AAFP Flashcards
Midshaft posteromedial tibial stress fx
- he can walk without pain, but NOT run without pain
Air stirrup leg brace
Decreased sexual desire, spontaneous erections, reduced beard growth
test for total testosterone (late-onset male hypogonadism)
Hypothyroid pt taking levo, TSH 0.2 (0.5-5.0). Next most appropriate step?
Decrease levo dosage
Sharp, searing, severe heel pain. Worst after prolong sitting, in the morning getting out of bed. Gets better with walking, but worst at end of day. Works as floor nurse, on feet all day. PE: point tenderness on plantar surface of heel at medial calcaneal tuberosity. How to treat? Dx?
Over-the-counter heel inserts
Plantar fasciitis
3yo infant, 3 day h/o fever and refusal to eat. Oral ulcers on buccal mucosa, soft palate, tongue, and lips. Cervical LAD. No rash. Tx? Dx?
Acyclovir suspension
HSV-1
ABD sxs w/ vesicular rash
Celiac sprue
Absolute contraindications for ECT?
None
MC cause of refractory HTN?
Primary Hyperaldosteronism
measure plasma aldosterone/renin ratio
ratio >20 and aldosterone >15 ng/dL
Sxs of CAP in child
Who are most susceptible
when is outpatient okay?
How to treat?
fever, cyanosis, any respiratory findings
<2 yo attending daycare
no signs of toxicity, hypoxemia, respiratory distress, or dehydration
Strep Pneumo MC –> high-dose amoxicillin
When to introduce solid foods?
4-6 months
Extrusion reflex (pushing foreign material out of mouth with tongue)
Soccer player, sudden cutting maneuver, right foot planted and ankle locked she felt her knee pop. She has moderate pain and swelling, loss knee hyperextension. Which test is abnormal?
Lachman test (most accurate 84%, vs. Anterior drawer test 62%)
Pt w/ MGUS, when does it become Multiple Myeloma?
Evidence of end-organ damage
- Hypercalcemia
- Renal Failure
- Anemia
- Skeletal lesions
60yo AAM w/h/o DM for 15yrs reports 1 week h/o left lower leg weakness, giving way of the knee, discomfort in anterior thigh. No trauma. Decreased pinprick and light touch, reduced motor strength on hip flexion and knee extension. MC dx?
Femoral neuropathy (a/w DM, but not directly caused by DM)
**Diabetic polyneuropathy characterized by symmetric and distal limb sensory and motor deficits.
**Meralgia paresthesia (no motor)
**Spinal stenosis pain but no neuro sx
**Iliofemoral atherosclerosis causes intermittent claudication but no motor weakness
Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the:
Ovary
also reduce endometrial and colorectal
Polymyalgia Rheumatica tx?
Dramatic response to corticosteroids
Become apathetic, lost interest in job and hobbies, accused of making sexually harassing comments and inappropriate touching at work, no longer helps with household chores, difficulty expressing himself and his speech can lack meaning.
Frontotemporal dementia (Pick’s disease)
88yo M hospitalized for 3 days, found cachetic and dehydrated at time of admission, started IVF and is now euvolemic, began nasogastric tube feeding and has now developed nausea, vomiting, hypotension, and delirium. What electrolyte abnormality?
Hypophosphatemia
Refeeding syndrome - fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving artificial refeeding. Results from hormonal and metabolic changes and may cause serious clinical complications.
Decrease risk of oral candidiasis for ICS in asthmatics?
Use valved holding chamber. Also rinsing the mouth after each administration.
3-month h/o hoarseness
Laryngoscopy
MC cause of right heart failure in adults?
Left heart failure
Also myocarditis, pulmonary stenosis, VSD
Morphine identified in an employee taking a prescribed cough medicine containing codeine
Negative drug test
Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication.
Morphine identified in an employee undergoing a prescribed methadone pain management program
Positive drug test
Morphine is not a metabolite of methadone
Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician
Positive drug test for Valium
Oxazepam is a metabolite of diazepam but the reverse is not true
Tetrahydrocannabinol identified in an employee taking prescribed tramadol (Ultram)
Positive drug test for THC
Tetrahydrocannabinol would not be found in the urine as a result of tramadol use
18yo M w/ sore throat, LAD, fatigue. No airway compromise, heterophil antibody positive. Management includes?
Avoidance of contact sports
Hydration, NSAIDs, throat sprays or lozenges
NO: bed rest, steroids, antivirals
65yo M w/h/o metastatic lung cancer hospitalized because of decreased appetite, lethargy, confusion.
Serum calcium……………………. 15.8 mg/dL (N 8.4–10.0)
Serum phosphorus…………………. 3.9 mg/dL (N 2.6–4.2)
Serum creatinine. …………………. 1.1 mg/dL (N 0.7–1.3)
Total serum protein………………… 5.0 g/dL (N 6.0–8.0)
Albumin………………………… 3.1 g/dL (N 3.7–4.8)
Most appropriate initial management?
Normal saline IV
Initial management of hypercalcemia of malignancy includes fluid replacement w/ normal saline to correct volume depletion and enhance renal calcium excretion.
Although IV Pamidronate has become the mainstay of treatment for hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for other calcium lowering agents.
Why myomectomy over ribroid embolization?
Desire for future pregnancy
Uterine fibroid embolization requires a shorter hospitalization and less time off work. General anethesia is not required, and a blood transfusion is unlikely to be needed. Uterine fibroids can recur or develop after either myomectomy or embolization
Brown to black leopard spotting of colonic mucosa in 70yo AAM. Next step?
Review his medications
Melanosis coli - benign condition resulting from abuse of anthraquinone laxatives such as cascara, senna, or aloe. The condition resolves with discontinuation of the medication.
Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in patients with what condition?
HOCM
Valsalva decreases venous return to heart (decreases preload)
12yo M w/ left hip pain. Overweight, afebrile, walks with a limp but no recall of injury.
Slipped Capital Femoral Epiphysis (SCFE)
Associated w/ Percutaneous Endoscopic Gastrostomy (PEG) tubes
Increased use of restraints
ADL drops so low, have to make a decision to insert PEG tubes. In general, they suck.
58yo M w/ acute bronchitis. “cold goes into my chest and lingers for months.” 30 smoking hx. PE: scattered rhonchi. CXR 4 months ago negative except hyperinflation and flattened diaphragm. Next diagnostic step?
Spirometry
Distinguish between COPD and Asthma. COPD: pressure of outflow obstruction is not fully reversible, demonstrated by postbronchodilator spirometry showing FEV//FVC ratio of <70%
50yo F w/ right eye pain. PE: no redness but reports pain w/ eye movement. Cause?
An orbital problem (inflamm, infxn, tumor invasion)
Other sxs: diplopia, proptosis
30 F asks for Colonoscopy, father was dx at age 58. No other FMHx.
High risk (one first-degree, at least two second-degree relatives)
Start colonscopy at age 40 or 10 yrs before the earliest dx relative, Q5yrs.
64yo AAM w/ persistnet pleuritic pain. Low-grade fever. Meds: simvastatin, lisinopril, baby ASA, spironolactone, furosemide, isosorbide mononitrate, hydralazine, carvedilol, nitroglycerin. CXR normal. Dx of pleurisy is made. Which med caused this?
"SHIPP" Sulfonamides Hydralazine INH Procainamide Phenytoin
30yo M presents to ED for racing heart, h/o WPW. Tx?
Procainamide
Adenosine, digoxin, CCB act by blocking conduction through the AV node, which may increase the ventricular rate paradoxically, initiating V Fib. These drugs are contraindicated in WPW.
Which drug are contraindicated in the second and third trimesters of pregnancy?
Doxycycline
Risk of permanent discoloration of tooth enamel in the fetus.
25yo adds 5 ounces of red wine a day, adding 100 calories to his diet. What effect will 3000 calories a month have on his body 10 yrs later?
No direct relation between daily calorie consumption and weight.
His weight will increase slightly and then stabilize
Just dx mild persistent asthma in 13 AAF. Initial medical management includes?
SABA (albuterol) PRN and ICS daily
Pt w/ RA should be screen for TB before which med?
Infliximab, Adalimumab, Certolizumab, Golimumab
TNF-alpha inhibitors a/w increased risk of infxn (TB and candidiasis).
42yo M w/h/o IVDA, HCV antibody enzyme immunoassay and recombinant immunoblot assay are both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative. Tests are consistent with?
Past infxn w/ HCV that is now resolved
HCV antibody enzyme immunoassay
- positive: should be followed by confirmatory test such as recombinant immunoblot assay (negative indicates false-positive antibody test, positive must be followed by HCV RNA PCR used to measure the amount of virus int he blood to distinguish active from resolved HCV infxn)
In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved.
Nursing-home resident develops skin ulcer w/ MRSA before discharge. Infection control when she returns to nursing home?
Strict handwashing practices by all staff, visitors, and residents
Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test?
CT Angiography
Since reduction in renal function (pyelography or angiography) can cause lactic acidosis in pts taking Metformin, the drug should be d/c 48 hours before and restarted 48 hours after the procedure if renal function is normal.
Recognition by the patient that the obsessions or compulsions are excessive or unreasonable
Obsessive-compulsive disorder
82yo w/ fever, difficulty breathing, cough productive of purulent sputum. O2 sat 86%, CXR w/ new infiltrate, pt is hospitalized. Most appropriate IV abx?
Ceftazidime, Levofloxacin, Vancomycin
Coverage for MRSA and Pseudomonas
Safe anti-depressant/mood stabilizer during pregnancy?
Fluoxetine (Prozac) and most SSRI
Paroxetine is an SSRI contraindicated during pregnancy. No Benzos (Xanax), Lithium, Bupropion.
11mo M w/ several paroxysms of ABD pain in last 2 hours. Episodes last 1-2 minutes, infant screams, turns pale, and doubles up. PE: fullness in the RUQ. Dx?
Intussusception (classic presentation, under age 2 w/ paroxysms of colicky ABD pain, palpable mass)
Malrotation presents within first 4 weeks of life and characterized by bilious vomiting.
62yo M w/h/o prostate cancer, well-controlled HTN, and severe osteoporosis. Brachytherapy and androgen deprivation for his prostate cancer. Meds: Lisinopril, alendronate, calcium, vitamin D. Never smoked, exercises 5x/week. What to consider next to treat osteoporosis?
Teriparatide (recombinant PTH analog given subQ daily, increases osteoblastic activity)
Indicated for severe osteoporosis, pts w/ multiple risk factors, or pts w/ failure of bisphosphonate therapy.
20yo F presents w/ painful and frequent urination of gradual onset over past week. No h/o UTI. No a/ hematuria, flank pain, suprapubic pain, fever, pruritis, discharge. UA/UCx with pyuria but no growth. Abx for 2 days w/ no relief. What agent?
Chlamydia trachomatis
Sexually transmitted urethritis caused by Chlam, GC, HSV. Tx includes tetracycline (doxy) and search for other STD.
82yo M recent fall middle of night to bo to bathroom. H/o bilateral dense cataracts, increased stance width and walks carefully and cautiously with arms and legs abducted. “En bloc” turn. Most likely cuase of this patient’s gait and balance disorder?
Visual impairment
“Timed Up and Go” test is reliable diagnostic tool for gait and balance d/o.
Time <10 seconds is considered normal.
Time >14 seconds is a/w increased risk of falls
Time >20 seconds suggest severe gait impairment
Abducted arms and legs, careful walking on ice movements, wide-based stance, “en bloc” turns.
Cerebellar degeneration have ataxic gait that is wide-based and staggering.
Parkinson’s disease patients have a typical gait that is short-stepped and shuffling, with hips knees spine flexed and may also exhibit festination and “en bloc” turns.
Motor neuropathy causes a “steppage gait” resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.
17 yo F h/o anorexia, BMI 17.4, serum electrolyte and EKG are normal. Intervention?
Family-based treatment
42yo M w/ well-controlled T2DM presents w/ influenza like sxs of sudden onset HA, fever, myalgia, sore throat, cough. CDC recommends intiating treatment in this situation:
on basis of clinical sxs alone.
52yo M has had a chronic course of multiple vague and exaggerated symptoms for which no cause has been found despite extensive testing. Most effective management approach for this patient?
Schedule for regular appointments Q2-4 wks
Who should be advised to take aspirin, 81mg daily, for the primary prevention of stroke?
- Men 45-79yo risks for MI outweighs risk of GI bleed
- Women 55-79yo risks for Ischemic stroke outweighs risk of GI bleed
- Not over 80yo
- Against women <55yo, men <45yo
12mo F w/ Hgb of 9.0 (10.5-13.5), started whole milk at 9mo, appears healthy and otherwise no FMHx, CBC reveals mild microcytic hypochromic anemia with RBC poikilocytosis, RDW elevated. Next Step?
Prescribe oral iron
Iron def is most likely. Patient’s response to trial of iron would be most helpful in establishing dx, additional tests might be necessary if there is no response.
Because of safety concerns, what med should be used only as additive therapy and not as monotherapy for asthma patients?
LABA
Because of risk of asthma exacerbation or asthma-related death.
16yo M w/ FMHx of Crohn’s disease presents w/ intermittent loose stools and has up to three bowel movements per day. No fever, pain, hematochezia, wt loss, or any extra-GI sxs. PE normal. Most appropriate preliminary testing?
CBC, CMP, ESR
IBD diagnosed via hx, labs, endoscopy.
Endoscopy reserved for more severe sxs or those prelim labs shows risks.
3do F develops rash, no cmplx, good prenatal care. Not irritable or in distress, afebrile, feeding well. PE: maculopapular rash and pustules on face, trunk, proximal extremities. Palms and soles are spared. A stain of pustule shows eosinophils. Most likely dx?
Erythema toxicum neonatorum
Staphylococcal pyoderma
Vesicular rash
Stain shows polymorphonuclear leukocytes and clusters of gram-positive bacteria.
51yo F w/ hyperplastic polyp, no FMHx for colon cancer. Most appropriate follow-up colonoscopy schedule?
10 years
Small (<10mm) hyperplastic polyps from rectum or sigmoid are not neoplastic.
One or two small tubular adenomas: 5-10yrs
Three of more tubular adenomas: 3yrs
Tx for symptomatic MVP?
Beta-blockers (Propranolol)
Lifestyle changes: reduction of caffeine and alcohol
Orthostatic hypotension can be managed w/ volume expansion (increase salt intake)
52yo M w/ stable CAD and controlled HTN asks prevention of altitude sickness. Pt has sulfa allergy. Most appropriate step?
Dexamethasone
Acetazolamide is effective, but contraindicated in pts w/ sulfa allergy. If used, should be started one day before ascent and continued until pt acclimatizes at the highest point.
Most commonly implicated in Interstitial nephritis?
Abx (penicillins, cephalosporins, sulfonamides) MC drug-related cause of acute interstitial nephritis.
Corticosteroids may be useful for treating this condition.
Effective at improving symptoms of varicose veins?
Horse chestnut seed extract
Contraindications to breastfeeding
- HSV lesion on breasts
- Maternal seropositive CMV ONLY of recent onset or mothers of low birthweight infants
- Active maternal TB
- Post radioactive isotopes, chemotherapies, recreational drugs, or certain prescription drugs
MC cause of erythema multiforme
HSV
25yo M presents w/ right index finger pain for past 4 days. Progressively worse, swollen and held in flexed position. Pain increases with passive extension, TTP from tip of finer into palm. Most appropriate management?
Surgical drainage and Abx (later stages: >48hrs)
Abx and splinting (early onset: <48hrs)
Pyogenic tenosynovitis
**NEVER use steroids on infected joint
81yo M T2DM w/ HgA1c 10.9%, already on maximum dosage of glipizide. Problems with renal insufficiency and moderate ischemic cardiomyopathy. Most appropriate change in regimen?
Start insulin.
Metformin - contraindicated in renal insufficiency
Sitagliptin - should not be added to a sulfonylurea, dosage has to be lowered in renal insuff, does not result in diabetic control when used alone
Pioglitazone - can cause fluid retention and therefore would be a good choice for a patient with cardiomyopathy
What seafood poisoning requires more than just supportive therapy?
Scombroid poisoning - improperly stored scrombroid fish such as tina. mackerel, wahoo, bonito (dark meat fish), but also some non-scombroid fish may cause poisoning. Poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine.
22yo F w/ dizziness after 2 weeks ago developed gastroenteritis that other family members also had. Since been lighheaded when standing, feels her heart race, and gets HAs or blurred vision if she does not sit or lie down. No passing out, has not been able to work due to sxs. PE: normal except heart rate, 72 when lying or sitting, 112 when standing. BP remains unchanged. Routine labs and EKG normal. Most likely cause of patient’s condition?
Postural orthostatic tachycardia syndrome (POTS)
Rise in heart rate >30 beats/min or by heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms include position-dependent HA, ABD pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lit down quickly enough. Most prevalent in white females between 15-50yrs. Genetic predisposition, often incited after a prolong viral illness, and has a component of deconditioning.
Tx: adequate fluid and salt intake, followed by regular aerobic exercise, beta-blockers
Greatest risk factor for AAA
Smoking
TSH 7.6 (0.4-5.1), free T4 within normal range
Subclinical hypothyroidism
Elevated TSH and normal thyroid hormone in asymptomatic pt.
Tinea infection in children that always require systemic antifungal therapy
Tinea capitis
Need systemic therapy to penetrate the affected hair shafts.
Tinea cruris and tinea pedis rarely require systemic therapy. Tinea corporis and tinea versicolor benefit from both oral and topical treatment, but localized infections only need topical.
BNP 459, what can you assume?
Unsure diagnosis
BNP lacks specificity necessary to function as absolute indicator of acute HF.
Preop on 55yo F w/ T2DM, unable to climb stairs or do heavy work at home, otherwise denies chest pain and healthy. Appropriate study prior to surgery?
Dipyridamole-thallium scan (cardiac stress test)
Preop eval:
- perioperative CV risk of procedure
- fxn status of pt
- clinical factors that may increase risk (DM, stroke, renal insuff., h/o HF, angina, previous MI)
62yo M taking omeprazole for over year for GERD. Asx, no problems w/ drug, ask about SE and benefits of continuing therapy. What do you tell him?
Decreased B12 absorption
Increased likelihood of pneumonia
Increased likelihood of C diff
Decreased Ca2+ absorption (hip fx)
48yo F AUB, periods last 3-5 days longer than usual, heavier, and some intermenstrual bleeding. PE: unremarkable, except parous cervix w/ dark blood at os and in vagina. No orthostatic hypotension, hgb 11.5, neg pregnancy test. Most important next step?
Endometrial Bx
Pt >35yo w/ AUB must have endometrial bx to exclude hyperplasia or cancer. Next would be TSH.
75yo AAM w/ no h/o cardiac presents w/ SOB and general weakness. sxs developed within 24hrs. PE: HR 160, rales to base of scapula bilat, moderate JVD, hepatojugular reflux. BP 90/55, becomes weak and diaphoretic when stand and complains of precordial pressure. EKG reveals atrial flutter w/ 2:1 block. Management?
Electrical cardioversion
Hemodynamically unstable, otherwise digoxin or verapamil
60yo M w/ HTN, 170/95, h/o lacunar stroke 10yrs ago. No other health problems, no smoke, no alcohol. ROS: minor residual weakness in his right upper extremity resulting from his remote stroke. Counsel him on lifestyle modifications, what is most appropriate treatment of HTN?
Thiazide diuretic and ACE inhibitor combo
CCB as well in JNC-8
Activation of sympathetic branch will decrease what in CV system?
PR interval
Increases HR, coronary flow rate, metabolic demand, contractility
40yo F w/ chronic plaque psoriasis requests topical treatment. Most effective and fewest SE?
high-potency corticosteroids (fewer local reactions) & topical vitamin D
43yo M w/ unipolar depression develops treatment resistance. Increases in SSRI and SNRI, currently taking citalopram 60mg daily. Most effective adjunctive therapy?
Lithium Bicarbonate or LOW dose T3
4yo ABD pain and 3+ proteinuria. 3 days later pain resolves, repeat UA shows 2+ proteinuria w/ normal findings on micro, BMP also normal. Most appropriate next step?
Sopt first morning urine protein/creatinine ratio
25yo M w/ 1 week of neck pain w/ radiation to left hand, intermittent numbness and tingling in left arm. Positive Spurling’s. Cervical radiographs are negative. Most appropriate step?
NSAIDs for pain relief
Pts w/ acute cervical radiculopathy and normal radiographs can be treated conservatively.
Referral to a specialist should be reserved for pts who have persistent pain after 6-8 weeks of conservative management and for those with signs of instability.
21yo AAF confused and delirious for 2 days. No PMHx, no meds. Recently returns from Southeast Asia. In ED, has several convulsions and rapidly comatose. 100.3F BP 80/50. No sxs meningeal irritation, normal CN. PE: mild, bilat, symm increase in DTR.
Laboratory Findings
Hemoglobin……………………… 7.0 g/dL (N 12.0–16.0)
Hematocrit………………………. 20% (N 36–46)
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6500/mm3 (N 4300–10,800)
Platelets. ……………………….. 450,000/mm3 (N 150,000–350,000)
Serum bilirubin
Total…………………………. 5.0 mg/dL (N 0.3–1.1)
Direct………………………… 1.0 mg/dL (N 0.1–0.4)
The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor infarction.
The most likely diagnosis is:
Malaria
Clinical clues:
- Travel hx
- Prodrome of delirium or erratic behavior
- Unarousable coma following convulsion
- Fever
- Lack of FND in presence of diffuse, symmetric encephalopathy
- Normochromic, normocytic anemia
Tx: IV quinidine gluconate
Ask stroke pt to stick out tongue, pt unable to do this, but a few moments later he performs this movement spontaneously.
Apraxia
transmission disturbance on the output side, which interferes with skilled movements.
Agnosia
Inability to recognize previously familiar sensory input, and is a modality-bound deficit
i.e., it results in a loss of ability to recognize objects.
Aphasia
Language disorder, and expressive aphasia is a loss of the ability to express language
