CCFP Flashcards
1
Q
Secondary causes of HTN ABCDES
A
Atherosclerotic, coarctation of the aorta
Bad kidneys - Renal parenchymal disease
Catecholamines
Drug, Diet
Endrocrine (Hypothyroid, aldosterone, Cushing), EtOH
Fibromuscular dysplasia
sleep apnea, stress
2
Q
Medications that raise BP
A
Steroids, NSAIDs, amphetamines, many psychiatric meds - SSRIs, SNRIs, carbamazepine, estrogen/progesterone/androgens, sympathomimetic (decongestant), licorice
3
Q
What does a lipid panel include
A
Chol, HDL, LDL, non-HDL, TG
4
Q
Risks of HCTZ?
A
Skin cancer non melanoma, possible 4x risk after 3 years
Avoid long acting Chlorthalidone, indapamine b/c of DM2, renal and electrolyte abnormalities
5
Q
Lifestyle interventions for HTN
A
Lower salt, exercise, weight loss, reduce alcohol, DASH diet, relaxation –> CBT
6
Q
HTN Meds to avoid in HTN
A
alpha blocker alone
Beta blockers if > 60
ACE if black
7
Q
Risk factors for uterine perforation
A
breast feeding grand multiparity history of csection nulliparity inexperienced HCP uterine abnormalities postpartum state in breastfeeding women
8
Q
when should you start various kinds of birth control when removing an IUD?
A
POP 2 days before, ocp/depo etc 7 days before
9
Q
contraindications to IUD
A
pelvic TB, pregnancy, uterine/cervical malignancy, puerperal sepsis, post-septic abortion, unexplained vaginal bleeding, gestational throphoblastic disease with persistently elevated betahcg (decreasing beta is relative), distorted uterine cavity, current PID/gonochlam
mirena: breast cancer, hx of ischemic heart disease, antiphospholipid antibodies, migraine with aura, severe cirrhosis
copper: severe thrombocytopenia
10
Q
What does SAD PERSONS stand for
A
Male sex Age <19, >45 Depression Previous attempt Excess EtOH/substances Loss of rational thinking Social supports lackings organized plan no spouse Sickness
11
Q
What else should you r/o with depression
A
mania, anxiety (does worry get in the way of your life?), OCD (thoughts/rituals you cannot stop), delusions (special powers/plot against you), hallucinations
12
Q
When to consider bipolar in absence of mania
A
age <25 >= 5 episodes family hx hypersomnia hyperphagia/increased weight lability of mood/irritability
13
Q
first line meds/treatments for PTSD
A
fluoxetine, paroxetine, sertraline
venlafaxine
CBT
group therapy
14
Q
first line meds/treatments for OCD
A
escitalopram, fluoxetine, paroxetine, sertraline
CBT
exposure with response prevention
15
Q
mimics for depression
A
hypothyroid, adrenal insufficiency, grief/adjustment disorder, drug use, bipolar, tumor, delirium
16
Q
SPIKES
A
setting up perception invitation knowledge emotion strategy, also SAFETY.
17
Q
SNOPQRST
A
Safety Next visit Offer Prevention Quit Refer Start Teach
18
Q
Osteoporosis risk factors
A
Age > 65 Sex - female post menopausal Alcohol Chronic disease i.e. RA Chronic steroid use Previous fragility fracture Malabsorption/eating disorder Hypogonadism low body weight <60kg for <50yo, fragility #, prolonged use of CS, high risk meds, hypogonadism/premature menopause, malabsorption syndrome, primary hyperparathyroidism, other d/o associated with rapid bone loss and/or fracture
19
Q
Chronic bronchitis criteria
A
Chronic bronchitis is defined as a cough with sputum expectoration for at least 3 consecutive months for at least
2 consecutive years
20
Q
Thalassemia regions
A
Southeast Asia Africa South America Middle East Carribbean Mediterranean
21
Q
Broad differential? VINDICATE
A
Vascular Infectious Neoplasm Drugs Idiopathic Congenital Autoimmune Trauma Endocrine
22
Q
COPDE sx
A
cough, purulence, dyspnea, CRP >40
Early warning score i.e. NEWS2
23
Q
Common ear bugs? what about (complicated) COPD? what about PNA?
A
Hemophilus,
Moraxella,
Strep pneumonia
(same as for COPD; if complicated add on klebsiella, gram negatives, pseudomonas; same for pneumonia, if comorbid add on staph aureus, if not comorbid, atypicals - mycoplasma and chlamydophila)
24
Q
COPD tx to prevent exacerbations
A
Flu/pneumonia shots Action plan to reduce hospital use CPAP? Daily macrolide (azithro, erythro) to decrease exacerbations Exercise Quit smoking Pulmonary rehab Puffers - SABA, LAMA, Respiratory therapy Teach inhaler technique
25
SNOPQRST
```
Safety
Next visit
Offer
Prevent
Quit
Refer
Start
Teach
```
26
Criteria for dx asthma in <6 yo
Wheeze that reverses
| it's not something else
27
What are the criteria for asthma dx
FEV1/FVC pre <0.75
FEV1 post increases 12%
vs. COPD; post <0.70 and not reversible
28
Asthma rx pyramid for pre-schoolers
mild - saba
mod - saba + ICS
severe - saba, ICS, oral steroids
29
Asthma rx pyramid for 6+
mild - LABA + ICS (symbicort) as needed
mod - saba + daily ICS OR as-needed ICS/LABA- formeterol (LTRA as alternative)
mod + - low dose ICS/LABA plus as needed SABA, OR low dose ICS/LABA plus as needed ICS/LABA
mod ++ - med dose ICS/LABA plus as needed SABA, OR low dose ICS/LABA plus as needed ICS/LABA
next! refer for phenotypic investigations + add-on treatment
severe - saba, ICS, LABA, LAMA, LTA, theophylline
**if uncontrolled, saba +/- ICS/LABA on demand
30
Good asthma control
<1 night time symptoms
<4 use of prn puffer
no activity restrictions, no missed school/work
31
Risk factors for asthma exacerbations
ICS not prescribed, poor adherence,
GERD, obesity, previous ICU/intubation for asthma, irritants - smoking/allergen/pollution, allergic rhinitis, food allergy, depression, anxiety, pregnancy, FEV1<60%
NSAIDs, betablockers
32
Frequency of asthma f/up? in pregnancy?
1-3 months after starting treatment then 3-12 months after that; in pregnancy, every 4-6 weeks
33
Testicular cancer workup and risk facrors BALLS CFP
Bhcg
Alpha fetoprotein
Lop it off
Cryptorchidism
Family hx
Personal hx
34
Lung cancer screening
age 55-74, 30pk/yr smoke, current or quit <15 years ago. CT annually up to 3 times
35
Cervical cancer screening indications and nor indications
```
25-69 every 3 years unless
- never sexually active
- weakened immune system
- symptoms of cervical ca
- previous abnormal results
- those who do not have a cervix
- immunosuppressed
CAN stop at age 70 if 3 normal in last 10 years
```
36
Skin cancer risk factors
```
Nevi > 15
older
white skin, red hair
hx of skin cancer, sun exposure
family history
multiple sunburns
actinic skin damage
--> refer if hi risk, skin checks q6 months
```
37
skin cancer ABCDE
Asymmetry
Border - gradual, indistinct vs. sharp cut off
Colour variation
Different dermatoscopic structures - pigment network, homogeneous areas, streaks, dots, globules
38
Colorectal screening
50-74
| flex sig q10 or FIT q2 years
39
Breast Ca screening (5)
```
1. Screen with mammography every 2-3 y
if aged 50-74 y
2. Do not routinely screen those aged
40-49 y
3. Do not screen with magnetic resonance
imaging
4. Do not perform clinical breast
examination
5. Advise patients not to perform self breast
examination
```
40
Feb neut
early antibiotic treatment, look for source and consider fungal
stabilize and assess
severe sepsis --> ICU
41
H Pylori quad therapy
PPI
Bismuth salicylate
Metronidazole
Tetracycline
42
what is Barrett's esophagus? prevention,
columnar cells replace squamous;
| prevention - high dose PPI and ASA
43
long term risks of PPIs
fractures
b12 deficiency
dementia
c diff
44
gallstone RF
female
forty
fat
fertile -- on OCP
45
pancreatitis RF
```
septra, flagyl
HCTZ, ACE
progesterone
atorva
estrogen
gall stones
ETOH
```
I = idiopathic
G = gallstones
E = EtOH
T = trauma
S = steroids
M = mumps/malignancy
A = autoimmune
S = scorpion stings … though this probably shouldn’t be your first guess for why your patient has pancreatitis
H = hypertriglyceridemia/hypercalcemia
E = (post) ERCP
D = drugs. Most commonly: thiazides, sulfa drugs, and didanosine
46
admission criteria - UN
uncontrolled symptoms
unstable
undiagnosed pain esp in elderly, immunocompromised
undischargable i.e. poor social support
47
fluid for peds
20 mg/kg bolus
maintenance 4/2/1
- 4 ml/kg for the first 10kg
- 2ml/kg for 11-20
- 1 ml/kg 20+
48
measures to monitor for severe dehydration
```
weight
gfr/creatinine
na, k
glucose
urea
```
49
c diff risk factors
```
abx esp fluoroquinolones
previous infxn
recent hospitalization
older age
immunocompromised
```
50
c diff pitfalls and rx
don't test kids <1
rx: vanco po
Can be community acquired
51
Crohn's medications
Immune system suppressors:
Azathioprine, nethotrexate, remicade
Anti-inflammatory: steroids (5 asa no longer used)
52
celiac testing
Anti tissue trans glutaminase + IGA
+/- upper endoscopy, small intestine biopsy
OR endomysial IGA (but this is +++expensive)
if IGa deficiency, DGP IgA and IgG
53
IBS treatment and medications
Lifestyle: Fluid, fibre, avoid fructose/sugar alcohols
Natural: peppermint oil, laxatives
Rx
1. ) Antidepressants (SSRI/TCA)
2. ) Anti-spasmodics (hyoscamine)
3. ) Anti-cholinergics (bentyl)
4. ) Linaclotide - for constipation type
5. ) Lotronex - for diarrhea
54
Restless legs treatment and medications
```
Lifestyle:
iron, mg
stretch calves
avoid caffeine
massage, heat
exercise
```
rx
non ergot dopamine agonists - pramipexole, ropinirole
gabapentin, pregabalin
55
restless legs dx
sensation or urge to move legs
worse with rest, improves with activity
worse in evening
56
restless legs risk factors
Etiology
1. Primary- genetics, young onset
2. Secondary
- fe/mg deficiency
- uremia
- neuropathy
- pregnancy
- varicose veins
- rx (dopamine agonists, lithium, antihistamines, antidepressants)
Associated diseases –ADHD, Parkinsons, DM, renal disease, depression
57
Tx hyperthyroid
Radioactive iodine uptake (NOT for ladies who are preggers), unless 100% sure it's graves
B block for symptoms
nodule? >1cm = FNA
don't treat subclinical hyperthyroid
58
suspicious features of thyroid nodule
>1cm
Taller than wide
irregular surface
calcifications within
59
Treating thyroid storm - BLOCK x 5
Beta blocker - propanalol
Block synthesis - methimazole, propylthiouracil
Block conversion T4 --> T3 propylthiouracil
Block release - iodine
Block Bile - cholestyramine
60
Treating graves, 3 Rs
Rx - First 4 Blocks - beta blocker, block synthesis, block conversion, block release
Radiation
Removal
61
Meds to stop when sick/at risk of dehydration
| SADMANS
```
SFU
ACE
Diuretics
Metformin
ARBs
NSAIDs
SGLT2
```
62
Three reasons people develop DKA
- acute illness,
- drugs: clozapine, terbutaline, cocaine, lithium, SGLT2
- non compliance
63
Diabetes complications, micro/macro
micro - retinopathy, neuropathy, nephropathy
| macro - atherosclerosis --> CVD, CVA, PVD
64
Biguanide
metformin
65
SGLT2 inhibitors
flozins - empagliflozin, canagliflozin
66
GLP-1R agonists
glutide - semaglutide, liraglutide
67
DPP4 inhibitors
saxagliptin
68
sulfonylureas
gliclazide, glyburide
69
driving 2-4-6 rule diabetes
test BS every 2 hours - if hypoglycemia unawareness
test BS every 4 hours - treat and wait 40 min
keep 6 lifesaver candies in the car for lows
70
risk factors for hep B
```
IVDU
sex with partner with hep B
child born to mother with hep B
tattoos
blood transfusions
living in crowded conditions
unimmunized
multiple sexual partners
MSM
occupation
prison
hx of STIs
breastfeeding OK if skin is in intact
```
71
medications to treat chronic gout
allopurinol
prboenecid
febuxostat
72
how to test for Hep C?
anti - HCV (unless known previous hep C)
HCV RNA serum
genotype and subtype
--> spontaneous clearance in 20-45%
73
how to test for Hep b?
```
HbsAg - infxn
Anti HBS - vaccine
Anti HBC --> IgM, total
if +ve
HBeAg
HBV DNA
Anti HBe
```
74
Mgmt and monitoring hep B
```
Refer to hepatology
Anti virals if severe, cirrhosis
U/S q6-12 months for HCC
scope every 1-3 years for varices
Cirrhosis/fibrosis - fibroscan, Child Pugh
```
The current approved treatments for HBV are interferon injections (standard or pegylated interferon) or oral nucleoside/nucleotide analogues (entecavir, lamivudine, tenofovir). As oral antivirals are excreted by the kidney, dose adjustments are required in renal failure.
Not all patients with chronic HBV infection need to be treated. The decision to treat depends on several factors including age, serial ALT and HBV DNA levels, and severity of liver disease. Co-infection, particularly with HIV and HCV, needs to be considered when deciding on which medications to use.
HBsAg (surface antigen) indicates infection. Persistence of HBsAg for 6 months or more indicates chronic infection. However, up to 50% of people with extended chronic infection will eventually clear HBsAg. By contrast, those with resolving acute HBV will clear HBsAg several months after initial infection.
Anti-HBs (surface antibody) is a protective antibody produced with recovery from infection or in response to immunization. Over time, titre may decline to undetectable levels. Note: There is a gap of several weeks to months between the disappearance of HBsAg and the appearance of anti-HBs; during this period, anti-HBc total is detectable as a marker of HBV infection.
Anti-HBc IgM (core antibody - IgM) appears early in acute HBV infection and persists for about 6 months. It may also be seen in chronic infection during flares of activity, so clinical/epidemiological correlation is required for interpretation.
Anti-HBc total (total core antibody - IgM and IgG) is a marker of past exposure or current infection. IgG usually persists for life. In low prevalence populations, a finding of isolated anti-HBc may signify a false positive result.
HBeAg (e-antigen) is a marker of viral replication; its presence indicates high infectivity. Implications for liver injury vary with stage of infection (see Module 7 for significance).
Anti-HBe (e-antibody) appears with recovery from acute infection. In chronic infection, the presence of anti-HBe is generally a marker of reduced viral replication, indicating a less infectious state. The implications for liver injury vary with stage of infection (see Module 7 for significance)
75
Mgmt and monitoring hep C
Refer to hepatology
Treat: interferon or new regimens (harvoni, epclusa)
U/S q6-12 months for HCC
scope every 1-3 years for varices
Cirrhosis/fibrosis - fibroscan, Child Pugh
76
NAFL vs NASH, and treatment?
NASH = NAFL + hepatitis (increased ALT/AST)
= signs of inflammation
NAFL - no inflammation or fibrosis = STEATOSIS
Rx - stop EtOh, weight loss, lipid control, DM control, if fibrosis >2 consider vitamin E
77
Ankylosing Spondylitis features
low back/SI pain stiffness
worse w/ rest, improves w/ movement
worse at night
30 minutes + for morning stiffness to recede
weight loss, fatigue
chest pain -- from insertion into sternum
enthesis i.e. plantar fasciitis, achilles tendonitis
anemia
uveitis
aortitis
heart block
78
what is Schober's test
find L5, measure 10cm above and 5cm below = 15cm
| if <20cm when bending forward = restrictive
79
investigations for Ankylosing Spondylitis
ESR, CRP
HLA b27
spine xray or MRI for early changes
80
mgmt Ank spond
```
nsaids
steroids for flares - oral, IM, into joint
anti TNF
monoclonal antibody
physio
no smoking
bisphosphonates if osteoporosis
```
81
Back pain physical exam
ALWAYS: numbness, weakness, pedal pulses, neuro exam
82
Lower limb Myotomes memory aid
L1/L2 buckle my shoe - hip flexion
L3/L4 kick the door - knee extension
C5/6 pick up sticks - biceps
C7/8 - shut the gates
83
Dermatomes memory aid
L4 down on all 4s - knees to first toe
L5 middle toes
S1 pinky toe
84
joint red flags
```
hot
boggy
AM stiffness
PM night pain
extra-articular symptoms? think genital infection, vasculitis, systemic illness
```
85
ADHD medication classes
Stimulants - methylphenidate (concerta, biphentin, ritalin), amphetamine (vyvanse, adderall)
SNRI - Atomoxetine
Alpha receptor antagonist - Guanfacine
86
ADHD meds -- Consider DATER before changing medication to 2nd/3rd line
Dosage
All - trial of all 1st line
Time - enough time given for response/side effects to resolve
Examine - what are the targets? what standardized measures
Review - comorbidity, lifestyle
87
ADHD non rx management
patient and family education
psychological treatment
education accommodations
driving -- restrict cell phone use, recommend manual transmission
88
ODD vs conduct disorder
ODD children do not show aggressions towards peope/animals; destroy property; pattern of theft and deceit
89
Bedwetting management
```
make toilet accessible
pee before bed
including in morning cleanup
training pants
avoid fluids/caffeine/chocolate before bed
do not punish, introduced diapers
enuresis alarms
desmopressin for short-term
```
90
Well baby care counselling safety
```
No honey
Choking hazards
Vitamin D
Breast/fed is best
button battery ingestion
No guns
Carbon monoxide detector
Cover electric plugs
Hot water heater
car seats
Storage and poison control
```
91
Milestones
```
2 months - two = coo, smiles
4 months - hold object - four fingers and hold head, laughs
6 - sit at six with support
8 - pincer grasp
1 year - walk, 1 word; responds to name
15 months- stranger danger
2 - run, 2 word sentence, 1-2 step directions
3 - 3 step instructions
5 - adult like sentences
```
92
Breastfeeding guideline
>=2 years
| 400IU daily vitamin D
93
circumcision, pros and cons
pros
- decreased infection - phimosis (rx with topical steroids), uti, hpv, cancer
cons
- pain, stenosis, damage to surrounding tissues
94
undescended testes sequelae
```
torsion
trauma
tumor
inguinal hernia
infertility
```
95
torsion TWIST score
```
absent cremasteric reflex
nausea/vomiting
testicle swelling
testicle hard
high riding testicle
```
96
When to refer for testicles in children
refer if
- not descended at 6 months
- not there anymore
- not there
- not positioned properly
97
AIDS defining illnesses
```
Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus
Candidiasis (oesophageal or bronchial)
Lymphomas (excluding Hodgkins)
Tuberculosis
```
98
when to give Tdap to pregnant ladies
>13, ideally 27-32 weeks
99
which vaccines can you NOT give if someone is breastfeeding?
BCG, yellow fever, japanese encephalitis
100
Under what circumstances do we have to delay vaccines if someone is ill?
lots of congestion -- don't give nasal flu
acute GI -- defer cholera, dukoral
mod to severe -- defer rotavirus
101
who gets flu vaccine?
kids > 6 months
everyone, but esp adults with neurologic/developmental conditions, work in health care, work with poultry
> 65 yo
102
vaccines in person with egg allergy
flu, MMR ok
| do not give yellow fever, tick-borne encephalitis or rabies
103
make vaccine less painful?
```
breastfeed
skin to skin
most painful last
sugar
tylenol after, otherwise blunts immune response
topical anesthetic
don't aspirate
```
104
what are the two shingles vaccines?
| what kind, how often, how $$$, how effective?
zostavax = live attenuated
1 dose, $170, >60 yo
shingrix = non live recombivant, adjuvanted
2 doses, 2(-6) months apart
2x as effective, 2x as much
>50yo
105
HPV vaccine - # of doses, #-valent
2 doses, 9-valent, all genders
106
who do you give meningitis C to? (5)
```
all travellers to Hajj
meningitis belt of africa
military recruits
asplenia and sickle cell
all canada adolescents
```
107
vaccine cautions for the immunocompromised? keep 3 things in mind
- no polio, varicella, MMR
- close contacts: avoid giving or avoid contact for 2 weeks
- consult public health/ID
108
vaccines contra-indicated in...
| pregnancy? TB? severe asthma/medical wheeze in last 7 days? uncorrected GI malformation? HIV?
pregnancy: live vaccines (polio, varicella, MMR), BCG --> flu ok
active TB: MMR, varicella, herpes zoster, BCG
asthma: live attenuated influenza
GI malformation: rotavirus (risk of intussception)
HIV: all live vaccines
109
Common cold treatment? (5)
NSAIDs, honey (> 1 year), intranasal ipratropium, nasal decongestant/anti-histamine (>5 year), zinc (not intranasal)
110
sinusitis risk factors? (4) which bugs?
```
allergic rhinitis
asthma
anatomy
smoking
ear bugs
```
111
Sinusitis complications and red flags? (9)
```
Osteomyelitis, intracranial abscess, epidural abscess, meningitis, periorbital/orbital cellulitis.
fever > 39
periorbital edema
cranial nerve palsies
abnormal EOM
proptosis
vision changes
severe headache
altered mental status
meningeal signs
```
112
what are the meningeal tests?
Brudzinski - flexed neck --> flexed extremities
| Kernig - with hips flexed cannot extend knee
113
PODS acute sinusitis
```
pressure/pain
obstruction (nasal)
dischage - thick, purulent
smell, loss of
2 or more -- persists for >7-10 days
```
114
mgmt of acute sinusitis
```
ct/xr only if red flags
amox 500 TID 5-10 days
nasal steroids!
nasal rinse
decongestants
analgesics
anti-inflammatories
mucolytics
```
115
why give abx for GAS? what does it NOT prevent?
```
prevent...
AOM
rheumatic heart disease
sinusitis
decrease illness <1 day
peritonsillar abscess
does NOT prevent glomerulonephritis
```
116
mono - how does it spread? symptoms? labs? recommendations re: spleen?
saliva
lymphadenopathy, fatigue, sore throat, splenomegaly, headache
lymphocyte count, serume AST/ALT, monospot
NO abx
no contact sports min. 3 weeks, can last up to 8 weeks
117
Jaundice beyond two weeks, order:
```
hemoglobin
serum conjugated bili
coomb's test
group and screen
peripheral smear
```
118
Symptoms of down syndrome - rule of 1s
1st toe web space
1 palmar crease
1% recurrence
119
Hip dysplasia risks, ffff
```
first born
feet -- breech
family history
fluid -- oligo
female
```
120
full septic workup in kids
CBC
LP
CXR
urine/blood cx
121
pediatric LIMPSS cannot miss
```
Legg calves perthe
Infectious
Malignancy - ewing's sarcoma, osteosarcoma
Pain from a fracture - abuse?
Slipped capital femoral epiphysis
Something else above/below
```
122
Classes and examples of constipation meds
Stool softeners – docusate (colace)
Osmotic laxatives – lactulose, Mg salts, sorbitol, PEG
Bowel stimulants (motility agents) – senna, bisacodyl, cascara, prune juice
Bulking agents – psyllium, bran (Metamucil ok)
Bowel lubricants – mineral oil, castor oil, glycerine
Enemas – tap water, saline, sodium phosphate (fleet), oil
123
Counselling pts for HCV - 4
Discussion of avoidance of alcohol
Monitoring of progression (ALT/AST, annual AFP)
Counsel on risk of transmission
Screening sexual partners
124
HCV treatments
```
Pegylated Interferon
Ribavirin
Telaprevir
Simeprevir
Sofosbrevir
Harvoni (ledipasvir/sofosbuvir)
Holkira Pak (dasabuvir, ombitasvir, paritaprevir, ritonavir)
velpatasvir
daclatasvir
```
125
Mechanism of scaphoid #
Extreme dorsiflexion of the wrist with compressive force to the radial side of the palm
Fall on outstretched hand/arm
Forceful radial deviation and dorsiflexion of wrist
Direct axial compression or hyperextension of the wrist
126
Physical exam for scaphoid fracture
Anatomic snuffbox tenderness
Scaphoid tubercle tenderness (extend the patient’s wrist with one hand and apply pressure to the tuberosity at the proximal wrist crease with the opposite hand)
Positive results on the scaphoid compression test (axially/longitudinally compressing a patient’s thumb along the line of the first metacarpal)
Swelling on the dorsoradial side of wrist or over the anatomical snuffbox
Pain in the snuffbox with pronation of the wrist followed by ulnar deviation
Reproduction of pain when patient pinches tips of their thumb and index finger together
127
Scapholunate disruption on xray
A gap of more than 3 mm between the scaphoid and lunate bones (the Terry Thomas sign)
128
Scaphoid #, reasons to refer to ortho
```
open fractures
neurovascular compromise
displacement of 1 mm or more
angulated fractures
associated tilt of the lunate bone
associated carpal instability
evidence of nonunion or displacement during follow up
osteonecrosis
possible scapholunate dissociation
proximal pole fractures
oblique fractures
unwillingness or inability of the patient to wear a cast for up to 3 months
```
129
Why does scaphoid have higher rates of fracture complications?
The scaphoid bone has a tenuous blood supply running from distal to proximal.
RATIONALE: The blood supply comes from the radial artery, feeding the bone on the dorsal surface near the tubercle and scaphoid waist with no direct blood supply to the proximal portion. Thus, there is an increased possibility of nonunion or osteonecrosis with fractures, particularly those of the proximal pole.
130
Symptoms of hypercalcemia
```
mental status change
confusion
poor concentration
abdominal groans (e.g. abdominal pain)
nausea
vomiting
anorexia
fatigue/lethargy
renal colic
dehydration
polyuria
polydipsia
constipation
bone pain
muscle weakness
anxiety
depression
```
131
Rx for hypercalcemia
Hydration with normal saline
Calcitonin
Bisphosphonates
132
Medications that cause hypercalcemia
```
ationale:
Thiazide diuretics (class or specific drug name of any thiazide acceptable)
Lithium
Teriparatide
Abaloparatide
Theophylline
Excessive vitamin A
Excessive vitamin D
```
133
1st blood test to order with dx of hypercalcemia
PTH
134
Risk factors for neonatal jaundice
Prematurity
Vacuum delivery leading to cephalohematoma
Asian background
Possible dehydration (poor weight gain)
135
Blood tests in neonatal jaundice
```
Blood type (ABO and Rh status) of infant
Direct antiglobulin test (direct Coomb’s test)
```
136
Inherited disorders that cause hyperbilirubinemia in infants
Glucose-6-Phosphate Dehydrogenase Deficiency
Pyruvate Kinase deficiency
Crigler-Najjar syndrome
Hereditary spherocytosis or elliptocytosis
Hemoglobinopathies (sickle cell, thalassemia, Hemoglobin H disease)
137
Side effects from phototherapy?
Dehydration
Bronze baby syndrome / bronze discolouration of the skin
skin rash
over or under heating of infant / temperature instability
loose stools/diarrhea
electrolyte disturbance (hyponatremia or hypokalemia)
interference with maternal –infant interactions
Ocular damage
138
Causes of hyperbilirubinemia in babies <24 hrs
hemolytic disease of the newborn (Rh or ABO incompatibility, spherocytosis, G-6PD deficiency, Kell Congential hemolytic states)
Maternal autoimmune hemolytic anemia (e.g. lupus) Type 1 – usually by day 3
Concealed hemorrhage/hematoma
Vitamin K deficiency
139
Treatment for ABRS
amox, nasal steroids
140
Classic sites for infantile eczema
Cheeks
Face
Scalp
Extensor surfaces (elbows and knees would count as 2 answers)
1/2 point for Flexor surfaces (flexor surfaces can be found in any age, however, extensor surface involvement is more classic for infantile eczema)
Trunk
141
Risk factors for infantile eczema
```
Positive family history of atopy (give ½ point for either “allergy” or “asthma”)
Weather changes (cold, dry)
Chemical irritants (scented soaps, detergents)
```
142
strategies to prevent/treat eczema
```
Reducing frequency of baths
Unscented products (soap, detergents)
Minimize soaps
Emollients
Barrier creams
Use luke warm water for baths
Avoiding triggers or irritants
Exclusive breastfeeding (although some small studies are refuting this)
Parental education
Topical steroids
Antibiotics in severe cases
```
143
when to treat asymptomatic BV?
Pregnant women with history of a high-risk pregnancy (previous preterm delivery)
Prior to IUD insertion
Second trimester even if asymptomatic (check this)
Prior to gynecologic surgery/therapeutic abortion/genitourinary instrumentation
Immunocompromised patient
144
abx to treat trich? what else can be used for BV?
metronidazole
| clinda, doxy
145
Pediatric Limps LIMPSS
```
Leg Calve Perthes Syndrome
- boys, age 4-10, white
Infection/inflammation
Malignancy - Ewing's Sarcoma (small round blue cells - pelvis, thigh, lower leg, upper arm, and rib), Osteosarcoma (Osteosarcoma usually develops at the edges of the long bones, in the “metaphysis” esp. the knee)
Pain from a fracture - abuse?
Slipped Capital Femoral Epiphysis
- obese, adolescent, black/latino
Something above or below?
```
146
HEADSS
```
Home environment - smokers, smoke alarms
Education - bullying
Activities - helmets
Drugs - prescription drugs
Sexuality/sex
Suicide
```
147
Kawasaki's CRASH
```
Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hands and feet swollen/rash/peeling
if you CRASH call the CAA --> coronary artery aneurysm
treat with ASA and IVIG kawASAkI
```
148
Violent/aggressive patient? Think of other causes
| DIM FACES
Drugs/dehydration
Infection
Metabolic/medication change
```
Failure
Anemia/alcohol
Cardiac/stroke/bleed
Electrolytes
Structural/seizure disorder/psychiatric
```
149
Which vaccines should you consider for travel?
General - Hep A and B, rabies
Country specific - typhoid, meningitis, yellow fever, encephalitis
routine - flu, shingrix, pneumococcal, tetanus, pertussis
150
Anti malarial medications and their pros/cons?
Malarone - only for 7 days after exposure daily, expensive
Doxy - cheap but photosensitivity rash. daily dose, need for 30 days after exposure
Mefloquine - frequent side effects, vivid dreams. once weekly
primaquine - only for 7 days after exposure; daily dose need test for G6Pd
chloroquine - cheap, safe, widespread resistance so check first, skin and corneal side effects
151
Rx for traveller's diarrhea and how to prevent
```
Azithro
oral rehydration solution
loperamide
bismuth subsalicylate
boil, peel; avoid ice cubes, salads, uncooked veggies use bottle water, wash hands often
```
152
medications for altitude sickness?
```
acetazolamide - carbonic anhydrase inhibitor
dexamethasone
nifedipine
sildenafil/tadalafil
prophylactic salmeterol
```
153
AAA screening
men 65-80 one time ultrasound
154
calculate sensitivity
specificity
ppv
npv
```
sens = true pos / true pos + fals neg
spec = true neg / true neg + fals pos
ppv = true pos / true pos + false pos
npv = true neg / false neg + true neg
```
155
DM screening
1. Screen every 1-5 y depending on risk
determined using a calculator, other risk
factors, or age ≥40 y
2. HbA1c level is the preferred screening test
(FPG level or OGTT are acceptable
alternatives)
3. HbA1c level of ≥6.5%, FPG level of
≥7 mmol/L, or 2-h plasma glucose level
in an OGTT of ≥11.1 mmol/L are diagnostic
156
DLP screening
1. Screen fasting lipid profile in men aged ≥40 y,
women aged ≥50 y (or postmenopausal), or
earlier if at increased risk
2. Screen with Framingham risk assessment
every 3-5 y if 10-y risk is <5%, or every y
if 10-y risk is ≥5%, until age 75 y
3. Framingham risk should be doubled if
positive family history for premature
cardiovascular disease
4. Discuss “cardiovascular age”
157
Colon Ca screening
1. Screen with FIT or FOBT every 1-2 y, or
flexible sigmoidoscopy every 10 y, if aged
50-75 y
2. Consider individualized opportunistic
screening with FIT or FOBT, flexible
sigmoidoscopy, or colonoscopy up to age
85 y
158
HPV recommendations
```
1. Recommended for women up to age 45 y
even if already sexually active and
regardless of past infection
2. Recommended for men up to age 26 y
3. Recommended for men who have sex
with men
```
159
Immigrant health, four areas - infection
HIV, Hep C, TB
| mantoux skin test is intradermal
160
TB rx, RIPE
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
161
Common parasitic infections? Ss
strongyloides
| Schistosomiasis
162
Unconscious patient? DONT
dextrose
oxygen
Narcan
Thiamine
163
Rx for new psychosis?
```
start med
1st gen = 2nd gen
maintain for 18 months
oral = depo
if depression, treat that too.
```
164
neuroleptic malignant syndrome FARM and treatment (5) and meds (3)
Fever
Autonomic - BP, HR, sweating
Rigidity
Mental status changes
stop the rx; IV NS; cooling blankets; ice packs; DVT prophylaxis
benzos if agitation; bromocriptine; dantrolene for muscle relaxation
165
qSOFA
resp rate >22
aMS
SBP < 100
166
STI abx
cefixime + azithro or doxy OR
| ceftriaxone + doxy if PID
167
sinusitis abx
amox or amox-clav
168
bronchitis abx
none
169
diverticulitis abx
none if CT confirmed with no abscess/free air
| cipro + flagyl or amox clav
170
sepsis abx
ceftriaxone or pip tazo +/- vanco
171
yeast vaginitis rx
fluconazole oral
172
pneumonia abx
macrolide or fluoroquinolone
173
meningitis abx
< 1mo - amp + gent
Group B Streptococci
E. coli
Listeria spp
```
1-3 mo
amp + cefotaxime
Group B Streptococci
E. coli
Listeria spp
S. pneumoniae
N. meningitidis
H. influenzae
```
```
> 3 months
cef + vanco
S. pneumoniae
N. meningitidis
H. influenzae
```
```
Adult > 50 years or Immunocompromised (including AIDS), Alcohol abuse, Debilitating illness, Pregnancy
cef + amp + vanco
S. pneumoniae
Listeria monocytogenes
N. meningitidis
Enterobacterales
```
174
cellulitis abx? MRSA?
with pus = ?mrsa = doxy, septra, clinda
| w/o = strep = amox clav, cephalexin
175
uti abx
nitrofurantoin, septra, cephalexin, fosfomycin
176
pyelo abx
ceftriaxone
| then cefixime or septra or cipro or amox-clav
177
remember your TOCC hx
travel
occupation
contacts
critters
178
4 strategies to minimize statin effects on muscles
lower dose
rink lots of fluids
stop interacting medications
alternative day dosing
179
rx for molluscum contagiosum
cantharidin topical
180
Describe arterial ulcer
Punched out full thickness ulcer with smooth wound edges often on lateral ankle or distal digits
181
Describe karposi sarcoma
Red-purple lesions/patches/nodules
182
Describe scabies
intensely pruritic and pimple like rash at the wrists and Intertriginous areas
183
describe herpes labialis
small grouped blisters/sores on lips that can coalesce into an ulcer that heals with 2-3 weeks
184
describe hand foot and mouth
lesions on oral mucosa, tongue, palms, soles and buttocks, grey-white vesiculo pustules
185
describe venous ulcers
shallow and superficial ulcers with irregular margins usually on the lower leg and ankle
rf: obesity, immobility, pregnancy, DVT, CHF, varicose veins, conditions with poor musculature
186
describe herpes zoster
grouped, unilateral vessicles in dermatomal distribution +/- pain and prodromal symptoms. anti virals with in 48-72 hours
--> do not confuse with eczema herpeticum
187
indications for shingrix vaccine
over 50 years, diabetes, heart disease, renal disease, immunosuppresion
188
describe BCC
shiny, pearly nodule located on sun exposed area of skin with telangectasia
rx: excision, cryotherapy, topical chemo
189
describe roseola infantum
high fever then rash on chest that turns into a pink maculopapular eruption lasting 1-2 days. 6th disease, HHV 6/7, supportive care
190
describe erythema infectiosum
macular erythema on face on day 1, then erythematous maculopapular eruption for up to 7 days on proximal extremities, then a reticulated or lacy erythema on extensor extremities up to 3 weeks. parvovirus/5th disease
191
Dx of HTN, work-up
AOBP > 135/85 or non-AOBP >140/90
Lipid panel (HDL, LDL, chol, trig, non-HDL)
Na, K, Creat, urinalysis, HbA1C, EKG
CPAP does not decrease morbidity/mortaliity
192
Recommendations for HTN lifestyle
```
reduce salt -
diet - DASH <1800mg
reduce weight
reduce stress - CBT
increase exercise 30-45 min, 3x/week
reduce alcohol <2.7 drinks/day
```
193
Fever? keep the ddx broad (11) and don't forget the most dangerous things
```
sepsis
meningitis
steven's johnston syndrome
PE
GCA
medication
cancer/feb neut
serotonin syndrome
neurleptic malignant syndrome
endocarditis
rheum -- still's disease
unclear? back to basics, serial exams/ekgs/imaging
```
194
DLP screening. When should it be fasting?
>40 and <75 consider earlier in at risk groups: South/East asians and First Nations, gestational HTN
Fasting if TG > 4.5
no evidence of mortality benefit of statins if >75
195
DLP management
Statin based on Framingham > 10 OR if CHD, CAD, PAD, AAA, DM2, CKD
Optimize renal, HTN, and CVD rx
dietician (med diet), counselling, stop smoking, kinesiology, cardiology, endocrinology (if familial)
196
Vertigo Exam (4)
Orthostatic BP
Gait
Hints
Dix-Hallpike
197
Vertigo ddx
```
BPPV
orthostatic
meniere's
migraine
neuritis
stroke
```
198
HINTS exam
Pt looks at nose; head impulse to one size
continues looking at you = normal (central vertigo)
corrective saccades = abnormal (peripheral vertigo)
199
Acute situatuation - ABC MOVIES and cereal
```
monitors
oxygen
vitals
IV large bore x 2
ECG
sugars
serial ekgABCs/vitals
```
200
GI Bleed rx
PPI infusion
Erythromycin prior to scope because it increases GI motility
Hgb only if <70
IF varices, give ceftriazone and somatostatin (octeotride)
201
what's the reversal agent for...
warfarin?
heparin?
dabigatran?
vit K
protamine, fresh frozen plasma
praxbind
202
what are the drug classes for anxiety?
```
benzodiazepines
buspirone
selective serotonin reuptake inhibitors
selective norepinephrine reuptake inhibitors
tricyclic antidepressants
monoamine oxidase inhibitor
atypical anti-psychotics
```
203
after SIGECAPS, r/o other conditions by asking about
- excessive worry, panic, PTSD
- hallucinations?
- rituals/compulsions that you cannot stop?
- mania -- feel better than good?
- delusions - do you have special powers? is there a plot against you?
204
Bipolar II, criteria and dx
| Bipolar meds
- hypomania, no psychosis
quetiapine is first line
Acute: abilify, paliperiodone, risperidone
Maintenance: quetiapine, lamotrigine, lithium, divalproe
205
1st gen antipsychotics - D2 antagonism, higher risk of neurological side effects
haldol
| chlorpromazine
206
2nd gen antipsychotics "atypicals" 5HT2A/D2 antagonism
| higher risk of metabolic side effects
```
abilify
olanzapine
paliperidone
quetiapine
risperidone
clozapine
```
207
Tourette syndrome rx
Tetrabenazine or Risperidone (dopamine blockers)
Botox - neuromuscular blocade
Habit reversal training
208
PICA rx
methylphenidate - CNS stimulant
olanzapine
Treat the complications -- radiography for a bezoar
209
Scabies rx
permethrin, invermectin
210
Mastitis rx
continue BF
NSAIDs, abx
usually staph
warm/cold compresses
211
Melanoma dx
```
Asymmetry
Border irregularity
Color not uniform
Diameter > 6mm
Evolving shape/size/colour
```
212
Measles description, symptoms
purplish red, maculopapular rash starting on the scalp/face/neck and spreading downwards
Four Cs: cough, coryza, photophobia, conjunctivitis, koplik spots on buccal mucosa
213
Alopecia areata
circular lesion on scalp/body with no hair, may have characteristic exclamation mark hairs. Focal, non scarring
ddx: trichotillomania
associated with SLE, thyroid, family hx
214
Marjolin ulcer
non healing ulcer or growth on the edge of a hronic wound - type of SCC
215
Pityrasis rosea
single lesion followed by all over body rash. Oval, dull pink colour involving the trunk and upper arms and legs. Christmas tree distribution
216
Head lice rx
permethrin or pyrethrin, repeat in 7-10 days
217
Rx for alopecia
stop offending meds
minoxidil
finasteride
hair transplant
218
Rosacea
superficial, dilated blood vessels and papules/pustules/swelling on the face
219
stevens-johnson syndrome
```
painful red or purplish rash involving the skin and mucous membranes
stop med/avoid drug class in future
```
220
Koebner's phenomenon
formation of psoriasis in areas of trauma
221
Rx for post herpetic neuralgia
```
topical capsaicin
NSAIDs
gabapentin
TCAs
glucocorticoids
paracetamol
topical lidocaine
```
222
investigations to order for dx osteoporsis
```
hgb
TSH
ionized Ca
Alk Phos
Creatinine
SPEP if vertebral #
Vit D --> after 3 months of Vit D supplementation
```
223
Osteoporosis rx - 3 options + 2 for high risk
| When can you stop it?
Bisphosphonates
- jaw osteonecrosis
- esophageal ulcers
- atypical fractures
Raloxifene --> selective estrogen receptor modulator
- VTE/PE
HRT
for high risk
Teriparatide - PTH analogy
- hypercalciuria, hypercalcemia - usually transient
- angioedema
Denosumab - monoclonal ab vs. RANKL
- joint muscle pain
- jaw osteo
- CI in pregnancy
Stop after 3-5 years if low risk take holiday
224
HIV med complications
DLP
hyperglycemia
BMD loss
Renal disease
225
HIV meds to know
Truvada for PREP
Zidovudine - peripartum and neonate
PEP - truvada, raltegravir
226
Opioid guidelines
maxmimum 50mg MED start
taper down to 90mg MED if they are above that
only use if no other options - TCAs, nabilone, NSAIDs, CBT, exercise, physio
227
ADL - DEATH
```
Dressing
Eating
Ambulating
Toileting
Hygiene
```
228
IADLS - SHAFT
```
Shopping
Housework
Accounting
Food and meds
Telephone, transportation
```
229
Frail elderly checklist
```
vision
hearing
skin - ulcers
mobility
cognition
pain
medications
rx monitoring
abuse
driving
incontinence
falls
teeth
```
230
Post phlebitic syndrom
horse chestnut seed extract for venoconstriction
231
DVT w/up and treatment
if low Pre test prob/Wells < 2 -- D-dimer. if +ve, proximal leg compression ultrasound or CTPA if you suspect PE
if high Pre test prob/Wells >2 -- ultrasound. if -ve, d dimer
if suspicion is high and testing will be delayed, treat first!
1 dose of oral Xa inhibitor or 1 dose of LMWH/IV heparin
232
Bell's palsy, dx and treatment
Stroke spares forehead
lubricant eye drops
steroids eg prednisone
add antivirals if severe
233
Ramsay Hunt Triad
aka Herpes Zoster reactivation
- ipsilateral facial paralysis
- ear pain
- vesicles in the auditory canal
234
Ischemic vs hemorrhagic findings
ischemic 80% - early, focal
| Hemorrhagic 20% - late focal deficits, compression effects (headache, vomiting)
235
Acute stroke management
1. ABCs, MOVIEs
2. Stroke scale
3. Labs: Na, K, Hgb, INR, aPTT, creatinine, troponin, glucose
4. Head CT non contrast --> if 4.5-6 hours adter symptoms add CT angiogram from vertex to arch OR CT perfusion. If 6-24 hours after symptoms add CT angiogram AND CT perfusion
5. Treat fever and severe hypertension >220/120
236
Acute stroke treatment options
1. Bust clot - alteplase, tenecteplase
- treatment within 3-4.5 hours, >18 yo
2. Yank clot 6-24 hrs- endovascular thrombectomy, aspiration/vacuum/removal stent
- acute ischemic stroke, anterior circulation, large vessel
237
Stroke w/up (cause - 4)
- Holter monitor
- Carotid doppler/duplex ultrasound
- manage A fib if found
- ECHO
238
Stroke prevention ABCDEs
```
A Fib
BP
CVD
DM2
Ethanol
```
239
cephalosporins
1st gen - cephalexin (keflex) PO, cefazolin (ancef) IM/IV
2nd gen - cefuroxime IM/IV
3rd gen - cefixime PO, ceftriaxone IV
no activity against LAME = listeria, atypicals, MRSA, enterococci
Good against gram +ves, increasing gram -ves as you progress at expense of gram +
240
Macule
flat lesion less than 1 cm, without elevation or depression
241
Patch
flat lesion greater than 1 cm, without elevation or depression
242
Plaque
flat, elevated lesion, usually greater than 1 cm
243
Papule
elevated, solid lesion less than 1 cm
244
Nodule
elevated, solid lesion greater than 1 cm
245
Vesicle
elevated, fluid-filled lesion, usually less than 1 cm
246
Pustule
elevated, pus-filled lesion, usually less than 1 cm
247
3 indications for using cannabinoids ? which product for which indications?
Muscle spasm 2/2 SCI, MS - nabiximol
Neuropathic pain refractory to standard therapies- nabilone or nabiximol
N/V from chemo - nabilone
248
4-6-8 rule for driving after cannabinoid
don't drive less than 4 hours
less than 6 hours for oral ingestions
and less than 8 if you experience euphoria
249
managing opioid withdrawal
treat type of pain - neuropathic vs other
clonidine if BP >150/90, HR >50; for nausea/vomiting/sweating/tremor
diarrhea - start loperamide, stop stool softeners
abdo cramping - buscopan (hyoscine), pinaverium
muscle cramping - quinine
sweating - oxybutynin (anti-cholinergic)
250
what are the domains for major neurocognitive disorder? 5 W's
WHO you are, WHAT you say, WHERE you go, WHY you do things, WHEN you remember
```
learning and memory
complex attention
executive function
language,
perceptual motor
social cognition
Alzheimer's is any one PLUS memory affected
mild = 1 domain
major = 2 or more plus impair function/decline
```
251
how to assess competency?
explain your treatment options? WHAT
reasoning? WHY
choice? WHAT ELSE
252
investigations for MNCI d/o?
TSH Hgb/ferritin B12 Na, Ca, glucose
| if less than 2 years ago/looking for something else
253
Management for MNCI
- cholinesterase inhibitors --> donepezil
- glutamatergic --> memantine
exercise
cognitive stimulation
avoid antipsychotics
254
Parkinson's symptoms TRAP SSSS
```
Tremor
Rigidity
Akinesia
Postural instability
Shaky
Stiff
Slow
Steps
```
255
DDx for Parkinson's
Essential - improves with EtOH?
Antipsychotic? - extrapyrimidal side effects
Parkinson's - at rest?
falls, slow vertical gaze - progressive supranuclear palsy
no L-dopa improvement, symmetric - MSA
256
Parkinson treatment, things to avoid (5), treat other features
first line - carbidopa/levidopa
30% don't respond, 20% who do have another dx
second line -
1. Dopamine agonists, non ergot - pramipexole, warn about impulse control d/o i.e. gambling, binge eating
avoid ergot derived i.e. bromocriptine
2. MAO inhibitors - selegiline, rasagiline
Avoid... anti psychotics (except quetiapine, clozapine); abruptly stopping meds; amantadine early on; genetic testing/PET scanning; vit E/coenzyme q10
constipation, drooling, ED, hypotension
257
Rx for postural hypotension
quit - large meals, EtOH, warmth, medications
start - compression stockings, increase salt intake, bed tilt, elastic stockings, midodrine (alpha 1 agonist) or corticosteroid
258
headache -- serious causes to r/o
```
GCA
SAH
Stroke
meningitis
Tumour
```
259
red flags for headache SNOOP
```
systemic features
neuro symptoms
older pt/onset
other red flags
pattern change
```
260
ottawa SAH tool
| r/o tool for 4 criteria, C/I (5),
```
alert patients
>15 years old
new severe atraumatic headache
maximum intensity in 1 hr
do NOT USE if: neuro deficits, prior aneurysm, prior SAH, known brain tumour, chronic recurrent headache
require investigations if:
1. neck pain or stiffness
2. => 40 yo
3. witnessed LOC
4. peak during exertion
5. thunderclap headache -- immediate peak intensity
6. limited neck flexion on exam
```
261
Migraine Rx - acute, chronic, lifestyle management
Migraine medications: A) Acute migraine medications. B) Prophylactic migraine medications.
A)
Type ACUTE MEdications
First line Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500-550 mg, acetaminophen 1000 mg
Second line Triptans (oral wafer/nasal spray/IM)
Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea
Third line Naproxen sodium 500-550 mg in combination with a triptan
Fourth line Fixed-dose combination analgesics (with codeine if necessary; not recommended for routine use)
also consider -- sphenopalatine ganglion block
B)
Prophylactic Medications
First line
• propranolol/metoprolol - avoid in asthma
• ami/nottriptyline - Consider if patient has depression,
anxiety, insomnia, or tension-type
headache
```
Second line
• topiramate
• candesartan
• gabapentin
Few drug interactions
Botox for chronic
```
Lifestyle management:
- decrease caffeine, improve sleep, increase exercise, relaxation, CBT
262
ABCDs of fractures
```
Antibiotics? Analgesia
Brace/splint
Consult ortho? Compartment syndrome?
Stick them with Tetanus
-- Tetanus immunoglobulin if dirty wound/not vaccinated or immunocompromised
```
263
Fractures of abuse (8)
```
multiple
multiple, many healing
non ambulatory
femur <12-18 months
humerus <18 months
skull
metaphyseal - bucket handle
rib posterior
```
264
Salter-Harris
```
Slipped Type I
Above Type II
Lower Type III
Through or transverse Type IV
Rammed Type V
```
265
causes of Afib (6)
```
ischemic
valvular
alcohol
hyperthyroid
HTN
pulmonary - COPD, pulmonary embolism
```
266
Afib rx, anticoagulate?
convert IF unstable, symptomatic/poor QOL, cardiomyopathy
otherwise bblockers or ccb
if unstable/low clot risk -- anticoagulate now and cardiovert now
if hi clot risk, OAC for 3 weeks or TEE
rate control if old, longstanding, asymptomatic, other disease
rhythm control if young, new dx, symptomatic, no other disease
267
CHADS2
```
CHF
HTN
Age >65
DM2
Stroke/TIA/embolism
```
268
Bleed risk management HAS BLED
HTN SBP>160
Abnormal liver/kidney fxn
Stroke
Bleeding
Labile INR
Elderly >65
Drugs/EtOH
269
Which anticoagulant for -- CKD? pregnancy? cancer? valvular afib?
UFH - renal disease CKD
LMWH - pregnant, cancer
Warfarin.- valvular
270
Systemic Exertional Intolerance
```
Functional impairment > 6 months
Non exertional new fatigue
Post exertion malaise
Rest does not refresh
At least 1 of cognitive impairment or orthostatic intolerance
```
271
Panic attack symptoms
```
Students Fear CCCs
Sweating
Trembling
Unsteadiness
Dyspnea
Excessive sweating
Nervousness
Tachycardia/tachypnea
Sensation weird
Fear of death
Choking
Chills
Chest pain
```
272
Lupus
| MD SOAP BRAIN
Mallar rash
Discoid Rash
Serositis - pericarditis, pleuritis
Oral ulcers
ANA +ve
Photosensitivity
Blood - thrombocytopenia, hemolytic anemia
Renal - GN
Arthritis
Immune - anti phospholipid, anti dsDNA, anti rho, C3/C4, anti smith
Neurological disorders, including psychiatric disorders - psychosis, seizures
273
Thyroid Storm
```
Altered mental status
Tachy
Fever
Dyspnea/orthopnea
Chest pain
Hypertension
Profuse sweating
```
274
IBD systemic features APIESAC
```
Apthous ulcers
Primary sclerosis cholangitis, pyoderma gangrenous
Iritis/uveitis
Erythema nodosum
Sacroilitis
Arthritis
Clubbing
```
275
Pro-thrombotic states
```
Protein c and s deficiency - like renal disease because you lose protein
Nephrotic syndrome
Hormonal meds
Pregnancy
Cancer
IBD, CHF
Factor V leiden
Anti phospholipid syndrome
```
276
Upper Arm DVT
CONSTANS score — upper arm DVT
1 point each, -1 if other dx more likely
Unilateral pain
Edema
Hx of central line/pacemaker placement “trauma”
277
Risk factors for AOM
maternal smoking
pacifiers
day care
bottle feeding
278
Ear bugs? 5
```
strep pneumo
moraxella catarrhalis
hemophilus influenza
staph aureus
group a strep
```
279
rx for AOM? if failure?
amoxicillin - high is BID, low if TID 40-90mg/kg
if failure? clavulin or ceftriaxone
tylenol 10mg/kg
advil 15 mg/kg
280
what are the indications for ear ventilation tubes?
```
>6/yr or 4 per 6 months
or
Chronic OM with effusion, "glue ear" > 3 months with hearing loss
or
retracted TM
```
281
CATCH2 for pediatric head injury, AVPU?
Minor head injury and any one of the following
GCS <15; Awake - Verbal - Responds to Pain - Unresponsive
worsening headache
Suspected open/depressed skull fracture
irritability
Sign of basal skull fracture
Large, boggy scalp hematoma
Dangerous mechanism
>4 episodes of vomiting (common pain response in kiddos)
282
types of SHOCK
```
septic
hypovolemic
obstructive
cardiac
AnaphylacticK
```
283
Burns - formulas? special sites?
>10% resuscitate - Brooke formula: 2mls x body surface areas burned (BSAB) x weight
Rule of 9s
adult - legs 18% x 2, arms 9% x 2, head 9%, chest 18%/back 18%, groin 1%
infant - legs 14% x 2, arms 9% x 2, head 18%, chest 18%/back 18%, groin 1%
special sites: face, hand, foot, genital, perineum, joint
284
Frostbite rx - 5 steps
```
rapid rewarming - water bath
possible thombolysis and heparin and iloprost
sterile wound care
consult surgery
tetanus
```
285
MAPLE hx
```
medications
allergies
past medical history
last meal
events leading up to
```
286
GCS
4 - eye response; 4 spontaneous - 3 sound - 2 pressure
5 - verbal; 5 oriented - 4 confused - 3 words - 2 sounds
6 - motor; 6 obeys - 5 localizes pain - 4 withdraws from pain 3 - flexion to pain 2 - extension to pain 1 - no movement
287
ATLS updates
give blood early! after 1L crystalloids
smaller chest tubes 28-32 french
needle decompression 4th/5th intercostal space laterally
use massive transfusion protocols
tranexamic acid 1g for 10 min and 1g for 8 hours
e-fast for pneumothorax
288
Trauma in pregnancy
```
Mom then fetus
Chest tube 1-2 spaces higher
NG tube
Left lateral decubitus
No vag exam until previa ruled out
Anti D immune globulin if Rh negative
Tetanus vaccine is safe
Document domestic violence
```
