE DOCUMENTOS 1. El aspirante convocado para cubrir el

 Lifestyle changes, 3 month trial: decrease SAFA, increase fiber, exercise, wt loss, smoking cessation, moderation of ETOH  Treat HTN and DM

 Lab tests: HbA1c/glucose, Cr/urea, lytes, TSH, GGT

 Statins: slow cholesterol formation (atorvastatin 10-80mg PO daily)  S/E include: <5% experience myalgia, also some get hepatoxicity  C/I: pregnancy

 Monitor muscle enzymes and LFT (myopathy and hepatoxicity)  ALT, AST, CK at baseline, 6 weeks then q6mo

 Niacin, bile acid-binding resins, fibric acid derivatives, ezetimibe  Lipids followed q3months

35 yo M asking about HTN and its treatment. Counsel her.  SBP (contracting heart), DBP (relaxing heart)

 Normal is 120/80, HTN is >140/90 (DM 125/80, renal dz 130/80) of >2 office visits

 Can be white coat hypertesion, thus can also do ambulatory BP  Cause is likely artery hardening (but unknown), other secondary

causes are (Cushing's, pheo, aldosteronism, hyperthyroidism, cocaine, aortic coarctation, renal artery stenosis)

 Risk factors: age, obesity, sedentary lifestyle, stress, smoking, ETOH, high salt, family Hx

 Complications: stroke, blindness, heart attack, kidney failure 1. HPI

 History of BP, previous treatment

 Headache, weakness, visual problems, CP/SOB, claudication  Snoring, daytime somnolence, morning headaches (OSA)  Sweating, tremor, muscle weakness, tachycardia (pheo)  Heat intolerance, sweating palpitations, diarrhea (thyroid)  Thinning of skin (Cushing's), flank pain (kidney dz) 2. Meds/OTC/Allergies

 NSAIDs, cocaine, sodium 3. PMHx/Surgery/Hospitalization

 Sleep apnea

 DM, high cholesterol  Afib, heart failure, MI 4. Social Hx

 Smoking/ETOH/IVDU, cocaine  Work schedule

5. FamHx 6. Counselling:

 Lifestyle changes x3months (exercises, salt, smoking/ETOH cessation, stress reduction)

 Lab work: HbA1c, creatinine/GFR, lipids, U/A, uACR, ECG

 First line HCTZ or ACEi: diuretic that prevent body from retaining too much salt

 S/E: urination, dizziness, may increase blood sugars  F/U every 3 months

45yo F new to clinic with a history of Diabetes. Take a history. 1. HPI

 Type I/II, when diagnosed, glucometer, levels in AM/PM, HbA1c  Hunger, dizziness, tingling, concentration

 Polydipsia, polyuria, nocturia, polyphagia, wt loss

 Blurred vision, impotence, constipation, bloating (gastroparesis), orthostatic, feeling in feet

 CP/SOB, claudication 2. Meds/OTC/Allergies

 Insulin use

3. PMHx/Surgery/Hospitalization  Foot/eye care

 Retinopathy, nephropathy, neuropathy  CAD/CVD, stroke, HTN, dLp

 PCOS, gestational diabetes  Hospitalizations for DKA 4. Social Hx

 Smoking/ETOH/IVDU, occupation, diet, exercise 5. FamHx

 DM

6. Counselling

 Diabetes is a disease of glucose dysregulation

 What are risk factors? First degree relative, high risk population, hx of IGT/GDM. Vascular dz, overweight, HTN, dLp, PCOS, acanthosis nigricans.

 Lifestyle trial for 3 months, then medications.

 Firstline antihyperglycemic agents? Metformin, sulphonylurea, alpha-glucosidase inhibitor.

 Increases sensitvity of cells to insulin. OD/BID.

 A/E include nausea, diarrhea, abdo pain, weight loss, lactic acidosis  C/I: kidney dz, low BMI

 What are complications of diabetes? Neuropathy (impotence, constipation, diarrhea, gastroparesis, orthostatic hypotension, paresthetic feet), Retinopathy, Nephropathy, CVS, foot care, hospitalizations (DKA, hyperosmolar nonketotic coma, hypoglycemia).

PEP Questions

 What are screening guidelines? q3yrs >40yrs no risk factors.

 Diabetes: Symptoms + random glucose >11.1; FPG > 7.0; HbA1c > 6.5%

1yr M brought in by mother to discuss immunzations. Counsel her. 1. Education

 Prevent serious illnesses. It is safe, majority of babies get it.  Also prevents spread of disease. E.g. smallpox eliminated  “Does this make sense?” “Do you have any questions?”  Inj: cry, irritable, low-grade fever, local reaction. Fluids+Tylenol  If large swelling, or around lips/mouth, rash, call doctor immediately.  Rare: 1/1000 high-grade fever, seizure, call 911. 1/500,000

anaphylaxis.

 “The disease is more srs than the complication, thus we vaccinate.” 2. MMR and Autism

 Paper published in 1990s in NEJM. Since been discredited.  The study was very small and the outcomes were biased.  Several large-scale epidemiological studies found no evidence. 3. Summarize

 With your consent, you child will be vaccinated for these vaccines. The reason is to benefit your baby and prevent any harm, as well as for the interest of public health.

 Vaccines are safe. There are minor side-effects such as slight fever and irritability, use Tyelnol. If baby has severe reaction call doctor.  “Does this make sense?” “Do you have any questions?”

65yo M dx with Alzheimer's. Inform the patient and counsel him.

4 A's of Alzheimer's: amnesia, aphasia, apraxia, agnosia

SPIKES: setting, perception, invitation, knowledge, empathy, summarize

1. Setting

2. Perception (“before you tell, ask”)

 Is it ok to share important news, if they want someone here, their knowledge of the test

3. Invitation (obtaining patient's invitation)

 “Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?” 4. Knowledge: “Unfortunately I've got some bad news to tell you”

 Positive for Alzheimer's, form of dementia: memory loss, confusion, word finding difficulties, concentration, problems with paying bills, getting lost etc..

 Later changes include behavioral changes (sometimes aggressive, sometimes passive), hallucinations, needing help with

eating/bathing/dressing, incontinence, driving will become dangerous/cooking

 Patient asks “how did I get it?”

 Unknown mechanism, deposits in the brain, risks: age and family hx  No cure, medications improve memory, slow progression >10 years  Death is due to other illness (pneumonia, bladder/kidney infection,

complication of fall)

 Meds are trialed for 8 weeks and monitored for side effects  For other symptoms such as depression we have SSRIs  Asks patient if he has any questions

Empathy

 “I can see how upsetting this is to you.”

 “I guess anyone might have that same reaction.”  Asks patient about social supports (family, friends)  Offers to help tell family

Summarize

 Advises patient to think about getting financial affairs in order  Advises patient to think about drawing up an advanced directive  There are also support groups available for you and your family  F/U q3 months

35yo F wants to quit smoking. Counsel her. 1. HPI

 Quantify cigarette use, previous attempts, health concerns, why they want to quite (pre-contemplative, contemplative, preparation, action, maintenance, relapse)

 Pts knowledge of health risk; educates risks of smoking (stroke, heart attack, sexual impotence, COPD, lung cancer, infections, other cancers, costs)

 Benefits of quitting (heart health, costs, better exercise tolerance, better breathing)

3. Treatment

 Counsels on quitting with friends or joining support groups; Reassures the patient that it won't be easy; Advises that patient takes on another activity (chew gum)

 If failed, can try medications (Champix, wellbutrin, patch) Stages of Change

Precontemplation No intention to change behavior (4R's: reluctance, rebellion, resignation, rationalizations).

Tx: provide information and raise doubt

Contemplation Aware of problem, not made commitment (ambivalent) Tx: explore the “good and less good” things

Preparation Intending to change withing next month

Tx: help patient create their own plan and reinforce pros of changing

Action Making modifications to life

Tx: focus on success, reaffirm commitment Maintenance Prevent relapse

Tx: manage crises by reviewing progress that has been made

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