Case Files-FM

Question 1

52 y.o. man comes to office for routine physical
New pt…no comorbidities, no meds, no smoking
BP 127/82, ht: 5,7 weighs 190. No abnormalities.
-What screening tests for cardiovascular dz?
-What screening tests for cancer?
-What immunizations?

Answer 1

52, here for annual physical
CVS: screen for HTN (BO), lipids, U/S for AAA men -65-75 who has ever smoked
Cancer: fecal occult blood testing, flexible sigmoidoscopy, colonoscopy or contrast barium enema for colorectal cancer. Prostate cancer- not determined whether for/against
IMMUNIZATIONS-
1.Tdap (if never had one or if over ten years since he had Td vaccine or if he needs booster protection against pertussis
2. Influenza annually

Question 2

Primary Prevention

Answer 2

u will intervene before the dz develops; you identify and manage risks - using statins to reduce LDL or removing colon polyps before they become cancerous.

Question 3

Secondary Prevention

Answer 3

reduces or prevents exacerbation of the current disease (using statins after you had an M.I.

Question 4

Who should be screened for lipid disorders?

Answer 4

men and women 45

young adults >20 with risk factors

Question 5

Is U/S screening of AAA for women recommended?

Answer 5

NO

Question 6

Who should be screened for colorectal cancer?

Answer 6

men and women >50 via

1. FOBT of three consecutive bowel movements - ANNUAL
2. Flexible sigmoidoscopy with/without occult blood testing-EVERY 3-5 yrs
3. Colonoscopy-EVERY 10 yrs

Question 7

Who should be screened for prostate cancer?

Answer 7

men over 75 via PSA and DRE. There is no recommendation for men younger than that

Question 8

What other cancer should be screen out?

Answer 8

Lung cancer, thyroud and oral caner

Question 9

Obesity

Answer 9

screening for obesity by measuring BMI and promoting behavioral intervenions

• Do we screen every obese person for T2DM?
• No, only adults with HTN and HLD

Question 10

What other things are screen for?

Answer 10

Depression, Tobacco, Alcohol abuse

Question 11

Immunizations

Answer 11

Tdap - q10 yrs or booster if waning immunity
Flu vaccine- age 6mos and up
Hep B- those higher risk of exposure (health care workers, MSM,
Hep A-liver dz, clotting factor problems, IV drug users, travelers
Varicella-those who never had Chicken pox or at risk
Meningococcal-dorm rooms, military recruits, no spleen, travelers

Question 12

Managing stable COPD-Stage 1

Answer 12

Encourage quit smoking
Appropriate Flu and pneumococcal vaccines
–>Inhaled short-acting bronchodilators (albuterol, beta-agonists, Ipatropium-anticholinergics)

Question 13

Managing stable COPD-Stage 2

Answer 13

add+ Long acting bronchodilators (Salmeterol), Tiotropium, oral Methylxanthines (less common)

Question 14

Managing stable COPD-Stage 3, 4

Answer 14

add inhaled STEROIDS (Fluticasone, Triamcinolone)

add oxygen if hypoxemia (Sao2

Question 15

Managing COPD exacerbation

Answer 15

short-acting bronchodilators, systemic steroids prednisolone 10-14 days).

Question 16

case: 68 y.o. smoker with COPD has PFT showing FEV1 of 40% with frequent exacerbations of COPD. His SaO2 by pulse ox is 91%. Which is most appropriate?

Answer 16

inhaled Fluticasone BID, inhaled tiotropium BID, inhaled albuterol as needed

Question 17

Gout Flare up (knee joint)

Answer 17

Dx: joint aspiration to exclude infection or to reveal crystals-negatively birefringement crystals
Tx: NSAID, colchicine
Factors causing gout–Thiazide diuretics, alcohol consumption , red meat

Question 18

Rheumatoid Arthritis

Answer 18

morning stiffness, involvement of hands, symmetric arthritis, positive serology[anti-CCP, RF], eleveated acute phase reactants, duration of symptoms >6 weeks,
TX: DMARDS (Methotrexate)

Question 19

Tx of Allergic Rhinitis

Answer 19

1. Antihistamines-cheap, available OTC
   eg. Benadryl,
   Side effects are anticholinergic (dry eyes, dry mouth, urine retention
   2nd gen antihistamines (Loratidine, Fexofenadine, Zyrtec do not penetrate the CNS.
2. Decongestants…constrict the nasal mucosa, reducing its volume
3. Corticosteroid nasal spray
4. Leukotriene inhibitors….for maintainance for persistent asthma
5. Oral steroids-inhibit cell mediated immunity
6. Desensitization therapy

Question 20

When do you try desensitization therapy?

Answer 20

• patients who have refractory symptoms despite adequate medical therapy
• Test for antigens that person is allergic to and then keep injecting them with diluted amounts of antigen in effort to eventually reduce the patient’s inflammatory response to the antigen

Question 21

Which therapy would and asthmatic with allergies get?

Answer 21

Monteleukast!

Question 22

Which therapy is best for a driver or forklift operator?

Answer 22

FEXOFENADINE

Question 23

Talking about quitting smoking-the 5 As

Answer 23

Ask- @ each visit about tobacco use
Advise-to quit 
Assess-willingness to quit (how do they feel about quitting)
Assist-counseling
Arrange-follow up and support

Question 24

Drugs to Quit Smoking

Answer 24

Nicotine replacement

Non-nicotine- Bupropion and Verenacline

Question 25

Buproprion

Answer 25

Blocks NE/Dopamine * do not give to people with eating disorders, seizures or MAOI (antidepressant) use in the past 2 weeks - can be used alone or IN COMBO with nicotine-based treatments

Question 26

Verenicline

Answer 26

Nicotinic receptor partial agonist Side effects: Neuropsychiatric disorders, suicidal thoughts and abnormal dreams do not give to anyone with a psych hx -NOT FOR COMBINATION

Question 27

Which of the two drugs can be used for pregnant patients patients?

Answer 27

both Bupropion and Verenacline

Question 28

Woman's Cardiovascular Health

Answer 28

18 and older- HTN 45 and older- HLD screening] postmenopausal women taking hormone replacement (estrogen alone or estrogen/progesterone combo) have higher risks of cardiovascular dz [stroke, heart dz or venous thromboembolism]

Question 29

Breast Cancer Screening (Mammograms)

Answer 29

USPSTF- after age 50, screening every 2 yrs (Level B) - under 50, could be individualized (take into acct benefits and harms) ACOG- varies for under age 50, but definitely screen every 1 to 2 years

Question 30

Cervical Cancer Screening/Pap Smears - when do you start?

Answer 30

@ age 21 or three years after first sexual encounter; come back 1 yr or at least 3 normal before going longer Amer Cancer Society-recommends annual pap smears until age 30 then every 2-3 years after that -HPV vaccine for age 9-26 USPSTF: If you had a hysterectomy, then you don't need cervical cancer screening- don't do a pap smear -if you have a cervix then you continue to have pap smears ACS: stop screening @ age 70 if after 3 consecutive positive and no abnormal in ten years

Question 31

Screening for Osteoporosis

Answer 31

-done by measuring bone density (T-score) osteoporosis if T-socre is below -2.5 osteopenia if T-score is -1 to -2.5 DXA scan after age 65 and in women >60 if they have high risk of osteo fractures

Question 32

how much calcium and Vit D

Answer 32

1200mg Calcium 400-800mg Vit D weight braring and muscle strengthening Meds: Bisphosphanates: alendronate, risedronate, Calcitonin, Estrogen, PTH, SERM (Raloxifene)

Question 33

Screening for Domestic Violence

Answer 33

Reporting is mandatory ' USPSTF finds no evidence for or against screening for Domestic Violence or that it affects outcomes. So you don't have to do it.

Question 34

Musculoskeletal Injuries

Answer 34

``` Ankle sprains- due to inversion of ankle that is plantar flexed. The AnterioTaloFibular(ATFL) Ligament form the lateral ankle is most often damaged in ankle spraing ```

Question 35

Grade 1 Sprain is STRETCHING of the ATFL,which causes pain and swelling. Patient can bear weight

Answer 35

Grade 2-partial tear of ATF and stretching of CFL, causing more pain, swelling and bruising- Non-weight bearing GRADE 3-complete tear of ligament

Question 36

Ottowa Ankle rules tells u to get plain XRAY if - it applies to 1) nonpregnant adults who don't have painful injuries 2) pts w. normal mental status 3) must be done within 10d of injury * so like a volleyball player who sprains her ankle

Answer 36

bony tenderness of the posterior edge or tip of the distal 6cm of either medial or lateral malleolus OR If patient is unable to bear weight immediately or when examined

Question 37

Ottowa Rule Foot XRAY should be performed when

Answer 37

bony tenderness over - navicular bone (medial midfoot) - fifth metatarsal (lateral midfoot) - unable to bear weight

Question 38

0ttowa Knee XRAY Rules on pts with one of 5 criteria:

Answer 38

1) age 55 and older 2) isolated patella tenderness 3) tender head of fibula 4) inability to flex knee to 90 degrees 5) inability to bear weight for four steps immediately an din the exam room, regardless of limping

Question 39

Management of sprains/ strains

Answer 39

``` P-PROTECTION from further injury R-Range of motion exercises start 48-72h after injury I-Ice to reduce swelling and pain C-Compression E-elevation to reduce edema +add NSAIDs for pain ``` The most common cause of persistently stiff joints is inadequate rehab

Question 40

Malignant Melanoma

Answer 40

seen before but enlarging-->completely excised with 2-3mm margins Larger lesions-->BIOPSY. If >5mm go to plastic surgeon to excise completely. Observe 1yr

Question 41

What kind of biopsy do you give for raised lesions?

Answer 41

shave biopsy

Question 42

What kind of biopsy do you give for flat lesions lesions?

Answer 42

punch biopsy or elliptical excision

Question 43

Prognosis in Melanoma/Breslow measurement

Answer 43

Melanomas

Question 44

Most common type of melanoma to both genders? Most aggressive and second most common? Most common type found in elderly (70s) usually in chronic sun-damaged face, ears, arms, upper trunk; usually found in Hawaii? Most common in Asians and African Americans?

Answer 44

Superficial spreading Nodular melanoma- grows quickly and is invasive Lentigo maligna Acral Lentiginous Melanoma