Family Med - FmCASES Flashcards
(196 cards)
0
Q
What are some conditions that predispose to secondary obesity?
What are their symptoms?
A
Cushing’s (easy bruising, hyperpigmentation, muscle weakness)
Hypothyroidism (cold intolerance, constipation, fatigue)
Hypogonadism (decreased libido)
1
Q
BMI Underweight: \_\_\_\_\_\_\_ Desirable: \_\_\_\_\_\_\_\_\_\_ Overweight: \_\_\_\_\_\_\_\_ Class I Obese: \_\_\_\_\_\_ Class II Obese: \_\_\_\_\_\_ Class III Obese: \_\_\_\_\_\_\_
A
Repeat
2
Q
In a standard lipid profile, LDL is _____ (calculated vs measured) while the other values ____, _______, and ______ are measured directly.
A
LDL is calculated.
Total cholesterol, HDL, and Triglycerides are directly measured.
3
Q
Lipid screening
When is screening recommended by the USPSTF:
A
Men >35 yrs. Women >45 yrs if they are at increased risk of CHD.
Men and Women > 20 yrs of age if they are at incr risk of CHD.
USPSTF has no recommendation for men 20-35 and women 20-45 with no identified CHD risk factors.
4
Q
What are the 5A’s of behavioral counseling?
A
Assess - pt’s dietary practices and related risk factors
Advise - to change _____ practices
Agree - w/pt on goals
Assist - pt in changing diet or addressing motivational barriers
Arrange - follow up, support, referral
5
Q
The ATP III Guidelines are with regards to _____ levels.
They are:
A
LDL, Total Cholesterol, and HDL levels.
LDL 160-189 High. >190 very high.
Total Cholesterol =240 high.
HDL >= 60 is high (desirable). <40 is low.
6
Q
What agent is first line to increase HDL?
A
Nicotinic acid
7
Q
What agents are first line for pts with elevated LDL?
A
Statins
8
Q
Fibric acid derivatives are first line to reduce just triglycerides.
A
Repeat
9
Q
After starting a statin or altering other lipid lowering therapy, check lipid levels at _____ (time interval) and then every ______ subsequently.
A
6 weeks; 6-12 months
10
Q
What caloric deficit is needed to lose 1lb of body weight?
A
3500 calories
11
Q
Saturated fat consumption should be less than _____g per day in a weight loss diet. Total fat < _____g per day.
A
Saturated fat: 15 grams/day.
Total fat: 70g/day (500-600 calories)
12
Q
For a diabetic - annual check:
A
HbA1c Spot urine albumin/Cr serum Cr, calculated GFR Serum B12 serum TSH Fasting Lipid Panel - HDL, LDL, Triglycerides
13
Q
JNC 8 HTN guidelines: Anti-hypertensives
Target BP if > ___yrs: ____/____
Target BP if <____yrs: ____/____
Target BP at any age with Diabetes or CKD: ____/____
A
Target BP 60 years. Target BP18yrs w/CKD: initial or add-on should be ACE-I or ARB
In pts >18yrs w/Diabetes: Thiazide diuretic, CCB or ACE or ARB (except if black
14
Q
If goal BP is not reached in ____ of treatment, add one of the drugs in one of the classes mentioned (thiazide diuretic, CCB, ACE-I and ARB.
A
1 month
15
Q
Moderate intensity statin therapy should be started in all diabetics btwn ____ and ___ yrs of age.
High intensity statin is reasonable if they also have a >___% ASCVD risk.
A
40-75 yrs of age.
16
Q
Use ______ for men aged 45 to 79 WHEN potential benefit of reduced MI outweighs risk of GI bleed.
A
Aspirin. For pts with CVD and documented aspirin allergy, use clopidogrel.
17
Q
Lowering A1c to <___% has been shown to reduce _________ complications of diabetes. Tailor treatment to avoid hypoglycemia and weight gain. Effect on ____________ complications unclear.
A
Microvascular have clear benefit from HbA1c<7% goal.
Macrovascular unclear.
18
Q
ADA Diabetes Treatment:
Diagnosis: HbA1c > ____%. Treatment:
If HbA1c > ____% Treatment:
If HbA1c > _____% Treatment:
A
HbA1c > 6.5% Treatment: Lifestyle changes + Metformin. Assess.
If HbA1c > 8%. Treatment: Lifestyle changes + Metformin + 2nd Gen Sulfonylurea or 3rd Gen Glimepiride or Basal Insulin or Insulin Determir on NPH (intermediate). Assess.
If HbA1c still > 8%, Treatment: Metformin + lifestyle changes + add basal insulin or intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia.
19
Q
Thiazolidendiones are associated with…
A
Heart failure, MI, edema, and bone fractures.
20
Q
Flu vaccine should be provided to ppl with diabetes _______
A
Annually
21
Q
Pneumomoccocal vaccine should be given to all people with diabetes over age ____yrs. For ALL pts aged 65 and over a one time PPSV23 vaccine is recommended. If they received the vaccine for another indication prior to 65, another dose should be given once they turn 65 unless their prior dose was within 5 yrs (btwn ages 60-65), in which case another dose should be given 5 years after their last dose. What special groups should get the pneumococcal vaccine from age 19 onward?
A
2 years of age.
Pts with Asthma, smokers, nephrotic syndrome, CKD, or immunocompromised patients.
22
Q
Hep B vaccine should be given to all unvaccinated adults with __________
A
Diabetes, HIV, other immunocompromising conditions, liver disease.
23
Q
Diabetic retinopathy guidelines
Type 1 DM should have first eye exam ____ yrs after diagnosis.
Type 2 DM should have first eye exam ____ yrs after diagnosis.
What type of eye exam should it be and how frequent subsequently?
A
Type 1 DM: Look for retinopathy 5 years after diagnosis.
Type 2 DM: Eye exam at time of diagnosis - 20% already have retinopathy.
Annual dilated eye exam for all diabetics from time of indicated first exam onward.
24
Psoriasis affects _________ (extensor/flexor) surfaces.
Atopic affects________ surfaces.
Psoriasis - extensor
Atopic eczema - flexor
25
Systemic steroids are required to treat which two dermatophyte infections:
```
Tinea capitis -Treat w/griseofulvin
Tinea unguium (onychomycosis - nail infection) -Treat with terbinafine or itraconazole
```
26
Squamous cell carcinoma in a non-sensitive region should be treated with...
Wide excision. If lesion is less than 2cm and has no high risk features, 4mm margin should be obtained. (95% cure rate).
Squamous carcinoma in-situ is Bowen's Disease
Any nonmelanoma skin cancer >2cm or with indistinct margins or near an important structure should be treated with Mohs microscopy surgery.
27
For a pt diagnosed with BPH, appropriate first line treatment is...
```
Behavior modification (avoid fluids before bedtime, limit consumption of mild diuretics like caffeine and alcohol, limit use of salt and spices, maintain voiding schedules)
and starting alpha adrenergic antagonists
```
28
Pts with a 30 pack year smoking history between ages ___ and ___ should be screened for lung cancer with a _______
Ages55 and 65.
Low dose CT
29
Pre-menopausal women need _____mg of CALCIUM daily. post-menopausal women need ____mg daily.
1000 mg
1500 mg
30
Offer one time Hep C screening to people born between _____ and _____
1945 and 1965
31
Shoulder joint: Loss of active and passive motion suggests _________(type of pathology)
Loss of active motion alone suggests:
Active and Passive Motion: Joint disease (adhesive capsulitis, glenohumeral arthritis)
Active motion alone: Muscle pathology (rotator cuff tear, rotator cuff impingement)
32
Risk factors for atherosclerotic cardiovascular disease (ASCVD)?
Age: Men > 45, Women > 55
HTN (controlled or uncontrolled)
Diabetes
Smoking
```
Family History (Men < 55; Female < 65)
Abnormal lipid levels: high LDL, low HDL
```
33
What interventions slow the progression of CAD?
1. Blood pressure control to appropriate JNC 8 goal. For diabetics or ppl with CKD it is 7.5%, a high-intensity statin.
2. Aspirin: Esp in men 45-79 (prevents MI) and women 55-79 (prevents ischemic stroke)
3. Statin: All Type 1 or 2 diabetic btwn 40 and 75 should be on a moderate-intensity statin or if their 10-yr ASCVD risk > 7.5%, they should be on a high-intensity statin
4. Beta-blockers: use whether or not pt has HT
Weight loss is NOT a good method. Large fluctuations in weight associated with incr risk.
34
To determine LVH, the best test is...
When the ________ (value) is reduced it suggests...
Echocardiogram
E/A value reduced suggests diastolic dysfunction
35
BNP > ____ pg/ml is abnormal and suggests ____
100pg/ml
| Suggests heart failure
36
A positive stress test does NOT indicate CAD and should be followed up with a ________
Cardiac catherization.
37
Systolic heart failure treatment:
1. ACE inhibitors (mainstay of systolic heart failure mgmt). More expensive alternative, ARBs.
2. Digoxin - improves symptoms and reduces hospitalizations in NYHA Class II-IV heart failure. DO NOT USE DIGOXIN IN RENAL INSUFFICIENCY
3. Loop diuretics - help minimize fluid overload so ACE and beta blockers can work better. Use w/caution in diastolic HF.
4. Certain beta blocker like metoprolol succinate. DO NOT USE IN DECOMPENSATED heart failure.
5. Eplenerone in Class II Heart Failure or Spironolactone in Class III or IV heart failure.
38
Appropriate test for CAD in an intermediate risk pt are:
Exercise treadmill stress test
Stress echocardiography
Nuclear stress testing
39
Acute bronchitis is a productive cough lasting 1-3 weeks.
| Chronic bronchitis is a productive cough for 3 consecutive months for the past 2 years.
Repeat
40
Decreased height of larynx is a common finding in ________ disease.
Obstructive lung disease including COPD.
41
```
COPD Diagnosis
An FEV1/FVC ratio ____ indicates mild disease.
An FEV1 ____< x < _____ moderate disease
An FEV1 _____ < x < _____ severe disease
An FEV1 < _______ very severe disease
```
FEV1/FVC < 0.7 - obstructive disease
FEV1 > 0.8 is mild disease - SABA
FEV1 between 50% and 80% is moderate disease. Treatment: inhaled anticholinergics alone or + SABA
FEV1 between 30% and 50% is severe disease - inhaled glucocorticoids + bronchodilators
FEV1 less than 30% is very severe disease
42
5A's of behavior change
ask, advise, assess, assist, arrange
43
What are the secondary causes of HTN?
```
Renovascular HTN - Renal artery stenosis, Fibromuscular dysplasia
Sleep apnea
CKD
Parathyroid/thyroid disease
Cushing's disease
Chronic steroid use
Coarctation of aorta
Primary Hyperaldosteronism
Pheochromocytoma
Drug-Induced
```
44
Thiazide diuretics (anti-HTN drug) should be avoided in:
Also, the 25mg dose of hydrochlorthiazide is equally as effective as 50mg and only the 25mg dose has impact on coronary heart disease.
People with a Hx of gout - may precipitate flares
| They may cause elderly pts to be incontinent of urine. Elderly pts should get a 6.25mg or 12.5mg dose NOT 25 mg.
45
For a pt with HTN, which tests a indicated:
```
EKG
UA
Blood Glucose (fasting)
Hematocrit - anemia
Serum K
Serum Ca - Nephrolithiasis in setting of hyperparathyroidism and HTN
Serum Cr or GFR estimate
Fasting Lipid Panel
```
Pg 15 Case 8
46
Resistant HTN is ____
Failure to reach goal BP with a 3-drug regimen that includes a diuretic.
47
Back pain worse with movement and sitting is suggesting of ...
Mechanical cause: lumbar strain, disc herniation, or degenerative arthritis.
48
Back pain radiating down the leg is suggestive of...
Nerve involvement - disc herniation.
49
Pain that improves with the supine position is suggestive of ...
Spinal stenosis and disc herniation.
50
Nerve impingement findings: L3-S1...
L3: Decr patellar tendon reflex, pain in lateral thigh and medial femoral condyle, trouble with extending quads, squat down and rise
L4: Trouble w/dorsiflexing ankles, walking on heels
L5: Decr medial hamstring reflex, pain in lateral leg and dorsum of foot, trouble w/dorsiflexing of great toe and walking on heels
S1: Decr Achilles tendon reflex, pain in posterior calf, sole of foot and lateral ankle, trouble with standing on and walking on toes (plantarflexion of ankle)
51
Pain in opposite leg during straight leg test is suggestive of...
Root compression due to Central disc herniation
52
Pain past the knee indicates...
Herniated disc (stretched nerve roots) usually L5 or S1
53
Treatment for disc herniation and ridiculous thy initially is...
NSAIDS and muscle relaxants
Heat/Cold (local therapy)
If pain does not improve in 4-6 wks or if there is progression of neurologic deficits, back surgeon or MRI/CT.
54
```
Migraine Headaches
Pain: _______ (moderate, severe, mild, moderate to severe)
Associated symptoms:
Quality of pain:
Aggravating Factors:
Duration:
Number of Episodes needed for diagnosis:
```
Migraine Headaches
Pain: moderate to severe
Associated symptoms: n/v, photophobia, photophobia, may be with aura
Quality of pain: pulsating, can be unilateral
Aggravating Factors: Worsened w/physical activity
Duration: 4hrs-3days
Number of Episodes needed for diagnosis: 5
55
```
Tension-type Headaches
Pain: _______ (moderate, severe, mild to moderate, moderate to severe)
Associated symptoms:
Quality of pain:
Aggravating Factors:
Duration:
Number of Episodes needed for diagnosis:
```
Tension-type Headaches
Pain: mild to moderate
Associated symptoms: May occur with photophobia or phonophobia
Quality of pain: Pressing, tightening, and bilateral. Radiates down to neck with tender occiput.
Aggravating Factors: not worsened with physical activity
Duration: 30min to 7 days
Number of Episodes needed for diagnosis: 10
56
```
Cluster Headaches
Pain: _______ (moderate, severe, mild, moderate to severe)
Associated symptoms:
Quality of pain:
Aggravating Factors:
Duration:
Number of Episodes needed for diagnosis:
```
Cluster Headaches
Pain: severe
Associated symptoms: rhinnorhea, lacrimation, facial swelling, miosis, eyelid edema, ptosis, conjunctival injection
Quality of pain: Severe unilateral orbital, periorbital, supra orbital or temporal pain
Aggravating Factors: ----
Duration: 15min to 3 hrs
Number of Episodes needed for diagnosis: 5
57
What are secondary causes of headaches that should never be missed...
Intracranial hemorrhage
Meningitis
Brain tumor
58
A headache due to depression or anxiety feels like which type of headache?
Tension headache
59
Medication overuse headache results in what setting:
Regular overuse of an analgesic for > 3 months. (at least 15x in a month)
More than 15 headaches a month
Headache improves slightly on analgesics, worse when they wear off
Treatment: Stop the medication
60
Imaging is indicated for a headache if...
Pt has migraine with atypical headache or neurologic signs
Pt is at higher risk of a significant abnormality
Results of the imaging study would alter mgmt
(You should image new onset headache in someone >35 yrs or with Hx of cancer, HIV or with MARKED changes in their usual headache pattern)
61
Anxiety screening questions (GAD-2)
Over the last 2 wks how often have you been bothered by any of the following problems:
Feeling anxious, nervous or on edge?
Being unable to stop or control worrying.
62
Depression screening (PHQ-2)
Over the last 2 weeks, how often have you been bothered by any of the following problems:
Have you had little interest or pleasure in doing things?
Have you felt down, depressed, or hopeless?
63
For a pt with HTN, the lifestyle change that decreases blood pressure the most is...
```
Weight reduction
DASH Diet
Reduced sodium intake
Physical activity
Moderate alcohol consumption
```
64
What are the criteria for a controlled headache?
What follow-up treatment is needed?
<8/month and they are relieved with lifestyle modification and acute treatment.
Follow-up: None
65
The differential diagnosis for a lateral ankle injury that permitted weight bearing right after the injury, without compartment syndrome, or clear point tenderness includes:
Lateral ankle injury occurs on ______ (inversion vs eversion)
Inversion
Lateral ankle sprain - warmth, pain, swelling following injury but no deformity
Fibular fracture
Peroneal tendon tear - persistent pain over lateral malleolus
Subtalar dislocation
Tamar dome fracture
66
In grading an ankle sprain, what is taken into consideration?
Grade I:
Grade II:
Grade III:
```
Pain
Swelling
Ecchymosis
Ligament tear
Loss of functional ability
```
Grade I: stretching of the ligament or small tear. No excessive stretching or opening of the joint with stress.
Grade II: incomplete ligament tear. Ecchymosis may be present. Moderate functional loss.
Grade III: complete ligament tear.
67
Ottawa ankle rules help determine ________
What are the rules:
Whether an ankle sprain should be X-rayed
Rules: Bone tenderness in the outlined spots OR an inability to bear weight both after the injury and in the ED (4 steps)
Lateral:
1. 5th metatarsal bone tenderness
2. Posterior edge or tip of lateral malleolus
Medial:
1. Navicular
2. Posterior or tip of medial malleolus
68
The inversion test tests the integrity of the __________ (anatomic, structure)
Calcaneofibular ligament
69
The crossed leg test (and the ankle squeeze physical exam maneuver) test for ________
Syndesmotic injury also known as high ankle sprains
70
What are the patient instructions following an ankle sprain?
How long should the ankle be rested following the injury?
What pain control meds are indicated?
What type of support should be used for an ankle sprain?
RICE (Rest, Ice, Compression, Elevation).
Rest ankle for FIRST 72 hrs following injury. You can stretch the ankle for optimal ROM after this.
2-3 ibuprofen at a time. Ensure no prior history of ulcers or issues with NSAIDs. Eat before taking them.
Semirigid support was best (Aircast, soft lace up brace)
71
Treat an uncomplicated UTI with _______ and if there is >20% resistance, treat with _______
Bactrim.
| Nitrofurantoin.
72
Ottawa knee rules
Age >55
Isolated patella tenderness (no tenderness anywhere else on knee)
Tenderness at head of fibula
Inability to flex knee to 90 degrees
Inability to bear weight both immediately and in the ED.
73
What are the major X-ray features of OA?
Joint space narrowing
Subchondral sclerosis
Osteophytes
Subchondral cysts
74
NSAIDs are NOT first line for mild to moderate osteoarthritis. What drug is?
If the knee is inflamed, ______ can be considered.
_________ has been shown to have NO benefit in reducing osteoarthritis pain.
Acetaminophen.
Steroid injections (not more than 3/yr).
Glucosamine has no benefit. Acupuncture may have some benefit for receiving osteoarthritis pain.
75
The definitive test for Carpal tunnel syndrome is ______ BUT it DOES NOT NEED TO BE DONE if history and physical suggest the diagnosis. Only perform if thenar atrophy is present or motor dysfunction is present or conservative management fails.
Conservative mgmt:
Electrodiagnostic test (nerve conduction study) but it has low sensitivity and high specificity.
Conservative mgmt: Night wrist splint
76
Chronic pain mgmt:
Long acting opioids side effect is: ______
TCAs have _______ (toxicology pattern) side effects. They are relatively contraindicated in ppl with ________ (underlying conditions).
Long-acting opioids: constipation
TCAs: anti-cholinergic side effects; contraindicated people with CV disease and conduction blocks because of risk of tachycardia and arrhythmia.
77
What are key side effects of NSAIDs?
GI upset
Increase effectiveness of sulfonylureas
Decrease effectiveness of Anti-HTN meds
78
Screening Guidelines
Colorectal Cancer: Colonoscopy btwn age ____to ____
Breast Cancer: Mammography btwn age ____ to ____
HTN: >___ age
Depression: Screen if ______
Cervical cancer: Screen from age ___ to ____
Fasting lipid panel: Screen ___ (male/females) over age ____. Screen ____ (male/females) over age ___ if at increased risk.
Colorectal Cancer: Colonoscopy btwn age 50 to 75
Breast Cancer: Mammography btwn age 50 to 74
HTN: >18 yrs
Depression: Screen if there are systems in place to assure accurate diagnosis, effective treatment, and follow-up
Cervical cancer: Screen from age 21 to 65
Fasting lipid panel: Screen Males > age 35. Screen females over age 45 if at increased risk (Diabetes, Smoking, Prior CHD/PAD/AAA/carotid stenosis, Family Hx - male under age 50 or female under age 60, obese (BMI>30))
79
Annual vaccinations for pt over 65:
Tetanus: Tdap one time for booster and then Td every 10 yrs
Influenza: Annual
Pmeunococcal polysaccharide (23-valent): One dose of >=65yrs
Zoster: >60 years
80
Alcohol use classification:
Risky/Hazardous: above recommended limit (4 drinks per occasion for men). Treatment: Motivational enhancement therapy, CBT, family physician intervention, AA
Problem drinking: experienced significant physical, social of psychological harm
Abuse: failure to fulfill work, school or social obligations, legal problems
Dependence: Tolerance, withdrawal, taken in larger qty than intended
81
Adolescent History-Taking
```
Home
Educ/Environment
Eating
Activities
Drugs
Sexuality
Suicide/Depression
Safety/Violence
```
82
Who should be screened for Chlamydia?
All sexually active women less than 24.
All sexually women above 24 at increased risk (prior Hx of STI, new or multiple sex partners, inconsistent condom use, transactional sex).
83
Vaccinations:
Tdap: 5 pediatric doses and then _____ recommended at ____ (age)
Varicella: ___ (total # doses) recommended
Meningococcus: 1 dose recommended at ___ (age) and booster at ____ (age)
Tdap: 5 pediatric doses and then BOOSTER recommended at 11-12yrs (age)
Varicella: 2 (total # doses) recommended; 12-18 mos, 4-6 years
Meningococcus: 1 dose recommended at 11-12 yrs (age) and booster at 16-18yrs (age)
84
Pre-conception counseling (planning to get pregnant) should include:
Prenatal vitamin supplementation (Folic acid - 400mcg/day, 1mg if diabetic, 4mg if child with prior neural tube defect)
Family history of CF, sickle cell, Tay-Sachs, thalassemia, non-syndromic hearing loss
Risk factors for HIV
Advise against Tobacco and Alcohol use
Review current meds (no ACE-I, ARBs or thiazide diuretics, switch warfarin to heparin, no benzos)
Review current weight and nutritional status
Screen for safety and domestic violence
85
Cervical Signs of pregnancy:
Cervix and uterus soften
| Cervix and vaginal walls have increasingly purplish-blue hue
86
An Rh- pregnant woman should get ______
50mcg of RhoGam
87
If concerned about miscarriage, order the following tests:
Get G/C and STI tests NOT cultures.
```
Pelvic ultrasound
Progesterone
Quant b-hCG
Wet mount
CBC
```
FYI, you cannot see intrauterine contents on transvaginal ultrasound until b-hCG >1500mIU/mL or transabdominal (5000mIU/ml)
88
Abortion Classification:
Threatened abortion - bleeding before 20 wks gestation
Inevitable abortion - dilation of cervical os
Incomplete abortion - expulsion of some but not all intrauterine contents
Missed abortion - fetal demise without cervical dilatation
Septic abortion - intrauterine infection, fever, abdominal tenderness
Complete abortion - products of conception completely expelled
89
Options to address an inevitable abortion:
Expectant management
Surgical - dilation and curettage
Medical - Misoprostol (vaginally)
90
What are the risk factors for dysmenorrhea?
Smoking and depression
91
Dyspareunia is common in _________(endometriosis vs leiomyoma)
OCPs, increased parity, and smoking DECREASE risk of fibroids.
Endometriosis
92
Boggy, mobile uterus suggests
Adenomyosis
93
What birth control device is a great option for heavy bleeding or abnormal bleeding (secondary to fibroids)?
Mirena (progesterone releasing IUD)
94
Which meds can be used to treat PMS?
OCPs
SSRIs
Danazol (androgenic medication with progesterone effects - that lowers estrogen and inhibits ovulation)
95
What is the mmenomic for assessing the severity of suicidal ideation. What is the cutoff for clinic concern? For hospitalization?
SAD PERSONS. Sex (male), age (less than 19 or greater than 45), Depression, Previous attempt, Ethanol or substance abuse, Rational thinking impaired (psychosis, delusions, hallucinations), Social support lacking, Organized plan, No significant other, Sickness
4-6 requires outpatient treatment
7-10 requires hospitalization
96
On the Geriatric Depression Scale, a score > ___ is consistent with a diagnosis of depression
>5
97
What are 3 common side effects of SSRIs/SNRIs?
Headaches
Insomnia
Nausea
98
Four mechanisms of TIAs or stroke:
Embolic
Thrombotic
Cardiogenic
Hemorraghic
99
The following tests are recommended in the initial emergency evaluation of a patient w/suspected acute ischemic stroke:
```
CT or MRI
Renal fn/electrolytes
EKG
Markers of Cardiac Ischemia
CBC
PT/PTT
Oxygen Saturation
```
100
Patients with parietal stroke can have:
Contralateral body hemiplegia
Functional impairments - denial of stroke disability
Spatial neglect
101
Following a stroke, 1/3 of patients experience ________
Post-stroke depression. Symptoms must be present for a week.
102
How do you treat strep throat?
1st Line: Penicillin V (PO)
Alternatives: IM Penicillin G, Amoxicillin. If allergic to Penicillin, treat with erythromycin.
103
Childhood vaccinations. Between 4-6 yrs kids need:
DTaP
IPV
MMR
Varicella
104
Signs and symptoms of hyperthyroidism:
```
Heat intolerance
Sweating
Weight Loss
Tachycardia
Tremor
Fatigue
Exertional Dyspnea
Frequent, Loose Stools
Depression
Hyperreflexia
```
105
A thyroid ultrasound is used to evaluate NODULES.
If I want to evaluate hyperthyroidism, I can use a _______ or ______.
Initially, for hyperthyroidism work up do TSH and T4.
Then further work-up:
Radioactive iodine uptake test and scan.
Thyroid antibodies
106
To replete thyroid hormone in a hypothyroid patient, start with a typical dose of ______ and then increase the dose slowly. TSH should be repeated in 6 WEEKS. Once a stable TSH level has been reached on thyroxine, check 1-2x/yr.
Thyroxine 1.5-1.8mcg
107
Smoking and obesity are two of the most powerful risk factors in developing DVT
Repeat
108
The Wagner Grading system grades diabeticfoot ulcers:
Grade 1 - superficial diabetic ulcer
Grade 2 - extension of ulcer (involves ligament, tendon, joint capsule, fascia) - no abscess or evidence of osteomyelitis
Grade 3 - Deep ulcer + Abscess or Evidence of Osteomyelitis
Grade 4 - Gangrene of forefoot
Grade 5 - Gangrene of whole foot
109
How long should a patient be anticoagulated?
First idiopathic DVT - 6 months of warfarin
First DVT from Trauma or Surgery - 3 months
Recurrent thromboembolic disease or inherited thrombophilia - indefinitely
Symptomatic, isolated calf thrombophlebitis - 6-12 wks
110
If you overshoot a patient's INR goal, _____
INR 5-9: Discontinue warfarin, repeat INR in 24 hrs
| INR>9: Discontinue warfarin, give oral Vit K
111
LMWH should be continued for at least 5 days and until INR is greater than or equal to 2 for 24 hrs. INR goal 2.0-3.0.
Repeat
112
Triple therapy for H.Pylori eradication includes:
To evaluate eradication use _______ or ______ test.
PPI + Amoxicillin + Clarithromycin
PPI + Metronidazole, Tetracycline + Bismuth subsalicylate
Evaluate eradication: Fecal antigen test (cheaper), urea breath test
113
Recalculate the 10-yr ASCVD risk every _____ years in ppl aged ____ without ASCVD risk who are not on a statin and have an LDL between 70-189.
Anyone with an LDL>___ should be on a _________ intensity statin
Anyone with Clinical ASCVD over 75 years should be on a _______ intensity statin, under 75 a _______ intensity statin.
4-6 years
Aged 40-75
LDL greater than 190, high intensity statin.
Anyone with clinical ASCVD under 75 should be on a high intensity statin, anyone above 75 moderate intensity statin.
114
Centor criteria for strep throat:
```
Tonsillar exudate
Age (age greater than 44 subtract 1pt, age less than 15 add 1pt)
Tender cervical LAD
Fever
No cough
```
0-1 no antibiotic or throat culture needed.
4-5 treat empirically with antibiotic
2-3 test for strep and treat if positive. If negative, perform throat culture.
115
Otitis media
At what age are you concerned?
What do you treat with?
0-6 months: Treat w/antibiotic
6mos-2yrs: If certain diagnosis, treat. If uncertain, only treat if it is SEVERE.
Greater than equal to 2: treat if severe, certain diagnosis. Observe of uncertain.
Treatment: Amoxicillin. Augmentin for recurrent otitis media.
116
Amsel criteria is used to make a diagnosis of bacterial vaginosis.
Repeat
117
Specific autism screening is recommended at ____ and ____ (ages)
18 months and 2 years of age.
118
The AAP mandates developmental screening check-ups at ____, ____, and _____
9 months, 18 months, and 30 months.
119
Never give a baby regular cow's milk until _____ months of age
12 months
120
Babies require 100cal/kg/day - 120cal/kg/day
Repeat
121
Moro reflex in a newborn should extinguish by ___ months. It involves _____, _____, and then ____ of the arms in response to quick change in the position of the baby's head.
It detects: ______, _____ (types of problems)
Moro extinguish by 4 months.
Involves abduction, extension, and then addiction of hands.
It detects congenital musculoskeletal abnormalities or neural plexus injuries.
122
Babinski reflex is normal in a child until ___ age.
1-2years
123
Exclusively breasted babies or infants that are drinking less than ____ (amount) of formula each day should be supplemented with ______
Exclusively breastfed babies or infants on for,HLA drinking less than one quart a day should get supplemental Vit D
124
Most babies sleep through the night by ______ (age)
Ages 4-6 months. Babies should sleep on their back to avoid SIDS
125
At a child's 2-month visit, you want to vaccinate against? (6 vaccines)
```
DTap
Hep B (2nd dose)
HiB
IPV
PCV13
RotaV
```
DO NOT vaccinate against MMR, HepA at this visit. They are not given until 12 months of age.
126
Childhood Immunizations:
| In the first five years, children should receive total doses of ___ of the ____ vaccines.
```
DTap (5)
IPV (4)
HiB (3 or 4)
PCV13 (4)
Rotavirus (2 or 3)
Hep B (3)
-----------
(Recommended after 12 months of age)
Hep A (2)
MMR (2)
Varicella (2)
```
127
Influenza vaccine is recommended for children _________ (age range) and their close contacts. Anyone with ________ should also receive the vaccine. Also children under _____ years should receive it.
Influenza vaccine is recommended for children 6months - 5 years and their close contacts. Anyone with asthma, heart disease, lung disease, or immunodeficiency should also receive the vaccine. Also children under 19 years should receive it.
128
Pediarix includes
DTaP, IPV, HepB
129
Pediacel
DTaP, IPV, HiB
130
An infant should double their birthweight by _____ (months), triple their birthweight by ______ (months).
Double birthweight by 5 months, triple birthweight by 12 months.
131
All babies should have a red reflex from birth. It's absence could indicate:
Glaucoma, cataracts, retinoblastoma, chorioretinitis
132
Anticipatory guidance at 6 month visit:
Install outlet covers
Put in cabinet locks
Set up stair barriers
Make sure cleaning supplies and medicines are safely stored
Car seat: Car seat should still be in back seat facing rear
Walker: Do not use a walker
Foods: New foods may be added to diet every 5-7 days.
Developmental changes: at 6 months, she may be resistant to being away from her mother but this stranger anxiety is normal. 6 months is a great time to start reading to her.
Sleeping pattern: She should be expected to take 2 naps during the day and probably sleep at night.
133
At a child's 4-month visit, you should vaccinate with: (5 vaccines)
```
DTaP (2nd dose)
IPV (2nd dose)
PCV13 (2nd dose)
HiB (2nd dose)
Rotavirus (2nd dose)
```
At the 4-month visit, there is NO Hep B vaccine
134
At a child's 6-month visit, the following vaccines are indicated: (6 vaccines)
DTaP (3rd dose)
PCV13 (3rd dose)
HiB (3rd dose)
Rotavirus (3rd dose)
Hepatitis B (3rd dose)
```
IPV (3rd dose) can be given anytime from 6 months to 18 months
Influenza vaccine (if correct season)
```
135
A 9 mo-old baby should be able to wave bye bye and sit without support. They should NOT yet be expected to have pincer grasp or walk well.
Repeat
136
By 12 months the developmental milestones include:
Gross motor: stands alone, many can walk well
Fine motor: has well developed pincer grasp
Language: can say mama, dada and 1-2 other words
Social/adaptive: hands parent book to read, points when wants sthg, imitates activities, plays ball with examiner
137
If there is an intra-abdominal, pelvic, or peri-rectal process in an infant, perform a ...
Rectal exam for hard stool or masses
138
Vanillylmandelic acid and homovanillic acid can suggests the presence of what type of pediatric tumor?
Neuroblastoma
139
To evaluate an intra-abdominal mass in a child, initial tests include:
CBC w/diff
catecholamine metabolites (VMA, HVA)
CXR - f/u with MRI, CT only if metastases seen on CXR.
Skeletal survey
Abdominal ultrasound - purely cystic masses are more likely to be benign. Perform further imaging (Abd CT or X-ray as needed)
140
The cardinal signs of ADHD are...
Inattention
Hyperactivity
Impulsivity
141
Objective vision screening should be part of them pediatric health maintenance visit beginning at age ____
Age 3
142
Stimulant meds may cause:
Appetite suppression
Insomnia
Develop tics
Decrease on growth velocity
143
Screen kids at risk of developing Type 2 DM beginning at ____ yrs or with onset of ______ every ___ yrs (screening interval).
Use ______ (tests)
10 yrs or onset of puberty (whichever is earlier)
Interval: 3 years
Tests: HbA1c, Glucose Tolerance Test, Fasting glucose (greater than 126))
144
```
HTN in children
Normal BP: less than ____ percentile
Pre-HTN: ____ - ____ percentile
Stage 1 HTN: ___-____ percentile + ____ mmHg
Stage 2 HTN: ____ percentile + ___ mmHg
```
Treatment:
```
HTN in children
Normal BP: less than 90 percentile
Pre-HTN: 90 - 95th percentile
Stage 1 HTN: 95-99th percentile + 5 mmHg
Stage 2 HTN: 99th percentile + 5 mmHg
```
Treatment: Therapeutic lifestyle changes and 6 month evaluation
145
Secondary causes of HTN in children:
Umbilical artery or vein access - predisposes to renal vascular disease
UTI - renal scarring
catecholamine excess - pheochromtocytoma or neuroblastoma
Family Hx - Renal Disease, HTN
Coarctation of aorta - pay attn to femoral pulses and document BP in lower extremity
146
Pediatric exercise recommendation and TV recommendation:
less than 2 hours screen time per day.
60 mins daily activity
147
Ideal BP cuff has a bladder length of ___% and a width of ___%
length: 80%
Width: 40%
148
PT/PTT are important in the setting of sepsis for the evaluation of ____ (disease)
DIC
149
Normal Hgb
Male:
Female:
male: 12-17
Female: 11-16
150
At age 11-12, the following vaccines are indicated:
Tdap
HPV
Meningococcal
Annual: Flu
151
Crackles are a sign of consolidation in the lungs
Repeat
152
An URI would not produce lower lung signs like____. Common URI symptoms include:
Duration:
There would be no Wheezing.
Low-grade Fever, rhinorrhea, nasal congestion, cough, sneezing, nasal discharge - clear progresses to yellow.
Duration: one week
153
Bronchiolitis is seen in _____ (demographic)
Symptoms:
Pathogens:
Treatment:
Young children (peaking at 6 months of age)
Symptoms: Wheezing, cough, dyspnea, cyanosis
pathogens: RSV
Treatment: Supportive (including oxygen)
154
Pneumonia often presents with:
Symptoms:
On exam:
Pathogen:
Work-up:
Treatment:
Fever (greater than 100.4), sputum production, usually no myalgias unless it is a viral pneumonia or atypical pneumonia.
Older pts: Pleuritic chest pain, fever/chills, dyspnea, cough
Half of pts have accompanying pleural effusion.
On exam: crackles
Pathogen: Pneumococcus, in children 3 months to adolescence - bacterial. In school age children atypical pneumonias are common too.
Work-up: CXR is only indicated in children if they are hypoxic or not responding to treatment. All children admitted to a hospital for pneumonia should have a PA and lateral X-ray.
Treat with amoxicillin 90mg/kg/day in young children and with Azithromycin for atypical coverage in school age children.
155
Viral pneumonia
| Presentation:
Fever, chills, dry, non-productive cough, and extrapulmonary symptoms like arthralgias and GI symptoms.
Pathogen: Influenza, RSV in kids or immunosuppressed,
Measles or varicella with characteristic rashes
Adenovirus, parainfluenza, rhinovirus, other viruses
Demographic: common in children aged 4 months to 5 yrs.
156
Acute bronchitis
Presenting symptoms:
Pathogen:
Symptoms: cough lasting more than five days, purulent sputum
Pathogen: usually viral
Treatment: over 90% viral so NO ANTIBIOTICS. Use a beta-2 agonist for people who are wheezing.
157
Influenza
Presenting symptoms:
On exam:
Treatment:
Complications of Influenza:
```
High fever (102-104), chills
Myalgias and headache
Sore throat
Abrupt onset
on exam: rhonchi
```
Treatment: antivirals like zanamivir, oseltamivir, amantadine, rimantadine decrease flu symptoms by 24 hrs if they are given in the first 48 hrs of symptoms. Otherwise, give ibuprofen or acetaminophen for pain and fever, fluids, and rest.
Only indications for giving anti-vitals beyond 48 hrs are:
A child with moderate to severe community acquired pneumonia w/findings consistent for influenza or if the patient is clinically worsening at the time of the outpatient visit.
Complications:
1. Bronchitis, Pneumonia
2. Otitis media (10-50% of kids with influenza)
3. Neurologic complications (Guillain-Barre, aseptic meningitis, febrile seizures)
A sign of complications is symptoms lasting longer than 5-7 days, worsening cough or breathing, difficulty maintaining hydration.
158
Group A Beta-hemolytic strep
| Presenting symptoms:
Sore throat, fever, tender cervical lymphadenopathy
159
Screen all kids with a BMI greater than the 85th percentile (overweight) with a _______ (test) to check their cholesterol level.
The goal total cholesterol is less than ____. The goal total LDL is less than ___.
Fasting lipid panel
Total cholesterol less than 170. LDL less than 130.
160
Screen children from age ___ upwards for steatosis if BMI is greater than ___ percentile or greater than ___-___ percentile with risk factors. Screen with _____ (lab tests) every ___ yrs. Refer GI if lab abnormalities are greater than ___ times the upper limit of normal.
Screen from age 10 for BMI greater than 95th percentile or 85th to 95th percentile with risks for steatosis with AST/ALT every two years. Refer to GI if lab abnormalities are greater than 2 times the upper limit of normal.
161
Obese females can get early menarche or PCOS.
Repeat
162
Vestibular neuritis that presents with eye nystagmus, nausea/vomiting, and vertigo is associated with recent ________ (infection)
URI
163
To distinguish peripheral vertigo from central vertigo:
Peripheral vertigo is usually unidirectional and is inhibited with gaze fixation. Frenzel glasses prevent fixation and bring out the nystagmus.
Central vertigo - purely horizontal, vertical or rotational. Gaze fixation does not lessen it. Persists for longer.
164
If vertigo is due to BPPV (benign paroxysmal positional vertigo), the appropriate test is ______ maneuver.
Dix-Hallpike
| The eyes best in the direction of the pathology
165
Treatment for peripheral vertigo includes:
Epley maneuver (for BPPV - reposition carnalith)
Vestibular suppressant - anti cholinergic (meclizine), anti-emetic (dimenhydrinate, promethazine, metclopramide) - cause sedation
Vestibular rehabilitation - safe, effective method
166
Symptoms of menopause
Hot flashes or vasomotor symptoms, Atrophic vaginitis (associated with dyspareunia and urinary symptoms), dyspareunia
167
Hormone replacement therapy in menopause helps....
Reduce vasomotor symptoms
Improve Atrophic vaginitis
Prevent osteoporosis
If a patient has an intact uterus, she also must be treated with progesterone to reduce risk of endometrial cancer.
168
Beyond 3 years hormone replacement therapy increases risk of breast cancer
Repeat
169
Mammogram screening should begin at age ____ and end at age ____ and should take place every ___ yrs.
Mammogram ages 50-74. Every 2 years.
170
Cervical cancer screening begins at age ___ to ___ every ___ years with a _____(test method).
From age ___ to ___ you can perform screening every ___ years with addition of a ________ (test) to the above testing method.
Age 21-30 every 3 years with a Pap Smear.
Age 30-65 every 5 years with HPV test and Pap Smear
171
Cervical polyps are most common _______ and ____ women (demographics)
Postpartum and perimenopausal. Uncommon in post menopausal women but possible.
172
Endometrial hyperplasia can occur with or without atypia. Hyperplasia without atypia only has a 5% risk of becoming cancer but _________ (type of atypia) is considered a pre malignant lesion with 25% risk of becoming a cancer.
Atypical complex hyperplasia
173
Post-menopausal bleeding is associated with a 6.6 times risk of ovarian cancer.
Repeat
174
Endometrial cancer is the ____ most common cancer in women. Consider once a women is greater ___ yrs.
Presenting symptoms: ____
4th most common cancer
Occurs especially in women over 35
Symptoms: spotting, menorrhagia (abnormal heavy bleeding), metrrohagia (irregular uterine bleeding)
175
Bleeding on hormone replacement therapy usually occurs in the first 12 months.
Repeat
176
Vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritus in a post-menopausal woman are concerning for ______
Symptoms:
Physical exam:
Treatment:
Atrophic vaginitis
Symptoms: Vaginal dryness, dyspareunia, vaginal pruritus, and urinary symptoms (recurrent UTI, incr frequency, dysuria)
Physical exam: smoother vaginal mucosa and cervix (due to decr estrogen levels in menopause)
Treatment: Local estrogens both for the urinary symptoms. Topical estrogen for the vaginal pruritus (use vaginal cream or estrogen ring).
177
Risk factors for endometrial cancer:
```
Unopposed estrogen therapy
Tamoxifen (Nolvadex)
Obesity
HTN (arterial HTN)
Diabetes
History of breast or colon cancer
Early menarche (before age 12)
Late menopause (after 52)
Nulliparity
Menstrual cycle irregularities, anovulatory cycles
```
OCPs and smoking are protective!
178
Is normal menopause, FSH is HIGH because the ovaries begin to produce less inhibin
Repeat
179
Appropriate work-up for a post-menopausal woman with abnormal uterine bleeding includes:
1. Transvaginal ultrasound - tells us thickness of endometrium. If endometrium is less than 4mm, that is good.
2. Endometrial biopsy - histologic analysis after D&C or pipelle is the GOLD STANDARD.
CBC
TSH
180
Osteoporosis risk factors:
```
Family history - esp if 1st degree relative fractured hip
Corticosteroid use
Smoking*
Heavy alcohol use
Caucasian race
Lower body weight (<70kg)
```
181
Calcium and Vit D supplementation to prevent osteoporosis. Right now the consensus is _____mg Calcium a day and ____IU VitD a day for women over age ____. _______(physical activity) is also recommended.
1200mg Calcium, 600 IU Vit D
Age 50.
Weight bearing exercise
USPSTF ruled insufficient evidence.
182
Osteoporosis TREATMENT includes:
Bisphosphonates - Alendronate, (zoledronic acid is IV once a year)
Parathyroid hormone - (Forteo=Teriparatide)
Estrogen replacement therapy - short-term use only
Calcitonin - reduces vertebral fracture but NOT hip
183
Non hormone replacement methods to manage hot flashes:
Mind body practices - yoga, tai-chi, acupuncture
SSRIs, SNRIs
Clonidine, Gabapentin
184
An indirect hernia develops because of a persistent processes vaginalis
A direct hernia occurs due to weakness in the transversalis fascia area of Hesselbach's triangle (defined by inguinal ligament, conjoint tendon, and inferior Epigastric)
Repeat
185
Testicular torsion
```
Demographics:
Presenting symptoms:
Risk Factors:
Physical exam:
Work-up:
Surgery:
```
Presenting symptoms: Inguinal, scrotal, lower abdominal pain that begins abruptly
Risk factors: Congenital anomaly, trauma, exercise, undescended testicle
Physical exam: absent cremasteric reflex, tender swollen scrotum
Demographics: Neonates, Boys 12-18 esp post-pubertal boys
Work-up: Color Doppler ultrasonography
Surgery: should be performed within 4-12 hours of testicular torsion.
186
Torsion of testicular appendages
Demographics:
Physical exam:
Demographics: Boys aged 7-14
| Physical exam: as in epididymitis, patient may appear comfortable except when examined.
187
Epididymitis
Demographics:
Presenting symptoms:
Physical exam:
Demographics: adults
Presenting symptoms: slowly progressive over several days. Usually preceded by UTI or STI symptoms. Also systemic symptoms (fever, rigors, irritating voiding symptoms)
Physical exam: cremasteric reflex intact, positive Prehn's sign
188
GAPS for adolescents addressing preventing of HTN, Hyperlipidemia, safety and injury prevention, promoting physical fitness BUT NOT preventing diabetes.
Repeat
189
Most testicular cancers occur between ages 15 and 35
Most common in _____ (race)
Symptoms:
Risk factors:
African-Americans
Symptoms: painless swelling of the testicle
No evidence to support routine screening
Risk factors: cryptorchidism, genetics (Klinefelter's 47xxy), family history, environment, prior testicular cancer.
190
Testicular tumor classification
Germ Cell Tumor (95%)
- Seminomas (45%)
- NSGCT (50%) - embryonal (20%), mixed (40%), teratomas ans teratocarcinomas (30%), yolk sac - most common pre-pubertal and usually require aggressive surgery and chemotherapy but prognosis is good, choriocarcinoma (1%) - most deadly, least common
Non-Germ Cell tumors (5%) -- only 10% of these are malignant
- Sertoli cell tumor
- Leydig cell tumor
Metastasis - Lymphoma, Leukemia, melanoma
Repeat
191
What are the mechanisms of musculoskeletal injury?
Trauma
| Overuse
192
In a musculoskeletal history, a pop indicates a ______
Tear of ligament, cartilage, muscle, or tendon
193
As far as the timing of swelling of a musculoskeletal injury is concerned, what are good guides for likely injury structure:
Immediate swelling: bone
Less than 1-2 hours: ligament
Delayed: cartilage
194
A strain or tendonitis will produce pain with ______ (passive vs active vs both) stretch.
Strain or tendonitis produces pain with passive AND active stretch
195
The order of the shoulder exam is:
Inspection, ROM, strength, special tests, palpation
