Flashcards in Family and Rural Medicine Clerkships Deck (706):
USPSTF Abdominal Aortic Aneurysm Screening?
Men Ages 65 to 75 Years who Have Ever Smoked: One-time ultrasound AAA screening
Men Ages 65 to 75 Years who Have Never Smoked: Selectively offer ultrasound AAA screening
Women Ages 65 to 75 Years who Have Ever Smoked: Insufficient evidence
Women who have never smoked: Recommend against AAA screening
USPSTF Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care
Adults aged 18 and older: screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse
Adolescents (under 18 years of age): insufficient evidence
USPSTF Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening
Adults aged 40 to 70 years who are overweight or obese: recommends screening for abnormal blood glucose as part of cardiovascular risk assessment. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
USPSTF Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication
Adults aged 50 to 59 years with a ≥10% 10-year CVD risk: recommends low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) given that the patient is not at increased risk for bleeding, has a life expectancy of at least 10 years, and is willing to take low-dose aspirin daily for at least 10 years.
Adults aged 60 to 69 years with a ≥10% 10-year CVD risk:
The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.
Adults younger than 50 years, Adults aged 70 years or older: insufficient evidence
USPSTF Asymptomatic Bacteriuria in Adults: Screening
Pregnant Women at 12 to 16 Weeks' Gestation: recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at their first prenatal visit, if later.
Men and Nonpregnant Women: recommends against screening for asymptomatic bacteriuria
USPSTF Autism Spectrum Disorder in Young Children: Screening
Children aged 18 to 30 months: current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician.
USPSTF Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery: Screening
Asymptomatic Pregnant Women, Low Risk: recommends against screening for bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery.
Asymptomatic Pregnant Women, High Risk: current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in asymptomatic pregnant women at high risk for preterm delivery.
USPSTF Bladder Cancer in Adults: Screening
Asymptomatic Adults: current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults.
USPSTF Blood Pressure in Children and Adolescents (Hypertension): Screening
Children and Adolescents: current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.
USPSTF BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing
Women who have Family Members with Breast, Ovarian, Tubal, or Peritoneal Cancer: recommends that primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
Women Whose Family History is not Associated with an Increased Risk: recommends against routine genetic counseling or BRCA testing for women whose family history is not associated with an increased risk for potentially harmful mutations in the BRCA1 or BRCA2 genes.
USPSTF Breast Cancer: Medications for Risk Reduction
Women, Increased Risk for Breast Cancer: recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.
Women, Not at Increased Risk for Breast Cancer: recommends against the routine use of medications, such as tamoxifen or raloxifene, for risk reduction of primary breast cancer in women who are not at increased risk for breast cancer.
USPSTF Breast Cancer: Screening
Women aged 50 to 74 years: recommends biennial screening mammography for women aged 50 to 74 years.
Women aged 40 to 49 years: decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. (Potential harms = over-diagnosis, over-treatment, biopsies etc). Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.
Women aged 75 years or older: insufficient evidence
All women: USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer.
Women with dense breasts: current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.
USPSTF Breastfeeding: Primary Care Interventions
Pregnant women, new mothers, and their children: recommends providing interventions during pregnancy and after birth to support breastfeeding.
USPSTF Carotid Artery Stenosis: Screening
General Adult Population: recommends against screening for asymptomatic carotid artery stenosis in the general adult population.
USPSTF Celiac Disease: Screening
Asymptomatic adults, adolescents, and children: current evidence is insufficient to assess the balance of benefits and harms of screening for celiac disease in asymptomatic persons.
USPSTF Cervical Cancer: Screening
Women 21 to 65 (Pap Smear) or 30-65 (in combo with HPV testing): recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
Women younger than 30 years, HPV testing: recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
Women younger than 21: recommends against screening for cervical cancer in women younger than age 21 years.
Women Older than 65, who have had adequate prior screening: recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
Women who have had a hysterectomy: recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
USPSTF Child Maltreatment: Primary Care Interventions
Children: current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. This recommendation applies to children who do not have signs or symptoms of maltreatment.
USPSTF Chlamydia and Gonorrhea: Screening
Sexually Active Women: recommends screening for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
Sexually Active Men: current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.
USPSTF Chronic Kidney Disease: Screening
Asymptomatic Adults: evidence is insufficient to assess the balance of benefits and harms of routine screening for chronic kidney disease (CKD) in asymptomatic adults.
USPSTF Chronic Obstructive Pulmonary Disease: Screening
Asymptomatic adults: recommends against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults.
USPSTF Cognitive Impairment in Older Adults: Screening
Older Adults: current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment.
USPSTF Colorectal Cancer: Screening
Adults aged 50 to 75 years: recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years.
Adults aged 76 to 85 years: The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history.
Adults in this age group who have never been screened for colorectal cancer are more likely to benefit.
Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy.
USPSTF Coronary Heart Disease: Screening Using Non-Traditional Risk Factors
Men and Women with No History of CHD: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors studied to screen asymptomatic men and women with no history of CHD to prevent CHD events.
USPSTF Coronary Heart Disease: Screening with Electrocardiography
Adults at Low Risk: SPSTF recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events. (D)
Adults at Intermediate or High Risk: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. (I)
USPSTF Dental Caries in Children from Birth Through Age 5 Years: Screening
Children From Birth Through Age 5 Years: USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B)
Children From Birth Through Age 5 Years: The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B)
Children From Birth Through Age 5 Years: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I)
USPSTF Depression in Adults: Screening
General adult population, including pregnant and postpartum women: USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B)
USPSTF Depression in Children and Adolescents: Screening
Adolescents aged 12 to 18 years: USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B)
Children aged 11 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I)
USPSTF Developmental Hip Dysplasia: Screening
Infants: USPSTF concludes that evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes (I)
USPSTF Drug Use, Illicit: Primary Care Interventions for Children and Adolescents
Children and Adolescents without a Substance Use Disorder: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. This recommendation applies to children and adolescents who have not already been diagnosed with a substance use disorder. (I)
USPSTF Drug Use, Illicit: Screening
Adolescents, Adults, and Pregnant Women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.
USPSTF Falls Prevention in Older Adults: Counseling and Preventive Medication
Community-Dwelling Older Adults, Aged 65 Years or Older: USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.
No single recommended tool or brief approach can reliably identify older adults at increased risk for falls, but several reasonable and feasible approaches are available for primary care clinicians. (B)
Community-Dwelling Older Adults, Aged 65 and Older: USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (C)
USPSTF Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication
Women who are planning or capable of pregnancy: USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (A)
USPSTF Genital Herpes Infection: Serologic Screening
Asymptomatic adolescents and adults, including those who are pregnant: USPSTF recommends against routine serologic screening for genital herpes simplex virus (HSV) infection in asymptomatic adolescents and adults, including those who are pregnant. (D)
USPSTF Gestational Diabetes Mellitus, Screening
Asymptomatic Pregnant Women, AFTER 24 Weeks of Gestation: USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. (B)
Asymptomatic Pregnant Women, BEFORE 24 Weeks of Gestation: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for GDM in asymptomatic pregnant women before 24 weeks of gestation. (I)
USPSTF Glaucoma: Screening
Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma (POAG) in adults. (I)
USPSTF Gynecological Conditions: Periodic Screening With the Pelvic Examination
Asymptomatic, nonpregnant adult women who are not at increased risk for any specific gynecologic condition: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic women for the early detection and treatment of a range of gynecologic conditions.
This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou [“Pap”] smear, screening for gonorrhea and chlamydia). (I)
USPSTF Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults WITH Cardiovascular Risk Factors: Behavioral Counseling
Adults who are overweight or obese and have additional CVD risk factors: USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. (B)
USPSTF Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults WITHOUT Known Risk Factors: Behavioral Counseling
Adults without obesity who do not have known cardiovascular disease risk factors: USPSTF recommends that primary care professionals INDIVIDUALIZE the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity. Existing evidence indicates a positive but small benefit of behavioral counseling for the prevention of cardiovascular disease (CVD) in this population. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling. (C)
USPSTF Hearing Loss in Older Adults: Screening
Asymptomatic Adults Aged 50 Years or Older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older. (I)
USPSTF Hepatitis B in Pregnant Women: Screening
Pregnant Women: USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. (A)
USPSTF Hepatitis B Virus Infection: Screening, 2014
Persons at High Risk for Infection: USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection. (B)
USPSTF Hepatitis C: Screening
Adults at High Risk: USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965. (B)
USPSTF High Blood Pressure in Adults: Screening
Adults aged 18 years or older: USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment (A)
USPSTF Human Immunodeficiency Virus (HIV) Infection: Screening
Adolescents and Adults 15-65 Years Old: USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (A)
Pregnant Women: USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (A)
USPSTF Idiopathic Scoliosis in Adolescents: Screening
Adolescents: recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. (D)
USPSTF Impaired Visual Acuity in Older Adults: Screening
Adults 65 years or older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I)
USPSTF Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Screening
Women of Childbearing Age: USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services. (B)
Elderly or Vulnerable Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect. (I)
USPSTF Iron Deficiency Anemia in Pregnant Women: Screening and Supplementation
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of SCREENING for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes. (I)
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine iron SUPPLEMENTATION for pregnant women to prevent adverse maternal health and birth outcomes. (I)
USPSTF Iron Deficiency Anemia in Young Children: Screening
Children ages 6 to 24 months: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children ages 6 to 24 months. (I)
USPSTF Latent Tuberculosis Infection: Screening
Asymptomatic adults at increased risk for infection: USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk. (B)
USPSTF Lead Levels in Childhood and Pregnancy: Screening
Asymptomatic Children, 1 to 5 years: USPSTF concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. (I)
Asymptomatic Children, 1 to 5 years: SPSTF recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk. (D)
Pregnant Women: USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic pregnant women. (D)
USPSTF Lipid Disorders in Children and Adolescents: Screening
Children and adolescents 20 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. (I)
USPSTF Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication
Pregnant Women Who Are At High Risk for Preeclampsia: USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. (B)
USPSTF Lung Cancer: Screening
Adults Aged 55-80, with a History of Smoking: USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years 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 curative lung surgery. (B)
USPSTF Menopausal Hormone Therapy: Preventive Medication
Postmenopausal Women: USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. (D)
Postmenopausal Women, Who Have Had a Hysterectomy: SPSTF recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. (D)
USPSTF Obesity in Adults: Screening and Management
All Adults: USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (B)
USPSTF Obesity in Children and Adolescents: Screening
Children and adolescents 6 years and older: USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. (B)
USPSTF Obstructive Sleep Apnea in Adults: Screening
Asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults. (I)
USPSTF Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive
All Newborns: USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum. (A)
USPSTF Oral Cancer: Screening
Asymptomatic Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. (I)
USPSTF Osteoporosis: Screening
Women, 65 and Older: USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (B)
Men: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I)
USPSTF Ovarian Cancer: Screening
Women: USPSTF recommends against screening for ovarian cancer in women. (D)
USPSTF Pancreatic Cancer: Screening
Asymptomatic Adults: USPSTF recommends against routine screening for pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or serologic markers. (D)
Rationale: The USPSTF found no evidence that screening for pancreatic cancer is effective in reducing mortality. There is a potential for significant harm due to the very low prevalence of pancreatic cancer, limited accuracy of available screening tests, the invasive nature of diagnostic tests, and the poor outcomes of treatment. As a result, the USPSTF concluded that the harms of screening for pancreatic cancer exceed any potential benefits.
USPSTF Peripheral Arterial Disease (PAD) and CVD in Adults: Risk Assessment with Ankle Brachial Index
Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for peripheral artery disease (PAD) and cardiovascular disease (CVD) risk assessment with the ankle–brachial index (ABI) in adults. (I)
USPSTF Preeclampsia: Screening
Pregnant women: USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. (B)
USPSTF Prostate Cancer: Screening
Men: USPSTF recommends against prostate-specific antigen (PSA)–based screening for prostate cancer. (D)
USPSTF Rh(D) Incompatibility: Screening
Pregnant women, during the first pregnancy-related care visit: USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (A)
Unsensitized Rh(D)-negative pregnant women: USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative. (B)
USPSTF Sexually Transmitted Infections: Behavioral Counseling
Sexually Active Adolescents and Adults: USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). (B)
USPSTF Skin Cancer: Counseling
Children, Adolescents, and Young Adults aged 10 to 24, Fair Skinned: USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (B)
Adults Older than 24: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than age 24 years about minimizing risks to prevent skin cancer. (I)
USPSTF Skin Cancer: Screening
Asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults. (I)
USPSTF Speech and Language Delay and Disorders in Children Age 5 and Younger: Screening
Children aged 5 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for speech and language delay and disorders in children aged 5 years or younger. (I)
USPSTF Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater: USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.
Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. (B)
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 7.5% to 10%: Although statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event risk of less than 10%, the likelihood of benefit is smaller, because of a lower probability of disease and uncertainty in individual risk prediction. Clinicians may choose to offer a low- to moderate-dose statin to certain adults without a history of CVD when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 7.5% to 10%. (C)
Adults 76 years and older with no history of CVDUSPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use for the primary prevention of CVD events and mortality in adults 76 years and older without a history of heart attack or stroke. (I)
USPSTF Suicide Risk in Adolescents, Adults and Older Adults: Screening
Adolescents, Adults, and Older Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. (I)
USPSTF Syphilis Infection in Nonpregnant Adults and Adolescents: Screening
Asymptomatic, nonpregnant adults and adolescents who are at increased risk for syphilis infection: USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A)
USPSTF Syphilis Infection in Pregnancy: Screening
Pregnant Women: USPSTF recommends that clinicians screen all pregnant women for syphilis infection. (A)
USPSTF Testicular Cancer: Screening
Adolescent and Adult Men: USPSTF recommends against screening for testicular cancer in adolescent or adult men. (D)
USPSTF Thyroid Cancer: Screening
Adults: USPSTF recommends against screening for thyroid cancer in asymptomatic adults. (D)
USPSTF Thyroid Dysfunction: Screening
Nonpregnant, asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults.
USPSTF Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
Adults who are not pregnant: USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco. (A)
Pregnant women: USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (A)
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (I)
All adults, including pregnant women: USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated). (I)
USPSTF Tobacco Use in Children and Adolescents: Primary Care Interventions
School-Aged Children and Adolescents: USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (B)
USPSTF Visual Impairment in Children Ages 1-5: Screening
Children, Age 3-5 Years: USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. (B)
Children, <3 Years of Age: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age. (I)
USPSTF Vitamin D and Calcium to Prevent Fractures: Preventive Medication
Men and Premenopausal Women: USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women. (I)
Noninstitutionalized Postmenopausal Women: USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (D)
Community-dwelling Adults, 65 Years or Older, at Increased Risk for Falls: USPSTF has previously concluded in a separate recommendation that vitamin D supplementation is effective in preventing falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (B)
USPSTF Vitamin D Deficiency: Screening
Community-dwelling, nonpregnant, asymptomatic adults age 18 years and older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I)
USPSTF Vitamin Supplementation to Prevent Cancer and CVD: Preventive Medication
Use of Multivitamins to Prevent Cardiovascular Disease or Cancer: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamins for the prevention of cardiovascular disease or cancer. (I)
Single- or Paired-Nutrient Supplements for Prevention of Cardiovascular Disease or Cancer: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of single- or paired-nutrient supplements (except β-carotene and vitamin E) for the prevention of cardiovascular disease or cancer. (I)
Use of β-carotene or Vitamin E for Prevention of Cardiovascular Disease or Cancer: USPSTF recommends against the use of β-carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. (D)
What are the 3 main components of a healthy adult annual physical?
Health maintenance should be employed to prevent future disease. In general, the approach is
2) cancer screening
3) screening for common diseases
At what age does colon cancer screening begin?
If a patient has a family hx of colon cancer, colonoscopy screening should be performed 10 years prior to the age of diagnosis in the relative, or at age 50, whichever comes first.
One of the main components of a healthy adult annual physical is immunizations. What immunizations are recommended for adults?
The influenza vaccine should be recommended annually, and the tetanus vaccine every 10 years. The acellular pertussis vaccine is also recommended as many adults have had waning immunity to pertussis and occasional outbreaks of whooping cough have been noted.
What is primary prevention?
Primary prevention is an intervention designed to prevent a disease before it occurs. It usually involves the identification and management of risk factors for a disease. Examples of this would be immunization against communicable disease, public health education about good nutrition, exercise and stress management, or removal of colon polyps to prevent the development of colon cancer.
What is secondary prevention?
Secondary prevention is an intervention intended to promote early detection of a disease or condition, so prompt treatment can be initiated. Examples of secondary prevention are the use of mammography for the detection of breast cancer or eye examinations for the detection of glaucoma.
What makes for effective screening? (6)
1) disease should be of high enough prevalence in the population to make the screening effort worthwhile.
2) there should be a time frame during which the person is asymptomatic, but during which the disease or risk factor can be identified.
3) there needs to be a test available for the disease that has sufficient sensitivity and specificity
4) test should be cost-effective
5) test should be acceptable to patients.
6) there must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality of the disease process.
How do you screen for colorectal cancer? (3 ways)
Colorectal cancer screening can take the form of...
1) fecal occult blood testing (FOBT) using guaiac cards on three consecutive bowel movements collected at home
2) flexible sigmoidoscopy with or without occult blood testing
What is the optimal interval for testing for colorectal cancer?
FOBT: recommended annually
Sigmoidoscopy: every 3-5 years
Colonoscopy: every 10 years
True or False: an abnormal test result of FOBT or sigmoidoscopy leads to the performance of a colonoscopy
What is tertiary prevention?
Tertiary prevention involves both therapeutic and rehabilitative measures once a disease has been diagnosed. Examples of tertiary prevention include core measure medications for congestive heart failure, rehabilitation programs for stroke patients to improve functioning, and chronic pain management programs.
True or False: USPSTF currently recommends routine digital examination for prostate cancer but not PSA.
FALSE. The USPSTF currently recommends against (Level D) routine screening for prostate cancer using digital examination or PSA.
(both are bad)
Tdap immunization for adults?
The CDC has recently recommended that all adults between 19 and 65 years of age should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis and the presence of an increasing number of cases of pertussis nationwide. Adults who have not had a Td booster in 10 years or more and who have never had a dose of Tdap as an adult should receive a booster vaccination with Tdap. Persons who may need an increase in protection against pertussis, including health-care workers, childcare providers, or those who anticipate having close contact with infants younger than 1 year, should also receive a Tdap booster.
What age to give influenza vaccine?
In a 2010 update, the CDC recommended routine vaccination against influenza for everyone 6 months of age and older. This replaced a recommendation of vaccination based upon risk factors.
Age for pneumococcal vaccines? Who else?
Pneumococcal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13) vaccination are recommended for all adults aged 65 or older. PPSV-23 and/or PCV-13 may also be recommended for previously unvaccinated adults younger than 65 in the presence of immunocompromising or certain chronic medical conditions.
Who should get hepatitis B vaccines?
High risk of exposure:
-those exposed to blood or blood products
-IV drug users
-persons with multiple sexual partners or recent sexually transmitted diseases
-men who engage in sexual relations with other men.
-patients with diabetes who have not previously been immunized.
Who should get hepatitis A vaccines?
-chronic liver disease
-who use clotting factors
-who have occupational exposure to the hepatitis A virus
-who use IV drugs
-men who have sex with men
-travel to countries where hepatitis A is endemic
Who should get varicella vaccination?
-those with no reliable history of immunization or disease
-who are seronegative on testing for varicella immunity
-who are at risk for exposure to varicella virus
Who should get meningococcal vaccine?
Meningococcal vaccine is recommended for persons in high-risk groups:
-college dormitory residents
-certain complement deficiencies
-functional or anatomic asplenia
-who travel to countries where the disease is endemic.
Exercise has been consistently shown to reduce the risk of cardiovascular disease, diabetes, obesity, and overall mortality. Even exercise of moderate amounts, such as walking for 30 minutes on most days of the week, has a positive effect on health. The benefits increase with increasing the amount of exercise performed. Studies performed on counseling physically inactive persons to exercise have shown inconsistent results. However, the benefits of exercise are clear and should be promoted.
Counseling to promote a healthy diet in persons with hyperlipidemia, other risk factors for cardiovascular disease, or other conditions related to diet is beneficial. Intensive counseling by physicians or, when appropriate, referral to dietary counselors or nutritionists, can improve health outcomes.
True or False: routine serum studies are done for adult annual physicals
False. There is no such thing as a “routine blood test” or a “routine chest x-ray.” All tests that are ordered should have evidence to support their benefit.
A 52-year-old man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, coughing, and wheezing.
Most likely dx?
Appropriate treatment? (3)
Interventions to reduce future episodes? (5)
Acute exacerbation of COPD
Treatment: antibiotic, bronchodilators, systemic corticosteroids
Reduce future episodes: smoking cessation, LABA, inhaled corticosteroids, influenza vaccine, pneumococcal polysaccharide vaccine
What are the 2 most common causes of dyspnea and wheezing in adults?
How do you distinguish between the two? (3)
1) often presents earlier in life
2) may or may not be associated with cigarette smoking
3) EPISODIC exacerbations with return to relatively normal baseline lung function
1) tends to present in midlife or later
2) usually the result of a long history of smoking
3) slowly progressive disorder which never returns to normal baseline
True or False: patients with chronic asthma can develop COPD over time
True or False: when a patient presents with acute exacerbation of dyspnea and wheezing, it's important to determine whether it is a COPD exacerbation or asthma exacerbation.
In the setting of an acute exacerbation, the differentiation between an exacerbation of asthma and an exacerbation of COPD is not necessary for determination of the immediate management. The assessment of the patient presenting with dyspnea should always start with the ABCs—Airway, Breathing, and Circulation. Intubation with mechanical ventilation should be performed when the patient is unable to protect his own airway (eg, when he has a reduced level of consciousness), when he is tiring because of the amount of work required to overcome his airway obstruction, or when adequate oxygenation cannot be maintained.
For both asthma and COPD exacerbations, the mainstays of medical therapy are oxygen, bronchodilators, and steroids.
What are the 3 agents used to treat both asthma and COPD exacerbations? Explain their mechanisms of action
1) Inhaled β2-agonists (most commonly albuterol): can rapidly result in bronchodilation and reduction in airway obstruction.
2) Inhaled anticholinergic agent (such as ipratropium) may work synergistically with the β-agonist. Anticholinergic agents antagonize bronchoconstriction, which results in bronchodilation.
3) Corticosteroids, given systemically (orally, intramuscularly, or intravenously), act to reduce the airway inflammation that underlies the acute exacerbation.
Clinically significant effects of steroids take hours to occur; consequently, steroids should be used with bronchodilators because bronchodilators act rapidly. Steroids used in combination with bronchodilators significantly improve short-term outcomes in the management of acute exacerbations of asthma and COPD.
The 2 subtypes of COPD are chronic bronchitis and emphysema. Define each.
CHRONIC BRONCHITIS: Cough and sputum production on most days for at least 3 months during at least 2 consecutive years
EMPHYSEMA: Shortness of breath caused by the enlargement of respiratory bronchioles and alveoli caused by destruction of lung tissue
Top 3 leading causes of death in USA?
1) Cardiovascular disease
What is the most common cause of COPD? Other etiologies? Genetic etiologies?
The most common etiology is cigarette smoking, which is associated with approximately 90% of cases of COPD.
Other etiologies of COPD include passive exposure to cigarette smoke (“second-hand smoke”) and occupational exposures to dusts (including mining, cotton, silica, plastics), chemicals, and fumes (welding, heavy metals).
Patients with symptoms of COPD, who do not smoke and work in high-risk occupations, warrant further evaluation. A rare cause of COPD is a genetic deficiency in α1-antitrypsin, which is more common in Caucasians and should be considered when emphysema develops at younger ages (<45 years), especially in nonsmokers.
COPD in younger person should make you think about?
COPD is a disease of inflammation of the airways, lung tissue, and vasculature. Pathologic changes include mucous gland hypertrophy with hypersecretion, ciliary dysfunction, destruction of lung parenchyma, and airway remodeling. The results of these changes are narrowing of the airways, causing a fixed airway obstruction, poor mucous clearance, cough, wheezing, and dyspnea.
85% of dyspnea is caused by what 6 things?
1) congestive heart failure
4) interstitial lung disease
6) psychogenic disturbances (including anxiety)
Physical exam findings of COPD? (4)
During exacerbation? (5)
1) “barrel chests” (increased anteroposterior chest diameter)
2) distant heart sounds, as a result of hyperinflation of the lungs.
3) Breath sounds may also be distant
4) expiratory wheezes with a prolonged expiratory phase of respiration may be noted
5) During an acute exacerbation, patients often appear anxious and tachypneic; they may be using accessory muscles of respiration, usually have wheezes or rales, and may have signs of cyanosis.
Chest X-ray findings of COPD? (3)
1) increased posteroanterior (PA) diameter
2) flattening of diaphragms
3) Bullae—areas of pulmonary parenchymal destruction—can also be seen in x-rays in more severe disease
How do you diagnose COPD? Explain what the test means.
Spirometry (pulmonary function test)
In normal aging, both the forced vital capacity (FVC) (a measure of the total amount of air that can be expired after a maximal inspiration) and FEV1 reduce gradually over time. In normal-functioning lungs, the ratio of the FEV1 to FVC is greater than 0.7... meaning that in one second, a normal person can expire greater than 70% of the air that was maximally inspired within 1 second.
In COPD, both the FVC and FEV1 are reduced and the ratio of FEV1 to FVC is less than 0.7, indicating an airway obstruction. Reversibility is defined as an increase in FEV1 of greater than 12% or 200 mL. Using a bronchodilator may result in some improvement of both FVC and FEV1, but neither will return to normal, making the diagnosis of a fixed obstruction. The severity of COPD, which can help to determine treatment, can be assessed using these measurements (Gold Staging).
What is Gold Stage 0 COPD? How do you treat?
Gold Stage 0 is when someone is at risk for COPD. They have normal spirometry findings but have cough and sputum production. Treatment includes decreasing exposure to risk factors (e.g. smoking, second-hand smoke, occupational exposures, pollution, cooking smoke, etc)
What is Gold Stage 1 COPD? How do you treat?
Gold Stage 1 = mild COPD
FEV1/FVC ratio under 0.7
FEV1 > or = 80% of predicted value
With our without symptoms
Treatment includes short-acting bronchodilators (β2-agonists (albuterol) and anticholinergics (ipratropium))
What is Gold Stage 2 COPD? How do you treat?
Gold Stage 2 = moderate COPD
FEV1/FVC ratio under 0.7
FEV1 between 50-80% of predicted value
With or without symptoms
-short-acting bronchodilators (inhaled β2-agonists (albuterol) and inhaled anticholinergics (ipratropium)) for rescue
-long-acting bronchodilators (salmeterol (an inhaled β2-agonist) and tiotropium (an inhaled anticholinergic)) scheduled
What is Gold Stage 3 COPD? How do you treat?
Gold Stage 3 = severe COPD
FEV1/FVC ratio under 0.7
FEV1 between 30-50% of predicted value
With or without symptoms
Treatment includes short-acting bronchodilators (albuterol, ipratropium), long-acting bronchodilators (salmeterol, tiotropium), and inhaled steroids ((fluticasone, triamcinolone, mometasone, etc)
What is Gold Stage 4 COPD? How do you treat?
Gold Stage 4 = very severe COPD
FEV1/FVC ratio under 0.7
FEV1 less than 30% of predicted value OR
FEV1 less than 50% with chronic hypoxemia
Treatment includes short-acting bronchodilators (albuterol, ipratropium), long-acting bronchodilators (salmeterol, tiotropium), inhaled steroids (fluticasone, triamcinolone, mometasone) and long-term oxygen therapy. Surgical intervention can be considered on a case by case basis.
Oxygen therapy is recommended in stage IV COPD because chronic hypoxia leads to polycythemia, pulmonary hypertension, and peripheral edema suggesting heart failure. Oxygen therapy is the only intervention that has been shown to decrease mortality and must be worn for at least 15 h/d.
True or False: smoking cessation greatly improves pulmonary function in patients with COPD
All patients with COPD should be encouraged to quit smoking. The pulmonary function of smokers declines more rapidly than that of nonsmokers. Although smoking cessation does not result in significant improvement in pulmonary function, smoking cessation does reduce the rate of further deterioration to that of a nonsmoker.
Remember that COPD is a diagnosis of FIXED obstruction. This is different from asthma which is episodic with returns to normal baseline.
Which vaccinations should COPD patients get?
Pneumococcal vaccination and annual influenza vaccination.
A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea,
cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note
conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows
hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia.
Most likely agent?
A. Staphylococcus species
B. Chlamydia trachomatis
C. Respiratory syncytial virus
D. Parainfluenza virus
-usually seen in infants 3–16 weeks of age
-these patients frequently have been sick for several weeks
-nontoxic, afebrile, but tachypneic with a prominent
-physical examination reveals diffuse crackles with few wheezes
-conjunctivitis is present in about 50% of cases.
-chest film will show hyperinflation and DIFFUSE interstitial or patchy infiltrates
-may have eosinophilia
-infant appears very ill and has a fever
-initially may have an expiratory wheeze simulating bronchiolitis
-Signs of abdominal distress, tachypnea, dyspnea,
and localized or diffuse bronchopneumonia or LOBAR disease may be present
-The WBC count will show a prominent leukocytosis.
Chlamydial infections can be differentiated from respiratory syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the mild wheezing. There may also be eosinophilia.
Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the
upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account
for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.
36-year-old obese female presents to your office with a chief complaint of amenorrhea. On
examination you note hirsutism and body acne. She is on no medications and a pregnancy test
is negative. Serum testosterone is at the upper limits of normal and TSH is within normal limits.
In addition to weight loss and exercise, which one of the following would be the most appropriate initial management?
A. High-dose combined oral contraceptives
B. Progestin-only contraceptives
C. Metformin (Glucophage)
D. Levothyroxine (Synthroid)
This patient has polycystic ovary syndrome, which is characterized by hyperandrogenism on clinical and
laboratory evaluations, polycystic ovaries on pelvic ultrasonography, and ovulatory dysfunction.
Hyperandrogenism and either polycystic ovaries or ovulatory dysfunction are necessary to make the
diagnosis. The first-line recommendation in obese patients is lifestyle modification, but metformin may
improve abnormal menstruation. Low-dose combined oral contraceptives are more frequently used to reduce the risk of endometrial cancer in patients with chronic anovulation and the resulting unopposed estrogen secretion. This patient does not have thyroid dysfunction, so levothyroxine is not indicated.
A factory worker sustains a forced flexion injury of the distal interphalangeal (DIP) joint, resulting in a small bone fragment at the dorsal surface of the proximal distal phalanx (mallet fracture). Which one of the following is the most appropriate management strategy?
A. Buddy taping and early range of motion
B. Splinting the DIP joint in extension
C. Splinting the DIP joint in flexion
D. Referral for surgical repair
Splinting the DIP joint in extension
The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension. The usual duration of splinting is 8 weeks. It is important that extension be maintained throughout the duration of treatment because flexion can affect healing and prolong the time needed for treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar to those of surgical treatment and therefore is generally preferred.
Which one of the following drugs is NOT effective for maintenance therapy in bipolar disorders?
B. Lamotrigine (Lamictal)
D. Quetiapine (Seroquel)
E. Valproate sodium (Depacon)
Lithium, valproate, lamotrigine, and some antipsychotics (including quetiapine) are effective treatments
for both acute depression and maintenance therapy of bipolar disorders. Haloperidol is an effective
treatment for acute mania in bipolar disorders, but not for maintenance therapy or acute depression.
A 30-year-old ill-appearing male presents with right hand and arm pain and a rapidly expanding area of redness. On examination he has a temperature of 38.9°C (102.0°F), a pulse rate of 120 beats/min, and a blood pressure of 116/74 mm Hg. He also has erythema from the dorsal hand to the elbow, violaceous bullae on the dorsal hand and wrist, and severe pain with dorsiflexion of the wrist or fingers.
Which one of the following is the most appropriate initial step in the management of this patient?
A. Oral dicloxacillin and outpatient follow-up within the next 24 hours
B. Intravenous metronidazole
C. Consultation with an infectious disease specialist for antibiotic management
D. Immediate surgical consultation for operative debridement
E. Incision and drainage with wound cultures in the emergency department
Immediate surgical consultation for operative debridement
This patient has physical findings consistent with a necrotizing skin and soft-tissue infection, or necrotizing
fasciitis. Severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration, are strong indications of necrotizing fasciitis. Antimicrobial therapy is essential but is not sufficient by itself; aggressive surgical debridement within 12 hours reduces the risk of amputation and death.
Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum levels of...
B. creatine phosphokinase
Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a patient on amiodarone have baseline thyroid function tests (free T4, TSH) with follow-up testing every 6 months to monitor for these conditions. Hyperadrenalism and hypoadrenalism are not associated with amiodarone treatment.
A mother brings her 2-year-old daughter to your office because the child is not using her left arm. Earlier in the day the mother left the toddler under the supervision of her 12-year-old sister while she went to the store. When she returned the toddler was playing with toys using only her right arm, and was holding the left arm slightly pronated, flexed, and close to her body. The older daughter was unaware of any injury to the girl’s arm, and the child does not seem distressed or traumatized.
Physical examination of the child’s clavicle, shoulder, wrist, and hand do not elicit any signs of pain or change in function. She does seem to have some tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow.
Which one of the following would be most appropriate at this point?
A. Plain radiographs of the affected elbow
B. Ultrasonography of the affected elbow
C. Evaluation by an orthopedic surgeon within 24 hours
D. Attempted reduction of the subluxed radial head
E. Placement in a splint and follow-up in the office if there is no improvement in the next 1–2 weeks
Attempted reduction of the subluxed radial head.
Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in
children 1–4 years of age, although it can be encountered before 1 year of age and in children as old as 9 years of age. The mechanism of injury is partial displacement of the radial head when the child’s arm
undergoes axial traction while in a pronated and fully extended position. The classic history includes a
caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is
As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt
reduction of the radial head before moving on to imaging studies. With the child’s elbow in 90° of flexion,
the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the
child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant
swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction,
then a plain radiograph is recommended.
A 12-year-old male uses a short-acting bronchodilator three times per week to control his asthma. Lately he has been waking up about twice a week because of his symptoms.
Which one of the following medications would be most appropriate?
A. Inhaled medium-dose corticosteroids
B. A scheduled short-acting bronchodilator
C. A scheduled long-acting bronchodilator
D. A leukotriene inhibitor
E. Ordering a free T 4
Inhaled medium-dose corticosteroids
This patient has moderate persistent asthma. Although many parents are concerned about corticosteroid
use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close growth plates and are the most effective treatment with the least side effects. Scheduled use of a short-acting bronchodilator has been shown to cause tachyphylaxis, and is not recommended. The same
is true for long-acting bronchodilators. Leukotriene use may be beneficial, but compared to those using inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring systemic corticosteroids.
Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?
A. Combined monophasic oral contraceptives
B. Combined multiphasic oral contraceptives
C. Subdermal etonogestrel (Nexplanon)
D. Intramuscular medroxyprogesterone (Depo-Provera)
The first-line treatment for primary dysmenorrhea should be NSAIDs. They should be started at the onset of menses and continued for the first 1–2 days of the menstrual cycle. Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized, controlled trials demonstrating pain improvement. They may be a good choice if the patient also desires contraception. Although combined oral contraceptives and intramuscular and subcutaneous
progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis, they are
not first-line therapy for primary dysmenorrhea.
While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ultrasonography. The most appropriate next step in the evaluation of this finding
A. serum calcitonin level
B. serum free T3 level
C. serum TSH level
D. serum thyroglobulin level
E. radionuclide thyroid scan
Serum TSH level
Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American Thyroid Association’s guidelines recommend that TSH be the initial evaluation and that this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study. Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended.
True or False: Inhaled medications are preferred over oral when treating COPD and asthma
True. Less side effects.
True or False: long-term oral steroids can be used to manage stage 3 and 4 COPD
FALSE. Long-term oral steroids is not recommended.
Long-term systemic steroids causes problems like osteoporosis, myopathy, and glucose intolerance.
True or False: antibiotic prophylaxis is recommended to decrease number of exacerbations in stage 3 and 4 COPD
While antibiotic prophylaxis does decrease the number of exacerbations, it does not reduce rate of mortality and the risk of antibiotic resistance makes this a controversial issue.
For very severe COPD (gold stage 4), oxygen therapy is the only intervention that has been shown to decrease mortality. How any hours a day must oxygen be worn to make a difference? must be worn for at least 15 h/d.
At least 15 hours a day.
It is important for patients to prevent chronic hypoxia as hypoxia leads to polycythemia, pulmonary HTN, and peripheral edema 2/2 right-sided HF.
What is an acute COPD exacerbation?
Acute exacerbations of COPD are common and typically present with change in sputum color or amount, cough, wheezing, and increased dyspnea.
What is the most common cause of COPD exacerbation? What is another common cause?
Respiratory tract infections (viral or bacterial) are the most common cause. Air pollutants are another common cause of acute COPD exacerbations.
For COPD exacerbation, what o2 saturation level are you targeting when giving oxygen supplementation? What a PaO2 level?
Oxygen should be given with a target saturation of 88% to 92% or PaO2 levels at about 60 mm Hg.
A patient with severe COPD exacerbation is admitted to the hospital. What serum study should be ordered?
Baseline arterial blood gas should be ordered to evaluate for hypercapnia, hypoxemia, and respiratory acidosis.
A 38-year-old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators. Which of the following is the most likely etiology?
This patient has a fixed airway obstruction consistent with COPD. The airway obstruction of asthma would be at least partially reversible on testing with a bronchodilator. α1-Antitrypsin deficiency should be considered in a patient who develops COPD at a young age, especially if there is no other identifiable risk factor.
A 68-year-old patient of your practice with known COPD has pulmonary function testing showing an FEV1 of 40% predicted has been having frequent exacerbations of his COPD. His SaO2 by pulse oximetry is 91%. Which of the following medication regimens is the most appropriate?
A. Inhaled salmeterol BID and albuterol as needed
B. Oral albuterol daily and inhaled fluticasone BID
C. Inhaled fluticasone BID, inhaled tiotropium BID, and inhaled albuterol as needed
D. Inhaled fluticasone BID, inhaled tiotropium BID, inhaled albuterol as needed, and home oxygen therapy
C. Inhaled fluticasone BID (inhaled steroid), inhaled tiotropium BIC (inhaled long-acting bronchodilator), and inhaled albuterol as needed (inhaled short-acting rescue bronchodilator)
This patient has stage III COPD with frequent exacerbations. He is best treated by a long-acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) used regularly, along with an inhaled, short-acting bronchodilator on an as-needed basis.
A 59-year-old man with a known history of COPD presents with worsening dyspnea. On examination, he is afebrile. His breath sounds are decreased bilaterally. He is noted to have jugular venous distension (JVD) and 2+ pitting edema of the lower extremities. Which of the following is the most likely cause of his increasing dyspnea?
A. COPD exacerbation
C. Cor pulmonale
JVD and lower extremity edema are suggestive of cor pulmonale, which is right heart failure due to chronically elevated pressures in the pulmonary circulation. Right heart failure causes increased right atrial pressures and right ventricular end-diastolic pressures, which then lead to liver congestion, jugular venous distension, and lower extremity edema.
Patient presents to the ED with dyspnea. What do you do first?
Always remember to evaluate the ABCs—Airway, Breathing, Circulation—when evaluating a dyspneic patient.
sudden onset of knee joint pain
no hx of trauma
no prior episodes
Takes HCTZ, drank a lot of alcohol before symptoms started.
Pain to movement and touch of left knee
Knee is erythematous and warm to touch
No other joints involved.
WBC count is 10,900 cells/mm^3
What's the next step for diagnosis?
Most likely diagnosis?
Next step in therapy?
What needs to be ruled out?
Next diagnostic step: Joint aspiration for examination of joint fluid to identify crystals and exclude infection
Most likely diagnosis: Crystal-induced gout of the left knee
Next step in therapy: Nonsteroidal anti-inflammatory drug (NSAID) and provide analgesia; may consider using colchicine
Need to rule out septic joint. A joint becomes septic by blood inoculation, by contiguous infection (such as from bone or soft tissue), or from direct inoculation from trauma or surgery. Exclusion of an infectious etiology is paramount as cartilage can be destroyed within the first 24 hours of infection. In this case, the patient’s history and clinical scenario do not favor an infectious cause, although it cannot be excluded by history and physical examination alone.
At what age does gout typically occur in men? How about in women?
Men: typically age 30-50
Women: typically age 50-70 (postmenopausal)
Premenopausal women are less likely to suffer from gout due to the increased level of female sex hormones, which aid in the urinary excretion of uric acid.
True or False: African Americans have a decreased risk of developing gout
False. African Americans have an increased risk of developing gout
What are two drug classes that can increase the risk of developing gout?
2) chemotherapeutic agents
What are some factors that may increase the risk of gout attack? (3)
3) Large meal
True or False: for gout work-up, the gross appearance of fluid collected from joint aspiration is similar between a septic joint and a gout attack.
The gross appearance of fluid is not very specific, as both a septic aspirate and a heavily condensed crystal-induced arthritis may have a thick, yellowish/chalky appearance.
To diagnose crystal-induced arthritis, polarizing microscopy must reveal monosodium urate (MSU) crystals, which will look like needles and have a strong negative birefringence. Other crystals that may be seen are calcium pyrophosphate dehydrate (CPPD), calcium hydroxyapatite, and calcium oxalate.
What are monosodium urate crystals (MSU) crystals and how do they look?
What are calcium pyrophosphate dihydrate (CPPD) crystals and how do they look?
What are calcium hydroxyapatite crystals and how do they look?
What are calcium oxalate crystals and how do they look?
Monosodium urate crystals (MSU) are from gout and look like needles with strong negative birefringence.
Calcium pyrophosphate dihydrate (CPPD) crystals are from pseudogout and can be rod-shaped, rhomboid-shaped, with weakly positive birefringence.
Calcium hydroxyapatite crystals are from calcium hydroxyapatite crystal deposition disease. On electron microscopy, you can see cytoplasmic inclusions that are nonbirefringent.
Calcium oxalate crystals have a bipyramidal appearance with strongly positive birefringence. These are mostly seen in end-stage renal disease patients.
Gout vs pseudogout?
GOUTY ARTHRITIS: Condition of excess uric acid leading to deposition of MSU (monosodium urate) crystals in joints
PSEUDOGOUT: Condition of joint pain and inflammation due to calcium pyrophosphate dehydrate crystals in the joints, which can be diagnosed by noting rod-shaped, rhomboid, weakly positive birefringence by crystal analysis
What are the 4 stages of gout?
1) asymptotic tissue deposition of crystals
2) acute gout flares
3) intercritical segments (occurring after an acute flare, but before the next flare)
4) chronic gout (symptoms of chronic arthritis and/or tophi).
Which joint is most closely associated with gout flares?
Classically, a gout attack involves the metatarsophalangeal joint of the first toe, called podagra, but it may involve any joint in the body.
WBC count of joint aspirate analysis for gout vs septic joint?
With gout (crystal-induced) arthritis, the WBC count is between 2,000 to 60,000 per microliter with less than 90% neutrophils. A septic joint will have an average of 100,000 WBC per microliter with more than 90% neutrophils.
Note that even if an aspirate suggests crystal-induced arthritis, the aspirate should still be cultured to rule out a coexisting or early infection.
True or False: serum uric acid is important to evaluate a gout flare.
During an acute attack, the serum uric acid level may be normal or even low, likely as a result of the existing deposition of the urate crystals. Uric acid levels are, however, useful in monitoring hypouricemic therapy between attacks.
What tests should be ordered when an infected joint is suspected? (5)
1) Arthrocentesis with examination of synovial fluid
2) Blood culture
3) Gram stain
Bacterial infections of a joint occur most commonly in persons with what disease or disorder?
Rheumatoid arthritis. The chronic inflammation of joints coupled with the use of steroids predisposes this group to Staphylococcus aureus infections.
Other populations with increased risk include HIV patients and IV drug users.
What does the range of motion of a joint tell you when working up a patient with a painful joint?
A septic joint will have a very limited ROM due to pain coupled with a joint effusion and fever. However, a nearby cellulitis, bursitis, or osteomyelitis will usually maintain the ROM of a joint.
Osteoarthritis vs Rheumatoid arthritis?
-most commonly found in people older than 65 years
-associated with trauma, history of repetitive joint use, and obesity (specifically for knee OA)
-primarily affects the cartilage, but ends up damaging the bone surface, synovium, meniscus, and ligaments
-dull, deep, ache-type pain
-gradual onset and progressive worsening
-activity exacerbating the pain, and rest decreasing it
-pain can be constant in later stages
-bony crepitus may be present on passive ROM
-progresses to joint deformity with decreased ROM
-X-rays are normal at first but progress to bone sclerosis, subchondral cysts, and osteophytes
Rheumatoid arthritis (RA)
-can start at any age but typically starts 30 to 55 years old.
-initial presentation is varied (monoarticular intermittent, polyarthritis progressive, etc)
-3:1 prevalence in women vs men
-proinflammatory cytokines in synovial cells of joints destroys cartilage and causes bony erosions
-Positive rheumatoid factor (RF) and anti-citrullinated protein antibody (anti-CCP), elevated ESR, and elevated CRP
-anemia, thrombocytosis, and low albumin
True or False: The level of hypoalbuminemia usually correlates with the severity of the rheumatoid arthritis
Typically, the lower the albumin, the worse the RA.
For gout attacks, what 3 drugs are typically used for analgesics?
In patients with recurrent gout attacks, chronic medication therapy can be used to maintain serum uric acid levels below ? mg/dL.
For patients with recurrent gout attacks, which medications can be used to maintain lower serum uric acid levels? Name 2 and describe what they do.
Probenecid: increases the urinary excretion of uric acid
Allopurinol: reduces the production of uric acid.
Someone presents with a swollen joint suggestive of gout attack. Can you give short-term corticosteroids as a first-line analgesic?
No. Don't give steroids until you rule out septic joint.
How do you treat a septic joint?
The preferred treatment for septic arthritis includes IV antimicrobials and surgery for drainage of the infected joint. Methicillin-resistant S aureus (MRSA) will usually require vancomycin, but coverage with antibiotics is dependent on the specific organisms isolated.
How do you treat degenerative joint disease?
-maintenance of adequate ROM
-weight loss, if appropriate
-Intra-articular corticosteroid injections may provide relief for varying amounts of time, but should only be done every 4 to 6 months so as to avoid cartilage destruction.
-Surgery, such as joint replacement, is usually reserved for people with severe disease that affects their daily functions.
True or False: Intra-articular corticosteroid injections may provide relief for degenerative joint disease but should only be done every 3 months.
Should only be done every 4-6 months so as to avoid cartilage destruction.
How do you treat rheumatoid arthritis? (7)
-patient education on disease progression, treatment options, and implications to lifestyle is essential
-exercises for joint mobility and strength to combat the natural course of RA which develops stiff, disabled joints.
-Disease-modifying anti-rheumatic drugs (DMARDS) are the first-line agents for treatment of RA including methotrexate and sulfasalazine.
-NSAIDS, glucocorticoids, anticytokines, and topical analgesics can be used with DMARDS during the first month of treatment.
-Infliximab and etanercept are anticytokine agents
-monitor for hepatotoxicity
Name 2 disease-modifying anti-rheumatic drugs (DMARDS) used to treat rheumatoid arthritis.
Methotrexate and sulfasalazine
Name 2 anti-cytokine medications that can be used to help treat rheumatoid arthritis (in addition to the DMARDS).
Infliximab and etanercept
26 y/o man
fever, dysuria, left knee pain
Left knee is swollen, erythematous, tender
Denies hx of arthritis
What's the next step?
A. CBC with differential
B. X-ray of the knee
C. Aspiration of synovial fluid
D. Serum uric acid level
C. Aspiration of synovial fluid
Infectious arthritis would need to be high on the differential diagnosis because of the danger of gonococcal arthritis. The history supports this diagnosis. This patient needs a joint aspiration to look for gram-negative diplococci, crystals, and to obtain a sample for culture. He will likely require surgical drainage of the swollen joint and IV antibiotic therapy.
A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a body mass index (BMI) of 40 kg/m2. Which of the following is the best therapy?
D. IV Ceftriaxone
E. Oral glucocorticoids
Obesity is a risk factor for osteoarthritis, which is common in the knees and typically presents with a gradual onset and worsening of symptoms. Along with exercise and efforts to lose weight, an NSAID medication, such as ibuprofen, may provide symptomatic relief.
A 35-year-old man with hypertension presents with the sudden onset of right big toe pain. Which of the following is the best treatment?
D. Intravenous antibiotics
Gouty arthritis often initially presents in the big toe (“podagra”) and the use of HCTZ, a common treatment for hypertension, also can increase the risk. Colchicine can provide effective acute treatment.
True or False: a red swollen joint does not need to be aspirated if the patient is afebrile and has no clear trauma for introduction of bacteria.
A red swollen joint always needs to be aspirated to rule out infection.
What is advanced maternal age?
Pregnant woman who will be 35 years or beyond at the estimated date of delivery (EDD).
What is isoimmunization?
The development of specific antibodies as a result of antigenic stimulation by material from the red blood cells of another individual. For example, Rh isoimmunization means a Rh-negative woman who develops anti-D (Rh factor) antibodies in response to exposure to Rh (D) antigen.
What are the indications for performing ultrasound in pregnancy? (5)
An ultrasound is not mandatory in routine, low-risk prenatal care.
An ultrasound is indicated for the evaluation of:
1) uncertain gestational age
2) size/date discrepancies
3) vaginal bleeding
4) multiple gestations
5) other high-risk situations (radiation exposure, etc)
What lab studies are recommended for the initial prenatal visit? (8)
2) hepatitis B surface antigen (HBsAg)
4) syphilis screening with a rapid plasma reagin (RPR)
5) urinalysis and urine culture
6) rubella antibody
7) blood type and Rh status with antibody screen
8) Papanicolaou (Pap) smear and cervical swab for gonorrhea and Chlamydia.
True or False: pregnant women should be examined with ultrasound if exposed to dental x-rays
Risk for the baby is increased once the radiation exposure is greater than 5 rad; the radiation exposure from routine dental x-rays is 0.00017 rad.
What is asymptomatic bacteriuria (ASB) and what are the risks to the mother and/or baby if gone untreated? (3 risks)
ASYMPTOMATIC BACTERIURIA (ASB): 100,000 cfu/mL or more of a pure pathogen of a mid-stream voided specimen without clinical symptoms.
ASB in pregnant women increase risk of:
1) acute pyelonephritis
2) preterm delivery
3) low birth weight
When to introduce solid foods to infant's diet?
4-6 months of age
Cow's milk is not recommended for children until the age of?
Ottawa Ankle Rules?
Radiograph is required if:
1) pain upon palpation of the midfoot zone or malleolar zones and bony tenderness over an area of potential fracture (E.g. distal fibula or tibia, lateral or medial malleolus, base of the 5th metatarsal, or navicular bone)
2) inability to bear weight immediately after the injury and when evaluated by a physician
48 y/o male
4 week hx rectal pain with minimal rectal bleeding
Examination shows small tear of the anorectal mucosa at 6 o'clock position
Drugs that dilate the internal sphincter including diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures. More serious tears often require an internal sphincterotomy.
Ventilator settings for ARDS? (2)
1) Lower tidal volume (6 mL/kg instead of the traditional 10-15 mL/kg)
2) High positive end-expiratory pressure settings
ARDS mortality rate may be as high as 55%. Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival.
Which one of the following should be monitored during testosterone replacement therapy?
b. Fasting glucose levels
c. Fasting lipid profiles
Testosterone replacement therapy can cause erythrocytosis, so monitoring hematocrit at regular intervals is recommended.
Women form certain ethnic background may be offered specific genetic screening. What populations can be offered screening for which disorders? (4)
1. African and African American - sickle cell trait
2. French-Canadian or Ashkenazi Jewish - Tay-Sachs carrier state
3. Southeast Asian and Middle Eastern - Thalassemia
4. Ashkenazi Jews and Caucasian women - Cystic Fibrosis
Women who will be 35 years old or older at the anticipated time of delivery should be educated about age-related risk for? What should they be counseled about?
Down syndrome. Counseled about the available screening and diagnostic testing available.
True or False: pregnant women and those looking to become pregnant should be screened for tobacco use
What should you do for patients who have drug, tobacco, or alcohol dependence who are looking to become pregnant?
Educate about the risks and refer to rehab/treatment centers to quit the drug prior to conception.
Preconception counseling includes? (5)
Social support during pregnancy and postpartum period
Issues of domestic violence
Long-term-care facility of 60 residents.
Several patients experience fever, cough, and upper respiratory symptoms
2 patients test positive for influenza A (H1N1) virus
What to do?
a. chemoprophylaxis with appropriate medications for all residents
b. treatment initiated on an individual basis once testing confirms that a resident has influenza
c. prophylaxis only for staff who have had direct patient contact with a resident with laboratory-confirmed infection
d. no chemoprophylaxis for staff or residents who have been appropriately vaccinated
Chemoprophylaxis with appropriate medications for all residents.
The occurrence of two or more laboratory-confirmed cases of influenza A is considered an outbreak in a
long-term care facility. The CDC has specific recommendations for managing an outbreak, which include chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation
is recommended; however, it cannot be strictly enforced due to residents’ rights.
Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time?
A. An allergy evaluation
B. Low-dose antihistamines
C. Hydrocortisone cream 0.5%
D. A sepsis workup
E. Observation only
This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first week or two of life. No testing is usually necessary because of the distinct appearance of the lesions. The cause is unknown.
A 30-year-old female with a history of prolonged QT syndrome presents with severe acute bacterial sinusitis. Which one of the following antibiotics should be avoided?
B. Clarithromycin (Biaxin)
C. Amoxicillin/clavulanate (Augmentin)
D. Moxifloxacin (Avelox)
E. Cefuroxime (Ceftin)
Which one of the following is associated with treatment of COPD with inhaled corticosteroids?
A. An increased risk of monilial vaginitis
B. An increased risk of bruising
C. Consistent improvement in FEV1
D. A decreased risk of pneumonia
E. Decreased mortality
B. An increased risk of bruising
Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia.
They also have the potential for increasing bone loss and fractures. They decrease the risk of COPD
exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.
A 5-year-old white male is brought to your office with a chief complaint of chronic nocturnal limb pain. His mother states that his pain is often severe enough that it awakens him at night and she often gives him ibuprofen to help alleviate his calf pain, but she has never seen him limp or
heard him complain of pain during the day. She also has not noticed any grossly swollen joints fever, rash, or weight change. She is concerned because of a family history of juvenile rheumatoid arthritis in a distant cousin. The physical examination is within normal limits, as are a CBC and an erythrocyte sedimentation rate.
Which one of the following would be most appropriate at this point?
A. Bilateral plain radiographs of the lower extremities
B. Testing for antinuclear antibody
C. Testing for rheumatoid factor
D. Referral to orthopedic surgery
E. No further workup
This patient has benign nocturnal limb pains of childhood (previously known as “growing pains”). These crampy pains often occur in the thigh, calf, or shin, occur in up to 35% of children 4–6 years of age, and may continue up to age 19. The pathology of these pains is unknown. The pain is nocturnal, without limping or other signs of inflammatory processes. The erythrocyte sedimentation rate and CBC are normal in this condition but testing is indicated in patients with chronic joint pain to rule out malignancy or infection. Rheumatoid factor and ANA have a low predictive value in primary care settings and
are not indicated in the pediatric population without evidence of an inflammatory process. Plain radiographs are more useful for excluding certain conditions such as cancer than for making a diagnosis of arthritis in children. Reassurance of the parents is indicated in this situation, along with instruction on supportive care and over-the-counter analgesics as necessary.
According to the guidelines developed by the JNC 8 panel, which one of the following should
NOT be used as a first-line treatment for hypertension?
A. ACE inhibitors
B. Angiotensin receptor blockers
C. Calcium channedl blockers
E. Thiazide-type diuretics
In 2014 new evidence-based guidelines for blood pressure management were published by the panel
members of the Eighth Joint National Committee (JNC 8). They looked only at randomized, controlled
trials that compared one class of antihypertensive agent to another to develop the treatment
recommendations. ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and
thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood
pressure in the nonblack population, including patients with diabetes mellitus. B-Blockers were not
recommended for the initial treatment of hypertension because one study found there was a higher rate of
the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these
drugs compared to the use of an ARB.
A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness
accompanied by upper arm tenderness. On examination there is soreness about both shoulders
and the patient has great difficulty raising his arms above his shoulders. There is no visual
disturbance, and no tenderness over the temporal arteries. C-reactive protein is elevated and the
erythrocyte sedimentation rate is 65 mm/hr (N 0–17).
Which one of the following would help to confirm the most likely diagnosis?
A. The use of published validated diagnostic criteria
B. Synovitis of the glenohumeral joint on ultrasonography
C. A response to treatment with prednisone
D. A response to NSAIDs
E. A lack of systemic symptoms
C. a response to treatment with prednisone
This patient has characteristic features of polymyalgia rheumatica, a disease whose prevalence increases
with age in older adults but is almost never seen before age 50. Most people will have accompanying
systemic symptoms including fatigue, weight loss, low-grade fever, a decline in appetite, and depression.
There are no validated diagnostic criteria available to assist in the diagnosis. The treatment response to 15
mg of prednisone daily is dramatic, often within 24–48 hours, and if this response is not seen, alternative
diagnoses must be considered. NSAIDs are not useful in the management of polymyalgia rheumatica and,
in fact, are associated with high drug morbidity. Ultrasonography may be useful in making the diagnosis,
with typical findings of subdeltoid bursitis and tendon synovitis of the shoulders, but synovitis of the
glenohumeral joint is less common.
True or False: polymyalgia rheumatica and temporal arteritis is almost never seen before age 50
A 65-year-old male presents to an urgent care center with a foot ulcer. His past medical history
is significant for hypertension, COPD, and diabetes mellitus. He has been hospitalized several
times in the past year for COPD exacerbations and a hip fracture. He does not have any other
On examination he has a temperature of 37.3°C (99.1°F), a pulse rate of 105 beats/min, a respiratory rate of 16/min, and a blood pressure of 142/83 mm Hg. His examination is unremarkable except for a 2-cm ulcer on the ball of his left foot that has 3 cm of surrounding erythema and some purulent drainage. His CBC is normal except for a WBC count of 14,300/mm3 (N 4300–10,800).
Which one of the following would be the most appropriate choice for initial treatment?
A. Amoxicillin/clavulanate (Augmentin)
B. Linezolid (Zyvox)
C. Ciprofloxacin (Cipro)
D. Ceftriaxone (Rocephin) and levofloxacin (Levaquin)
E. Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)
E. Piperacillin/tazobactam (zosyn) and vancomycin (vancocin)
This patient has a severe diabetic foot ulcer. It appears to be infected and there are signs of a systemic inflammatory response. This is an indication for intravenous antibiotics. Piperacillin/tazobactam and
vancomycin would be the most appropriate choice of antibiotics because together they cover the most common pathogens in diabetic foot ulcers, as well as MRSA, which is present in 10%–32% of diabetic foot ulcers. This patient has recently been hospitalized and would thus be at high risk for a MRSA infection. Moderate to severe diabetic foot ulcers are often polymicrobial and can include gram-positive cocci, gram-negative bacilli, and anaerobic pathogens.
A 70-year-old male with hypertension, benign prostatic hyperplasia, depression, and well-controlled diabetes mellitus sees you because of increasing fatigue. His medical history also includes stent placement for coronary artery disease. A physical examination is unremarkable except for decreased peripheral pulses. A CBC, basic metabolic profile, hemoglobin A1c level, free T4 level, and TSH level are all normal, except for a serum sodium level of 125 mEq/L (N 135–145). His serum osmolality is 268 mOsm/kg (N 275–290). His urine sodium level is 50 mEq/L (N <20) and his urine osmolality is 300 mOsm/kg.
Which one of the patient’s medications is most likely to cause this problem?
A. Losartan (Cozaar)
B. Tamsulosin (Flomax)
C. Metformin (Glucophage)
D. Atorvastatin (Lipitor)
E. Sertraline (Zoloft)
Patients who are euvolemic but have hyponatremia, decreased sodium osmolality, and elevated urine osmolality are likely to have SIADH. Other causes to rule out include thyroid disorders, adrenal insufficiency, and diuretic use. Renal function has to be normal as well.
Common drugs that cause SIADH include SSRIs (particularly in patients over 65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, and NSAIDs. Treatment of the problem consists of discontinuing the offending drug. Temporary fluid restriction may also be required.
Which one of the following is the most common cause of unintentional deaths in children?
A. Motor vehicle accidents
Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent
cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most
effective way to prevent injury or death, and the American Academy of Family Physicians and the
American Academy of Pediatrics strongly recommend that physicians actively promote the proper use of
motor vehicle restraints for all patients. Drowning accounts for 10.9% of all unintentional deaths in
children, poisoning for 7.7%, fires 5.7%, and falls 1.4%.
A 45-year-old male presents with shortness of breath and a cough. On pulmonary function
testing his FVC is <80% of predicted, his FEV1/FVC is 90% of predicted, and there is no
improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide
(DLCO) is also low.
Based on these results, which one of the following is most likely to be the cause of this patient’s
D. Cystic Fibrosis
E. Idiopathic pulmonary fibrosis
E. Idiopathic pulmonary fibrosis
Based on the results of pulmonary function testing, this patient has a pure restrictive pattern with a low
diffusing capacity for carbon monoxide. Pulmonary fibrosis is compatible with this pattern. A patient with
any of the other listed diagnoses would be expected to have an obstructive pattern on testing.
A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest
pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An
EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion.
Which one of the following is the most appropriate initial treatment?
Patients with acute pericarditis should be treated empirically with colchicine and/or NSAIDs for the first
episode of mild to moderate pericarditis. B-Blockers would only be appropriate if the cause of the patient’s
chest pain were an infarction or ischemia. Nitrates do not relieve the pain of pericarditis. Glucocorticoids
are typically reserved for use in patients with severe or refractory cases or in cases where the likely cause
of the pericarditis is connective tissue disease, autoreactivity, or uremia.
A 71-year-old female comes in for follow-up of hypertension. She is worried about her heart and
says that some of her friends have had stress tests and she would like to get one as well just to
be on the safe side. She has no chest pain, shortness of breath, or exercise intolerance, and a
complete review of systems is negative.
The patient’s current medications include lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol
succinate (Toprol-XL), 25 mg daily; and omeprazole (Prilosec), 20 mg daily. Her past medical
history includes hypertension, obesity, and gastroesophageal reflux disease. A physical
examination reveals a blood pressure of 130/70 mm Hg, a heart rate of 90/min, and a BMI of
31.2 kg/m2. An EKG 2 years ago was normal.
Which one of the following should be ordered to assess this patient’s cardiovascular risk?
A. A lipid profile
B. A coronary artery calcification scor
C. A C-reactive protein level
D. An EKG
E. An exercise stress test
A. A lipid profile
There is no indication for cardiac testing in a low-risk asymptomatic person, and testing may lead to harm
resulting from false positives. The U.S. Preventive Services Task Force does not recommend resting or
stress EKG testing for asymptomatic low-risk patients (D recommendation). Asymptomatic patients should
be risk stratified to assess the risk of chronic heart disease, and this patient should have a lipid profile for
risk stratification. Low-risk patients do not benefit from nontraditional risk assessments, including
high-sensitivity C-reactive protein or coronary artery calcium assessment.
Which one of the following is true regarding respiratory syncytial virus (RSV) infection?
A. Most infections in the United States occur between August and December
B. Corticosteroids should be a routine part of treatment
C. The diagnosis is usually based on positive serology
D. It is rarely associated with bacterial co-infection
D. It is rarely associated with bacterial co-infection
Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The
infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young
infants, prematurely born infants, or those with pre-existing heart/lung conditions, the infection can be
severe. In North America, RSV season is November to April. Treatment is primarily supportive, including
a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and
antibiotics are not routinely indicated. Routine laboratory and radiologic studies should not be
used in making the diagnosis, as it is based on the history and physical examination.
What months is respiratory syncytial virus most commonly seen in North America?
November through April
In "N"orth "A"merica, the months of RSV are "N"ovember through "A"pril.
An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now
has difficulty with normal activities such as getting out of a chair and brushing her teeth. Her
medical problems include hypertension, diabetes mellitus, and hyperlipidemia. Her medications
include glipizide (Glucotrol), simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on
examination are within normal limits except for diffuse proximal muscle weakness and normal
deep tendon reflexes. A CBC, urinalysis, erythrocyte sedimentation rate, TSH level, and serum
electrolyte levels are normal. Her blood glucose level is 155 mg/dL and her creatine kinase level
is 1200 U/L (N 40–150).
Which one of the following is the most likely diagnosis?
A. Statin-induced myopathy
B. Polymyalgia rheumatica
C. Guillain-Barre syndrome
D. Diabetic ketoacidosis
A. Statin-induced myopathy
This patient is most likely suffering from a drug-induced myopathy caused by simvastatin, which is associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated erythrocyte sedimentation rate. Guillain-Barré syndrome is associated with depressed deep tendon reflexes. This case has no clinical features or laboratory findings that suggest ketoacidosis.
3 y/o F
Cough, tactile fever, mild rhinorrhea
100.8F temp, mild tachypnia
Decreased breath sounds and crackles in right lower lung field
No allergies to meds.
Which one of the following would be the most appropriate treatment?
B. Azithromycin (Zithromax)
D. Moxifloxacin (Avelox)
E. Ceftriaxone (Rocephin)
Amoxicillin is the recommended first-line treatment for previously healthy infants and school-age children
with mild to moderate community-acquired pneumonia (CAP) (strong recommendation; moderate-quality
evidence). The most prominent bacterial pathogen in CAP in this age group is Streptococcus pneumoniae,
and amoxicillin provides coverage against this organism. Azithromycin would be an appropriate choice
in an older child because Mycoplasma pneumoniae would be more common. Moxifloxacin should not be
used in children. Ceftriaxone and cefdinir can both be used to treat CAP, but they are broader spectrum
antibiotics and would not be a first-line choice in this age group.
True or False: Moxifloxacin should not be used in children
It can cause problems in joints, bones, and tissues around bones.
When compared to a figure-of-eight dressing, which one of the following modalities of treatment
has been shown to have similar fracture-healing outcomes and increased patient satisfaction for
nondisplaced mid-shaft clavicular fractures?
A. A shoulder sling
B. A short arm cast
C. A long arm cast
D. Operative fixation
A. shoulder sling
Compared to figure 8 dressing, shoulder sling has been shown to have similar fracture healing rates in patients with non displaced mineshaft clavicular fractures. Shoulder slings are more comfortable, easier to adjust, and have reported increased patient satisfaction.
It should be noted that a Cochrane review of interventions for clavicle fracture pointed out that the studies of this problem were done in the 1980s and did not meet current standards. One of the conclusions of this review was that further research should be done.
6 y/o male
Mother observes snoring and stop in breathing for a few seconds at a time.
Child has day-time somnolence.
Height and weight are normal.
Polysomnography confirms OSA.
Which one of the following would be the most appropriate primary treatment?
A. Methylphenidate (Ritalin)
B. Lorazepam (Ativan)
C. Fluoxetine (Prozac) on a daily basis
D. A mouthguard
In children, OSA is most commonly due to enlarged tonsils and adenoids. Onset typically between ages 2-8, coinciding with peak tonsil growth. Adenotonsillectomy is the primary treatment for most non-obese children with OSA.
SSRIs can treat nightmares and suppress REM sleep.
Benzos can treat sleep terrors.
Methylphenidate is a stimulant used to treat ADHD.
The use of a mouthguard at night is recommended for management of TMJ syndrome to reduce excessive teeth grinding during sleep.
Slipped capital femoral epiphysis is most likely in which one of the following patients with no history of trauma?
A. A 3-day-old male with a subluxable hip
B. A 7-year-old male with groin pain and a limp
C. A 13-year-old male with knee pain
D. A 16-year-old female with lateral thigh numbness
B. 13 y/o male with knee pain
Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt (11–13 years of age for girls, 13–15 years of age for boys). While the cause is unknown, associated factors include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral epiphysis, in addition to being overweight. African-Americans are affected more commonly as well.
The patient may present with pain in the groin or anterior thigh, but also may present with pain referred to the knee. That is also the case for Legg-Calvé-Perthes disease, also known as avascular or aseptic necrosis of the femoral head. This condition most commonly occurs in boys 4–8 years of age. In addition to hip (or knee) pain, limping is a prominent feature.
Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is
attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity or wearing clothing that is too tight in the waist or groin. Developmental dysplasia of the hip is identified
by a click during a provocative hip examination of the newborn, using both the Barlow and Ortolani
maneuvers to detect subluxation or dislocation.
43 y/o F
Recent diagnosis of symptomatic peripheral arterial disease.
Started on atorvastatin, offered a supervised exercise program, and discussed smoking cessation and interventions.
Which one of the following should be recommended to prevent cardiovascular events in this patient?
B. Cilostazol (Pletal)
C. Enoxaparin (Lovenox)
E. Warfarin (Coumadin)
Patients with symptomatic peripheral arterial disease should be started on a daily dose of either aspirin or
clopidogrel to prevent cardiovascular events such as acute myocardial infarction or stroke
Weight classifications based on BMI in children?
Obese >95th percentile
Overweight 85th-95th percentile
Healthy weight 5th-85th percentile
Underweight <5th percentile
What is failure to thrive in pediatrics?
-weight below the third or fifth percentile for age
-deceleration of growth that has crossed two major growth percentiles in a short period of time
True or False:
Children who are raised in a bilingual environment may have some language and development delay.
Proficiency in both languages is often reached by age 5.
First dental visit?
By 12 months
35 y/o woman
Chronic nasal congestion worse in spring and fall
Most likely dx? Treatment?
Tx: antihistamines, decongestants, intranasal steroids
Alone or in combination
Mild: treat with intranasal steroids
Moderate to severe: antihistamines and decongestants
Physical examination findings of allergic rhinitis?
1. “allergic shiners" which are dark circles around the eyes related to vasodilation or nasal congestion
2. "nasal crease" which is a horizontal crease across the lower half of the bridge of the nose caused by repeated upward rubbing of the tip of the nose by the palm of the hand
3. swollen turbinates
4. cobble stoning of posterior pharynx
5. "dennie-morgan lines" - prominent creases below the inferior eyelid
What is the single greatest cause of preventable death?
Pharmacologic therapy for smoking cessation? (2) What are their mechanisms of action?
Bupropion (wellbutrin), varenicline (chantix)
Bupropion blocks uptake of norepinephrine and dopamine. Varenicline is a partial nicotinic receptor agonist.
True or False: Varenicline (chantix) should be used with caution in anyone with a history of psychiatric disorders.
True. It has been associated with neuropsychiatric symptoms including changes in behavior, agitation, depression, and suicidal behaviors.
True or False: nicotine replacement therapy (gum, inhaler, nasal spray, lozenge, patch, etc) can be used in combination
Combination has been shown to be more effective
What is the strongest risk factor for smoking initiation among children and adolescents?
What are the 2 most common pitfalls in using nicotine supplementation?
1) only using nicotine supplementation when having withdrawal symptoms
2) failing to use nicotine gum correctly. The gum should be chewed briefly and then parked in the cheek.
What is the most common cause of microcytic anemia?
What is the serum iron, ferritin, TIBC in iron deficiency?
Low serum iron
What causes macrocytic anemia? (2) How can you tell which is which?
B12 deficiency and folate deficiency
Homocysteine is elevated in both vitamin B12 and folate deficiencies, whereas methylmalonic acid is only elevated in vitamin B12 deficiency.
Folate deficiency is usually seen in what population?
What is different with iron studies between anemia of chronic inflammation/disease and iron deficiency anemia?
In anemia of chronic inflammation, the iron stores (measured by serum ferritin) are normal but the capability of using the stored iron becomes decreased (Low TIBC- because inflammation hides away iron).
What is TIBC?
Think of it as your body's ability to mobilize and use iron. It is high in iron deficiency because your body is deficient in iron (low serum iron and serum ferritin) but so it's trying hard to mobilize and use what's not there. In anemia of chronic inflammation, TIBC is low because inflammation causes your body to store/hide iron. Anemia of chronic inflammation can have low or normal serum iron but normal or high ferritin (stored iron).
What is the most common cause of B12 deficiency?
Lack of intrinsic factor from pernicious anemia
How long does it typically take for people on strict vegetarian or vegan diets to become B12 deficient?
Several years on strict diet
40 y/o man returned from mexico
Profuse, acute, non bloody diarrhea
Dry mucous membranes on examination
Ill family member with identical symptoms
What is the dx and treatment?
Treat with oral or IV fluids and send for fecal leukocyte or fecal lactoferrin testing.
Fecal leukocytes will be elevated with infection. Fecal lactoferrin suggests bacterial infection as activated PMNs release lactoferrin. Lactoferrin is low in viral infections, making this test good for distinguishing viral from bacterial diarrhea. In general, parasite and ova evaluation is unhelpful unless the history strongly points towards a parasitic source or diarrhea is prolonged. While the majority of diarrheas are viral, self-limited, and do not need further evaluation, this particular patient traveled in Mexico so traveler's diarrhea should be strongly considered and treated with appropriate antibiotic.
True or False: up to 90% of acute diarrhea is infectious in etiology
Acute diarrhea vs subacute vs chronic diarrhea?
Acute - fewer than 2 weeks
Subacute - 2-4 weeks
Chronic - longer than 4 weeks
Diarrhea within 6 hours of eating salad containing mayonnaise. Cause?
8-12 hours within ingesting food?
12-14 hours within ingesting food?
Staph Aureus (within 6 hours! acute... think of sketchy)
Clostridium perfringens (8-12 hours)
E coli (12-14 hours)
Diarrhea from undercooked chicken?
Salmonella or shigella
Diarrhea from undercooked hamburger?
Diarrhea from raw seafood? (3)
Vibrio, salmonella, or hepatitis A
Diarrhea in nursing homes and hospitals?
Think C difficile
Diarrhea from daycare? (3)
Shigella, Giardia, rotavirus
Diarrhea in AIDS patients?
Consider parasitic as well as the usual
True or False: any antibiotic can cause pseudomembranous colitis (c. diff)
When do you test for C diff toxins? (3)
Patients who develop diarrhea
-within 3 days of hospitalization
-during abx treatment
-within 3 months of discontinuing antibiotics
What class of antibiotics is typically used for traveler's diarrhea prophylaxis?
Treatment for traveler's diarrhea? (2)
Ciprofloxacin 500mg BID for 3 days
However, avoid quonolones in children and pregnant women. Give single 1,000mg azithromycin dose in pregnant women or 10mg/kg daily for 3 days in children.
Fluoroquinolones should be avoided in which 2 populations?
Children, pregnant women
Several friends develop vomiting and diarrhea within 6 hours after eating food at a party. What is the most likely etiology?
c. e coli
d. s aureus
S aureus toxin usually causes vomiting and diarrhea within a few hours of food ingestion. Remember the sketchy.
40 y/o man travels to mexico and develops diarrhea 1 day after coming back to USA. Which of the following is the most likely cause?
c. e coli
d. s aureus
The most common cause of traveler's diarrhea.
Woman eats raw seafood and 2 days later develops fever, abdominal cramping, and watery diarrhea. What's the bug?
Most common among people who eat raw seafood
Young daycare worker develops watery diarrhea. Which bug?
c. e coli
d. s aureus
rotavirus is the most common for watery diarrhea from daycare workers, especially in the winter
Treatment for c diff?
Metronidazole or oral vancomycin
What is contraindicated when a patient has c diff colitis?
True or False: USPSTF recommends against hormone replacement therapy for treatment of menopause symptoms (hot flashes, osteoporosis, etc)
True. The use of estrogen alone or combined with progesterone increases adverse cardiovascular outcomes, stroke, and venous thromboembolic disease.
The use of estrogen hormone replacement therapy is not advised and any use of estrogen replacement therapy should be of the lowest effective dose for the shortest effective time period.
Age for HPV three-series vaccination?
When to stop pap smears? (USPSTF rec)
Stop at age 65 in women who have had 3 consecutive negative pap results or two consecutive negative HPV results within the last 10 years. Basically... either two consecutive negative co-tests (5 years in between) or three negative pap smear cytologies (3 years in between)
Risks for osteoporosis? (13)
1. Advancing age
2. Tobacco use
3. Low body weight
4. Poor nutrition
7. Family hx of osteoporosis
8. Low calcium intake
9. Sedentary lifestyle
10. prolonged corticosteroid use
11. chronic kidney or lung disease
12. low testosterone in men
True or False: half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime
Osteopenia vs osteoporosis?
Osteoporosis T score at or below -2.5
Osteopenia T score -1.0 through -2.4
USPSTF recommendation for DEXA scan in women. What age?
Women over age 65. If first scan is normal, there is no current recommendation for repeat screening.
A 21-year-old woman presents for her first Pap smear. She received the full HPV vaccine series at age 19. Assuming that her examination and Pap smear results are normal, when would you recommend that she return for a follow-up Pap smear?
A. 6 months, as the first Pap smear should be followed up soon to reduce the false-negative rate associated with this screening test
B. 1 year, as she is higher risk because of her age
C. 3 years, as the Pap smear was normal
D. 5 years, as she is at low risk because she received the HPV vaccine
How does hysterectomy change pap smear screening?
If cervix was removed with hysterectomy for benign indications, discontinue pap smear screening. If cervix is left, continue screening as usual.
What's the number 1 killer of women in america?
Risk factors for CVD in women need to be managed as aggressively as they are in men
25 y/o man
inversion injury of right ankle during basketball game
Ankle is swollen but patient able to bear weight
No focal tenderness and no ligament laxity
Whats the dx? Further testing? Treatment?
Dx - sprain of right ankle
Further testing? none
Protection, rest, ice, compression, and elevation
PRICE acronym for sprain and strain treatment?
(and NSAIDs PRN)
Which ligament is most commonly injured in ankle sprains?
Anterior talofibular ligament
Which 3 ligaments can be injured with inversion injury ankle sprains?
Anterior talofibular ligament (ATFL), Posterior talofibular ligament (PTFL), and Calcaneofibular ligament (CFL)
What are the 3 grades of ankle sprains?
Grade 1: stretch of single ligament, minor swelling, no mechanical instability, no significant loss of function
Grade 2: partial ligament tain, severe pain, swelling, bruising, mild to moderate joint instability, pain with weight bearing, loss of range of motion
Grade 3: complete ligamentous tear, significant joint instability, swelling, loss of function, and inability to bear weight
True or False: ottawa ankle rules have a sensitivity approaching 100% in ruling out significant malleolar and midfoot fractures
Near 100% sensitive, however, specificity is around 30-50%
True or False: surgery is often needed for ankle sprains in the presence of chronic pain and persistent functional instability.
Surgery is rarely needed. Surgery for ankle sprains has been shown to increase stiffness of the joint, lead to longer recovery times, and result in impaired mobility when compared to conservative treatment only. Therefore, surgical consideration should be a last resort when all else has failed and should be discussed in a case by case manner.
Sprain vs strain?
Sprain - stretching or tearing injury of a ligament
Strain - stretching or tearing injury of a muscle or tendon
Empty can test. Muscle(s)?
External rotation. Muscle(s)?
Infraspinatus and teres minor
Internal rotation. Muscle(s)?
Patient is unable to lower his arm slowly from a raised position
Large rotator cuff tear(s)
What is the squeeze test?
Examiner compresses tibia/fibula at mid-calf
This tests for syndesmosis. Pain at anterior ankle joint (below where the examiner is squeezing) suggests syndesmotic ("high ankle") injury
Anterior drawer test vs Lachman test?
Lachman - knee in 20 degree flexion, examiner pulls forward on upper tibia while stabilizing upper leg
Anterior drawer - knee in 90 degree flexion, examiner pulls forward on upper tibia while stabilizing leg
Ottowa Knee Rules?
Recommend knee x-ray with any one of the following 5 criteria:
1. age 55 or older
2. isolated patella tenderness
3. tenderness of the head of the fibular
4. inability to flex the knee at 90 degrees
5. inability to bear weight for 4 steps immediately and in the exam room (regardless of limping)
What should be done with sprain or strain injuries to prevent persistently stiff, painful, or unstable joints from developing at the site of injury?
32 y/o man
right shoulder pain for past 3 weeks
Thinks that he possibility injured when playing softball but does not remember specific injury.
No bruising or swelling.
Pain in joint on external rotation and abduction but has preserved range of motion.
What is the initial imaging test of choice?
c. CT scan
Plain film x-rays are the diagnostic imaging test of choice for the initial evaluation of a painful joint. In patients who have normal x-rays and who have a suspected soft-tissue (ligament, tendon, or cartilage) injury, MRI scanning is usually the next most appropriate imaging study to perform.
Adequate x-ray series must include at least 2 views at 90 degrees to each other.
What is an abscess?
A closed pocket containing pus
What is a bulla?
A blister greater than 0.5 cm in diameter (plural: bullae)
What is a cyst?
A closed, saclike, membranous capsule containing a liquid or semisolid material
What is a macule?
A discoloration on the skin that is neither raised nor depressed
What is a nodule?
A small mass of rounded or irregular shape that is greater than 1.0 cm in diameter
What is a papule?
A small, circumscribed elevated lesion of the skin that is less than 1.0 cm in diameter
What is a plaque?
A plateaulike, raised, solid area on the skin that covers a large surface area in relation to its height above the skin
What is a ulcer?
A lesion through the skin or mucous membrane resulting from loss of tissue
What is a vesicle?
A small blister less than 0.5 cm in diameter
What is the most important risk factor for the development of skin cancer?
Exposure to natural or artificial UV radiation
In addition to UV radiation exposure, what are risk factors for skin cancer? (6)
Red or blonde hair
Propensity to burn easily
Chronic exposure to toxic compounds
Suppressed immune system
ABCDE of suspicious skin lesions?
Borders (well defined vs ragged or blurred)
Color (uniform vs not)
Diameter (less than 6 mm vs more)
Elevation (flat surface vs raised surface.. raised being worse)
Evolving (stable in size and appearance vs enlargement or bleeding))
How to prevent skin cancer?
1. avoid sun between 10am and 4pm
2. wear sun-protective clothing when exposed to sunlight
3. wear sunscreen with SPF (sun protection factor) at least 15
4. avoid artificial sources of UV radiation
True or False: asymptomatic microscopic hematuria justifies work-up for etiology
Hematuria in adults should always be evaluated. If no source is found on a thorough initial workup, patients should be followed for at least 3 years to monitor for an underlying condition. In every case of a first-time microscopic hematuria, a repeat urinalysis with microscopy is required at 6 week interval before any other management is done.
5% turn out to have cancer. Other things on the differential are interstitial nephritis, glomerular disease, exercise induced, UTI, etc.
Urinary sediment shows eosinophils. What should be on your diff?
Interstitial nephritis caused by analgesics or other drugs
Urinary sediment shows dysmorphic RBCs and RBC casts. What should be on your diff?
Renal glomerular disease
Most common cause of non-iatrogenic hyperthyroidism?
Symptomatic treatment for Graves disease? (3) Definitive treatment?
1. Propylthiouracil (PTU)
3. B-blockers to block peripheral effects of excessive thyroxine
Definitive treatment is radioactive iodine. This is used only in adult patients who are not pregnant. It should not be used in children or breast-feeding mothers.
Antithyroid drugs are especially useful in treating adolescents, in whom Graves disease may go into spontaneous remission after 6-18 months of therapy. Surgery is reserved for patients in whom medications and radioactive iodine ablation are unacceptable treatment modalities or in whom a large goiter is present that is compressing nearby structures or is disfiguring.
What is thyroid storm?
Acute hyper metabolic state associated with the sudden release of large amounts of thyroid hormone into circulation.
Thyroid storm is a medical emergency that requires prompt attention and reversal of the metabolic demands of acute hyperthyroidism.
Symptoms include fever, confusion, restlessness, and psychotic-like behavior. Exam may show tachycardia, elevated BP, fever, and dysrhythmias.
What is Graves disease?
Autoimmune disorder caused by immunoglobulin IgG antibodies that bind to TSH receptors, initiating the production and release of thyroid hormone.
What is the 2nd most common cause of hyperthyroidism?
Autonomous thyroid nodule that secretes thyroxine. These nodules do not rely on TSH stimulation and continue to excrete large amounts of thyroxine despite low or nonexistent circulating TSH levels.
PTU vs methimazole in pregnant patients?
PTU for first trimester. Methimazole for the rest. Methimazole has adverse effects on fetal development and shouldn't be used until 2nd and 3rd trimesters.
How do you treat thyroid storm?
PTU, methimazole, B-blockers
True or False: in older patients, hypothyroidism can be confused with alzheimer disease
What is the most common non-iatrogenic condition causing hypothyroidism in USA?
True or False: Further workup of identified nodules is indicated, even if the nodules are solitary
Incidence of malignancy in solitary nodule is estimated at 5-6%
True or False: functional adenomas that present with hyperthyroidism are usually malignant
False. They are rarely malignant. A patient who has a thyroid nodule and is found to be hyperthyroid should have a radioactive iodine uptake study to confirm functionality of the nodule. Hyperfunctioning nodules are treated with surgery or radioactive ablation therapy, depending on the level of hyperthyroidism.
Thyroid nodules measuring greater than 1 cm by ultrasonography in a person with a normal or elevated TSH require what action?
Biopsy (fine-needle aspiration)
How do you treat thyroid nodules discovered during pregnancy?
Radioisotype scanning is contraindicated. FNA is safe during pregnancy and thyroidectomy can be performed relatively safely during the 2nd and 3rd trimester. However, because thyroid cancer is relatively indolent, it may be wise to defer definitive diagnosis and treatment until the postpartum period in patients with indeterminate lesions on FNA.
35 y/o at 11 weeks gestational age
palpitations, weight loss, nervousness, tremor
Denies hx of thyroid disease
Lab confirms that TSH is severely suppressed.
Which of the following is the best treatment for the patient at this time?
Methimazole should not be used in the first trimester because it has adverse effects on fetal development
24 y/o woman who is 8 weeks present is found to have a thyroid nodule.
Biopsy shows malignancy of the thyroid.
What to do?
a. confirm the diagnosis of cancer using radioisotope scanning
b. perform an immediate thyroidectomy
c. follow clinically until after delivery of child
d. treat with radioactive iodine ablation in the 2nd or 3rd trimester
c. follow clinically until after delivery of child
Thyroid cancer detected during pregnancy can usually be observed until after the pregnancy is complete. If needed, thyroid surgery can be performed safely in the 2nd or 3rd trimesters. The use of radioactive iodine is contraindicated in pregnancy.
28 y/o man
Firm nodule palpated in left lobe of thyroid
Ultrasound measures 0.8cm nodule
What to do?
a. radioactive iodine uptake study
b. fine-needle aspiration
c. repeat US in 6 mo
d. referral to surgeon for open biopsy
c. repeat US in 6 mo
For thyroid nodules that are less than 1 cm, benign appearing, and no presence of positive clinical history of thyroid cancers, observation and repeat thyroid US in 6 mo is appropriate. Thyroid nodules greater than 1 cm should undergo FNA, as this is a sensitive and specific test for thyroid nodules and can help to determine whether it is malignant
What are the first steps once thyroid nodule is palpated on examination?
TSH level and thyroid ultrasound
True or False: thyroid disease in pregnancy is relatively harmless
Thyroid dx in pregnancy needs to be evaluated and treated as both hypothyroidism and hyperthyroidism can have serious effects on fetal development
Where is most of the calcium in the body found?
What is responsible for regulating calcium levels and maintaining calcium homeostasis? (3)
3. 1,25-dihydroxyvitamin D3 (calcitriol)
What is calcitonin and what does it do?
Calcitonin is produced by the thyroid parafollicular cells. When calcium levels increase, calcitonin attempts to lower calcium levels through renal excretion of calcium and by opposing osteoclast activation.
What is PTH and what does it do?
PTH is parathyroid hormone. It is produced by the parathyroid glands. When calcium is low, PTH causes osteoclast activation which mobilizes calcium from bone and effects calcium resorption at the kidneys, thereby retaining circulating calcium.
PTH and Calcitonin do opposite things.
What does PTH do to calcium levels? Phosphate levels? Calcitriol levels?
PTH increases calcium levels, decreases phosphate levels, and increases calcitriol (1,25-dihydroxyvitamin D3) levels.
What does calcitriol do?
Calcitriol is 1,25-dihydroxyvitamin D3. It acts as the GI tract to promote both calcium and phosphate absorption.
Most common cause of hypercalcemia in ambulatory patient? Second most common?
Hyperparathyroidism, Cancer (tumor secretion of PTH-rP)
4 causes of increased bone resorption?
1. primary hyperparathyroidism
2. malignancy (tumor secretion of PTH-rP)
3. hypervitaminosis A
3 causes of increased calcium absorption?
1. hypervitaminosis D
2. granulomatous disease (e.g. tuberculosis, sarcoidosis, hodgkin disease)
3. Milk alkali syndrome (excessive intake of calcium-containing antacids)
4 miscellaneous causes of hypercalcemia?
1. medications (thiazide diuretics, lithium)
2. rhabdomyolysis (calcium released from injured muscle)
3. adrenal insufficiency (increased bone resorption and increased protein binding of calcium)
4. thyrotoxicosis (usually very mild calcium elevation. increased bone resorption)
Physical manifestations of hypercalcemia?
Stones, Bones, Abdominal moans, Psychiatric overtones
Renal calculi, bone pain, poor concentration, weakness, fatigue, stupor, coma, abdominal pain, constipation, nausea, vomiting, pancreatitis, anorexia
What is primary, secondary, and tertiary hyperparathyroidism?
Primary hyperparathyroidism is caused by an adenoma of one of the four parathyroid glands or hyperplasia of multiple.
Secondary hyperparathyroidism is caused by parathyroid glands overproducing PTH in response to low serum calcium levels.
Tertiary hyperparathyroidism is caused by parathyroid glands overproducing PTH in response to renal failure. Patients in renal failure initially present with hypocalcemia, hyperphosphatemia, and low vitamin D levels. If untreated, it leads to hyperplasia of the parathyroid glands, an increased PTH secretion, and subsequent hypercalcemia.
What is familial hypocalciuric hypercalcemia?
Genetic disorder related to a defect in a gene that codes for a calcium-sensing receptor. Consequently, simply measuring PTH alone may confound the diagnosis, which may be mistaken for primary hyperparathyroidism. To distinguish between these entities, a 24 hr urinary calcium level is obtained. In hyperparathyroidism, the kidneys spill calcium into the urine at a normal or elevated level. With FHH, the urinary calcium level is low.
Which cancers can produce PTH-rP?
Lung cancers, squamous cell cancers of the head and neck, and renal cell cancer
What is the most common cause of severe vision loss in the elderly?
Age-related Macular Degeneration. This is characterized by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the loss of central vision.
Treatment options for exudative AMD include laser photocoagulation, and intravitreal injections of vascular endothelial growth factor.
True or False: the combination of the "clock draw" and "3-item recall" is a rapid and fairly reliable office-based screening for dementia
However, if patients fail either of these screening tests, further testing with Folstein Mini-Mental State questionnaire should be performed.
True or False: well-informed, competent adults have a right to refuse medical intervention, even if refusal is likely to result in death
What are advance directives?
Oral or written statements made by patients when they are competent that are intended to guide care should they become incompetent.
About what percentage of patients who undergo CPR in the hospital survive to hospital discharge?
True or False: smoking is associated with osteoporosis
True or False: in adults, the vast majority of pharyngitis is bacterial
How do you treat acute bronchitis?
Treat with bronchodilators, analgesics, and antitussives. Antibiotics have not been consistently shown to be beneficial. The illness is usually self-limited.
True or False: the color of sputum is not diagnostic of the presence of a bacterial infection
45 y/o man
No hx of lung disease
No hx of smoking
3 weeks of productive cough following an URI
Treat with bronchodilators, analgesics, and antitussives. Antibiotics have not been consistently shown to be beneficial. The illness is usually self-limited.
Common non-infectious causes of cough? (7)
4. Postnasal drip
6. Medications (ACE inhibitors)
Treatment of acute sinusitis?
Amoxicillin and trimethoprim-sulfamethoxazole are widely used as first-line agents typically for 10 to 14 day regimens.
Second-line agents include amoxicillin-clavulanic acid, 2nd or 3rd generation cephalosporins (cefuroxime, cofactor, cefprozil), fluoroquinolone, or macrocodes (azithromycin, clarithromycin)
True or False: tonsillar exudates distinguishes between bacterial and viral causes of pharyngitis
Both viral and bacterial infections can cause tonsillar exudates.
Findings frequently associated with group A strep pharyngitis?
1. abrupt onset sore throat and fever
2. tonsillar and/or palatal petechiae
3. tender cervical adenopathy
4. absence of cough
Infectious mononucleosis, caused by infection with EBV, is extremely difficult to distinguish clinically from GAS infection. What are some ways that you can tell EBV apart from GAS?
Features suggestive of mononucleosis include retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear.
True or False: patients with group a strep pharyngitis should be restricted from contact sports.
Patients with infectious mononucleosis should be restricted from contact sports in which abdominal trauma may occur. Even minor trauma can cause splenic rupture from splenomegaly.
Do rapid antigen tests for GAS pharyngitis have high specificity and low sensitivity or high sensitivity with low specificity?
High specificity but low sensitivity.
Positive rapid antigen would prompt antibiotic treatment while negative test should be followed by a throat culture. Rapid antigen tests can be conducted in a few minutes in the office or ED setting.
Throat cultures are the gold standard for diagnosis of GAS infections. Cultures can take 1-2 days. This is acceptable in most instances as the risk of complication from GAS infections is low if treatment is instituted within 10 days of onset of symptoms.
Modified Centor criteria?
1 point for each:
absence of cough
enlarged/tender anterior cervical adenopathy
fever of 100.4 or higher
one point is awarded if the patient is age 3-14 and one is deducted for the age of 45 or higher
0-1: no further testing and no abx indicated
2-3: perform rapid strep or throat culture and treat with abx if positive
4 or more points: consider empiric abx treatment
True or False: poststreptococcal glomerulonephritis can occur whether or not the patient receives appropriate antibiotic treatment
Complications from untreated group A strep infections? (6)
1. Rheumatic fever
3. Toxic shock syndrome
4. Peritonsillar abscess
Antibiotic of choice for GAS pharyngitis?
10 day oral therapy of penicillin V or intramuscular therapy of penicillin G.
In penicillin-allergic patients, treatment options include cephalosporins and macrolides.
How does GERD cause cough?
The afferent limb of the cough reflex is activated by the acid interfering with the upper respiratory system. GERD presents with a cough that gets worse in a supine position, heartburn and increased symptoms after meals.
Although definitive test is 24-hour esophageal pH monitoring, GERD is usually a clinical diagnosis. A trial of PPI is both diagnostic and therapeutic.
What patients are at risk for invasive external otitis by pseudomonas?
How do you treat invasive external otitis (malignant OE)?
Surgical debridement of necrotic tissue and 4-6 weeks of IV antibiotics.
Common symptoms of otitis media? (5)
2. ear pain
3. diminished hearing
True or False: most cases of acute otitis media will resolve spontaneously
Indications for treating otitis media with antibiotics?
Prolonged, recurrent, or severe symptoms
What is the recommended antibiotic for otitis media?
What are alternative antibiotics?
or Augmentin, trimethoprim-sulfamethoxazole, or 2nd and 3rd generation cephalosporins
Complications of otitis media are uncommon. What are some of the complications? (4)
2. bacterial meningitis
3. brain abscess
4. subdural empyema
30 y/o woman no PMH
productive cough of 2 week duration.
Runny nose, body aches, congestion, and fevers for the past week.
Normotensive with normal pulse and 101.2 F temp.
Physical exam: sinus tenderness, boggy nasal turbinates, and crackles in the left lower lobe lung fields.
Best initial step in management?
a. reassure patient that she likely has a viral infection and it will resolve on its own
b. order a rapid strep test and treat if positive
c. prescribe amoxicillin for a likely bacterial infection
d. order chest x-ray to rule out possible pneumonia
D. CXR to rule out pneumonia
Acute bronchitis is a diagnosis of exclusion in the absence of clinical or radiographic findings concerning for pneumonia. In this patient with fevers, productive cough, and rales on lung examination, it is important to rule out pneumonia. If there is a strong clinical suspicion of community-acquired pneumonia, a CXR is not necessary and outpatient treatment with ABX can be initiated.
Top 3 causes of cough?
1. upper airway cough syndrome
13 y/o girl
Fever and sore throat for 48 hour duration.
101 F in office.
Tachycardic with 118 bpm. PE is positive for tender, enlarged left cervical lymphadenopathy. Pharynx is erythematous but without tonsillar enlargement or exudate. She has had no cough.
Next step in management?
A. treat empirically with abx
B. order rapid strep test, and if positive, treat with abx
C. neither further testing nor abx
D. order throat culture and, if positive, treat with abx
A. treat empirically with abx
Management of strep pharyngitis is frequently guided by modified Centor criteria, which calculates a probability of strep throat based on a scoring system. This patient gets one point for presence of fever over 100.8, tender cervical adenopathy, absence of cough, and age. You can reasonably consider an empiric abx treatment for GAS in her.
What is upper airway cough syndrome (UACS)?
UACS is an umbrella term that encompasses a variety of upper respiratory conditions including rhinitis and sinusitis.
New York Heart Association (NYHA) classification of angina? Class 1-4
Class 1: angina only with unusually strenuous activity
Class 2: angina with slightly more prolonged or slightly more vigorous activity than usual
Class 3: angina with usual daily activity
Class 4: angina at rest
Angina of new onset, angina at rest or with minimal exertion, or a crescendo pattern of angina with episodes of increasing frequency, severity, or duration.
Initial therapy for acute coronary syndrome (ACS)?
Morphine (initiated rapidly if nitroglycerin cannot alleviate the discomfort)
Oxygen (2-4 L/min nasal cannula, may discontinue after 6 hours if o2 sats normal w/o complications)
Nitroglycerin (sublingually q5min x3, then advance to IV or transdermal routes)
Aspirin (325mg chewed and swallowed)
Contraindications for nitroglycerin use?
Sildenafil and hypotension
All patients who rule in for MI should receive what 2 treatments?
Aspirin and antithrombotic treatment like heparin
These reduce the risk of subsequent MI and cardiac death in patients with unstable angina. It is reasonable to give clopidogrel 300mg orally to patients with suspected ACS (without ECG or cardiac markers) who are either allergic to or have GI intolerance of aspirin
All patients admitted for angina or MI should receive what kind of diet?
Diet with reduced saturated fat and cholesterol
What drug reduces short-term mortality when started within 24 hours of acute MI?
Postinfarction ACE inhibitors prevent left ventricular remodeling and recurrent ischemic events.
Low levels of what can increase the incidence of torsades de pointes?
Give magnesium sulfate if levels are low
Substernal pressure <30 min. Radiation to arm, neck, jaw, w/wo dyspnea, N/V, diaphoresis, increased with exertion, decreased with rest and nitroglycerin
Anginal symptoms but duration > 30 min
Sharp pain radiates to trapezius, increased with inspiration, decreased sitting leaning forward
Sudden onset of tearing pain with radiation to back
Dyspnea, fever, cough, +/- pleuritic pain
Unilateral sharp pleuritic pain of sudden onset
Sudden onset of pleuritic pain, tachycardia, tachypnea, hypoxemia
Burning epigastric/substernal pain, acid taste in mouth, increased with meals
Epigastric pain decreased with antacids and PPIs
Peptic ulcer disease
Severe epigastric and back pain
Localized chest pain that is easily reproducible, tender to palpation
Sensation of "tightness" in chest, SOB, tachycardia
What is the most common cause of chest pain in the outpatient setting?
The patient's chest wall must be palpated. Abdominal examination is also important as GI etiology is the 2nd most common culprit for chest pain in an outpatient setting.
While the most common etiology in primary care settings is MSK, it is imperative to rule out cardiac cause of chest pain before making a msk-related diagnosis.
58 y/o man
Presents for f/u of HTN and HLD
Chest pain and SOB with exertion
Symptoms resolve with rest.
Which is contraindicated as first-line agent?
The patient has new onset angina. Rapid release, short-acting dihydropyridines (nifedipine) are contraindicated because they increased mortality in multiple trials. B-blocking agents are the agents of choice since they increase survival; nitroglycerin helps to abate chest pain, but has not been shown to impact survival.
What is CKD?
A spectrum of processes associated with abnormal kidney function and progressive decline in GFR
What is ESRD?
End-stage renal disease is the irreversible loss of kidney function such that the patient is permanently dependent on renal replacement therapy (dialysis or transplantation). It is also defined as a GFR of less than 15 mL/min.
3 most common causes of CKD?
What are GFR levels for:
Stage 1 CKD
Stage 1: >90 in the presence of signs of kidney disease such as proteinuria, hematuria, or abnormal renal structure
Stage 2: 60-89
Stage 3: 30-59
Stage 4: 15-29
What imaging finding shows irreversible kidney disease?
What does asymmetry in kidney size suggest?
Managing CKD includes treatment of reversible causes. What are the reversible causes? (4)
Infection leading to sepsis
Drugs (NSAIDs, aminoglycosides, radiographic contrast)
Urinary tract obstruction
56 y/o man w/ CKD
3 day hx of SOB and rapid weight gain.
PE: S3, crackles at bases, moderate JVD
c. Cr to calculate GFR
d. check for cardiac enzymes
The patient has CKD with volume overload. Simple first step is to do a CXR to confirm what you already suspect--pulmonary edema. After initiating furosemide (lasix), the CXR may be repeated to see what degree the dieresis has improved the overload. Cardiac workup is also indicated but would not be the first step done.
78 y/o man
on DAPT (ASA and clopidogrel) as a result of a stroke 6 months ago. He recently underwent coronary angiography and his cardiologist scheduled a coronary artery bypass surgery for a week from today. Which one of the following is recommended with regard to his DAPT?
a. stopping only aspirin 5 days before surgery
b. stopping only clopidogrel 5 days before surgery
c. stopping both aspirin and clopidogrel 5 days before surgery
d. continuing both aspiring and clopidogrel
B. stopping only clopidogrel 5 days before surgery
Patients receiving DAPT who require bypass surgery should continue taking aspirin. Clopidogrel or prasugrel should be stopped 5 days before the surgery due to the increased risk of major bleeding during surgery.
Anxious 30 y/o white female.
SOB, circumoral paresthesia, and carpopedal spasms.
Which blood gas is expected?
a. ph 7.25, pCO2 25, pO2 100
b. ph 7.25, pCO2 50, pO2 80
c. ph 7.50, pCO2 25, pO2 100
d. ph 7.55, pCO2 50, pO2 80
Anxiety, SOB, paresthesia, and carpopedal spasm are characteristic of hyperventilation
Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is elevated and pCO2 is depressed.
39 y/o woman with multiple medical problems.
Worsening renal insufficiency.
Which of the following is most important in the prevention of end-stage renal disease?
a. tobacco cessation
b. triglyceride control
c. glycemic control
d. weight control
e. dietary sodium restriction
c. glycemic control
Optimal control of HTN, acidosis, volume depletion, and cholesterol are all important to prevent worsening renal function. DM is the leading cause of ESRD. Tight glycemic control can prevent microvascular complications of diabetes such as diabetic nephropathy, though it has not been shown to decreased significantly the occurrence of microvascular complications of DM such as CAD or peripheral vascular disease.
72 y/o man.
Long hx of HTN.
Presents to ED with 2 day hx of emesis and 36 hours without urination.
On examination, the abdomen is firm and tender, and the prostate is enlarged.
Serum Cr is 3.4
What to do next?
a. give IV fluids and see if he begins to make urine
b. perform renal ultrasound in the ED
c. maintain tight control of his blood pressure
d. place an indwelling foley catheter
d. foley catheter
The patient has an enlarged prostate that has caused urinary obstruction and potentially reversible renal failure, depending on at which point the obstruction is resolved. Placing the Foley catheter will usually allow for significant reversal of an elevated Cr. Following catheter placement, the urine output needs to be carefully monitored and the Cr repeated later. Another clue is the tense lower abdomen that is caused by a very enlarged bladder. It is especially important to rely on clinical examination skills in elderly patients who have less-than-optimal communication skills as a consequence of dementia or who have a history of stroke when evaluating for a cause.
True or False: shrunken kidneys should always be biopsied
Small kidneys should rarely be biopsied as the result of the biopsy will usually not alter the treatment or prognosis of the condition. Small kidneys usually reflect irreversible disease.
25 y/o woman. Foul-smelling vaginal discharge.
Greenish, frothy discharge and a "strawberry" cervix.
What is this and how do you treat?
Treat with metronidazole 2g by mouth in a single dose for both patient and her sexual partner. Metronidazole 500mg BID for a week is an alternate regimen.
Potential cause of vaginitis? (3)
1. Candida albicans
2. Trichomonas vaginalis
3. Polymicrobial mix of bacterial vaginosis (gardnerella vaginalis predominant)
Who is more prone to developing candida vaginitis? (2)
Who is more prone to developing trichomonas vaginalis? (1)
Candida vaginitis: recent abx use, DM
Trichomonas vaginalis: hx of multiple sexual partners
Thick vaginal discharge suggests?
Thinner vaginal discharge with "fishy" odor suggests?
Frothy discharge that's foul smelling with erythematous cervix suggests?
Thick - candida
Thinner, fishy - gardnerella
Frothy, foul smelling, strawberry cervix - trichomonas vaginalis
How do you determine the cause of vaginal discharge?
Sample of discharge is examined both as a "wet mount" (mixed with a small amount of normal saline) and as a "KOH prep" (mixed with a small amount of 10% potassium hydroxide).
On the wet mount, the examiner can evaluate the normal epithelial cells and look for white blood cells, red blood cells, clue cells, and motile trichomonads. The hyphae or pseudohyphae of candida are best seen on KOH prep.
What is bacterial vaginosis?
It is a condition of excessive anaerobic bacteria in the vagina, leading to a discharge that is alkaline
What is candida vulvovaginitis?
Vaginal and/or vulvar infection caused by candida species, usually with heterogenous discharge and inflammation
What is trichomonas vaginitis?
Infection of the vagina caused by the protozoa T vaginalis, usually associated with frothy green discharge and intense inflammatory response.
How do you treat vulvovaginal candidiasis?
Uncomplicated candidiasis can be treated with short-term intravaginal preparations (creams or vaginal suppositories) or single dose oral therapies (fluconazole 150mg).
Treating of complicated or recurrent infection should begin with an intensive regimen for 10-14 days followed by 6 months of maintenance therapy to reduce the likelihood of recurrence.
Treatment of sexual partners is not indicated unless symptomatic (e.g. male partners with balanitis)
Risk factor for trichomonas vaginitis? (3)
1. multiple sex partners (as it is classified as a STD)
Risk factor for bacterial vaginosis?
Although not an STD, it is associated with having multiple sex partners.
How do you treat bacterial vaginosis?
Treatment includes both oral and topical vaginal preparations of metronidazole or clindamycin. There are no advantages to any of these regimens with regard to cure rates or recurrence, although patients do report more satisfaction with the vaginal preparations.
Treatment of sexual parters is not necessary and does not reduce the risk of recurrent infection.
True or False: treatment of bacterial vaginosis in asymptomatic pregnant women may reduce the incidence of preterm delivery
True or False: approximately 5% of gonococcal infections and 7% of chlamydial infections are asymptomatic in women
approximately 50% of gonococcal infections and 70% of chlamydial infections are asymptomatic in women
What is mucopurulent cervicitis?
Infection characterized by purulent or mucopurulent discharge from the endocervix, which may be associated with vaginal discharge and/or cervical bleeding. May be caused by gonorrhea and chlamydia.
How do you treat gonorrhea and chlamydia?
Gonorrhea: Ceftriaxone 125mg IM
Chlamydia: Azithromycin single 1,000mg oral dose OR doxycycline 100mg BID for 7 days.
Treatment of sexual partners is advised.
Typically treat for both as rate of co-occurance is significant.
What is pelvic inflammatory disease? How do you diagnose it?
PID is inflammation of the upper genital tract including pelvic peritonitis, endometritis, salpingitis, and tuboovarian abscess caused by infection with gonorrhea, chlamydia, or vaginal and bowel flora.
The presence of lower abdominal tenderness with both adnexal and cervical motion tenderness, without other explanation of illness, is enough to diagnose PID.
Other criteria that enhance the specificity of the diagnosis include temperature more than 101, abnormal cervical or vaginal discharge, elevated sedimentation rate, elevated CRP, and cervical infection with gonorrhea or chlamydia.
What should also be ruled out when there is concern for pelvic inflammatory disease?
Pregnancy due to clinical similarity. Serum pregnancy test should be performed on all patients suspected of having PID
24 y/o nulliparous woman.
Vaginal discharge. Homogenous with fishy odor.
Which is also likely to be noted?
a. motile protozoa on wet mount
b. pH more than 4.5
c. strawberry cervix on speculum exam
d. budding hyphae on KOH exam
b. pH more than 4.5
Discharge of homogenous and fishy odor is most likely bacterial vaginosis associated with alkaline pH
38 y/o woman.
New-onset vaginal discharge and irritation.
Recent UTI 10 day ago with resolution following abx treatment. Which of the following is the best empiric therapy for her condition?
a. oral metronidazole
b. vaginal metronidazole
c. oral fluconazole
d. oral clindamycin
e. oral estrogen and progestin therapy
c. oral fluconazole
This patient most likely has candida vulvovaginitis, since her discharge appeared after her cystitis was treated with abx.
24 y/o woman.
Lower abdominal tenderness, cervical motion tenderness, and vaginal discharge.
Low-grade fever of 100.5 F.
Which is best therapy?
a. ceftriaxone IM and doxycycline orally
b. ampicillin orally and azithromycin orally
c. metronidazole orally as single dose
d. ciprofloxacin orally as single dose
a. ceftriaxone IM and doxycycline orally
An option for outpatient therapy of salpingitis (PID) is IM ceftriaxone and oral doxycycline. Could also use azithromycin over doxycycline.
Screening for chronic hepatitis B infection is not recommended for which of the following?
a. patients on chronic immunosuppressive therapy
b. patients with ESRD who are on hemodialysis
c. household contacts of individuals with chronic hepatitis B
d. pregnant women with no risk factors for hepatitis B
e. all new borns
e. all newborns
The CDC recommends screening for hepatitis B in patients on hemodialysis, household contacts of individuals with chronic hepatitis B, patients on immunosuppressive therapy, and all pregnant women. Other individuals who should be screened include anyone exposed to bodily fluids of infected individuals, such as sexual partners or infants of infected mothers. Behavioral risk factors such as IV drug use are also an indication for screening. Patients from areas where HBsAg prevalence is >2% should also be screened.
What are hemorrhoids?
Dilated veins in the hemorrhoidal plexus of the anus
What are risk factors for hemorrhoids? (4)
Chronic constipation, straining for bowel movements, pregnancy, and prolonged sitting (e.g. truck drivers)
How do you treat hemorrhoids?
Conservative treatment: high-fiber diet, stool softeners, and precautions against prolonged straining
When necessary, various surgical procedures can be performed for definitive treatment.
True or False: diverticula are typically symptomatic
They are typically asymptomatic and found incidentally on endoscopy or bowel imaging studies. When symptomatic, they can cause massive painless bleeding.
How do you treat diverticula?
Most diverticular disease is self-limited and stops bleeding on its own (75%). Recurrence rate of approximately 38%.
When the bleeding is extremely heavy or fails to stop, surgical resection of the affected portion of the colon may be necessary.
Asymptomatic diverticulosis is managed with dietary modification, primarily a high-fiber diet.
What is diverticulitis?
Diverticulitis is a painful inflammation and infection of a diverticulum. It frequently presents with LLQ abdominal pain with fever, nausea, diarrhea, and constipation.
Perforation of a diverticulum resulting in peritonitis or intra-abdominal access formation can be a complication.
How do you treat diverticulitis?
Diverticulitis is typically treated with bowel rest and antibiotics effective against gut flora. A combination of a quinolone and an agent for anaerobic organisms, such as metronidazole, is one commonly used regimen.
n severe cases, recurrent cases, or when perforation occurs, surgery is indicated.
True or False: any patient older than age 50 who has lower GI bleeding must be evaluated for the presence of colon cancer
What are colon polyps?
Polyps are benign neoplasms of the colon
Colon adenomatous polyps are benign growths that have a potential to become malignant. List in order of potential for becoming cancerous (from least to most) 3 types.
1. tubular adenomas (lowest risk of becoming malignant)
2. tubulovillous adenomas
3. villous adenomas (highest risk of becoming malignant)
52 y/o man.
Presents with BRBPR.
HR 110, BP 90/50
Cool and clammy appearing. Blood present on rectal examination although he does not appear to be bleeding at the moment.
What's the best initial next step?
b. flexible sigmoidoscopy
c. place a nasogastric tube
d. start a bolus of IV normal saline
e. give a transfusion of type O-negative blood
d. start a bolus of IV normal saline
The initial evaluation of this acutely ill patient is "ABC" for airway, breathing, and circulation. As he appears to be in hypovolemic shock, with tachycardia and hypotension, a bolus of a crystalloid fluid such as normal saline or lactated ringer solution is necessary before proceeding with any of the other evaluations.
On a screening colonoscopy, a patient is noted to have several diverticuli in the sigmoid colon. He has never had any complaints of constipation, diarrhea, abdominal pain, or rectal bleeding. Which of the following is the best step in the management of this patient?
a. annual colonoscopy
b. sigmoid colectomy
c. high-fiber diet
d. proton pump inhibiter
c. high-fiber diet
Asymptomatic diverticuli are common findings on screening colonoscopies. The initial management of this is a high-fiber diet. Diverticulosis by itself does not increase one's risk of developing colon cancer. Surgery is typically reserved for severe or recurrent symptomatic cases.
What is pneumonia?
Pneumonia is an infection of lung parenchyma caused by agents that include bacteria, viruses, fungi, and parasites.
What is pneumonitis?
An inflammation of the lungs from a variety of noninfectious causes such as chemicals, blood, radiation, and autoimmune processes.
What is the most common mechanism triggering pneumonia?
Upper airway colonization by potentially pathogenic organisms that are subsequently aspirated.
What is community acquired pneumonia?
Pneumonia that occurs in persons who are not hospital in-patients or residents of long-term care facilities.
Common viral causes of pneumonia? (4)
Influenza A and B
Respiratory syncytial viruses
What is the most common bacterial cause of community-acquired pneumonia? What are others? (3)
Others: mycoplasma pneumoniae, haemophilus influenza, and moraxella catarrhalis
What is atypical pneumonia? What are the 3 "atypical" pneumonias?
Atypical pneumonia are organisms that tend to cause bilateral, diffuse infiltrates, rather than focal lobar infiltrates on x-ray.
1. mycoplasma pneumoniae
2. chlamydia pneumoniae
3. legionella pneumophilia
Risk factors of health-care-associated pneumonia? (4)
1. hospitalization within 90 days
2. home infusion therapy
4. resident of nursing home
Causative organisms of health-care-associated pneumonia?
1. all pathogens involved in community-acquired pneumonia
5. Staphylococcus aureus
Pneumonia after influenza? Which bug?
Pneumonia with diarrhea, hyponatremia, and sometimes elevated liver enzymes
Pneumonia with abrupt onset or abruptly worsening
True or False: all patients with suspected pneumonia should have a CXR
The presence of an infiltrate can confirm the diagnosis. Absence of an infiltrate does not rule out pneumonia as a diagnosis. A CXR can also identify a pleural effusion, which may be a complication of pneumonia
Bilateral, ground glass infiltrate seen on CXR.
Patient with AIDs
True or False: legionella can be confirmed in suspected cases by urine antigen testing
What is the treatment of choice for healthy persons suitable for outpatient treatment who get pneumonia?
What about for a patient with chronic comorbidities such as DM, heart dx, or lung dx?
Macrolide (clarithromycin or azithromycin)
Patients w/ chronic comorbidities:
Fluoroquinolones (levofloxacin, moxifloxacin)
Combination of a B-lactam (high-dose amoxicillin, amoxicillin w/ clavulanate, cefpodoxime, or cefuroxime) plus a macrolide (clarithromycin or azithromycin)
Bacteremia occurs in approximately __ % of patients with pneumococcal pneumonia.
And mortality rates for patients with bacteremia range from 20-30% and as high as 60% in the elderly.
How do you treat parapneumonic pleural effusion?
If more than a minimal amount of fluid is present, as evidenced by significant blunting of the costophrenic angle on x-ray, it may be necessary to perform a thoracentesis with Gram stain and culture of the pleural fluid.
Parapneumonic pleural effusion develops in about __% of hospitalized patients with pneumococcal pneumonia. Fewer than __% of cases progress to empyema.
How do you treat empyema from pneumonia?
Drainage with chest tube or surgical procedure
Who should get the pneumococcal vaccine? (4)
1. all persons aged 65 and older (give both 23-valent and 13-valent in series)
2. all adults with chronic cardiopulmonary diseases
3. cigarette smokers
4. immunocompromised persons
If a patient has pneumonia and a pleural effusion and continues to have a fever despite appropriate antibiotic therapy, what should you consider?
All antidepressants carry a FDA "black box" warning describing what?
That they increase the risk of suicidal thoughts and behaviors in children, adolescents, and young adults, especially in the first months of treatment.
Common causes of treatment failure in depression? (3)
2. inadequate duration of therapy
3. inadequate dosing
At least __% of MDD patients will experience a relapse at some point, and recurrent depression needs to be treated for longer periods of time.
Once in remission, patients treated for a first episode of major depression should be treated for at least how many months?
What are the maternal benefits of breast-feeding? (8)
1. more rapid return of uterine tone with reduced bleeding and quicker return to nonpregnant size
2. more rapid return to pre pregnancy body weight
3. long-term reduced incidence of ovarian and breast cancer
4. contraceptive effects
5. convenience of always having a readily available feeding supply for the baby
6. lower cost (no need to purchase formula)
7. mother-child bonding
What is the recommended oral contraception for breast-feeding women?
In breast-feeding women, the progestin-only "minipill" is recommended, as combined hormonal contraceptives can interfere with milk supply (reduce lactation)
In women who are not breast-feeding, menstruation usually restarts by the ____ postpartum month.
In breast-feeding women, ovulation and menstruation can be suppressed for much longer. Anovulation will persist for longer periods of time in women who exclusively breast-feed their babies.
Breast engorgement, signaling increased milk production, typically occurs ____ days after delivery and can cause breast pain, milk leakage, and fever.
How do you manage this in breast-feeding women? How do you manage in non-breastfeeding women?
In breast-feeding women, this is best managed by increasing the frequency of feedings.
In women who are not breast feeding, the use of ice packs, supportive bras, and SAIDs can reduce discomfort.
The uterus increases in size and weight during pregnancy. How do you assist with involution?
Oxytocin release assists with involution. Oxytocin increases during breast-feeding, so early breast-feeding is encouraged to assist involution. Supplemental oxytocin (Pitocin) given IV during or immediately after the 3rd stage of labor will also aid in increasing uterine tone.
How many weeks does postpartum involution of the uterus typically take? What should be assessed if the involution hasn't occurred by that time?
Assess for infection or retained placenta if involution doesn't occur by 6 weeks.
What is postpartum hemorrhage?
Loss of more than 500mL of blood after delivery.
This occurs in 4% of vaginal deliveries. Early postpartum hemorrhage occurs within 24 hours of delivery, most often immediately postpartum. Late postpartum hemorrhage occurs between 24 hours and 12 weeks after delivery and is usually the result of abnormal placental site involution.
What are the causes of postpartum hemorrhage? Remember the 4 T's
Tone (uterine atony) 70%
Trauma (cervical, vaginal, or perineal lacerations; uterine inversion) 20%
Tissue (retained placenta or membranes) 10%
Thrombin (coagulopathies) 1%
Failure of the uterus to contract adequately results in continued bleeding from uterine vasculature. Uterine atony causes approximately 70% of postpartum hemorrhage.
Risk factors for uterine atony? (4)
1. prolonged labor
2. prolonged use of oxytocin during labor
3. large baby
4. grand multipara (5+ previous children)
What is initial management of uterine atony?
Bimanual uterine compression and massage and administration of oxytocin IV or IM
Postpartum fever, uterine tenderness, foul-smelling lochia.
Dx and treatment?
Treat with broad-spectrum abx that cover vaginal and GI flora such as ampicillin and gentamicin. Following C-sections, abx must also cover for anaerobes and a combination of clindamycin and gentamicin may be used.
Breast engorgement, erythema, induration, and tenderness.
Dx and treatment?
Prompt treatment with continued breast-feeding or pumping from the affected breast and antibiotics that cover staph infections are helpful in preventing breast abscess development. Mastitis should not result in discontinuation of nursing.
True or False: breast-feeding mothers found to have mastitis should discontinue breast feeding.
Mastitis should not result in discontinuation of nursing.
Prompt treatment with continued breast-feeding or pumping from the affected breast and antibiotics that cover staph infections are helpful in preventing breast abscess development.
Are SSRIs safe for breast feeding?
SSRIs are first-line therapy for postpartum depression as they are considered safe in breast-feeding.
Neonatal benefits of breast feeding? (3)
1. ideal nutrition
2. increased resistance to infection
3. reduced risk of GI infections and atopic dermatitis
There are few contraindications to breast-feeding. What are they? (5)
1. HIV infection
2. Miliary tuberculosis
3. acute hepatitis B
4. herpetic breast lesions
Thromboembolic disease is higher during the postpartum period. When can non-breast-feeding women start combined OCPs?
3 weeks after delivery before starting combined OCPs as the risk of thromboembolic disease is higher after delivery. Breast-feeding women should avoid combined OCPs as they can decrease milk production. They should use progestin-only pills.
When can an IUD be placed after delivery?
6 weeks after. Earlier placement is associated with increased rate of expulsion of the device.
True or False: diaphragms and cervical caps can be used after delivery for contraception.
However, they should be refitted at the 6-week postpartum visit to ensure an appropriate fit.
Lactation-induced amenorrhea provides a high level of natural contraception postpartum. Women who breast-feed exclusively and who are amenorrmheic have a __% contraceptive protection for ___ months.
99%, 6 months
After 6 months, if menses start or if breast-feeding is reduced, the risk of pregnancy increases and alternate forms of contraception should be used.
29 y/o first-time mother.
6-week postpartum visit.
Tearful much of the time. Not sleeping well, has little energy, reduced appetite.
No SI, HI, and AVH. No negative thoughts towards the baby.
What to do?
a. reassurance that these feelings will pass within a week or so
b. referral to a psychiatrist for outpatient management
c. institution of SSRI therapy and close follow-up
d. admission to the hospital and urgent psychiatric consultation
c. institution of SSRI therapy and close follow-up
This patient has postpartum depression. The symptoms are identical those of major depressive episode. The maternity blues is a self-limited condition that starts in the first postpartum week and resolves in the second. This patient still has these feelings at 6 weeks and appropriate management includes use of an SSRI, counseling, and close follow-up.
What is the most common cause of hospitalization in patients older than 65 y/o?
One of the earliest CXR findings in CHF is?
What are later findings?
Cephalization of the pulmonary vasculature (upper lobe pulmonary vein dilation with lower lobe pulmonary vein constriction) which indicates increased preload.
Later findings include interstitial pulmonary edema seen as perihilar infiltrates, often in a butterfly pattern. Kerley lines, which are spindle-shaped linear opacities in the periphery of the lung bases. Pleural effusions can also be found.
What is the gold-standard diagnostic modality in the presence of CHF?
Wat is initiaal management for acute CHF?
Stabilization of the cardiopulmonary system. Supplemental oxygen, initially 100% via non-rebreather face mast, should be administered. If necessary, ventilation can be assisted with CPAP, BiPAP, or mechanical ventilation. Cardiac and continuous pulse oximetry monitors should be placed and IV access obtained.
90% of patients admitted to the hospital with decompensated heart failure are volume overloaded. What drug do you give to treat this?
Loop diuretic. Furosemide (Lasix) is generally the treatment of choice, both for its potent diuretic effect and for its rapid bronchial vasculature vasodilation.
When should nitroglycerin be used in acute CHF?
Nitrates, particularly nitroglycerin when given IV, reduce myocardial oxygen demand by reducing preload and afterload. Nitroglycerin also can rapidly reduce blood pressure and is the treatment of choice in a patient who has CHF and whose BP is elevated. It should be avoided or used with caution in hypotensive patients.
What is considered to be first-line therapy in patients with CHF and reduced LV function?
ACEIs or ARBs
These reduce preload, afterload, improve cardiac output without increasing heart rate, and inhibit tissue renin-angiotensin systems which improves myocardial relaxation and compliance.
These reduce mortality and hospitalization. Survival is increased by 20% in patients with systolic CHF and with LV systolic dysfunction after MI even without signs or symptoms of CHF.
True or False: ACEIs should be maintained at the highest tolerable dose for CHF patients.
Better outcomes are seen at higher doses, so patients should be maintained at the highest tolerable dose.
ACEIs and ARBs are contraindicated in? (5)
4. bilateral renal artery stenosis
5. renal insufficiency
True or False: the administration of B-blockers, especially in high doses, in the setting of acute CHF can worsen symptoms.
They should preferentially be started when patients have minimal evidence f fluid retention and few symptoms. Initial doses should be low and titrated up over several weeks. B-blockers reduce sympathetic tone and the cardiac muscle remodeling associated with CHF. In combination with ACEIs, B-blockers improve mortality.
Contraindications to B-blockers? (5)
1. symptomatic bradycardia
2. AV block in absence of a pacemaker
4. severe peripheral vascular disease
5. severe bronchospasm
What drug class, in general, increase mortality in systolic CHF and should be avoided?
Calcium channel blockers.
The exception to this is the dihydropyridine calcium channel blocker amlodipine (Norvasc). This does not increase or decrease mortality and can be very effective in treating hypotension.
Nondihydropyridine calcium blockers (diltiazem, verapamil) may be useful in heart failure caused by diastolic dysfunction, as they promote increased cardiac output by lowering heart rate, which allows for more ventricular filling time.
When to use biventricular pacemaker for CHF?
About 1/3 of patients with NYHA class 3 or 4 heart failure and reduced ejection fraction have ECG evidence of abnormal ventricular conduction, which causes ventricular dyssynchrony. This results in reductions in ventricular filling, left ventricular contractility, paradoxical septal wall motion, and worsening of mitral regurgitation. These patients can be helped with a biventricular pacemaker. This process, known as cardiac resynchronization therapy, has been shown to reduce mortality and hospitalization in patients with symptomatic CHF in spite of maximal medical therapy, as well as improve quality of life, exercise capacity, and LVEF.
57 y/o man
NYHA class 2 CHF. Dyspneic with exertion.
PE: BP 140/86, HR 86, RR 20. 2/6 pan systolic murmur at right sternal border.
No JVD. 1+ pretrial and pedal edema noted.
Currently on an ACEI and aspirin.
Which of the following has been shown to improve longevity in this situation?
d. Nondihydropyridine calcium channel blocker
These are recommended to reduce mortality in symptomatic patients with HF.
Digoxin is only recommended in patients who are already on maximal therapy.
Amiodarone is used for treatment of arrhythmias.
52 y/o man. Long hx of marginally controlled HTN.
Gradually increasing SOB and reduced exercise tolerance.
Pain in calves that causes him to stop walking after 1 block.
Medications: enalapril and metoprolol.
PE: BP 140/90, RR 22, HR 88, bibasilar rales, trace pitting edema.
Which of the following diagnostic tests is most appropriate for further evaluation?
a. cardiac MRI
b. 12-lead ECG
c. spiral CT of chest
d. 2-D echocardiography with doppler
e. PA and lateral chest radiographs
D. 2-D echocardiography with doppler
The most useful diagnostic tool for evaluating patients with HF is echocardiography to assess LVEF, LV size, etc. It should be performed during the initial evaluation. Chest radiography and 12-lead ECG should be performed in all patients presenting with HF but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure.
Absolute contraindications to combined hormonal contraception? (7)
1. previous thromboembolic event
2. cerebral vascular disease
3. coronary occlusion
4. impaired liver function
5. known or suspected breast cancer
6. smokers (>15 cigarettes/day) older than 35 years
7. congenital HLD
Relative contraindications to combined hormonal contraception?
1. severe vascular headache (classic migraine, cluster)
2. severe HTN
4. Gallbladder disease
5. obstructive jaundice in pregnancy
7. morbid obesity
When starting an OCP, when should a patient ideally take the first pill?
On the first day of menses
What should a patient do if they forget a dose of OCP?
If a pill is missed, it should be taken as soon as possible and the next dose should be taken as usual. If two or more pills are missed, the patient should be directed to the package insert for instructions and additional backup contraception should be used for at least 7 days following resumption.
The effectiveness of OCPs may be reduced by? (3)
3. antifungal meds
True or False: the patch's efficacy and side effects are comparable to that of combined OCPs
True or False: surgical sterilization (tubal ligation or vasectomy) is irreversible
True. They should be considered irreversible. Although there has been some success in reopening the fallopian tubes and the vas deferent, the success rate is low.
Well-woman exam at county jail.
Openly tells you that she was arrested for hx of prostitution.
On arrest, she was found to be HIV positive.
She is to be released next week and would like contraception.
Which of the following agents is most appropriate for this patient?
a. oral contraceptive agent
b. depot medroxyprogesterone
c. intrauterine contraceptive device
e. cervical cap
Protection from STDs for this patient, and prevention from transmitting HIV to her future patients is of utmost concern. Condoms are the most effective agents to prevent the transmission of STDs.
___% of women having unprotected intercourse will be pregnant in 1 year.
True or False: tubal ligation is considered safer than vasectomy
Vasectomy is considered safer than tubal ligation.
Combination oral contraceptives offer protection against?
1. ovarian cancer
2. endometrial cancer
3. iron-deficiency anemia
5. fibrocystic breast disease
General appearance is an important part of sports pre participation examinations. What are you noting with general appearance?
Marfan habits should be noted. These signs, which include arachnodactyly, an arm span greater than height, precuts excavated, tall-thin habits, high-arched palate, and ocular lens subluxations, should prompt further evaluation. Marfan patients can have aortic abnormalities that predispose to rupture during sports.
Where is the murmur best heard for hypertrophic cardiomyopathy?
Left sternal boarder. Louder with standing and louder with valsalva.
Who should be evaluated by a cardiologist prior to clearance for athletic participation? (4)
1. adolescent with stigmata of Marfan syndrome
2. murmur suggestive of hypertrophic cardiomyopathy
3. grade 3/6 or louder systolic murmur
4. any diastolic murmur
What is the study of choice for diagnosing hypertrophic cardiomyopathy?
A high school student is being seen for a sports pre-participation examination. Which of the following should prompt a referral to a cardiologist prior to clearance to participate in high school sports?
a. grade 2/6 systolic murmur in an asymptomatic 16 y/o girl
b. grade 1/6 diastolic murmur heard at the apex in a 16 y/o girl
c. grade 2/6 systolic murmur in a 17 y/o boy that is heard while lying down and gets softer when standing
d. an asymptomatic 16 y/o girl whose GF died of MI at age 72
b. grade 1/6 diastolic murmur heard at the apex in a 16 y/o girl
Any patient with a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of HOCM, or signs of marfan syndrome should be evaluated by a cardiologist prior to clearance to participate in athletics.
The or False: true indications to participation in all sports are rare. Almost everyone should be able to participate in some form of athletic activity.
The risk of cardiovascular disease double with each increase in blood pressure of __/__ above __/__.
20/10 above 115/75
True or False: elevated diastolic blood pressure is a greater risk for CVD complications than elevated systolic blood pressure.
Elevated systolic blood pressure is a great risk for CVD complications than elevated diastolic pressure.
Control of systolic blood pressure tends to be more difficult to achieve, and when it is achieved, the diastolic BP usually comes under control as well.
What is the goal blood pressure in adults up to 59? How about adults over age 60? For persons with diabetes or kidney disease?
140/90, 150/90, 140/90
How is diagnosis of HTN made?
2 properly taken BP measurements at 2 or more office visits. (With appropriate technique... patient sitting quietly in chair with supported back and feet on the floor for 5 minutes with appropriately sized cuff for the patient.)
What are secondary causes of HTN? (8)
1. coarctation of the aorta
2. renovascular and renal disease
3. cushing disease
What should be assessed when HTN is diagnosed?
3. cardiovascular risks
4. identification of possible 2ndary causes of HTN
5. determination of presence of end-organ damage
HTN physical exam assessment? (7)
1. Funduscopic examination for signs of retinopathy
2. Oropharynx and neck signs of OSA
3. Palpation of the thyroid
4. Auscultation for carotid, femoral, and renal bruits
5. Palpation of peripheral pulses
6. Abdominal palpation for signs of organomegaly or aortic aneurysm
7. Complete cardiopulmonary examination
What is the initial lab testing for a patient diagnosed with HTN?
Creatinine (with GFR)
Urinalysis to look for proteinuria or cellular components suggestive of renal disease.
ECG to evaluate for changes consistent with coronary artery disease and to screen for LVH.
(CMP, CBC, lipids, UA, ECG)
Nonpharmacologic management of HTN?
1. lose weight if overweight or obese
2. increase physical activity
3. reduce consumption of alcohol
4. smoking cessation
5. High K and high Ca diet, or Dash diet
For nonpharmacologic management of HTN, men should consume no more than __ alcoholic beverages a day and woman no more than __.
How affective is high K and high Ca diet and the DASH diet?
They reduce BP in an amount comparable to single-agent drug therapy. Calcium and potassium are associated with lower blood pressure.
What is the DASH diet?
Eating plan rich in fruits, vegetables, and low fat or nonfat dairy. It mostly includes whole grains, lean meats (fish and poultry, nuts, and beans. It is high fiber and low to moderate in fat.
Primary pharmacologic treatment of HTN in african-american patients? Non-african-american patients?
Thiazide diuretics or calcium channel blockers are first-line therapy in AA patients.
Diuretics, calcium channel blockers, ACE inhibitor, or ARB for non-AA patients.
When to start a 2nd anti-hypertensive drug?
The goal of therapy is to attain and maintain goal blood pressure (140/90 in those under 60 y/o and 150/90 in those 60 y/o or greater).
If goal BP is not reached with one agent after 1 month, then the physician can either increase the dose of the initial agent or add a second drug.
JNC8 recommendations for starting anti-HTN medications in AA patients?
Calcium channel blocker or thiazide diuretic
JNC8 recommendations for starting anti-HTN medications in non-AA patients younger than 60?
ACE-I, ARB, thiazide diuretics, calcium channel blockers
JNC8 recommendations for starting anti-HTN medications in non-AA patients 60 or older?
Calcium channel blocker, thiazide diuretic, ACEI, ARB
JNC8 recommendations for starting anti-HTN medications in patients with CKD?
JNC8 recommendations for starting anti-HTN medications in patients with hx of CAD?
B-blocker (especially if reduced systolic function), ACE, ARB
JNC8 recommendations for starting anti-HTN medications in patients with heart failure?
ACEI, ARB, B-blocker, Spironolactone
Normal BP vs preHTN vs HTN?
Normal blood pressure – Systolic <120 mmHg and diastolic <80 mmHg
Prehypertension – Systolic 120 to 139 mmHg or diastolic 80 to 89 mmHg
Stage 1 hypertension – Systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg
Stage 2 hypertension – Systolic ≥160 mmHg or diastolic ≥100 mmHg
62 y/o woman presents for routine physical.
Asymptomatic, no medications.
BP found to be 145/85 on two readings, BMI is 29. Review of chart shows BP was 143/84 on a visit 4 months ago for a UTI. Which of the following is the most accurate statement?
a. her BP is normal and she is at avg risk for developing HTN
b. she is at risk for needing pharmacologic treatment for HTN
c. she has HTN and should be started on a thiazide diuretic
d. she has HTN and should be started on multi drug therapy
b. she is at risk for needing pharmacologic treatment
This patient's BP falls within the definition of HTN but outside the need for immediate pharmacologic intervention, She would benefit from the institution of lifestyle modifications to reduce her risk of progression.
66 y/o caucasian woman with avg BP of 155/70 despite lifestyle modification efforts.
Other medical problems: osteopenia, kidney stones, and mild depression.
Her last lipid panel showed total cholesterol of 160, HDL of 40, and LDL of 90.
Which of the following would be the most appropriate treatment at this time?
In JNC 8 guidelines, Ca channel blockers, thiazides, ARBs, and ACEIs are first-line for non-black patients over age 60. In this case, B-blockers may worsen the depression. Thiazide diuretics may improve osteoporosis and reduce hypercalciuria which can reduce nephrolithiasis.
48 y/o T2DM with persistent BP readings of 150/95 for the past 6 months.
Current medications: glyburide and metformin.
Last A1C was 7.9. BMI of 24.
On PE, position sense is intact but peripheral neuropathy is detected in stocking and glove pattern.
Vibratory sensation is decreased bilaterally on both lower extremities.
Eye exam shows mild papilledema but no cotton wool spots.
When questioned, he says he still occasionally sneaks a cookie after dinner and drinks alcohol nightly.
Which is the most appropriate treatment for him?
a. DASH diet and recheck BP in 3 months.
b. thiazide diuretic alone
c. ACEI alone
d. combination of ACEI and thiazide diuretic
c. ACEI alone
Thie patients BP goal is less than 140/90. He is above this goal so an ACEI or ARB is first-line therapy for a diabetic regardless of BMI or A1C. The dose of medication can be increased if the BP is not controlled after 1 month; or another agent can be added.
Most common cause of HTN in children less than 10 y/o?
Renal parenchymal disease.
Perform a UA, urine culture, renal US
What is the most common cause of GI obstruction in infants?
Hypertrophic pyloric stenosis
What does currant jelly stool suggest?
Ongoing bowel ischemia
When does hypertrophic pyloric stenosis typically present?
Age 3-6 weeks
Hungry baby, projectile vomiting, 4 weeks old, male
Hypertrophic pyloric stenosis
How do you treat hypertrophic pyloric stenosis?
True or False: hypertrophic pyloric stenosis can usually be suspected if a 5 week old baby comes in looking severely malnourished
Due to the early age and dramatic nature of the projectile vomiting, parents usually seek help before the infant becomes severely ill from not eating.
What is the diagnostic test of choice if malrotation is suspected?
Upper GI series
An upper gastrointestinal series (UGI) is a radiographic (X-ray) examination of the upper gastrointestinal (GI) tract. The esophagus, stomach, and duodenum (first part of the small intestine) are made visible on X-ray film by a liquid suspension. This liquid suspension may be barium or a water-soluble contrast.
What are the diagnostic findings of malrotation on an upper GI series?
Misplaced duodenum, duodenal obstruction with beak-like appearance of the contrast medium.
How do you treat GI malrotation?
Foreign bodies ingested by patients typically only need intervention about 10% of the time. 90% of patients will pass the foreign body spontaneously. When does immediate intervention need to be done?
1. "button" batteries
2. foreign bodies that are lodged in the esophagus
3. sharp or elongated objects already passed through the stomach and duodenum should be tracked daily with X-rays to follow progress of the object. Those that do not advance within 3 days need surgery for removal.
A ____ is recommended in cases when GI obstruction has set in and the patient is ill.
6 y/o boy left alone for 10 hours, now has hematemesis and pneumomediastinum on chest x-ray
The presence of blood in the vomitus and a pneumomediastinum points to an esophageal perforation, most likely from a foreign body in the esophagus.
3 week old male infant with 2 days of projectile, non-bilious vomiting, and constant feeding.
The young age, presence of projectile non bilious vomiting after feedings are the keys to this diagnosis. The diagnosis of pyloric stenosis is much more common in males than females.
7 y/o boy with 3 episodes of severe abdominal pain and vomiting in the last month, previously diagnosed with failure to thrive.
This is the presentation of a malrotation that did not cause enough symptoms at a younger age to lead to a diagnosis.
8 month old female infant with bilious vomiting, constant abdominal pain for 12 hours, and upper GI study showing beak-life appearance of contrast
An infant with bilious vomiting and abdominal pain has a volvulus until proven otherwise. The upper GI study is diagnostic of this condition.
11 month old male.
Intermittent bouts of crying and non-bilious vomiting.
History of Meckel's diverticulum.
Small, elongated mass is felt on the right side of his abdomen
The intermittent nature of the symptoms and the palpable mass are highly suggestive of intussusception.
4 y/o girl with profuse vomiting, sweating, lacrimation, and diarrhea, who seizes in the ED.
These symptoms are characteristic of cholinergic syndrome, possibly caused by insecticide or nicotine poisoning.
An infant with bilious vomiting and abdominal pain has a ___ until proven otherwise.
When evaluating for dementia, you should also screen for...
1) Depression. Depression in the elderly can present with symptoms of memory disturbance known as pseudodementia.
3) B12 deficiency
4) neurosyphilis if there are high-risks factors or history of the disease
5) neuroimaging with noncontrast CT or MRI
True or false: for alzheimer disease medications, treatment may delay the progression of the disease but may not reverse any decline that has already occurred
3 medications for mild-moderate Alzheimer dementia?
1 medication for moderate-severe Alzheimer dementia?
Mild-moderate: cholinesterase inhibitors: donepezil, galantamine, rivastigmine
Moderate-severe: NMDA antagonist: Memantine
True or False: you should avoid using memantine (NMDA antagonist) with the cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
You can use them in combination
Dementia that causes personality to change significantly, becoming antisocial or disinhibited from social norms with poor impulse control. Patients can develop apathy, emotional blunting, and perseveration behaviors including echolalia, and stereotypical behaviors such as toe tapping and repetitive motor activity.
Frontotemporal lobe dementia
Dementia, gait disturbance, urinary incontinence
Normal pressure hydrocephalus
True or false: AIDS can cause dementia
What metabolic abnormalities can cause dementia?
hyponatremia or abnormal calcium levels
Many medications can cause memory disturbances. Name 4 classes.
1. anticholinergic medications
2. sedatives (benzodiazepines)
3. sleeping pills
4. narcotic pain medications
What is metabolic syndrome?
Metabolic syndrome is diagnosed when 3 or more of the following are met:
-waist circumference > 102cm (M), >88 cm (F)
-hypertriglyceridemia (>150mg/dL or on medications)
-low HDL cholesterol (<40 if male or <50 if female)
-HTN (BP >130 systolic or >85 diastolic, or on meds)
-Fasting plasma glucose >100 or on meds for T2DM
Adult BMI categories?
Normal 18.5 - 24.9
Overweight 25.0 - 29.9
Extreme obesity (aka morbid) >40
Super obesity >50
Dietary intervention is the cornerstone of weight-loss therapy. Treatment with a calorie deficit of _____ compared to the patient's habitual diet is recommended.
This results in a weight loss of 1-2 lbs a week
Loss of more than _% of initial body weight can improve CVD risk.
5-15% is a great goal
True or False: Physical activity alone is not an effective method for achieving weight loss
It is very important for long-term weight management and CVD health benefits
It can improve insulin sensitivity and glycemic control, decrease abdominal fat, and reduce cardiovascular risk
What are some behavioral modifications to help people lose weight? (7)
1. avoiding triggers
2. maintaining diet diaries
3. using portion-controlled plates
4. slowing rate of eating to enhance satiation
5. avoidance of high-risk situations
6. increasing physical activity
7. breaking repetitive behaviors such as watching TV while eating
Pharmacologic therapy for weight loss can be offered for those with BMI greater than ____ or BMI of ___ to ____ with comorbid conditions
30, 27 to 30 with comorbid conditions
First line medications for weight loss include? (3)
Orlistat (selective inhibitor of pancreatic lipase resulting in reduced intestinal digestion of fat and increased fecal fat excretion)
Lorcaserin (serotonin receptor agonist)
Phentermine-topiramate (increased norepinephrine release)
With exception of ____, which inhibits the absorption of dietary fat, all medications approved for obesity act as anorexiants. What are anorexiants?
Orlistat (selective inhibitor of pancreatic lipase resulting in reduced intestinal digestion of fat and increased fecal fat excretion).
All others are anorexiants. Anorexiants increase satiation by affecting the monoamine system in the hypothalamus.
True or False: weight loss medications are generally recommended for long-term use for best efficacy.
They are generally only recommended for short-term use. Their use should be tapered off after prolonged use or if there is lack of efficacy.
Orlistat is the only one indicated for the long-term treatment of obesity. The pure stimulant medications should be for short-term use only.
____ can help with weight loss in patients with PCOS.
Patients with BMI greater than ___ who have failed diet and exercise (with or w/o drug therapy) or greater than ___ with serious comorbid conditions are potential candidates for surgical treatment of obesity.
40, or 35 with serious comorbid conditions
What are the 2 types of bariatric surgery?
Restrictive (lap banding) and restrictive-malabsorptive (roux-en-y)
Lap banding is a silicone gastric band that is laparoscopically placed around the upper stomach just distal to the gastroesophageal junction. The band has a balloon that is connected to a subcutaneously implanted port, which can be inflated or deflated to reduce the circumference of the band. Complications of the banding procedure are less common and less severe than gastric bypass, but the long-term weight loss may also be less.
Roux-en-y gastric bypass is the construction of a small gastric pouch that empties into a segment of the jejunum. The small pouch and small outlet limits caloric intake and causes malabsorption.
Which weight loss medication is indicated for long-term treatment of obesity?
All others are pure stimulant medications and should only be used short-term.
Non-pharmacologic obesity treatment should include what 3 components?
1. dietary restriction
2. increased activity
3. behavioral modifications
Sudden-onset maximum severity "worst headache"
New headache after age 50, especially if jaw pain on chewing (jaw claudication)
Headache with signs of illness (fever, stiff neck, rash)
New-onset headache in patient with risk factors of HIV or cancer
Meningitis, brain abscess, metastasis
What are migraine headaches?
Vascular headaches typically throbbing unilateral in character, may be present w/ or w/o aura. High female predominance
What are tension headaches?
The most common primary headache, typically presenting with pericardial muscle tenderness and a description of bilateral band-like distribution of the pain.
What are cluster headaches?
Unilateral headaches that have high male predominance, can be located in the orbital, supraorbital, or temporal region. Generally described as deep, excruciating pain lasting from 15 minutes to 3 hours. Headaches are episodic, but a small subset may have chronic headaches.
Treatment for tension HA?
Aspirin, acetaminophen, and NSAIDS.
Combination of analgesics containing caffeine are second-line options.
Minimize risk of medication-overuse headaches by limiting drugs to treat acute headaches to 2-3 days per week. Avoid opioids and sedative hypnotics.
Prophylaxis for tension HAs? (5)
Ampitriptyline, mirtazapine, venlafaxine, calcium channel blockers, b-blockers
Treatment for cluster HA?
1st line: 100% oxygen at 6L/min and triptans
Formerly known as "rebound" headache may occur following frequent use of any analgesic or headache medication. This includes both prescription and nonprescription medications. Caffeine use is another culprit.
When patients have migraines with nausea, they may benefit from?
Nonoral medication like triptan delivered by injection or nasal spray.
52 y/o woman.
Presents to office with acute headache that began 2 hours ago.
Sudden onset without trauma and is the worst headache she has ever had.
She has had migraines since she was an early adult.
Pain described as "stabbing" and more severe on the left side.
BP 145/95. No focal neurologic abnormalities. AOx4.
a. prescribe a triptan medication
b. schedule a non-contrast CT for tomorrow morning
c. call 911 and transfer the patient to the nearest ER
d. prescribe an antihypertensive medication and f/u in 2 weeks
c. call 911 and transfer patient to the nearest ER
Acute onset most severe HA in a patient's life is concerning for subarachnoid hemorrhage. This is a medical emergency and the patient should be transported by EMS to the nearest emergency facility for stabilization and management.
LDL cholesterol levels?
100-130: near optimal
130-160: borderline high
190 or greater: very high
Total cholesterol levels?
200-240: borderline high
240 or greater: high
HDL cholesterol levels?
60 or greater: high
Statin therapy is recommended in all patients with? (4)
1. known cardiovascular disease
2. LDL greater than 190
3. patients 40-75 y/o with DM and LDL greater than 70.
4. patients 40-75 y/o with 10-year CVD risk greater than 7.5% and LDL greater than 70.
Atorvastatin dose for patient with existing cardiovascular disease?
Atorvastatin dose for patient with 10-y cardiovascular disease risk >10%?
Atorvastatin dose for patient with 10-y cardiovascular disease risk <10%?
No statin. Optimize other modifiable cardiovascular risk factors.
Some may consider low-dose statin for greater than 7.5%
Secondary causes of dyslipidemia? (5)
3. obstructive liver disease
4. chronic renal failure
5. medications (progestins, anabolic steroids, corticosteroids)
First-line therapy for reducing LDL? Second-line therapy for patients who don't tolerate statins?
Contraindications for statins?
1. Active or chronic liver disease
2. relative contraindication with cytochrome P-450 inhibitors
62 y/o smoker with known hx of coronary heart disease (CHD).
LDL 105. HDL 28. Total cholesterol 170.
According to NICE guidelines, what medication to be initiated at this time?
Patient has known CHD
55 y/o woman. Discharged from hospital 1 week ago following MI.
Quit smoking since then and vows to stay off cigarettes forever.
Total cholesterol 240, HDL 50, LDL 150, Triglycerides 150.
Which to do now?
a. therapeutic lifestyle changes alone
b. therapeutic lifestyle changes plus statin
c. statin alone
d. therapeutic lifestyle changes, statin, and nicotinic acid
b. therapeutic lifestyle changes plus statin
Patient has known CHD documented by recent MI.
All guidelines recommend therapeutic lifestyle changes. Patients with known CHD should get high-dose statin therapy.
48 y/o man. Asymptomatic. No PMH. Found to have elevated cholesterol.
What's part of routine evaluation of this problem?
b. stress test
Hypothyroidism is a potential cause of secondary dyslipidemia. TSH is reasonable to test in this setting. There is no indication to screen for CHD with an ECG or stress test as the patient is asymptomatic. Other tests to perform include fasting blood glucose, liver enzymes, and measurement of renal function.
When intimate partner violence or home abuse is identified, what's the initial priority of assessment?
Assess safety of the home situation. Direct questioning regarding levels of violence, the presence of weapons in the home, as well as the need for a plan for safety for the victim and others at home (children, elders) is critical.
Resources and support, such as shelters, community-based treatment, and advocacy programs should be provided.
It may be helpful to allow the patient to contact a shelter, law enforcement, family members, or friends, while still in the doctor's office.
True or False: you must report intimate partner violence at all times.
The laws regarding clinician reporting of partner violence varies from state to state. Many states do not require contacting legal authorities if the victim of acute is a competent adult.
Delay in seeking medical care for an injury should make you consider?
Which of the following injuries is most likely to be caused by abuse of a toddler?
a. 3-4 bruises on the shins and knees
b. spiral fracture of the tibia
c. displaced posterior rib fracture
d. forehead laceration
c. displaced posterior rib fracture.
Most often the result of grabbing and squeezing the chest violently. It is very suspicious for abuse.
What is ombudsmen?
An official appointed to investigate individuals' complaints against maladministration.
True or False: Suspected child and elder abuse must be reported.
Reporting of abuse of competent adults is not mandated by law in most states but suspected child and elder abuse is mandated.
What is the most common nontraumatic hip pathology in adolescents?
Slipped capital femoral epiphysis.
Hip pathology will frequently present with pain in the groin, thigh, or even knee.
What classic age, gender, and body habits is most classic for slipped capital femoral epiphysis?
Overweight adolescent males
Kid with painless limp?
Congenital dysplasia, dislocation, length discrepancy, bowing, etc.
Radiographic findings with collapse, flattening, and widening of the femoral head
Avascular necrosis of the femoral head
How do you treat avascular necrosis of the femoral head?
Treatment is usually conservative, with protection of the joint and efforts to maintain range of motion. Children who develop severe necrosis or who develop the disease at older ages may have a worse outcome and a higher risk of developing degenerative arthritis.
Overweight adolescent boy presents with pain in the hip, thigh, and knee. Lips when he walks.
Slipped capital femoral epiphysis
Treatment for slipped capital femoral epiphysis?
Surgical pinning of the femoral head.
Patients must be closely followed. Approximately 20-50% of them will develop avascular necrosis and 33% will develop SCFE in the contralateral hip.
Night-time extremity pain, bilateral, not present during the day
This is a diagnosis of exclusion. You must rule out other diagnoses.
What is transient synovitis?
It is a self-limited inflammatory response that is a common cause of hip pain in children. It typically occurs in children ages 3-10 and is more common in boys than girls. It often follows a viral infection.
A CBC and ESR should be drawn. With a normal CBC and ESR, and if follow-up can be assured, this child could be treated expectantly, given an oral nonsteroidal anti-inflammatory drug (NSAID) with the expectation of a recovery in a few days.
6 y/o boy.
Painful hip. Limping and not wanting to walk for the past 2 days.
Feels a little better with ibuprofen.
No fever and no other symptoms, although he had "the flu" last week.
Vital signs normal. Right hip has pain with internal rotation and the patient walks with pronounced limp.
Which of the following statements is most appropriate?
a. he can be sent home with a prescription for ibuprofen
b. he should have a CBC and ESR
c. he should have an aspiration of his hip in the office
d. if his X-ray is normal, no further workup is needed
b. CBC and ESR
The case presented is suspicious for transient synovitis following a viral illness. A CBC and ESR should be drawn. With a normal CBC and ESR, and if follow-up can be assured, this child could be treated expectantly, given an oral nonsteroidal anti-inflammatory drug (NSAID) with the expectation of a recovery in a few days.
True or False: Spiral fracture of the tibia in a child or infant is suspicious for abuse.
Spiral fracture of the tibia is common resulting from twisting on a planted foot. This is classic for a toddler's fracture.
Spiral fractures of other long bones (femur, humerus) are more suspicious for abuse.
6 y/o boy presents to the office
2 month hx of slight limp.
No PMH and no meds.
Normal vital signs. Antalgic gait and decreased ROM in left hip.
Mild pain on palpation of the anterior capsule on the left side.
X-ray shows fragmentation of the femoral head.
Which of the following is the most likely diagnosis?
A. Toxic synovitis of hip
B. Avascular necrosis of hip (Legg-Calvé-Perthes)
C. Slipped capital femoral epiphysis
D. Femoral shaft fracture
Avascular necrosis of hip (Legg-Calvé-Perthes)
This child is in the correct gender and age group with signs, symptoms, and radiologic findings associated with Legg-Calvé-Perthes disease. It is often a self-healing disorder. Treatment is focused on limiting pain and avoiding functional loss. Depending on severity and age, treatment may include watchful waiting, physical therapy, casting, and surgery.
Slipped capital femoral epiphysis often effects both sides. What should be done?
Because of the high risk of bilateral disease, follow-up in SCFE cases should include examination and x-rays of the unaffected hip until the growth plate closes.
What is a drug fever?
Fever that coincides with the administration of a particular drug and cannot otherwise be explained by clinical and laboratory findings. Resolution of the fever occurs with discontinuation of the suspected drug. Drugs that are usually implicated are β-lactams, sulfa derivatives, anticonvulsants, allopurinol, heparin, and amphotericin B.
What drugs can cause drug fever? (6)
2) sulfa derivatives
6) amphotericin B.
True or False: Fever is a common postoperative complication.
As an integral part of informed consent prior to surgery, patients need to be made aware by the physician of the possibility of experiencing postoperative febrile episodes.
50% of patients who undergo major surgeries get postoperative febrile episodes.
Most postoperative fevers are not infectious but require a good thorough history and physical to rule infectious causes out.
What are the 5 most common causes of postoperative fever in order of frequency?
5 W's of postoperative fever
1) Wind (pneumonia)
2) Water (UTI)
3) Wound (SSI, surgical site infection)
4) Walking (DVT)
5) Wonder drugs (drug fever)
Within the first 48 to 72 postoperative hours, _____ causes 90% of pulmonary complications of surgery, particularly following abdominal and thoracoabdominal procedures.
Atelectasis (partial collapse of peripheral alveoli)
Instructing patients on deep inspiration and coughing, the use of incentive spirometry, and the provision of adequate pain control can facilitate the opening of alveoli. Without resolution of atelectasis, pneumonia may ensue.
Drug fever typically resolves within ___ hours after the discontinuation of the offending agent.
72 to 96 (3-4 days)
True or False: half of the time patients with DVT are asymptomatic
Fever caused by DVT usually occurs how many weeks postoperatively?
A 50-year-old woman with diabetes was recuperating from left inguinal hernia repair. Her glycosylated hemoglobin (HbA1c) prior to surgery was 10%. During postoperative follow-up a week after surgery, the surgical site was markedly erythematous, warm, and tender with pus.
Which of the following is the next step in treatment?
A. Apply topical antibiotic to the surgical site.
B. Warm compresses alone will relieve the inflammation.
C. Open the surgical site and drain the infected material.
D. Send the patient home with prescription for oral antibiotics for 7 days.
C. Incision and drainage are the most important therapy for SSI. Antibiotics are used solely in cases of significant systemic involvement.
True or False: Postoperative fevers in the first few days are common and usually resolve on their own.
____ is a very common cause of airway obstruction in children 6 months to 6 years and is a leading cause of hospitalization for children younger than 4 years.
Viral infection that causes inflammation of the subglottic region of the larynx. Characteristic barking couch, hoarseness, stridor, and differing degrees of respiratory distress more severe at night.
Croup typically occurs during which seasons?
Fall and winter
How do you diagnose croup?
Typically with clinical presentation. Imaging can confirm diagnosis with frontal neck x-rays showing the "steeple sign" which is indicative of subglottic narrowing of the tracheal lumen. When the diagnosis is uncertain, CT neck can offer a more sensitive evaluation.
How do you treat croup?
Assess airway obstruction and give oxygen.
Glucocorticoids and nebulizer epinephrine.
Dexamethasone 0.60 mg/kg by mouth or parenterally as a single dose is beneficial for its long half-life and anti-inflammatory action. Nebulizer racemic (mixture of d-isomers and l-isomers) or L-epinephrine is typically reserved for patients with moderate-to-severe distress. It works with adrenergic stimulation which causes constriction of the precapillary arterioles, thereby leading to fluid resorption from the interstitium and improvement in laryngeal edema. Its B2 adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilator.
What bug causes epiglottitis?
Usually Haemophilus influenzae. However, with the H influenzae type b (HiB) vaccine, Strep pyogenes is now the leading bug for epiglottitis.
4 y/o presents to children's ED.
Drooling, fever, sore throat, dysphagia, "toxic" looking
How do you treat epiglottitis?
It's a medical emergency. Visualization to confirm the presence of severely erythematous epiglottis is preferably done in the OR with an experienced surgeon or anesthesiologist. Endotracheal intubation should be done to reduce mortality rate.
Patient should be kept calm to prevent sudden airway obstruction. Supplemental oxygen administration should be provided. Clinicians should avoid oral and throat examinations which can provoke anxiety and acute obstruction.
Antibiotics (2nd or 3rd generation cephalosporins or ampicillin sulbactam), airway management, usually in setting of ICU with team ready to respond for intubation or tracheostomy.
Radiographic finding characteristic of epiglottitis?
"Thumb sign" or protrusion of enlarged epiglottis from anterior wall of the hypopharynx seen on lateral neck X-ray.
What is bacterial tracheitis?
Uncommon life-threatening infection most often seen in 5-8 y/o. It often follows a URI that suddenly worsens with high fever, stridor, and cough. Treat bacterial tracheitis like epiglottitis.
Abx, airway management, in ICU with team ready to respond for intubation or tracheostomy.
Most common cause of acute wheezing in children less than 2 years old?
Young kids are most affected owing to smaller, more easily obstructed airways and decreased ability to clear secretions. RSV accounts for 50-80% of cases with the rest being caused by parainfluenza, adenovirus, influenza, mycoplasma pneumoniae, chlamydia pneumoniae, and metapneumovirus.
Bacterial tracheitis is typically caused by what bug?
12 y/o girl presents to ED.
Severe sore throat, muffled voice, drooling, fatigue.
Sick for past 3 days unable to eat bc of painful swallowing.
Parents deny history of recurrent pharyngitis.
PE shows abscess at upper pole of the right tonsil. Examination of neck reveals large tender lymph nodes.
What is the most appropriate management?
c. nebulizer racemic epinephrine
d. incision and drainage of the abscess
e. tonsillectomy and adenoidectomy
d. incision and drainage of abscess
A patient initially presents with wheezing. The wheezing disappears. What's up?
Sufficient airflow is required for the airway to produced a wheezing sound. Disappearance of wheezing in a patient who initially presents with wheezing is an ominous sign that suggests complete blockage of airway or imminent respiratory failure.
True or False: always perform blind finger sweep of a foreign object aspirated by an infant or child as 90% of the time you can catch the foreign object.
Never do that plz.
28 y/o woman.
Several year hx of crampy abdominal pain, alternating between diarrhea and constipation.
Patient denies fevers, weight loss, heart burn, and bloody stools. PMH and FMH are unremarkable.
PE is normal.
Irritable bowel syndrome
Rome III diagnostic criteria for IBS? (3)
Recurrent abdominal pain or discomfort at least 3 d/mo for the past 3 mo with 2 or more of the following:
improvement with defecation
onset associated with a change in the frequency of stool
onset associated with a change in form (appearance) of stool.
Criterion fulfilled for the past 3 months. Onset at least 6 months ago.
What are red flags for the GI system? (7)
3. involuntary weight loss greater than 10 lb
6. family hx of ovarian or colon cancer
7. family hx of celiac or IBD
A patient with IBS symptoms and the absence of red flags should get what minimal workup?
CBC to check for blood loss.
Age-appropriate colon cancer screening.
Celiac disease testing labs?
IgA tissue transglutaminase antibody
65 y/o man. Lifelong hx of IBS.
No red-flags but has worsening diarrhea and constipation from IBS.
No colonoscopy before.
Stool is negative for blood and leukocytes.
b. polyethylene glycol trial
c. psychiatric evaluation
e. increase fiber intake
Age-appropriate cancer screening of the colon is indicated for IBS patients due to high pretest probability.
What is first-line treatment for mild-to-moderate abdominal pain from IBS?
Dicyclomine, an antispasmodic anticholinergic medication, can be used on a PRN basis for mild-to-moderate abdominal IBS pain. For more severe pain, low-dose TCAs, like amitriptyline, are beneficial.
True or False: psychiatric disorders can cause IBS
False. Psychiatric disorders can worsen IBS symptoms but have not been shown to cause IBS directly. Successfully treating an underlying psychiatric disorder may improve IBS but will not likely resolve all symptoms of IBS.
What is first-line therapy for constipation-predominant IBS?
Fiber supplementation (e.g. psyllium)
Genetic susceptibility accounts for between ___ and ___ % of a person's vulnerability to addiction
Physical examination for drug use:
Stimulant or hallucinogen use. Withdrawal from opioids.
Physical examination for drug use:
Treatment of choice for acute opioid intoxication?
FDA approved pharmacologic treatments for alcohol dependence? (3)
Naltrexone, acamprosate, disulfiram
Most common valvular hear defect in USA?
Mitral valve prolapse.
It's typically asymptomatic but can present with palpitations, fatigue, or dyspnea.
What to do when mitral valve prolapse is identified?
Get echocardiogram to establish a baseline. 2% of patients with MVP will have complications resulting in progression to mitral regurgitation with subsequent left-sided two-chamber enlargement.
Enlargement of which chamber can cause atrial fibrillation?
Left atrium. It can happen 2/2 to mitral regurgitation.
Long QTc is ___ in men and ____ in women
QT interval greater than ____ puts the patient at risk for dangerous dysrhythmias
True or False: 12 lead ECG is appropriate in all patients with palpitations, even if they are symptom free during the physician encounter.
The presence of LVH, prolonged QT, atrial enlargement, AV block, old MI, and delta waves can be detected.
First-line treatment for primary supraventricular rhythm disturbances?
B-blockers or calcium channel blockers (the rate control drugs)
Symptomatic paroxysmal supraventricular tachycardia can be self-managed by patients with vagal stimulation techniques like? (3)
1. carotid sinus massage
2. valsalva maneuver
3. cold applications to the face
How do you break an episode of supraventricular tachycardia?
Chronic atrial fibrillation should be treated with?
B-blockers or calcium channel blockers (rate control drugs)
Which class of rate/rhythm control drugs should not be used in the presence of structural cardiac disease or cardiac hypertrophy?
Class 1C such as flecainide and propafenone
What should be done before cardioversion?
Transesophageal echocardiogram (TEE) should be done prior to cardioversion in order to rule out the presence of a thrombus that might dislodge with the cardioversion.
Patient in ventricular fibrillation. What to do?
V fib is not compatible with life and needs to be treated immediately.
What should be given to a patient with stable ventricular tachycardia?
What should be given to patients who have ventricular tachycardia or fibrillation who are converted back into a sinus rhythm through cardioversion?
When is automatic implantable cardioverter-defibrillator indicated?
Conditions that commonly result in ventricular fibrillation or tachycardia:
1. advanced dilated cardiomyopathy
2. long QT syndrome
3. hypertrophic cardiomyopathy
4. Brugada syndrome
What is Brugada syndrome?
Brugada syndrome is a genetically inherited condition that is characterised by abnormal electrocardiogram (ECG) findings and an increased risk of sudden cardiac death. Average age of death is 41. Usually happens in sleep. Can do genetic testing for diagnosis. Family hx important.
What is the most common cause of palpitations?
Primary rhythm disturbances. They make up about 40% of cases.
While psychiatric (anxiety, panic), medication, metabolic, and structural heart disease can cause palpitations, you should never disregard the possibility of primary rhythm disturbances.
What are primary rhythm disturbances? (cardiac)
Premature atrial contractions
Premature ventricular contractions
Sick sinus syndrome
A 42-year-old asymptomatic woman is noted to have an abnormal finding on ECG. Which of the following is an indication for referral to a cardiologist or cardiac electrophysiologist?
A. PVCs on a resting ECG that resolve with exercise
B. Delta waves on an ECG
C. Isolated unifocal PVCs found on ECG
D. Sinus arrhythmia
B. delta waves on ECG
The presence of delta waves indicates WPW syndrome and the presence of an accessory tract that can be ablated by an electrophysiologist.
True or False: for bee stings, you should leave the stinger in for as long as possible.
Rapidly removing the stinger is preferable as leaving it in results in continued injection of the bee venom. Try scraping it off with a credit card rather than grasping it as grasping it can cause compression of the stinger causing increased venom release.
Treatment of anaphylaxis?
ABCs (airway, breathing, circulation)
Intubation if necessary
Fluid resuscitation ASAP.
Subcutaneous or intramuscular epinephrine ASAP and repeated 5-10 minutes if needed.
Antihistamines, steroids, and bronchodilators may be required as well.
Observation in hospital for 12-24 hours as symptoms can recur.
What should persons with known anaphylactic reactions should be prescribed?
Epinephrine injector kits to carry with them for immediate access at all times
True or False: spider bites are dangerous
Most are not significantly dangerous. Area should be cleansed with soap and water and a cool compress should be applied to the area. NSAIDs and acetaminophen are recommended.
Watch out for cellulitis from inoculated bacteria.
Treatment of animal bites?
Local cleaning of wound(s) with soap and water, irrigation with sterile saline solution, and debridement of devitalized tissue should take place as soon as possible.
For minor and superficial to shallow wounds, these treatments are often all that's required. Larger and deeper wounds are more likely to become infected.
Bites from ___ and ___ have high risk of infection and should always be treated empirically with antibiotics, whereas only 20% of ____ bites become infected.
Cats and humans - high risk
Dog - 20% become infected
All patients who sustain cat bites should be treated with what abx and for how long?
10 to 14 days of oral amoxicillin-clavulanate (augmentin)
Antibiotic treatment of dog and human bites?
amoxicillin-clavulanate (augmentin) for 5-7 days for moderate-to-severe wounds. 10-14 if cellulitis persists.
Human "bite" wounds are not always the result of a bite. Why?
A punch to the mouth can cause a serious inoculation and infection to the knuckles of the puncher. Treat these wounds the same.
Single most important risk factor for stroke?
Initial imaging test of choice in evaluation of acute stroke?
Non-contrast CT head
What is a transient ischemic attack?
Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITHOUT acute infarction.
True or False: Most transient ischemic attacks (TIAs) last less than 1 hour.
Patients with TIAs are at increased risk of a subsequent ____
True or False: patients with HIV/AIDS should be referred to a physician with expertise in treating these conditions, including an infectious disease specialist.
The complexity of the treatment regimens and frequently changing treatment guidelines warrants referral.
Prophylaxis against P jiroveci pneumonia should be instituted when CD4 count falls below? What abx?
Below 200. Use TMP-SMX (BACTRIM)
Live virus vaccines are contraindicated in HIV patients if their CD4 count is below ___.