AAFP Review Questions

Question 1

Infant w/ several week h/o increasing dyspnea, cough, poor feeding. Nontoxic and afebrile. Conjunctivitis. Tachypnea and crackles. CXR: hyperinflation and diffuse interstitial infiltrates. Eosinophilia.

Answer 1

Chlamydia trachomatis

Seen in infants 3-16 weeks of age 
Prominent cough 
PE: 
-diffuse crackles w/ few wheezes 
-conjunctivitis in 50%
CXR
-hyperinflation and diffuse interstitial or patchy infiltrates

Question 2

BPH w/ lower UT sx pharmacological options

Answer 2

• Alpha-adrenergic blocker
• 5-alpha-reductase inhibitor (if evidence of prostatic enlargement or PSA > 1.5)
• PDE-5 inhibitor
• antimuscarinic therapy

First 3 proven as effective monotherapies

Question 3

Mallet fracture management

Answer 3

Forced flexion injury of DIP resulting in small bone fragment @dorsal surface of proximal distal phalanx

Splint the DIP in extension

Question 4

Presentation and management of necrotizing fasciitis

Answer 4

Presentation: severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration

Management: Immediate surgical consultation for operative debridement

Question 5

Nursemaid’s elbow (radial subluxation) presentation and management

Answer 5

Most common ortho condition of elbow in kids 1-4

Arm slightly probated, flexed, and close to body. Tenderness near lateral elbow

Reduce the subluxed radial head (elbow at 90 degrees, hand fully supinated by examiner, elbow brought into full flexion)

Question 6

Asthma step-up from short-acting bronchodilator

Answer 6

Inhaled medium-dose corticosteroids

Question 7

Most appropriate first-line therapy for primary dysmenorrhea

Answer 7

NSAIDs

-started @onset of menses and continued for first 1-2 days of menstrual cycle

Question 8

What to do in an outbreak of Influenza A (H1N1) in a long-term care facility

Answer 8

Chemoprophylaxis w/ appropriate meds for all residents who are asymptomatic, and treatment for all residents who are symptomatic. All staff should be considered for chemoprophylaxis

Question 9

Neonate w/ flesh-colored papules on an erythematous base on face and trunk containing eosinophils

Dx? Management?

Answer 9

Erythema toxicum neonatorum

Usually resolves in first few weeks of life

Question 10

SEs of inhaled corticosteroids for COPD

Answer 10

Increased risk of bruising, candidal infection of the oropharynx, and pneumonia.

Decrease risk of COPD exacerbations but have no mortality benefit and do not improve FEV1 consistently.

Question 11

Polymyalgia rheumatica dx and tx

Answer 11

> 50 y.o., bilateral shoulder pain and stiffness accompanied by upper arm tenderness, soreness about both shoulders, difficulty raising arms above shoulders. Accompanying systemic sx of fatigue, lo-grade fever, weight loss, decreased appetite, depression. Elevated CRP and ESR.

15mg prednisone

Question 12

Tx of infected diabetic foot ulcer with systemic sx

Answer 12

IV Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)

Question 13

Drugs that cause SIADH

Answer 13

SSRIs (esp. in >65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, NSAIDs

SIADH = euvolemic pt w/ hyponatremia, decreased serum osmolality, and elevated urine osmolality

Question 14

Most common cause of unintentional deaths in children

Answer 14

Motor vehicle accidents (58.2% of childhood deaths)

Drowning: 10.9%
Poisoning: 7.7%
Fires: 5.7%
Falls: 1.4%

Question 15

Treatment of acute mild/mod pericarditis

Answer 15

NSAIDs (glucocorticoids in severe or refractory cases)

Acute, sharp chest pain relieved only by leaning forward. Pericardial friction rub. Diffuse ST-elevations.

Question 16

First-line tx for previously healthy infants and school-age children w/ mild/mod CAP

Answer 16

Amoxicillin

Most common pathogen: Streptococcus pneumoniae

(Azithromycin would be appropriate in an older child since Mycoplasma pneumoniae is more common)

Question 17

Tx for non-obese children with obstructive sleep apnea

Answer 17

Adenotonsillectomy

Question 18

Tx of anemia of CKD

Answer 18

Oral ferrous sulfate or erythropoieten

Question 19

Signs and sx of hip labral tear

Answer 19

Dull or sharp groin pain which may radiate to lateral hip, anterior thigh, or buttock. Insidious onset or acutely after traumatic event. 50% have mechanical sx like catching or painful clicking w/ activity. FADIR and FABER tests good SN but low SP. MRA is diagnostic.

Question 20

Which vaccine may cause febrile seizures up to 2 weeks after vax?

Answer 20

MMR (measles component)

Postimmunization seizures are more likely to occur in kids w/ past hx of seizures or 1st degree relative w/ epilepsy.

Question 21

What is a pathogen more common in corticosteroid-dependent COPD pneumonia than in other patients?

Answer 21

Pseudomonas aureuginosa

Question 22

Cow’s milk is not recommended for children until the age of?

Answer 22

12 months

Whole cow’s milk doesn’t supply kids with enough vitamin E, iron, and essential fatty acids. It also overburdens them with too much protein, sodium, and potassium. Also fails to provide adequate calories for growth. (Skim and low-fat do the same.)

Question 23

Tx for acute flare-up of multiple sclerosis

Answer 23

Methylprednisolone (Medrol)

Question 24

Tx serotonin syndrome

Answer 24

Discontinue offending agent, supportive care, IV benzodiazepine (lorazepam or diazepam). If no response, cyproheptadine

Question 25

When to give antibiotics in asplenics?

Answer 25

Anytime there is a fever

Question 26

JNC8 HTN

Answer 26

1. In >60, start drugs at >150 or >90 (treat to <150, <90) 2. In <60, start drugs at >90 (treat to <90) 3. In <60, start drugs >140 (treat to <140) 4. In >18 w/ CKD, start drugs at >140 or >90 (treat to <140 and <90) 5. In >18 w/ DM, start drugs at >140 or >90 (treat to >140 and >90) 6. In nonblacks (including w/ DM), initial drugs include THIAZIDE DIURETICS, CALCIUM CHANNEL BLOCKERS, ACE INHIBITORS, or ARBs. 7. In blacks (including w/ DM), begin w/ THIAZIDE DIURETIC or CCB 8. In >18 w/ CKD, initial (or add-on) drugs should include an ACE inhibitor or an ARB to improve kidney outcomes. [Regardless of race or DM] 9. If BP goal not met w/in 1mo of tx: -increase dose of initial drug OR -add a second drug (thiazide, CCB, ACEi, or ARB) If BP cannot be attained w/ 2 drugs, add and titrate a third drug (Do not use ACEi and ARB in same pt) If goal BP still cannot be reached OR if can’t use one of the drugs from 6 d/t contraindication, antihypertensive drugs from other classes may be used Refer to HTN specialist

Question 27

Lifestyle management in pre-diabetes and diabetes

Answer 27

Advise in pre-diabetes and new-onset diabetes Diet and exercise May include - DM education - frequent individual and group counseling from dieticians, behavior psychologists, exercise specialists - caloric restriction - regular exercise Weight loss strategies - weekly self-weighing - regular breakfast consumption - reduced intake of fast food

Question 28

Non-insulin DM drugs and MoA

Answer 28

-Alpha glucosidase inhibitors: inhibit enzyme at intestinal brush border; slow absorption of carbohydrates -Biguanides: decrease hepatic glucose production; increase insulin sensitivity peripherally; and decrease intestinal absorption of carbohydrates [Metformin] -DPP4 inhibitors: increase GLP-1; increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas [Alogliptin, linagliptin, saxagliptin, sitagliptin] -GLP-1 receptor agonists: increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas; suppress hepatic glucose production; delay gastric emptying [Albiglutide, dulaglutide, exenatide, liraglutide] - Meglinitides: close K+ channels in beta-cells; stimulate release of insulin from the pancreas - SGLT2 inhibitors: lower renal threshold for cluse and reduce reabsorption of filtered glucose from tubular lumen; increase urinary glucose excretion -Sulfonylureas: bind to K+ channels in beta-cells; stimulate release of insulin from the pancreas [Glimepiride, glipizide, glyburide] -Thiazolidinediones: increase hepatic glucose uptake; decrease hepatic glucose production; increase insulin sensitivity in the muscle and adipose tissue [Pioglitazone, rosiglitazone]

Question 29

Criteria for type 2 diabetes

Answer 29

A1c > 6.5 OR Fasting plasma glucose >126 OR Random plasma glucose >200 w/ sx of hyperglycemia Two-hour plasma glucose >200 during an oral glucose tolerance test

Question 30

Management approach to type 2 diabetes

Answer 30

Initial drug monotherapy: METFORMIN If still not at target A1c [<7] after 3 months: Two drug combinations w/ metformin (no particular order) -SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal) If still not at target A1c after 3 months: Add a third drug not already part of the patient’s regiment -SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal) If still not at target: -more complex insulin strategies

Question 31

Diabetes A1c goals

Answer 31

Most diabetics: <7% <6.5% reasonable for patients w/ short duration of DM, long life expectancy, and no significant CV disease 7.5-8% reasonable for patients w/ short life expectancy, CV disease, 2+ CVD RFs, or duration of disease 10+ yrs

Question 32

First line therapy for type 2 diabetes

Answer 32

METFORMIN

Question 33

Glucose monitoring in non-insulin DM?

Answer 33

Self-monitoring of blood glucose levels for patients taking non-insulin therapies does NOT significantly affect glycemic control

Question 34

Drugs for postherpetic neuralgia

Answer 34

Topical: lidocaine patches, capsaicin cream Oral: gabapentin, pregabalin, amitriptyline

Question 35

Risks of PPIs

Answer 35

Fractures of the hip/wrist/spine, CAP, C. diff and other enteric infections, hypomagnesemia, cardiac events if administered w/ clopidogrel

Question 36

First-line therapy for constipation in kids

Answer 36

Oral osmotic (e.g., PEG)

Question 37

When can kids with lice return back to school?

Answer 37

Immediately

Question 38

Recurrent uveitis should raise suspicion for?

Answer 38

Most comon conditions assx w/ uveitis: - séronégative spondyloarthropathies - sarcoidosis - syphilis - RA - reactive arthritis

Question 39

When should red eye be referred to ophtho?

Answer 39

Vision changes (could be glaucoma)

Question 40

Empiric tx for classic pyelonephritis

Answer 40

Ciprofloxacin (cipro)

Question 41

Immune thrombocytopenic purpura presentation and treatment

Answer 41

Easy bruising, low platelets, giant platelets Corticosteroids (IVIG and rituximab have also been used as first-line)

Question 42

Pertussis treatment

Answer 42

Azithromycin (Zithromax) TMP/SMX if allergic or intolerant to macrolides

Question 43

Which diabetes medication does not cause hypoglycemia?

Answer 43

Metformin (but there is risk for lactic acidosis)

Question 44

Which vessels are present in the newborn umbilicus?

Answer 44

2 arteries and 1 vein

Question 45

How to avoid kidney injury in rhabdomyolysis?

Answer 45

Rapid large infusions of isotonic saline

Question 46

How to diagnose fibromyalgia?

Answer 46

Symptoms (NOT tender points)

Question 47

How to enhance oral absorption of supplemental iron?

Answer 47

Vitamin C (or a meal high in meat protein)

Question 48

Changes to pharmacokinetics that occur with aging

Answer 48

In older persons there is a relative increase in body fat and a relative decrease in lean body mass, which causes increased distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such medications. The volume of distribution of water-soluble compounds such as digoxin is decreased in older patients, which means a smaller dose is required to reach a given target plasma concentration. There is also a predictable reduction in glomerular filtration rate and tubular secretion with aging, which causes decreased clearance of medications in the geriatric population. The absorption of drugs changes little with advancing age.

Question 49

Which NSAID is not associated with an increased risk of MI and thus preferred in patients with cardiovascular risk factors?

Answer 49

Naproxen NSAIDs cause an elevation of blood pressure due to their salt and water retention properties. This effect can also lead to edema and worsen underlying heart failure. In addition, all NSAIDs can have a deleterious effect on kidney function and can worsen underlying chronic kidney disease, in addition to precipitating acute kidney injury. Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk of cardiovascular adverse effects and myocardial infarction, compared with placebo. However, naproxen has not been associated with an increased risk of myocardial infarction and is therefore preferred over other NSAIDs in patients with underlying coronary artery disease risk factors

Question 50

Acute laryngitis treatment

Answer 50

Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate. A Cochrane review concluded that antibiotics appear to have no benefit in treating acute laryngitis.

Question 51

How to check for hyperaldosteronism?

Answer 51

Peripheral aldosterone concentration (PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred screening tests for hyperaldosteronism. A PAC >15 ng/dL and a PAC/PRA ratio >20 suggest an adrenal cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma.

Question 52

Tinea capitis treatment

Answer 52

ORAL antigungal (e.g. griseofulvin)

Question 53

If a patient had shingles, should they get vaccine?

Answer 53

YES

Question 54

Acne management

Answer 54

Mild: 1-3 topicals Mod: 2-3 topicals +/- oral Severe: orals w/ 2-3 topicals

Question 55

What is a level D recommendation?

Answer 55

A “D” recommendation means the U.S. Preventive Services Task Force (USPSTF) recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Question 56

What is a level I recommendation?

Answer 56

An “I” recommendation means the USPSTF concludes that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Question 57

What is a level C recommendation?

Answer 57

A “C” recommendation means the USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences.

Question 58

What is a level B recommendation?

Answer 58

A “B” recommendation means the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Question 59

What is a level A recommendation?

Answer 59

An “A” recommendation means the USPSTF recommends the service and there is high certainty that the net benefit is substantial. The highest levels of evidence and most recent evidence available are used by the USPSTF in making all of its recommendations.

Question 60

According to the DSM-5, what is the severity of anorexia nervosa based on?

Answer 60

According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass index (BMI). Mild is a BMI >17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of 15.0–15.9 kg/m2, and extreme is a BMI <15.0 kg/m2.

Question 61

First-line therapy for nausea and vomiting of pregnancy

Answer 61

Vitamin B6 Scopolamine is effective for nausea and vomiting of pregnancy but should be avoided in the first trimester due to the possibility of causing trunk and limb deformities. Likewise, methylprednisolone is also effective but should be avoided in the first trimester as it is associated with an increased risk of cleft palate if used before 10 weeks of gestation.

Question 62

Who should get antibiotics before dental work?

Answer 62

``` According to the American Heart Association’s 2007 guidelines, prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease. ``` Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are associated with mitral regurgitation. The American Dental Association has endorsed this guideline.

Question 63

Side effect of methimazole

Answer 63

AGRANULOCYTOSIS Other rare complications of methimazole include serum sickness, cholestatic jaundice, alopecia, nephrotic syndrome, hypoglycemia, and loss of taste. It is associated with an increased risk of fetal anomalies, so propylthiouracil (PTU) is preferred in pregnancy.

Question 64

Target LDL for diabetes

Answer 64

<100 (but lower is better, so <70 ideally!) | Patients with DM are considered to have known CAD, so 100 is target.

Question 65

Apart from diabetic medications, what should all DM patients be on?

Answer 65

ACE-inhibitor or ARB for cardiovascular and renal protection Microalbuminuria is a RF for CVD and progression of renal disease to ESRD and dialysis. ACE-Is/ARBs have been shown to decrease risk EVEN IN NORMOTENSIVE PATIENTS

Question 66

If new-onset migraine with nuchal rigidity, think...

Answer 66

SUBARACHNOID HEMORRHAGE Get LP (If there was a similar headache a few weeks before, think SENTINEL BLEED from an aneurysm)

Question 67

3-6 week old infant with projectile vomiting, visible peristaltic wave, and olive-like mass

Answer 67

PYLORIC STENOSIS Hypochloremic, hypokalemic metabolic alkalosis

Question 68

Acid-base status in pyloric stenosis

Answer 68

Hypochloremic, hypokalemic metabolic alkalosis

Question 69

Best breast screening for concerning mass in: <35 >35

Answer 69

<35: Ultrasound (since breast tissue is too dense for mammogram) >35: Mammography

Question 70

Treatment of enterobiasis (pinworm)

Answer 70

Albendazole or mebendazole in ALL HOUSEHOLD MEMBERS (pyrantel pamoate if pregnant since azoles are teratogenic) Also wash clothes and bedding, and trim nails (since under nails is most common place for eggs to hide out)

Question 71

What things are needed to evaluate acute coronary syndrome?

Answer 71

EKG and serial troponins | Unstable angina, NSTEMI, STEMI

Question 72

Treatment of vulvar candidiasis

Answer 72

Single dose of oral fluconazole or several days of miconazole or clotrimazole vaginal creams

Question 73

Presentation of vulvar candidiasis

Answer 73

- vulvar pruritis [dominant sx] - discharge: white with curd-like consistency ("cottage cheese") - low vaginal pH (<4.5) - KOH: budding yeast and hyphae Other symptoms could include: - dysuria - vulvovaginal irritation - dyspareunia

Question 74

Alport syndrome

Answer 74

Glomerular hematuria along sensorineural deafness and ocular abnormalities (can't see, can't pee, can't hear). Since this is an inherited disease, there should also be a family history of renal failure and deafness. The primary defect is a genetic mutation in collagen type IV.

Question 75

Immediate treatment of hyperkalemia

Answer 75

IV calcium gluconate | even if very high and need dialysis, start with IV calcium as a temporizing measure to stabilize the myocardium

Question 76

Hyperkalemia on EKG

Answer 76

Peaked T waves Medical emergency: IV calcium to stabilize myocardium

Question 77

If HTN <30 y.o., think...

Answer 77

secondary HTN (as opposed to essential HTN), such as fibromuscular dysplasia

Question 78

Drugs for uterine atony

Answer 78

- Carboprost (Hemabate) [contraindicated in asthma] - Methylergonovine [contraindicated in HTN] - Misoprostol (Cytotec) - Oxytocin (Pitocin)

Question 79

Treatment of acute parotitis

Answer 79

Amoxicillin/clavulanate (Augmentin) Staphylococcus most common pathogen

Question 80

Fever in child under 29 days old

Answer 80

Any child younger than 29 days old with a fever and any child who appears toxic, regardless of age, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated

Question 81

Ottawa ankle rules

Answer 81

X-ray only needed if one or more of the following are positive: 1. Tenderness of the distal 6 cm POSTERIOR edge of tibia (medial malleolus) 2. Tenderness of the distal 6 cm POSTERIOR edge of fibula (lateral malleolus) 3. Tenderness of the navicular 4. Tenderness of the proximal 5th metatarsal 5. Inability to bear weight for four steps immediately after the injury or at examination

Question 82

Finklestein test

Answer 82

De Quervain tenosynovitis Place thumb in palm, close fingers around it; maximally deviate in ulnar direction. + is pain when maximally ulnar deviated

Question 83

Phalen test

Answer 83

Carpal tunnel syndrome Dorsum of hands together with wrists in forced flexion for 30-60 sec + is numbness of palmar thumb, index finger, and middle finger

Question 84

Tinel test

Answer 84

Carpal tunnel syndrome Lightly tap median nerve at palmar wrist + is electric jolt down middle finger

Question 85

Spurling maneuver

Answer 85

Cervical nerve root pain Turn head toward affected side with neck extended; exert downward pressure + is pain, numbness, weakness down arm

Question 86

Speed's test

Answer 86

Tendinitis of long head of the biceps Arm supinated, elbow extended, resist forward flexion at shoulder + is pain in biceps groove

Question 87

Empty can test

Answer 87

Supaspinatus tendon Arms extended at 30 degrees, thumbs pointing down, resist upward motion + is weakness or pain

Question 88

Drop arm test

Answer 88

Supraspinatus tendon tear Passively hold arm extended at shoulder level and release; allow patient to slowly lower arm to waist + is instability to control maneuver to waist

Question 89

Lift off test

Answer 89

Subscapularis Dorsum of hands in lumbar area, resist straight lift off + is pain or weakness

Question 90

External rotation test (arm)

Answer 90

Infraspinatus and teres minor Arm against ribs, elbows flexed at 90 degrees, resist external rotation + is pain or weakness

Question 91

Neer test

Answer 91

Rotator cuff impingement Arm extended and pronated, examiner passively lifts arm up past head + is pain

Question 92

McMurray test

Answer 92

Meniscus Patient supine, thumb and fingers in knee joint line, grasp heel, fully flex and extend knee while exerting valgus stress while externally rotating knee; repeat with varus stress while internally rotating knee + is catching

Question 93

Cross arm test

Answer 93

AC joint Arm at shoulder level, elbow 90 degrees, examiner brings across to touch other shoulder + is pain at AC joint

Question 94

Apprehension test

Answer 94

Subluxation of the glenohumeral joint Arm at shoulder level, elbow at 90 degrees, hand toward ceiling; anterior pressure on humerus + is apprehension of joint dislocating or pain

Question 95

Straight leg raise test

Answer 95

Lumbar nerve root compression Leg extended, hip at 90 degrees + is radiation pain or numbness down past knee

Question 96

FABER test

Answer 96

SI joint Hip in flexion, abduction, and external rotation ("figure 4") + is pain

Question 97

Trendelenburg test

Answer 97

Hip abductor weakness Patient stands on affected leg and lifts other leg + is pelvic drop to contralateral side

Question 98

Colles fracture

Answer 98

Fracture of distal radius/ulna Usually from fall onto an outstretched hand

Question 99

Lachman test

Answer 99

ACL Patient supine, knee flexed at 30 degrees, stabilize femur (hold it), pull tibia anteriorly + is lack of clear endpoint of displacement of tibia

Question 100

Posterior drawer test

Answer 100

PCL Patient supine, knee flexed at 90 degrees, fix foot (sit on it), push tibia posteriorly + is posterior displacement of tibia

Question 101

Valgus stress test

Answer 101

LCL Patient supine, leg slightly abducted at the hip, knee 30 degrees flexed, stabilize tibia, push knee inward + is laxity

Question 102

Varus stress test

Answer 102

MCL Patient supine, leg slightly abducted at the hip, knee 30 degrees flexed, stabilize tibia, push knee outward + is laxity

Question 103

McMurray test

Answer 103

Meniscus Patient supine, thumb and fingers in knee joint line, grasp heel, fully flex and extend knee while exerting valgus stress while externally rotating knee; repeat with varus stress while internally rotating knee + is catching

Question 104

Gout treatment

Answer 104

Acute flare: NSAIDs + low dose colchicine Maintenance: allopurinol (xanthine oxidase inhibitor), probenecid (increases uric acid excretion in the urine)

Question 105

Target serum uric acid level in gout

Answer 105

<6

Question 106

Most common joints involved in gout and pseudogout

Answer 106

Gout: first MTP Pseudogout: knee

Question 107

CASPAR criteria for psoriatic arthritis

Answer 107

3 or more out of 6 is positive ``` -psoriasis of the skin present (2 pts) past (1 pt) FHx (1 pt) -nail lesions (1 pt) -dactylitis (1 pt) -negative RF (1 pt) -juxtaarticular bone formation on XR (1 pt) ```

Question 108

Management of stable COPD

Answer 108

inhaled beta agonists (albuterol) and anticholinergic bronchodilators (tiotropium or ipratropium). Oral steroids may be need for patients with more severe disease. Supplemental oxygen has clearly been shown to prolong life in COPD patients – the only other intervention that does so is smoking cessation!

Question 109

Colles fracture

Answer 109

Fracture of distal radius/ulna Usually from fall onto an outstretched hand

Question 110

Gonorrhea treatment

Answer 110

Ceftriaxone and azithromycin Want to treat both chlamydia and gonorrhea to avoid development of PID which can lead to infertility (G is much less common than C, and patients infected with G are likely to also be infected with C- the reverse is not true since C is so common/easy to acquire statistically)

Question 111

If a patient tests + for chlamydia or gonorrhea, should the partner be treated?

Answer 111

Yes, or the patient will become reinfected

Question 112

Combined OCP vs. progestin-only

Answer 112

Progestin only pills (a.k.a. “POPs” or “the mini pill”) are associated with more break-through bleeding and slightly higher failure rates than the combination pill that contains both estrogen and progesterone. Progestin only pills are more difficult to take, because they must be taken at the same time every day to maintain their efficacy. They are usually reserved for women who have a compelling reason avoid estrogen. Such patients might include women with migraine headaches, smokers over age 35, patients in the postpartum period, or women with clotting disease, cardiovascular disease, uncontrolled HTN, SLE, or hypertriglyceridemia

Question 113

If a patient has myasthenia gravis, what conditions need to be considered?

Answer 113

Do a CT for thymic pathology. 75% will have thymic hyperplasia, and 15% will have an overt thymoma (removal of the thymus can be curative in some patients who fail medical therapy) Also in younger females, consider autoimmune (SLE, RA, hyperthyroidism)

Question 114

Mitral valve prolapse murmur

Answer 114

Midsystolic click followed by a late systolic murmur heard best at the apex of the heart

Question 115

Atrial septal defect physical exam findings

Answer 115

Buzzword: fixed splitting of S2 Loud S1 with a fixed and widely split S2. Soft, midsystolic ejection murmur heard best at L 2nd ICS MCL. ASDs are silent! The murmur heard is a systolic ejection flow murmur out of the pulmonic valve due to increased flow. ASDs can remain asymptomatic for a long time, but eventually get pulmonary hypertension and shunt can reverse --> Eisenmenger syndrome

Question 116

Medications beneficial in acute COPD exacerbations

Answer 116

corticosteroids, antibiotics (amoxicillin, trimethoprim/sulfamethoxazole, and doxycycline), and inhaled bronchodilators

Question 117

Antibiotics used in COPD exacerbations

Answer 117

amoxicillin, trimethoprim/sulfamethoxazole, and doxycycline

Question 118

Classic COPD x-ray

Answer 118

hyper-inflated lungs, flattened diaphragms, and a narrow cardiac silhouette

Question 119

Management of stable COPD

Answer 119

inhaled beta agonists (albuterol) and anticholinergic bronchodilators (tiotropium or ipratropium). Oral steroids may be need for patients with more severe disease. Supplemental oxygen has clearly been shown to prolong life in COPD patients – the only other intervention that does so is smoking cessation!

Question 120

X-ray appearance of coarctation of the aorta

Answer 120

Rib notching (d/t collateral circulation formation)

Question 121

Hallmark lab finding in polymyalgia rheumatics

Answer 121

Markedly elevated ESR

Question 122

OCPs and cancer

Answer 122

Prevent ovarian cancer and may cause breast cancer

Question 123

Combined OCP vs. progestin-only

Answer 123

Progestin only pills (a.k.a. “POPs” or “the mini pill”) are associated with more break-through bleeding and slightly higher failure rates than the combination pill that contains both estrogen and progesterone. Progestin only pills are more difficult to take, because they must be taken at the same time every day to maintain their efficacy. They are usually reserved for women who have a compelling reason avoid estrogen. Such patients might include women with migraine headaches, smokers over age 35, patients in the postpartum period, or women with clotting disease, cardiovascular disease, uncontrolled HTN, SLE, or hypertriglyceridemia

Question 124

First step in evaluating short stature

Answer 124

Growth velocity - if normal: - familial short stature - constitutional delay of growth - if abnormal: - endocrinopathies - GH deficiency - malnutrition - abuse - malignancy

Question 125

Distinguish between familial short stature and constitutional delay of growth

Answer 125

Bone age (X-ray of hand and wrist) - FSS: bone age matches chronological age - CDG: bone age lags behind chronological age (both have normal growth velocity)

Question 126

Do we treat bacteruria of pregnancy?

Answer 126

YES (EVEN IF ASYMPTOMATIC), to prevent pyelonephritis From UpToDate: - Without treatment, as many as 30 to 40 percent of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection (UTI). - We screen all pregnant women at least once for asymptomatic bacteriuria. Screening for asymptomatic bacteriuria is performed at 12 to 16 weeks gestation with a midstream urine for culture. The diagnosis is made by finding high-level bacterial growth (≥105 colony forming units [cfu]/mL or, for group B Streptococcus, ≥104 cfu/mL) on urine culture in the absence of symptoms consistent with UTI. - Management of asymptomatic bacteriuria in pregnant women includes antibiotic therapy tailored to culture results, which reduces the risk of subsequent pyelonephritis and is associated with improved pregnancy outcomes. Potential options include beta-lactams, nitrofurantoin, and fosfomycin

Question 127

Treatment of bacteruria in pregnancy

Answer 127

[common bugs: E. coli, Klebsiella, GBS] cephalexin, amoxicillin, amoxicillin/clavulanate, nitrofurantoin, and sulfonamides (but NO sulfonamides in 1st trimester d/t causing hyperbilirubinemia of the newborn]

Question 128

Kawasaki disease

Answer 128

At least 5d At least 4 of: - peripheral edema - desquamation (esp. of fingertips, palms, and soles) - bilateral conjunctivitis - polymorphous, nonvesicular rash - cervical lymphadenopathy (often unilateral) - dry or fissured lips - "strawberry tongue" [Ddx: scarlet fever or Kawasaki disease] DO-NOT-MISS DIAGNOSIS d/t life-threatening coronary artery aneurysms Patients need serial echos to monitor aneurysms. Treatment of Kawasaki disease includes intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis

Question 129

Treatment of Kawasaki disease

Answer 129

Patients need serial echos to monitor aneurysms. Intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis

Question 130

How to choose allopurinol vs. probenecid

Answer 130

24 hour urine collection for uric acid <600 mg: underexcreter --> probenecid >600 mg: overproducer --> allopurinol

Question 131

Two most common nonpathological reasons for high alfa-fetoprotein

Answer 131

1. Multiple gestations | 2. Inaccurate gestational date

Question 132

Blood on dipstick but no RBCs

Answer 132

Myoglobinuria (myoglobin cross reacts w/ hemoglobin on dipstick)

Question 133

Prevent myoglobin-induced ATN in rhabdomyolysis

Answer 133

IV saline

Question 134

Hypertensive urgency

Answer 134

>200 / >120 in the absence of symptoms

Question 135

Hypertensive emergency

Answer 135

increased blood pressure with signs and symptoms of end-organ damage such as papilledema, stroke, hematuria, headache, altered mental status, acute coronary syndrome, etc.

Question 136

Treatment of hypertensive emergency

Answer 136

IV antihypertensive

Question 137

Treatment of hypertensive urgency

Answer 137

Oral antihypertensives (e.g., labetalol)

Question 138

How to begin a new-onset eneuresis workup

Answer 138

Urinalysis This single test will allow screening for urinary tract infection, a common cause of new-onset enuresis, as well as diabetic ketoacidosis, diabetes insipidus, and water intoxication. Imaging and referrals are reserved for patients with histories and physical exams that suggest a structural cause.

Question 139

Intusussusception presentation

Answer 139

The patient (usually 6 mo - 36 mo) usually presents with a history of sudden onset severe, crampy abdominal pain that is accompanied by drawing the legs up toward the abdomen and inconsolable crying. These episodes usually last 20 minutes and pain-free periods can follow. Usually the episodes become more severe and spaced closer together over time. Non-bilious vomiting can become bilious as the obstruction worsens. “Currant jelly” stool is a common description of the blood and mucus mixed stool that can occur with intussusception. Palpation of a “sausage-shaped” mass is also classic, but is not always appreciated on physical exam. Ultrasound imaging is not mandatory for diagnosis, but if performed, it may reveal pathognomonic “bull’s eye” or “coiled spring” lesions. Prompt treatment is necessary to avoid irreversible intestinal ischemia or bowel perforation. Air contrast enema is diagnostic and therapeutic.

Question 140

Congenital rubella findings

Answer 140

Deafness and cataracts as well as numerous purpuric skin lesions, (“blueberry muffin” baby). Congenital rubella syndrome occurs when the mother contracts rubella early on in her pregnancy – the risk of congenital rubella syndrome is very low after 20 weeks. Since the MMR vaccine contains a live attenuated virus, there is at least a theoretical risk of causing congenital rubella syndrome, and for this reason the vaccine is avoided in pregnant women.

Question 141

HIV patient w/ CD4 < 200 needs what?

Answer 141

TMP/SMX for prophylaxis of pneumocystis jirovecii pneumonia

Question 142

HIV patient w/ CD4 < 100 needs what?

Answer 142

TMP/SMX for prophylaxis of toxoplasma gondii

Question 143

HIV patient w/ CD4 < 50 needs what?

Answer 143

Azithromycin or clarithromycin for prophylaxis of MAC

Question 144

What is a positive PPD in a high risk patient?

Answer 144

>5 mm induration | HIV/AIDS, immunocompromised/suppressed, close TB contact

Question 145

What is a positive PPD in a moderate risk patient?

Answer 145

>10 mm induration | homeless, comes from a country with high TB rates, or is an i.v. drug user

Question 146

What is a positive PPD in a low risk patient?

Answer 146

> 15 mm induration | no major TB RFs

Question 147

Management of shoulder dystocia

Answer 147

1. Fundal pressure (sufficient in most cases) 2. Corkscrew maneuver: delivery of the posterior arm and shoulder, flexion of the maternal hips, and rotation of the infant 3. fracturing the fetal clavicles or maternal symphysi (RFs for shoulder dystocia: Fetal macrosomia, gestational diabetes, maternal obesity, postdate pregnancy, and prolonged second stage of labor)

Question 148

Most common complication of shoulder dystocia

Answer 148

Erb palsy Damage to C5-C6 --> waiter's tip

Question 149

Congenital syphilis findings

Answer 149

Rash involving palms and soles, blood-tinged purulent nasal discharge ("the snuffles"), lymphadenopathy, organomegaly

Question 150

Classic triad of congenital toxoplasmosis

Answer 150

Hydrocephalus, chorioretinitis, intracranial calcifications

Question 151

Congenital rubella findings

Answer 151

Deafness and cataracts as well as numerous purpuric skin lesions, (“blueberry muffin” baby). Congenital rubella syndrome occurs when the mother contracts rubella early on in her pregnancy – the risk of congenital rubella syndrome is very low after 20 weeks. Since the MMR vaccine contains a live attenuated virus, there is at least a theoretical risk of causing congenital rubella syndrome, and for this reason the vaccine is avoided in pregnant women.

Question 152

Most common causes of hypercalcemia

Answer 152

Malignancy and hyperparathyroidism CHIMPANZEES - calcium supplementation - hyperparathyroidism - immobility // iatrogenic (from thiazide diuretics) - milk alkali syndrome - Paget's disease - Acromegaly // Addison's disease - Neoplasm - Zollinger-Ellison syndrome (when associated w/ MEN-1) - Excess vitamin D - Excess vitamin A - Sarcoidosis

Question 153

Signs of hypercalcemia

Answer 153

Bones, stones, abdominal groans, psychiatric overtones bone fractures, kidney stones, vomiting and constipation, and weakness, fatigue, and altered mental status

Question 154

Hypercalcemic crisis

Answer 154

MEDICAL EMERGENCY d/t heart conduction abnormalities Calcium > 14 or severe symptoms Check EKG and begin IV fluids and furosemide (lose Ca++)

Question 155

Charcot's triad

Answer 155

of acute cholecystitis RUQ pain, jaundice, and fever/chills

Question 156

Reynold's pentad

Answer 156

of acute cholecystitis Charcot's triad (RUQ pain, jaundice, and fever/chills) plus shock and mental status changes

Question 157

Treatment of isolated chlamydia infection

Answer 157

Azithromycin (single dose) or doxycycline (1 wk) (1 wk of erythromycin also reasonable but causes GI upset) (Fluoroquinolones like ofloxacin and levofloxacin are more expensive alternatives) (Pregnant: azithromycin or erythromycin)

Question 158

Treatment of acute dystonia

Answer 158

Benztropine or diphenhydramine

Question 159

What is leukoria and what does it signify?

Answer 159

Leukoria is a white pupillary reflex (as opposed to the normal red reflex). It can indicate - disorders of the lens (e.g., cataracts) - disorders of the vitreous (e.g., hemorrhage) - disorders of the retina (e.g., retinoblastoma)

Question 160

Isolated elevated opening pressure

Answer 160

Cryptococcal meningitis also see lymphocytosis in CSF

Question 161

Treatment of cryptococcal meningitis

Answer 161

amphotericin B and flucytosine

Question 162

If early pregnancy loss, think:

Answer 162

cytogenetic abnormalities (abnormalities of chromosome number or structure)

Question 163

Elevated BUN/Cr ratio

Answer 163

Pre-renal azotemia

Question 164

Causes of late pregnancy loss

Answer 164

- cervical incompetence - uterine anomalies - leiomyoma - intrauterine synechiae

Question 165

PANDAS

Answer 165

pediatric autoimmune neuropsychiatric disorder associated with group A streptococci - pediatric onset - presence of obsessive compulsive disorder and/or a tic disorder - abrupt onset with episodic symptom course - associated with group A strep infections - association with neurological abnormalities like motoric hyperactivity, choreiform movements and tics

Question 166

Superficial thrombophlebitis treatment

Answer 166

rest, elevation, NSAIDs, heat NO NEED FOR ANTICOAGULATION

Question 167

SVT vs. DVT

Answer 167

Palpable cords: superficial vs. deep Both cause swelling, pain, and warmth Only DVT can cause PE The saphenous vein is a superficial vein; the femoral (and superficial femoral) and popliteal veins are deep veins!

Question 168

What antibodies are found in primary biliary cholangitis?

Answer 168

Anti-mitochondrial

Question 169

What antibodies are found in celiac sprue?

Answer 169

Anti-TTG (most SN + SP), anti-gliadin, anti-endomysial

Question 170

What is leukoria and what does it signify?

Answer 170

Leukoria is a white pupillary reflex (as opposed to the normal red reflex). It can indicate - disorders of the lens (e.g., cataracts) - disorders of the vitreous (e.g., hemorrhage) - disorders of the retina (e.g., retinoblastoma)

Question 171

Treatment of mild comedonal acne

Answer 171

topical retinoid and/or other topical agents such as salicylic acid, azelaic acid, glycolic acid, and benzoyl peroxide

Question 172

Test for primary adrenal insufficiency (Addison's disease)

Answer 172

Cosyntropin (synthetic ACTH) stimulation test, along with a measurement of plasma cortisol If adrenals are functioning: cortisol should rise upon stimulation

Question 173

Symptoms of Addison's disease

Answer 173

fatigue, weight loss, hypotension, hyponatremia, and hypoglycemia

Question 174

Elevated BUN/Cr ratio

Answer 174

Pre-renal azotemia

Question 175

Otitis media antibiotic guidelines

Answer 175

The American Academy of Pediatrics (AAP) recommends antibiotic therapy for children 6 months of age or older with severe signs and symptoms of acute otitis media (AOM), including moderate or severe otalgia or otalgia for more than 48 hours, or a temperature ³39°C (102°F), whether the AOM is unilateral or bilateral (SOR B). Children younger than 24 months without severe symptoms should receive antibiotic therapy for bilateral AOM, whereas older children or those with unilateral AOM can be offered the option of observation and follow-up. The usual treatment for AOM is amoxicillin, but an antibiotic with additional beta-lactamase coverage, such as amoxicillin/clavulanate, should be given if the child has received amoxicillin within the past 30 days, has concurrent purulent conjunctivitis, or has a history of AOM unresponsive to amoxicillin (SOR C). Penicillin-allergic patients should be treated with an alternative antibiotic such as cefdinir, cefuroxime, cefpodoxime, or ceftriaxone.

Question 176

Treatment of salmonella infection

Answer 176

NOTHING The recommended management for patients who have non-severe Salmonella infection and are otherwise healthy is no treatment. Patients with high-risk conditions that predispose to bacteremia, and those with severe diarrhea, fever, and systemic toxicity or positive blood cultures should be treated with levofloxacin, 500 mg once daily for 7–10 days (or another fluoroquinolone in an equivalent dosage), or with a slow intravenous infusion of ceftriaxone, 1–2 g once daily for 7–10 days (14 days in patients with immunosuppression).

Question 177

Treatment of cervical lymphadenitis

Answer 177

Systemic symptoms, unilateral lymphadenopathy, skin erythema, node tenderness, and a node that is 2–3 cm in size. The most common organisms associated with lymphadenitis are Staphylococcus aureus and group A Streptococcus. Empiric antibiotic therapy with observation for 4 weeks is acceptable for children with presumed reactive lymphadenopathy (SOR C). If symptoms do not resolve, or if the mass increases in size during antibiotic treatment, further evaluation is appropriate.

Question 178

What needs to be tested before beginning PrEP w/ Truvada (emtricitabine/tenofovir disoproxil )

Answer 178

HIV antibody test Need to make sure they're HIV negative since Truvada is insufficient for treating HIV

Question 179

What is recommended in all patients w/ croup, even with mild disease?

Answer 179

Single dose of po dexamethasone

Question 180

Most common cause of toxic megacolon

Answer 180

IBD (esp. UC)

Question 181

CSF of bacterial meningitis

Answer 181

Elevated white count w/ neutrophilic predominance, increased protein, decreased glucose

Question 182

Key feature distinguishing DKA from HONK

Answer 182

ACIDOSIS DKA will have an ELEVATED ANION GAP

Question 183

What things can precipitate DKA or HONK?

Answer 183

Stress- infections, dehydration, drug use Increased stress hormones and glucagon increase the patient’s blood sugar and begin the pathological cascade

Question 184

Pseudohyponatremia

Answer 184

Pseudohyponatremia occurs whenever there is a high concentration of glucose, triglycerides, or ketones in the blood. Though the relationship between glucose increase and sodium decrease is nonlinear, a useful rule of thumb is that the sodium concentration will drop 2.5 mEq/L for every 100 mg/dL of glucose rise above normal.

Question 185

Colon cancer screening

Answer 185

Colon cancer screening should begin at age 50 in normal patients (and even younger for high-risk patients) with flexible sigmoidoscopy or colonoscopy or FOBT (with abnormal referral to colonoscopy or normal repeat every year)

Question 186

Cervical cancer screening

Answer 186

Annually once a woman is >18 years old or becomes sexually active. However, if a woman has had no new sexual partners and three normal Pap smears in a row, you can safely screen her once every three years instead of annually

Question 187

Breast cancer screening

Answer 187

every year or two at age 35 or 40, and then annually after age 50

Question 188

What does a rising pCO2 indicate in asthma attack?

Answer 188

A rising pCO2 in an asthma attack signals impending respiratory failure, not improvement! It is important to recognize that this patient is getting worse, not better. Typically, in an acute asthma attack, the patient's tachypnea causes them to "blow off" CO2, resulting in a primary, uncompensated respiratory alkalosis. Rising CO2 in the face of sustained tachypnea is a very ominous sign - it shows that the patient's airways are so constricted that he is no longer able to get rid of CO2!

Question 189

Management of grade II-III vesicoureteral reflux

Answer 189

Medical management: TMP/SMX or nitrofurantoin until documentation that VUR has disappeared

Question 190

How to classify ascites fluid

Answer 190

SAAG If the difference between the serum albumin and the ascites albumin is greater than 1.1, then the ascites is caused by portal hypertension [TRANSUDATE] (cirrhosis, right sided CHF, and Budd-Chiari syndrome). If the SAAG is less than 1.1, then the ascites is NOT caused by portal hypertension [EXUDATE] (pancreatitis, peritonitis, and peritoneal carcinomatosis).

Question 191

Spontaneous bacterial peritonitis ascitic finding

Answer 191

>250 PMNs in the ascitic fluid

Question 192

Lab finding to confirm menopause

Answer 192

Elevated FSH

Question 193

Ddx for non-AG metabolic acidosis

Answer 193

Renal tubular acidosis and GI bicarbonate loss (diarrhea)

Question 194

CV screening recommendations

Answer 194

- HTN: >18 - lipids: M > 35, F > 45, patients > 20 w/ hi risk - AAA: M never smokers 65-75 - obesity: BMI for all CAD screening NOT recommended in low-risk individuals

Question 195

Cancer screening recommendations

Answer 195

- colon cancer: > 50 (FOBT annually, flexible sigmoidoscopy every 3-5 yrs, or colonoscopy every 10 yrs) - lung cancer: M 50-80 w/ 30+ pack-year hx who continue to smoke or who quit less than 15 yrs ago- annual low-dose CT Routine PSA screening or DRE NOT recommended Screening for pancreatic cancer or testicular cancer NOT recommended in asymptomatic individuals

Question 196

Tobacco and alcohol screening

Answer 196

Tobacco: Grade A Alcohol: Grade B

Question 197

Tdap booster

Answer 197

All 19-65

Question 198

Influenza vaccination

Answer 198

Everyone over 6 months

Question 199

Pneumococal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13)

Answer 199

All 65+ Select younger (e.g., immunocompromised)

Question 200

Hep B vaccination

Answer 200

health care workers, people exposed to blood or blood products, dialysis patients, IV drug users, individuals with multiple sexual partners or recent STDs, MSM, DM

Question 201

Hep A vaccination

Answer 201

chronic liver disease, use clotting factors, occupational exposure to Hep A, IV drug users, MSM, travel to endemic Hep A areas

Question 202

Meningococcal vaccine

Answer 202

high-risk groups, college dorm residents, military recruits, certain complement deficiencies, functional or anatomic asplenia, travel to endemic countries

Question 203

If emphysema <45 y.o. and/or nonsmoker, think:

Answer 203

alpha-1-antitrypsin deficiency

Question 204

PFTs in COPD

Answer 204

Decreased FVC and FEV1 | FEV1/FVC < 0.7 --> OBSTRUCTION

Question 205

Management of stage I COPD

Answer 205

prn short-acting bronchodilators these include: - beta-2 agonists (albuterol) - anticholinergics (ipratropium) Inhaled > po d/t fewer SEs

Question 206

Management of stage II COPD

Answer 206

long-acting bronchodilator these include: - beta-2 agonists (salmeterol) - anticholinergics (tiotropium) po methylxanthines (aminophylline, theophylline) are options but have narrow therapeutic windows and multiple DDIs

Question 207

Management of stage III-IV COPD with complications

Answer 207

inhaled steroids (fluticasone, triamcinolone, mometasone) DO NOT AFFECT RATE OF DECLINE OF LUNG FUNCTION but do reduce the frequency of exacerbations OXYGEN therapy also recommended in stage IV if there is evidence of hypoxemia [DECREASES MORTALITY if at least 15h/d] No benefit of oral steroids and many complications Continuous Abx is controversial- decreases exacerbations but not mortality

Question 208

What precipitates COPD exacerbations?

Answer 208

Bacterial and viral infections, air pollutants

Question 209

Which type of drug is known to precipitate gout attacks?

Answer 209

Thiazide diuretics, since they increase urinary urate reabsorption, causing hyperuricemia Loop diuretics and chemotherapeutic agents also may cause gout attacks

Question 210

Gout crystal

Answer 210

Monosudium urate (MSU): Needle-shaped, with strong negative birefringence

Question 211

Pseudogout crystals

Answer 211

CPPD: rod shaped, rhomboid, weakly positive birefringence

Question 212

Indications for ultrasound in pregnancy

Answer 212

Not mandatory in routine pregnancy. Indicated for: - evaluation of uncertain gestational age - size/date discrepancies - vaginal bleeding - multiple gestations - other high-risk situations

Question 213

Advanced maternal age

Answer 213

Pregnant women who will be 35 or beyond at the estimated date of delivery

Question 214

Women considering conception should take what?

Answer 214

Folic acid (400-800 μg if low risk, 4 mg if previous child w/ NTD, 1 mg if DM or epilepsy)

Question 215

Naegele's rule

Answer 215

Subtract 3 months from the first day of the LMP and add 7 days to date the pregnancy

Question 216

Screening for gestational diabetes

Answer 216

Between weeks 24-28 1-hour 50 g glucose challenge test If positive, 3-hour 100 g GGT after overnight fast. Assess fasting, 1 hr, 2 hr, and 3 hr postload serum glucose samples. -2 out of 4 positive values indicate GDM Women diagnosed with GDM should be screened for T II DM at 12 weeks postpartum

Question 217

Group B streptococcus screening

Answer 217

Between 35-37 weeks Colonized women should be treated w/ IV abx at the time of labor or rupture of membranes

Question 218

Late-term pregnancy

Answer 218

41 weeks, 0 days - 41 weeks, 6 days

Question 219

Post-term pregnancy

Answer 219

Beyond 42 weeks or 294 days

Question 220

Pre-term pregnancy

Answer 220

Birth before 37 weeks If h/o pre-term, women should be given progesterone injections weekly from 16-37 weeks

Question 221

Vaccinations during pregnancy

Answer 221

- prenatal visit: influenza - 27-36 weeks: tetanus toxoid, diphtheria, Tdap Varicella, rubella, and live attenuated influenza NOT recommended

Question 222

What to do if woman is Rh negative

Answer 222

Assess antibody screen or do indirect Coomb's If Ab screen is negative, no isoimmunization --> give RhoGAM at 28 weeks and again at delivery if baby is determined to be Rh + If Ab screen is positive, and the identity of the Ab is confirmed to be Rh (anti-D), check titer - low titer: observe - high titer: US +/- amniocentesis

Question 223

BMI in children

Answer 223

Underweight: <5 percentile Healthy weight: 5-85 percentile Overweight: 85-95 percentile Obese: >95 percentile

Question 224

Pediatric failure to thrive

Answer 224

Weight below the 3rd or 5th percentile OR Decelerations of growth that have crossed two major growth percentiles in a short period of time

Question 225

Mandatory newborn screens

Answer 225

PKU and congenital hypothyroidism Hearing is almost always tested too

Question 226

Lead testing

Answer 226

Between 12-24 months OR at 36 and 72 months

Question 227

Screen for strabismus

Answer 227

Cover-uncover test Positive: uncovered eye deviates to focus on the object If positive, refer to ophtho immediately

Question 228

Rear-facing car seat

Answer 228

Until 2 y.o. or until child has reached the maximum height or weight limit of the rear-facing seat >40 lbs: booster seat

Question 229

Top three causes of death in infants < 1

Answer 229

1. congenital abnormalities 2. short gestation 3. sudden infant death syndrome (SIDS) [babies should sleep on their BACK]

Question 230

2 month vaccinations

Answer 230

``` RV #1 DTaP #1 Hib #1 PCV #1 IPV #1 ```

Question 231

4 month vaccinations

Answer 231

``` RV #2 DTaP #2 Hib #2 PCV #1 IPV #2 ```

Question 232

6 month vaccinations

Answer 232

DTaP #3 PCV #3 IPV #3

Question 233

12 month vaccinations

Answer 233

MMR #1 Varicella #1 HepA #1

Question 234

Treatment of allergic rhinitis

Answer 234

- antihistamines - first gen: diphenhydramine, chlorpheniramine, hydroxizine [SE: sedation, dry mouth, dry eyes, blurred vision, urinary retention; careful in elderly] - second gen: loratadine, desloratadine, fexofenadine, azelastine, cetirizine - intranasal corticosteroids - decongestants (alpha agonists) - leukotriene inhibitors - zafirlukast, montelukast, zileuton - systemic corticosteroids (in severe cases) - desensitization therapy

Question 235

Non-nicotine smoking cessation therapy

Answer 235

Bupropion (Zyban) and Varenicline (Chantix) Bupropion (Zyban) - NDRI - contraindications: eating disorders, seizures, MAO-I, careful in heart disease - 7-12 weeks, can be used up to 6 mo - SE: insomnia, dry mouth - pregnancy category C Varenicline (Chantix) - partial nicotinic receptor agonist - SE: neuropsychiatric symptoms including behavior changes, agitation, depression, SI; nausea, insomnia, abnormal/vivid/strange dreams - CI: h/o depression, heart disease - pregnancy category C

Question 236

Principles of medical ethics

Answer 236

- Autonomy - Benificence - Nonmaleficence - Justice

Question 237

MMA and homocysteine levels

Answer 237

High MMA: B12 deficiency | High homocysteine: folate deficiency

Question 238

Anemia of chronic disease

Answer 238

- Normal ferritin | - TIBC decreased

Question 239

Iron deficiency anemia iron studies

Answer 239

- Serum iron: low - TIBC: high - Transferrin saturation: low - Serum ferritin: low

Question 240

Common bugs causing traveler's diarrhea

Answer 240

Bacteria - E. coli - Salmonella - Shigella - Vibrio (non-cholerae) - Campylobacter Viruses - Rotavirus - Norovirus Parasites - Giardia lamblia - E. histolytica - Cryptosporidium parvum

Question 241

Mammograms

Answer 241

Starting at 50: every 2 years D/c after 75

Question 242

Pap smears

Answer 242

Begin at 21 and do every 3 years For women over 30, can do every 5 years by co-testing with HPV cytology Stop at 65 if had 3 consecutive negative Paps or two consecutive negative HPV results within the last 10 years If cervix has been removed, testing is no longer necessary

Question 243

Osteoporosis diagnosis

Answer 243

DXA T-score at or below -2.5 Osteopenia: -1 - -2.5

Question 244

DXA scan

Answer 244

65 and over, and under 65 with high risk

Question 245

Calcium and vitamin D for primary prevention of fractures in osteoporosis

Answer 245

Level D

Question 246

Ottowa knee rules

Answer 246

Perform X-ray if any one: 1. >55 2. isolated patella tenderness 3. tenderness of the head of the fibula 4. inability to flex the knee to 90 degrees 5. inability to bear weight for 4 steps immediately and in the exam room (regardless of limping)

Question 247

Management of most acute sprains

Answer 247

PRICE - protection - rest - ice - compression - elevation NSAIDs or acetaminophen for pain control Early mobilization of injured ligaments promotes healing and recovery -begin ROM exercises 48-72 hours after injury

Question 248

Excision borders of melanoma in situ

Answer 248

5mm

Question 249

Superficial spreading melanoma location

Answer 249

Men: torso Women: legs

Question 250

Acral lentiginous melanoma

Answer 250

More common in blacks and Asian Under nails, soles of feet, palms

Question 251

ABCDEs of melanoma

Answer 251

``` Asymmetry Borders (irregular) Color (variegated) Diameter (>6 mm) Elevation/Evolving ```

Question 252

Excision margins for lesion concerning for melanoma

Answer 252

2-3mm If biopsy confirms malignancy, want 5mm margins

Question 253

What factor is most important in the prognosis of melanoma?

Answer 253

Breslow factor (depth): <1 mm thick have a low rate of metastasis

Question 254

First-time microscopic hematuria

Answer 254

Follow up with repeat UA and microscopy in 6 weeks before any other management is done

Question 255

Graves disease finding on radionucleotide scan

Answer 255

Diffuse increased uptake

Question 256

Graves disease treatment

Answer 256

Radioactive iodine (in non-pregnant patients- don't use in children or breastfeeding mothers) In adolescents: - antithyroid drugs: PTU, methimazole, carbimazole (inhibit organification of iodine; PTU also inhibits peripheral conversion) - may go into spontaneous remission after 6-18 months of therapy

Question 257

PTU vs. methimazole

Answer 257

Methimazole is first-line unless pregnant (PTU preferred for 1st trimester) PTU: black box warning for HEPATOTOXICITY Watch for agranulocytosis

Question 258

Evaluation of thyroid nodule

Answer 258

TSH and ultrasound Nodules >1 cm on US require biopsy (FNA)

Question 259

Stages of labor

Answer 259

1. onset of labor until cervix is completely dilated - latent phase: contractions become stronger, longer lasting, and more coordinated - active phase: usually starts at 3-4 cm of dilation; rate of cervical dilation at its maximum; contractions usually strong and regular [INDICATION FOR ADMISSION TO BIRTHING UNIT] 2. complete cervical dilation (10 cm) through delivery of fetus - normal < 2 hrs in nulliparous woman and < 1 hr in parious woman - epidural can prolong by up to 1 hr 3. delivery of baby until delivery of placenta and membranes - prolonged if > 30 min

Question 260

Determinants of the progress of labor

Answer 260

1. Power - strength of uterine contractions - strength of maternal pushing efforts 2. Passenger - fetus size, lie, presentation, position within birth canal 3. Pelvis - size, shape

Question 261

Confirm rupture of membranes

Answer 261

Exam: - fluid leaking from cervical os (either spontaneously or w/ Valsalva) - presence of amniotic fluid pooling in the posterior vaginal fornix Amniotic fluid: - Nitrazine test: pH > 6.5 (normal vaginal secretions < 5.5) - ferning (under microscope)

Question 262

Fetal cardinal movements

Answer 262

1. Flexion 2. Internal rotation 3. Extension 4. External rotation

Question 263

Treatment of maternal GBS

Answer 263

penicillin (or ampicillin)

Question 264

Hypovolemic hyponatremia etiologies and treatment

Answer 264

Cerebral salt wasting, skin loss, diuretic use, GI losses, mineralocorticoid deficiency, third-spacing See signs of volume depletion Tx: normal saline and treat underlying condition Severe symptomatic: <125 - confusion, seizures, coma - urgent treatment with 3% (hypertonic saline) - but go slow d/t risk of osmotic demyelination ("from low to high your pons will die")

Question 265

Hypervolenic hyponatremia etiologies and treatment

Answer 265

Heart failure, cirrhosis, nephrosis Exhibit signs of volume overload Tx: diuretics and restriction of sodium and water intake

Question 266

Euvolemic hyponatremia etiologies and treatment

Answer 266

SIADH (d/t infections, malignancy, drugs, CNS disorders), primary polydipsia, water intoxication, hypothyroidism, low solute intake ("tea and toast syndrome") Tx: fluid restriction and treat underlying cause

Question 267

Pseudohyponatremia

Answer 267

Low plasma [Na+] in the setting of hyperglycemia, hypertriglyceridemia, hyperproteinemia, laboratory errors, or mannitol use Usually have normal volume status with normal osmolality

Question 268

Management plan for hyperkalemia

Answer 268

1. stabilize myocardium w/ IV calcium gluconate 2. shift K+ intracellularly with insulin and glucose 3. lower total body K+ with Kayexalate, loop diuretics, or dialysis 4. Address underlying cause

Question 269

Centor criteria

Answer 269

For suspicion of GAS Points given for: - absence of cough - enlarged/tender anterior cervical adenopathy - fever of 100.4 or higher - tonsillar swelling/exudates 0-1: no further testing or abx warranted 2-3: perform rapid strep or throat culture and treat w/ abx if positive 4+: consider empiric abx treatment

Question 270

GAS treatment

Answer 270

Penicillin | IM penicillin G or 10-day course of po penicillin V

Question 271

Swimmer's ear bug

Answer 271

Pseudomonas aureuginosa

Question 272

Malignant otitis externa

Answer 272

Patients w/ DM at risk Pseudomonas aureuginosa

Question 273

Most common presentation of Hodgkin's lymphoma

Answer 273

Asymptomatic lymphadenopathy or an incidentally found widened mediastinum Presence of symptoms generally indicates a worse prognosis Typicaly symptoms include B symptoms (fever, night sweats, chills) More rarely: - pruritis (esp. after a hot shower) - severe pain after ingesting alcohol

Question 274

Ann Arbor staging for Hodgkin's lymphoma

Answer 274

Stage I: involves only a single lymph node region Stage II: involves two or more lymph node regions on the same side of the diaphragm Stage III: involves lymph node regions on both sides of the diaphragm Stage IV describes disseminated disease. In addition to the stage, the designations “A” and “B” are used to describe the absence (A) or presence (B) of the “B symptoms”

Question 275

Acute bronchitis features and treatment

Answer 275

Cough with purulent sputum in the setting of other findings suggestive of a URI Tx: pseudephedrin and acetaminophen [NO ABX- IT IS ALMOST ALWAYS VIRAL]

Question 276

What constitutes controlled asthma?

Answer 276

If a patient’s asthma is controlled, then he or she should require their rescue inhaler less than 2 times per week in the day and less than 2 times per month at night.

Question 277

Appearance of basal cell carcinoma

Answer 277

smooth, pearly, with telangiectasias

Question 278

Impetigo d/t MRSA resistant to cephalosporins

Answer 278

clindamycin or TMP/SMX

Question 279

Migraine prophylaxis

Answer 279

- beta blockers (propranolol, timolol) - anticonvulsants (valproic acid, topiramate) - TCAs (amitriptyline)

Question 280

Lab results most indicative of pancreatitis

Answer 280

Elevated lipase

Question 281

What is alprostadil?

Answer 281

INIJECTABLE prostaglandin analog for ED

Question 282

What class of drugs is contraindicated with nitrites?

Answer 282

Phosphodiesterase inhibitors (sildenafil, vardenafil, or tadalafil) In patients on nitrites who have ED, consider injectable PG analog alprostadil

Question 283

Most common cause of isolated bloody nipple discharge in healthy young woman

Answer 283

Intraductal papilloma

Question 284

Normal pressure hydrocephalus symptoms and CT findings

Answer 284

dementia, gait disturbance, and urinary incontinence (wet, wobbly, wacky) CT: ventricular enlargement (hydrocephalus) WITHOUT cerebral atrophy

Question 285

Antibiotics for acute mastitis

Answer 285

dicloxacillin and cloxacillin, amoxicillin/clavulanate, cephalexin Incision and drainage is indicated for breast abscesses, which are a common complication of mastitis

Question 286

Consideration about breast development

Answer 286

Breast development often begins asymmetrically, and breasts can differ by as much as two Tanner stages before such development is considered abnormal

Question 287

Signs and symptoms of endometriosis

Answer 287

fixed, retroverted uterus or blue spots in the posterior fornix Other clues include dyspareunia (especially with deep thrusting), rectal pain during menstruation, pain with defection, or tender bilateral adnexal masses palpable during menstruation. Though you may suspect endometriosis clinically, to confirm the diagnosis, you need to directly visualize the endometrial implants surgically, by laparoscopy or laparotomy. (The lesions will appear as dark red, blue, or purple lesions, frequently called “powder burns,” “mulberry lesions,” or “chocolate cysts.”

Question 288

Endometriosis treatment

Answer 288

Endometriosis can be treated either medically (with OCPs, Depo-Provera injections, danazol, or GnRH agonists like leuprolide) or surgically (by hysterectomy, lysis of adhesions, or removal of endometrial implants).

Question 289

MEN1 syndrome

Answer 289

Parathyroid hyperplasia, pancreatic islet tumors, and pituitary tumors in addition to gastrinomas and ZES

Question 290

MEN-2A syndrome

Answer 290

"2 MPH" medullary thyroid cancer, phenochromocytomas, and hyperparathyroidism

Question 291

MEN-2B syndrome

Answer 291

"2 PM" medullary thyroid carcinoma and pheochromocytoma

Question 292

What to do with postmenopausal bleeding

Answer 292

Endometrial biopsy Postmenopausal bleeding is NEVER normal

Question 293

Surruptitious insulin use (factitious disorder) labs

Answer 293

High insulin, low c-peptide

Question 294

Treatment of acute bacterial prostatitis

Answer 294

ciprofloxacin or levofloxacin or TMP/SMX

Question 295

Stages of kidney failure

Answer 295

``` Normal GFR: 90-120 Stage 1: GFR > 90 w/ proteinuria, hematuria, or abnormal renal structure Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: GFR 15-29 Stage 5: GFR < 15 or dialysis ```

Question 296

Strawberry cervix

Answer 296

Trichomonas vaginalis po metronidazole (also treat partner to prevent reinfection)

Question 297

Atypicals

Answer 297

- Mycoplasma pneumoniae - Chlamydia pneumoniae - Legionella pneumophilia - viruses Tend to cause bilateral, diffuse infiltrates (cf focal, lobar infiltrates)

Question 298

Clues for legionella pneumonia

Answer 298

Pneumonia with diarrhea, hyponatremia, and elevated liver enzymes

Question 299

X-ray appearance of pneumocystis pneumonia

Answer 299

Bilateral ground glass infiltrate

Question 300

Empiric therapy for community acquired pneumonia

Answer 300

Clarithromycin or azithromycin, or doxycycline If DM or heart/lung disease: fluoroquinolones (levofloxacin, moxifloxacin), or combo beta-lactam plus macrolide

Question 301

Hospitalized treatment of CAP (non-ICU)

Answer 301

IV beta-lactam (cefoxatime, ceftriaxone, or ampicillin/sulbactam) and an IV macrolide (erythromycin or azithromycin). Or IV fluoroquinolone

Question 302

Post-influenza pneumonia is most commonly caused by

Answer 302

staph aureus

Question 303

Hypertension in pregnancy after 37 weeks

Answer 303

Admit and induce

Question 304

What medication may reduce the risk of preeclampsia?

Answer 304

Aspirin

Question 305

Preferred narcotic in kidney disease

Answer 305

Fentanyl (99% hepatic metabolism)

Question 306

Test for hereditary hemochromatosis

Answer 306

random measurement of serum ferritin and calculation of transferrin saturation. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is 45% the HFE gene should be checked

Question 307

What is most helpful for narrow-complex supraventricular tachycardias

Answer 307

IV adenosine and vagal maneuvers

Question 308

Causes of postpartum hemorrhage

Answer 308

The 4 Ts: - Tone: uterine atony (70%) - Trauma: cervical, vaginal, or perineal lacerations; uterine inversion (20%) - Tissue: retained placenta or membranes (10%) - Thrombin: coagulopathies (1%)

Question 309

Endometritis

Answer 309

Postpartum fever associated with uterine tenderness and foul-smelling lochia Treat w/ broad-spectrum abx that cover vaginal and gastrointestinal flora (e.g., combo gentamicin and ampicillin). For C-section must also cover anaerobes (eg., combo gentamycin and clindamycin)

Question 310

When does postpartum blues resolve?

Answer 310

Typically by 10th postpartum day Tearfulness, sadness, emotional lability

Question 311

Contraindications to breast feeding

Answer 311

HIV infection, miliary TB, acute hepatitis B, herpetic breast lesions, chemotherapy Abuse of cocaine, heroin, PCP, alcohol Women who have had breast reduction surgery with nipple transplantation will be unable to breast feed

Question 312

What type of birth control pill is preferred in breast feeding women?

Answer 312

Mini-pill (progesterone only) since combined OCP can reduce lactation Wait until 6 weeks postpartum Depo Provera injection also ok Non-breast feeding women should wait 3 weeks after delivery to start contraception d/t increased risk of thromboembolic disease

Question 313

Early CHF CXR finding

Answer 313

Cephalization of the pulmonary vasculature (upper lobe pulmonary vein dilation with lower lobe pulmonary vein constriction) Indicates increased preload

Question 314

CHF CXR findings

Answer 314

Interstitial pulmonary edema can be seen as perihilar infiltrates, often in a butterfly pattern Kerly lines (spindle-shaped linear opacities in the periphery of the lung bases) Pleural effusions (often bilateral, but if unilateral, R > L)

Question 315

Drugs for heart failure

Answer 315

ACE-i/ARBs, beta-blockers (carvedilol, metoprolol, bisoprolol), loop diuretics (furosemide, bumetanide, torsemide, ethacrynic acid), aldosterone antagonists (spironolactone, eplerenone) African-American: hydralazine + nitrates (in combo with ACE-is, beta blockers, and spironolactone) CCBs increase mortality Digoxin may help symptoms but has no mortality benefit

Question 316

Progression of vascular dementia

Answer 316

Stepwise degeneration

Question 317

Features of metabolic syndrome

Answer 317

- waist circumference > 102 cm (M) or 88 cm (F) - hypertriglyceridemia (> 150) - low HDL (<40 (M) or <50 (F)) - HTN (>130/>85) - Fasting plasma glucose (>100, or previously diganosed T2DM)

Question 318

BMI

Answer 318

``` Underweight: <18.5 Normal: 18.5-24.9 Overweight: 25-29.9 Obese: I: 30-34.9 II: 35-39.9 III (morbid obesity): >40 IV (super obesity): >50 ```

Question 319

Candidates for bariatric surgery

Answer 319

-BMI > 40 who have failed diet and exercise or -BMI >35 with serious comorbid conditions

Question 320

Migraine features

Answer 320

``` Repeated attacks lasting 4 hours to 3 days At least 2: -unilateral pain -throbbing pain -aggravation by movement -moderate or severe intensity Plus at least 1: -nausea/vomiting -photophobia and phonophobia ```

Question 321

Who needs a statin?

Answer 321

- Patients under 75 w/ clinical CVDa - Patients w/ LDL >190 - Patients 40-75 with DM and LDL >70 - Patients 40-75 w/ 10-yr CVD risk >7.5% and LDL >70 Monitor LFTs If statin is contraindicated or not tolerated, offer exetimibe

Question 322

Kocher criteria for septic arthritis in children

Answer 322

1. fever >101.3 (38.5) 2. non-weight bearing 3. ESR >40 4. WBC >12,000

Question 323

Legg-Calvé-Perthes disease

Answer 323

avascular necrosis of femoral head in kids 4-8 - boys>girls - gradual onset of hip, thigh, or knee pain, and limping over a few months - treatment is conservative

Question 324

Slipped capital femoral epiphysis

Answer 324

separation of the growth plate, which results in the femoral head being medially and posteriorly displaced - most common in adolescent overweight boys - pain in hip, thigh, or knee along with a limp - limited internal rotation and obligate external rotation when hip is passively flexed - treatment is surgical pinning of the femoral head

Question 325

Transient synovitis

Answer 325

self-limited inflammatory response that is a common cause of hip pain in children 3-10 - boys>girls - often follows viral infection - gradually increasing hip pain that results in a limp or refusal to walk

Question 326

Most common causes of postoperative fever by frequency

Answer 326

5Ws - wind (pneumonia) - water (UTI) - would (surgical site infection) - walking (DVT) - wonder drugs (drug fever)

Question 327

Croup

Answer 327

- barking cough - "steeple sign" - glucocorticoids and nebulized epinephrine

Question 328

Treat cat bites

Answer 328

Amoxicillin/clavulanate (10-14d) Also for dog and human bites (5-7d)

Question 329

First step in evaluation of acute stroke

Answer 329

Non-contrast CT May not show ischemia for up to 72h

Question 330

Who should get tPA

Answer 330

Ischemic stroke patients whose strokes began <3 hrs ago Contraindications: - recent surgery - trauma - GI bleed - MI - certain anticoagulant meds - uncontrolled HTN

Question 331

Diagnosis of hepatitis A

Answer 331

Conjugated hyperbilirubinemia, elevated serum transaminases, and positive antibody titers Acute: anti-HAV IgM Previous infection: elevated HAV IgG, negative IgM

Question 332

Diagnosis of hepatitis B

Answer 332

- HBsAg present in acute and chronic infections - HBeAg is a marker of HBV replication and infectivity - anti-HBcAg IgM is diagnostic of an acute infection [only marker present during window period of seroconversion] - Anti-HBs Ab is seen in resolved infections and is the marker produced by the HBV vaccine Chronic: HBsAg without anti-HBcAg IgM

Question 333

Diagnosis of hepatitis C

Answer 333

HCV RNA

Question 334

Liver enzymes in alcohol abuse

Answer 334

>2:1 ratio of AST to ALT GGT elevated

Question 335

Most common cause of peptic ulcer disease

Answer 335

Helicobacter pylori Gold standard diagnosis: EGD w/ mucosal biopsy

Question 336

Roseola

Answer 336

- HHV6 - prodromal illness with mild respiratory symptoms and high fever for up to 5 days, then defervescence - followed by characteristic erythematous maculopapular rash that appears suddenly on the trunk and spreads rapidly to the extremities, with sparing of the face - rash disappears 1-2d - no treatment

Question 337

Varicella

Answer 337

- varicella zoster virus - chicken pox in kids - development of rash (papules or vesicles on an erythematous base = "dewdrops on a rose petal") in clusters followed by malaise, fever, and anorexia - the vesicles then progress to shallow, crusted erosions and ulcerations - may also develop enanthems, with lesions on the oral, nasal, or GI mucosa - common complication: superinfection of vesicles w/ GAS and staph aureus - rare serious complications: encephalitis, meningitis, pneumonitis - treatment in patients >2: acyclovir, valacyclovir, or famcyclovir (if start w/in 24 hours of exanthem) - varicalle vaccine (live attenuated) at 12 and 15 months, booster at 4 yrs Shingles (herpes zoster) is reactivation of VZV which remains dormant in dorsal root ganglia - vesicular eruption along a dermatome - extremely painful - may cause posterherpetic neuralgia - vaccine in >60

Question 338

Erythema infectiosum

Answer 338

aka fifth disease or slapped cheek disease - parvovirus B19 - prodrome of mild fever and upper respiratory symptoms - rash that lasts 4-14d: confluent erythematous macules on the face, which usually spares nose and periorbital regions (slapped cheek appearance) - facial rash lasts 2-4d, followed by lacy, pruritic exanthem on the trunk and extremities that lasts 1-2wks Parvovirus B19 in older adolescents and adults can caue more serious illness -rheumatic complaints including arthralgias In sickle cell disease, parvovirus B19 can cause aplastic anemia In pregnancy can cause hydrops fetalis

Question 339

Complications of group A beta-hemolytic streptococcus

Answer 339

- streptococcal pharyngitis - scarlet fever - rheumatic fever - postinfectious glomerulonephritis - impetigo, erysipelas, cellulitis, necrotizing fasciitis

Question 340

Scarlet fever

Answer 340

- complication of GAS - rash starts 2d after sore throat and fever - rash: punctuate, raised, erythematous eruptions that can become confluent (Pastia lines) and feel like sandpaper - rash starts on upper trunk and spreads to rest of trunk and to the extremities - enanthem can cause "strawberry tongue" - rash fades and desquamation typically occurs 4-5d after appearance of rash

Question 341

GAS treatment

Answer 341

Penicillin (cephalosporin or macrolide if allergic)

Question 342

Rocky Mountain Spotted Fever

Answer 342

- d/t rickettsia rickettsii - early: fever, headache, myalgias, arthralgias, fatigue - kids may complain of abdominal pain - exanthem: macular, papular, or petichial eruption that starts on the wrists and ankles and spreads both centrally and to the palms and soles - low WBC, low platelets, hyponatremia, elevated liver enzymes - doxycycline

Question 343

Causes of breast pain

Answer 343

- cyclic mastalgia (diffuse, bilateral, often radiates to axilla and upper arm, related to menstrual cycle) - noncyclic mastalgia (continuous or intermittent, not related to menstrual cycle) - extra-mammary pain Common causes - pregnancy - mastitis - thrombophlebitis - cyst - benign tumors - cancer - musculoskeletal cause - stretching of Cooper ligaments - pressure from bra - fat necrosis from trauma - hidradenitis suppurativa - meds (OCPs, ADs, antipsychotics, anti-hypertensives) Breast pain is NOT a common presentation of breast cancer

Question 344

Chronic paroxysmal hemicrania

Answer 344

These resembles cluster headache but have some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.

Question 345

Electrolyte disturbance side effect of carbamazepine + hydrochlorothiazide

Answer 345

hyponatremia (esp. elderly)

Question 346

Treat hypoglycemia in an unconscious patient

Answer 346

IM glucagon

Question 347

Grapefruit

Answer 347

Inhibits P450

Question 348

Cauda equina syndrome

Answer 348

Increasing neurologic deficits and leg weakness, bowel and/or urinary incontinence, anesthesia or paresthesia in a saddle distribution, and bilateral sciatica Pain on straight leg test, reduction in anal sphincter tone, decreased bilateral ankle reflexes Need immediate eval w/ MRI, corticosteroids, and commonly immediate surgical decompression

Question 349

L4, L5, and S1

Answer 349

L4: knee strength and reflex L5: great toe and foot dorsiflexion S1: plantar flexion and ankle reflexes

Question 350

Symptoms of Parkinson disease

Answer 350

Distal resting tremor, micrographia, cogwheel rigidity, bradykinesia, postural instability, shuffling gait, asymmetric onset

Question 351

First-line therapy for osteoporosis

Answer 351

Bisphosponates (alendronate, risendronate, ibandronate) Empty stomach with full glass of water, upright for 30 min SE: osteonecrosis of jaw

Question 352

In patients w/ hemoglobinopathies, recent blood loss, or recent drastic changes in diet, what level is better to get than HbA1c?

Answer 352

Serum FRUCTOSAMINE (gives you 2-3 wk)

Question 353

Long QT syndrome

Answer 353

- autosomal dominant - M >470 ms, F >480 ms Any QT >500 is at risk for dangerous dysrhythmias

Question 354

When should labor be induced?

Answer 354

41 weeks

Question 355

Which vaccine should not be started after 15 weeks?

Answer 355

Rotavirus

Question 356

Rotterdam criteria for PCOS

Answer 356

2 or more: 1. Hyperandrogenism, as evidenced by hirsutism or elevated serum androgen levels 2. Oligomonorrhea with cycle length greater than or equal to 35d 3. Multifollicular ovaries on pelvic US, defined as 12 or greater small follicles in an ovary

Question 357

First-line treatment for aspirin-sensitive asthma

Answer 357

Leukotriene receptor antagonists

Question 358

Treatment of tropical sprue

Answer 358

ANTIBIOTICS Not gluten avoidance

Question 359

What type of immunization is rotavirus and when is it contraindicated?

Answer 359

Oral CI if ever had intuscusseption

Question 360

Treatment of postpartum endometritis

Answer 360

Gentamicin + clindamycin

Question 361

Typical use failure rate for OCPs, IUDs, injectable progestin, condoms, and withdrawal

Answer 361

The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method.

Question 362

H. pylori and drug dosing

Answer 362

H. pylori infection cam impair absorption, requiring higher doses of certain drugs

Question 363

Uncomplicated UTI treatment

Answer 363

3 days of trimethoprim/sulfamethoxazole

Question 364

Best antipsychotic for aggression in dementia

Answer 364

Aripiprazole

Question 365

What type of medication hastens the passage of ureteral stones?

Answer 365

Alpha-1 blockers (doxazosin, prazosin, and tamsulosin)

Question 366

Impaired fasting glucose

Answer 366

100-125

Question 367

Treatment for lupus arthritis

Answer 367

Hydroxychloroquine

Question 368

Treat M vs. F hair loss

Answer 368

Female pattern hair loss is categorized as diffuse and nonscarring. It presents with parietal hair thinning with preservation of the frontal hairline. Minoxidil 2% produces regrowth of hair in female pattern hair loss (SOR B). Oral finasteride is appropriate only for men with male pattern hair loss

Question 369

Osgood-Schlatter disease

Answer 369

Osgood-Schlatter disease is seen in skeletally immature patients. Rapid growth of the femur can cause tight musculature in the quadriceps across the knee joint. It typically appears between the ages of 10 and 15, during periods of rapid growth. Pain and tenderness over the tibial tubercle and the distal patellar tendon is the most common presentation. The pain is aggravated by sports participation, but also occurs with normal daily activities and even at rest.

Question 370

Patellofemoral pain syndrome

Answer 370

Patellofemoral pain syndrome is one of the most common causes of knee pain in children, particularly adolescent girls. Pain beneath the patella is the most common symptom. Squatting, running, and other vigorous activities exacerbate the pain. Walking up and down stairs is a classic cause of the pain, and pain with sitting for an extended period is also common. The physical examination reveals isolated tenderness with palpation at the medial and lateral aspects of the knee, and the grind test is also positive. Can also see lateral tracking of the patella. on extension of the knee

Question 371

First sign of SIADH

Answer 371

Hyponatremia Inappropriate release of ADH increases free water reabsorption, which increases circulating blood volume, dilutes sodium, and lowers hematocrit and hemoglobin. Urine output is often lowered because of this reabsorption, and the urine is more concentrated (urine osmolality > plasma osmolality) with sodium levels >20 mEq/L

Question 372

Urine in SIADH

Answer 372

Inappropriate release of ADH increases free water reabsorption, which increases circulating blood volume, dilutes sodium, and lowers hematocrit and hemoglobin. Urine output is often lowered because of this reabsorption, and the urine is more concentrated (urine osmolality > plasma osmolality) with sodium levels >20 mEq/L

Question 373

FSH and LH in PCOS

Answer 373

Polycystic ovary syndrome usually results in normal to slightly elevated LH levels and tonically low FSH levels.

Question 374

LH and FSH in primary ovarian failure

Answer 374

Elevated FSH and LH

Question 375

Diabetes medications that cause weight loss

Answer 375

GLP-1 receptor agonists, metformin, amylin mimetics, and SGLT-2 inhibitors.

Question 376

Lung cancer screening recommendation

Answer 376

The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults 55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have lung surgery

Question 377

Treatment of smoldering multiple myeloma

Answer 377

Nothing

Question 378

Occlusion of the circumflex artery is most likely to cause EKG changes in

Answer 378

I and AVL (and possibly V5 and V6 too)

Question 379

Left anterior descending coronary artery occlusion causes changes in

Answer 379

V1-V6

Question 380

Right coronary occlusion causes changes in

Answer 380

II, III, and AVF

Question 381

Telogen effluvium

Answer 381

A nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.

Question 382

Anagen effluvium

Answer 382

the diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair.

Question 383

Contraception in breast-feeding vs. non-breast-feeding women

Answer 383

Non-breast feeding: wait 3 weeks, and then combined OCP Breast-feeding: wait 6 weeks, and then progestin-only (Mini Pill), Depo Provera, or IUD

Question 384

Effectiveness of lactation-induced amenorrhea as birth control

Answer 384

99% effective for 6 months

Question 385

What to do if pregnant woman is positive for HBsAg

Answer 385

Treat newborn with HepB Ig and vaccination

Question 386

Most common cause of hospitalizations in >65

Answer 386

CHF

Question 387

Stool gap

Answer 387

measured osm - calculated osm (290) - 2(Na + K) <50: secretory >100: osmotic

Question 388

When should we get stool cultures for acute diarrhea?

Answer 388

- bloody diarrhea - diarrhea lasting more than 3-7d - immunocompromised - evidence of systemic disease or severe dehydration

Question 389

Step up treatment of asthma

Answer 389

``` I: SABA prn II: SABA + ICS III: SABA + LABA + ICS IV: increase dose of ICS + SABA + LABA V: po steroids ``` (Can use LTA for ICS)

Question 390

Weight loss drugs

Answer 390

- orlistat - locaserin - phentermine/topiramate

Question 391

Sprain vs. strain

Answer 391

Sprain: stretching or tearing injury of a LIGAMENT Strain: stretching or tearing injury of a MUSCLE or TENDON

Question 392

Complications of CKD

Answer 392

1. Anemia of CKD 2. Secondary hyperparathyroidism and marrow bone disease 3. Volume overload 4. Acidosis

Question 393

When does nausea of pregnancy typically resolve?

Answer 393

~22 wks

Question 394

Dieulafoy lesion

Answer 394

- a dilated aberrant submucosal vessel that erodes the overlying epithelium in the absence of a primary ulcer - brisk painless bleeding - patients typically men with comorbidities including cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse; NSAID use also common - dx: EGD [a raised nipple or visible vessel without an associated ulcer; however, the aberrant vessel may not be seen unless there is active bleeding from the site] - tx: resection

Question 395

Common causes of microscopic hematuria

Answer 395

Exercise, sex, recent DRE, urologic procedures, contamination by menses, meds

Question 396

AAA screening

Answer 396

Men 65-75 who have ever smoked

Question 397

Prostate cancer screening

Answer 397

55-69: shared decision making about PSA | >70: no

Question 398

HDL

Answer 398

>40 >60 is high

Question 399

Antibiotics or not? Which? - shigella - salmonella - campylobacter - EHEC - ETEC

Answer 399

- shigella: fluoroquinolone (or TMP/SMX if sensitive) - salmonella: none (unless severe) - campylobacter: erythromycin or fluoroquinolone - EHEC: fluoroquinolone or TMP/SMX - ETEC: fluoroquinolone or TMP/SMX [if pregnant or kid or quinolone resistant, use azithromycin]

Question 400

IBS meds

Answer 400

1. abdominal pain - antispasmodics (dicyclomine and hyosycamine prn) - low dose TCAs (careful in patients with constipation) - SSRIs if comorbid depression and anxiety - rifaximin (if diarrhea) - probiotics and peppermint oil 2. constipation - solube fiber (psyllium) - polyethylene glycol - lubiprostone (activates intestinal Cl- channels, inducing secretion) - linaclotide (stimulates cGMP production) 3. diarrhea - loperamide - alosetron (only for severe, SE is ischemic colitis) - rifaximin

Question 401

If Rh-

Answer 401

May be susceptible to Rh disease. If Ab screen negative, give RhoGAM at 28 weeks, after any trauma, obstetrical complication, or invasive procedure, and also after delivery if baby is Rh+

Question 402

Mesenteric ischemia

Answer 402

"gut attack" Patient usually a vasculopath or has a reason for emboli formation (e.g., recent angiography, A-fib). Pain out of proportion to exam. Pain with eating, so avoids eating --> weight loss. Dx: angiogram Tx: revascularization or resection

Question 403

If patient can't tolerate statin

Answer 403

Ezetimibe

Question 404

HPV vaccine

Answer 404

All boys and girls 9-26

Question 405

Child w/ nasal polyps

Answer 405

Any child 12 years or younger who presents with nasal polyps should be suspected of having cystic fibrosis until proven otherwise.

Question 406

Antibiotics for diverticulitis

Answer 406

Metronidazole or amoxicillin/clavulanate

Question 407

SCFE physical exam finding

Answer 407

limited internal rotation of the hip | Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°

Question 408

ALT > 3x AST

Answer 408

gallstone pancreatitis

Question 409

Behçet syndrome

Answer 409

recurring genital and oral ulcerations and relapsing uveitis (can lead to blindness) Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations. This disease is also associated with cutaneous hypersensitivity more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults

Question 410

Erythrasma

Answer 410

tender erythematous plaque with mild scaling found in skin folds (e.g., groin) coral-red fluorescence under a Wood’s light Corynebacterium infection Erythromycin (topical or systemic)

Question 411

Orthostatic proteinuria

Answer 411

This benign condition occurs in about 3%–5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections

Question 412

Rapid strep test specificity and sensitivity

Answer 412

High specificity, low sensitivity

Question 413

Treatment of lateral epicondylitis (tennis elbow)

Answer 413

1. activity modification and NSAIDs 2. use of brace 3. stretching/strengthening 4. steroid injection 5. surgical debridement of tendon

Question 414

Consideration when prescribing topical retinoids for acne

Answer 414

Avoid sun (PHOTOSENSITIVITY) Same with tetracycline

Question 415

Management of recurrent UTI

Answer 415

Prophylactic post-coital antibiotics (TMP/SMX, nitrofurantoin, cephalexin)

Question 416

Pleurodynia

Answer 416

aka "the devil's grip" Often caused by coxsackie virus. Symptoms may include fever and headache, but most characteristic is attacks of severe pain in the lower chest, often on one side

Question 417

Metformin contraindication

Answer 417

Renal insufficiency (Cr >1.7)

Question 418

Nicotine patch contraindications

Answer 418

Angina pectoris, CAD

Question 419

Prevention of swimmer's ear

Answer 419

Daily use of alcohol-acetic acid ear drops

Question 420

What causes hyponatremia in heart failure?

Answer 420

Decreased cardiac output --> decreased baroreceptor stretch and renal perfusion --> RAAS --> ADH secretion

Question 421

Positive PPD + negative CXR

Answer 421

Latent TB (9 mo INH + B6)

Question 422

Tinea versicolor treatment

Answer 422

Topical selenium sulfide

Question 423

Shingles vaccine

Answer 423

Shingrix everyone after 50 regardless of whether they've had singles or Zostavax

Question 424

Pap smear

Answer 424

Every 3 years Every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).

Question 425

Lipid guidelines

Answer 425

F: >45 unless RFs (start 20) M: >35 unless RFs (start 20)

Question 426

Routine asymptomatic CBC and electrolytes?

Answer 426

NO

Question 427

What vaccine should asthma patients get?

Answer 427

PPSV 23 (Pneumovax)

Question 428

DM screening

Answer 428

40-70 y.o. who are overweight A1c

Question 429

Hep C screen

Answer 429

High risk (injection drugs users, transfusions before 1992, long term hemodialysis, incarceration), born 1945-1965

Question 430

ASCUS + HPV+

Answer 430

Colposcopy

Question 431

ASCUS + HPV-

Answer 431

Pap in 4-6 mo or 1 year or colposcopy Low risk, 1 yr

Question 432

Low grade SIL on Pap

Answer 432

Colposcopy

Question 433

Atypical glandular cells on Pap

Answer 433

Colposcopy or endometrial biopsy (if of endometrial origin)

Question 434

RDW in iron deficiency anemia

Answer 434

Elevated

Question 435

How to clinically distinguish folate from B12 deficiency

Answer 435

Neurologic symptoms are only present in B12 deficiency

Question 436

Lyme disease treatment

Answer 436

Early localized: oral doxycycline or amoxicillin | Late disseminated: IV ceftriaxone

Question 437

Lice treatment

Answer 437

Permethrin 1%

Question 438

Palpable breast mass that is mammogram negative

Answer 438

US and biopsy

Question 439

Acoustic neuroma symptoms

Answer 439

Unilateral tinnitus and hearing loss Eventually may have vertigo, facial weakness, and ataxia

Question 440

Menière disease symptoms

Answer 440

Discrete attacks of vertigo lasting several hours, associated with nausea, vomiting, hearing loss, and tinnitus

Question 441

Distinguish central vs. peripheral vertigo

Answer 441

Dix-Hallpike maneuver is negative in central

Question 442

First-line therapy for peripheral vestibular disorders

Answer 442

Antihistamines (meclizine, diphenhydramine)

Question 443

BNP measurement

Answer 443

Can rule out CHF (has 99% NPV)

Question 444

Low vs high D-dimer

Answer 444

Low: high NPV --> no PE High: low PPV --> confirmatory spiral CT (or pulmonary angiogram which is the gold standard)

Question 445

Interstitial cystitis symptoms

Answer 445

Dysuria and hematuria without pyuria Dx: cystoscopy

Question 446

Sleep onset vs sleep maintenance pharmacotherapy

Answer 446

Onset: zolpidem (Ambien) or eszopiclone (Lunesta) Maintenance: zaleplon (Sonata)

Question 447

Most common cause of primary amenorrhrea

Answer 447

(Def: absence of menses at 16) Gonadal dysgenesis (e.g., Turner syndrome)

Question 448

Palpable preauricular lymph node

Answer 448

Viral conjunctivitis

Question 449

Short acting insulin

Answer 449

Aspart (Novolog), lispro (Humalog), glulisine (Apidra): onset between 15-30 min, peak between 30-60 min, last 3-5 hrs

Question 450

Intermediate acting insulin

Answer 450

Regular insulin: onset between 30-16 min, peaks 2-3 hrs, last 4-12 hrs

Question 451

Long acting insulin

Answer 451

NPH: onset between 1-2 hours, peak 4-8 hours, lasts 10-20 hrs glargine (Lantus), detemir (Levemir): onset between 1-2 hours, peak unpredictable, and last ~24 hrs

Question 452

What type of hearing loss is presbyacusis?

Answer 452

Presbyacusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and sensorineural

Question 453

Most common cause of erythema multiforme

Answer 453

Herpes simplex virus

Question 454

Treatment of cocaine-associated chest pain

Answer 454

Aspirin, nitroglycerin, IV benzodiazepines NOT beta-blockers, which can worsen coronary vasospasm d/t unopposed alpha action

Question 455

How to diagnose Duchenne muscular dystrophy in kids who have not started walking yet

Answer 455

Elevated CK

Question 456

Bowel rest after acute pancreatitis?

Answer 456

NO Bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from te gut So: Early initiation of a low-fat diet

Question 457

Most common cause of wheezing in infants

Answer 457

Gastroesophageal reflux

Question 458

Skin tags are associated with

Answer 458

Diabetes and obesity

Question 459

Which fluoroquinolone should not be used in UTIs?

Answer 459

Moxifloxacin Doesn't attain high enough urinary concentrations

Question 460

Treatment of shingles

Answer 460

ORAL antivirals (acyclovir, valacyclovir, famcyclovir)

Question 461

Prevent renal failure induced by contrast

Answer 461

adequate hydration and the use of N-acetylcysteine

Question 462

Most effective treatment of lice

Answer 462

Malathion

Question 463

Which tocolytic also causes respiratory depression?

Answer 463

Magnesium sulfate

Question 464

What does it mean if mother is anti-D antibody positive?

Answer 464

The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive

Question 465

TNF inhibitor black box warning

Answer 465

All drugs in this class carry an FDA black-box warning about the potential for developing primary tuberculosis or reactivating latent tuberculosis. These drugs are also associated with an increased risk for invasive fungal infections and opportunistic bacterial and viral diseases. The FDA also warns of reports of lymphomas and other malignancies in children and adolescents taking these drugs.

Question 466

Antidote to respiratory depression from magnesium

Answer 466

Calcium