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121

Hallmark lab finding in polymyalgia rheumatics

Markedly elevated ESR

122

OCPs and cancer

Prevent ovarian cancer and may cause breast cancer

123

Combined OCP vs. progestin-only

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

124

First step in evaluating short stature

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

125

Distinguish between familial short stature and constitutional delay of growth

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)

126

Do we treat bacteruria of pregnancy?

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

127

Treatment of bacteruria in pregnancy

[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]

128

Kawasaki disease

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

129

Treatment of Kawasaki disease

Patients need serial echos to monitor aneurysms.

Intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis

130

How to choose allopurinol vs. probenecid

24 hour urine collection for uric acid

<600 mg: underexcreter --> probenecid
>600 mg: overproducer --> allopurinol

131

Two most common nonpathological reasons for high alfa-fetoprotein

1. Multiple gestations
2. Inaccurate gestational date

132

Blood on dipstick but no RBCs

Myoglobinuria (myoglobin cross reacts w/ hemoglobin on dipstick)

133

Prevent myoglobin-induced ATN in rhabdomyolysis

IV saline

134

Hypertensive urgency

>200 / >120 in the absence of symptoms

135

Hypertensive emergency

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

136

Treatment of hypertensive emergency

IV antihypertensive

137

Treatment of hypertensive urgency

Oral antihypertensives (e.g., labetalol)

138

How to begin a new-onset eneuresis workup

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.

139

Intusussusception presentation

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.

140

Congenital rubella findings

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.

141

HIV patient w/ CD4 < 200 needs what?

TMP/SMX for prophylaxis of pneumocystis jirovecii pneumonia

142

HIV patient w/ CD4 < 100 needs what?

TMP/SMX for prophylaxis of toxoplasma gondii

143

HIV patient w/ CD4 < 50 needs what?

Azithromycin or clarithromycin for prophylaxis of MAC

144

What is a positive PPD in a high risk patient?

>5 mm induration

(HIV/AIDS, immunocompromised/suppressed, close TB contact)

145

What is a positive PPD in a moderate risk patient?

>10 mm induration

(homeless, comes from a country with high TB rates, or is an i.v. drug user)

146

What is a positive PPD in a low risk patient?

> 15 mm induration

(no major TB RFs)

147

Management of shoulder dystocia

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)

148

Most common complication of shoulder dystocia

Erb palsy

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

149

Congenital syphilis findings

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

150

Classic triad of congenital toxoplasmosis

Hydrocephalus, chorioretinitis, intracranial calcifications