Family Medicine 1 Flashcards Preview

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Flashcards in Family Medicine 1 Deck (560):
1

coracoid process ant or post to acromioclavicular joint?

ant

2

which articulates w clavicle, coracoid or acromion

acromion
acromioclavicular joint

3

apley scratch test

reach hand to spine
over shoulder - abduct/ext r - most reach down to C7
under shoulder - abduct/int r - most reach up to T7

4

roughly what are the normal limits of full shoulder range of motion

flex 180
abduct 180
ext rot 90
int rot 90
apley over down to c7
apley under up to t7

5

empty can jobe test

flex humerus
int rot shoulder
pronate forearm
upward against resistance

pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear

6

empty can test aka

jobe test

7

jobe test aka

empty can test

8

coracoacromio arch formed by

coracoacromial ligament

9

neers test

empty can position with passive motion 90-180 flexion

pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear

10

empty can test vs neer test

resisted vs passive

shoulder
flex to 90
internally rotate
pronate forearm
elbow straight

pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear

11

hawkins-kennedy test

shoulder
ff 90
int rot
bend elbow
passive further int rot

drives greater humeral tuberosity under coracoacromial arch, impinging supraspinatus tendon

12

rotator cuff tendons

sits
supraspinatus
infraspinatus
teres minor
subscapularis

13

speeds test

shoulder
ff 90
supinate
resist downwards force

pain suggests biceps tendon or rotator cuff pathology

14

yergason test

shoulder
flex Elbow to 90
forearm neutral
passively flex elbow and supinate simultaneously

pain/snapping suggests bicipital tendonitis, tear/laxity of transverse humeral ligament (secures long head of biceps tendon into bicipital groove - long biceps snaps over lesser tuberosity)

15

long vs short head biceps tendon relative position

long head from supraglenoid tuberosity laterally thru bicipital groove between humeral tuberosities like pulley
short head more anterior and medial from coracoid

16

resisted external rotation of shoulder tests...

infraspinatus (more w shoulder neutral)
teres minor (more w shoulder abducted 90)

17

posterior liftoff test

arm behind back elbow at 90 push away against resistance
tests subscapularis

18

internal rotators of the shoulder

Latissimus Dorsi
Pectoralis Major
Subscapularis
Teres Major

19

shoulder ROM tests

flex
aduct
int rot
ext rot
apley scratch

20

rotator cuff tests

empty can / jobe
resisted ext rot
resisted int rot
post liftoff
neer
hawkins-kennedy

21

biceps tests

speed
yergason

22

load and shift test

stabilize scap and acromion
shift glenohumeral joint
^50% shift is severely abnorm

23

sulcus sign

stabilize scap and ac joint
inf traction down on arm

sulcus appears inf to acromion suggests glenohumeral laxity

24

apprehension test

shoulder
abduct to 90
flex elbow to 90
externally rotate backward

patient apprehensive if feels risk for anterior dislocation

25

what is the "dislocation position" of the shoulder

abduct to 90
flex elbow to 90
externally rotate backward
push forward

26

relocation test

anterior force on glenohumeral joint relieves apprehension test

27

surprise test

release relocation test (release anterior force on apprehension/crank position) see if shoulder anteriorly dislocates

28

crank test aka

apprehension test
shoulder
abduct to 90
flex elbow to 90
externally rotate backward

patient apprehensive if feels risk for anterior

29

shoulder instability tests

load and shift
sulcus sign
anterior apprehension/crank
relocation
surprise

30

obrien test

like empty can position but some adduction ~30
resist downward pressure w wrist pronated (positive if painful labral tear) and supinated (no pain with labral tear)

31

shoulder pain provocation test

crank position (90 abduct, 90 flex elbow)
pain worse w pronation than supination
all the single ladies

for labral tear

32

shoulder labral tests

obrien
pain provocation all the single ladies

33

all the single ladies test aka

shoulder pain provocation test
crank position (90 abduct, 90 flex elbow)
pain worse w pronation than supination

for labral tear

34

spurling test

patient side-flexes neck
if no pain, doc flexes a bit further

for cervical rediculopathy

35

scapular winging suggests

serratus anterior weakness
long thoracic nerve damage

36

ottowa knee rules

knee xr only needed if one of these
-age ^55
-isolated patellar tenderness (not elswehere in knee)
-fibular head tenderness
-can't flex to 90
-can't bear weight 4 steps (limp ok)

37

define binge drinking

BAC .08
usually
5 drinks M
4 drinks F
in v2hrs

38

define heavy drinking

5+ drinks on same occasion 5+/30 past days

39

% gen pop experience severe headache
% v6yo
% ^16yo

~20
v5 (rare, extra concerning in kid)
^25 (common in adults

40

gender presominance of severe headaches

M v12yo
F ^12yo (post puberty)

41

cluster headache falls under a larger headache category called

trigeminal autonomic cephalalgia

42

scientific name for headache

cephalalgia

43

cephalalgia means

headache

44

mnemonic for characterizing pain

old carts
Onset
Location
Duration
Character
Aggravating/alleviating
Radiation
Timing
Severity
Prior

45

pediatric blood pressure reference range of normal is adjusted for

age and height

46

common behavioral change strategies for conservative mgmt of headache syndrome

hydration
dec caffeine
adequate good sleep
adequate exercise
limit stress

47

typical duration of migraine wo aura

4-72 hr adult
2-72 hr peds

48

common sympx assoc w migraine

nausea vomiting
photophobia phonophobia

49

typical duration of migraine aura

5-60 min

50

tf
migraine aura can consist of aphasia

t
can consist of lots of things

51

routine ladder of migraine pharm mgmt

motrin (nsaid ibuprofen)
tylenol (acetaminophen)
triptans
dhe dihydroergotamine if intractible

prochlorperazine
metoclopramide for n/v

52

Motrin ibuprofen moa

Reversibly -| cox1 and 2
v prostaglandin precursors
antipyretic, analgesic, antiinflam

53

reversibly -| cox1 and 2
v prostaglandin precursors
antipyretic, analgesic, antiinflam

name that drug

nsaids (Motrin ibuprofen)

54

Motrin generic

ibuprofen nsaid

55

Tylenol generic

acetaminophen

56

Tylenol acetaminophen moa

Reversibly -| cox in cns
v prostaglandin precursors
analgesic not antiinflam
inactivated peripherally
antipyretic by -| hypothalamic temp center

57

Compazine generic

prochlorperazine

58

prochlorperazine moa

-| mesolimbic D1 D2 including chemoreceptor zone (antipsychotic (1st gen) antiemetic... anxiolytic)
-|a
-|AchR
-|hypothalamic and hypophyseal hormone release

59

metochlopramide moa

--| D
-| 5ht serotonin R in chemoreceptor CNS brain
potentiates response to Ach in upper GI for motility w/o secretions... also inc LES tone

60

dhe
dihydroergotamine moa

-| a
vasoconstricts

61

tf
triptans
nsaids
coffee
can all cause med overuse headache

T

62

acute migraine therapies work best when

administered ASAP at first aura or symptoms

63

vitamin you can try supplementing in peds migraine
and SE of this supplement

B2
orange urine

64

typical peds tension headache duration

30min - 7 days

65

tf
there is no n/v assoc w tension headache

t
a diagnostic criteria

66

tf
there is no photo or phonophobia w tension headache

fish
there can be one or none but not both

67

peds migraine ppx ladder

amitryptiline best studied
propanalol
topiramate

68

diathesis

~predisposition basically

"hereditary or constitutional predisposition to a disease or other disorder"

69

what FH puts pt at risk for breast cancer

1st degree relative

70

does the USPSTF recommend breast self exams

no (2016)

just increases number of biopsies

71

does USPSTF recommend clinical breast exams

no - insufficient evidence.. but do in pt w symptoms

but ACS does, q3 for 20-40, q1 ^40yo

72

bmi formula

kg/m^2

73

for what body types is BMI not a good estimate of obesity

extremes of
height
and
muscle mass

74

BMI categories

underweight v18.5
normal v25
overweight v30
moderate obesity v35
severe v40
very severe (morbid) ^40

75

another body measure other than BMI assoc w risk of HTN, DM, HLD, CHD

waist circumference
^88cm 35 in F
^102c, 40in M

76

visual inspection for __ in breast exam

skin changes
erythema
retractions
dimpling
nipple changes

77

maneuver to accentuate skin retraction or dimpling of brest

ask pt to lift hands overhead

78

breast exam starts sitting up or lying down

sitting up for inspection

lying down with hands over head for palpation

79

perform a clinical breast exam

pt sit up
lower gown to waist
inspect for skin changes (erythema, retractions, dimpling, nipple changes... asymmetry), lift hands over head to accentuate

lie down for palpation in vertical strips lateral to medial

palpate axillary and supraclavicular nodes

80

perform a pelvic speculum exam

table to 30-45
heels in stirrups adjusted
cover to knees
slide down to edge, let knees fall to side

inspect
palpate labia maj and min

warm and lubricated speculum (warm water or minimal gel away from tip -- distorts cytology)
peace sign to spread introitus below, inert spec at 45 down, rotate horizontal, continue to insert until handle at perineum
open to visualize cervix

inspect vag wall and cerv
spatula 720, brush 180, get squamo-columnar junction

withdraw, clear cervix, close, withdraw rotating 45

81

tf
bimanual exam to screen for ovarian cancer

f
not to screen
to eval symptomatic pt

82

preform a pelvic bimanual exam

lub index and middle non dom gloved hand
palpate cervix for tenderness and motion
use dom hand not gloved to palp uterus, ovaries (difficult in obese or tense woman)

83

describe a normal bimanual exam

cervix freely moveable nontender
uterus normal size and position
ovaries not palpable (maybe palpable in slender woman)

84

cervical cancer screening guidelines

21-29yo q3y
30-65yo q5y if cotested for HPV, or q3 if cytology alone -- stop after 65 if normal last 3 paps + cyt or last 2 paps + hpv

more freq if immunosuppresed, HIV, CIN hx, DES exposure in utero diethylstilbestrol

85

what is a total hysterectomy

remove uterus and cervix

86

what is a salpingoopherectomy

remove
fallopian tubes (salpinx)
and ovaries

87

risks for cervical cancer

early sex
multiple partners
immunosuppressed
smoking
DES in utero

88

tf
smoking is independently correlated w 4x inc risk of cervical cancer

t

89

possible pap results

normal
LSIL low grade squamous epithelial cell
HSIL high grade
AGUS atyp glandular cell of undetermined sig
ASCUS atyp squam cell undetermined sig

90

reflex f/u to ASCUS pap

HPV PCR using pap cells

atyp squam cell undet sig

91

sensitive test means few...

false negatives
(detects positive disease well)

92

specific test means few...

false positives
(detects negative disease well)

93

this test to screen these pts for lung cancer

low-dose CT
55-80yo w 30py smoking hx

94

tf
screen routinely for ovarian cancer

f
don't screen asymptomatic women's ovaries USPSTF

95

key was that USPSTF differs from specialist society guidelines

USPSTF is strictly evidence-based

societies introduce expert opinion as well (and therefore bias)

96

screening mammo USPSTF guidelines

q2y 50-74yo
can start early depending on pt context

97

key breast lump hx

location
how noticed
how long
nip disch
change size (menstural?)

98

describe breast lump

number
firmness
mobility
size
borders

99

next diagnostic step cystic vs solid breast lump

fna cyst
vs
mammo solid

100

imaging to determine cystic from solid breast mass

us

101

causes of nip disch

preg
excessive stim

prolactinoma
brca
hormonal imbalance
trauma
abscess
meds (antidep, antipsych, antihtn, opiates)

102

workup nip disch

mammo
us
ductogram
bx

imaging

prolactin lvl for milky

103

what age group has more false negatives mammo

young
denser breasts
harder to find abnorms

104

tf
mammo involves radiation

t
but negligible amount modernly

105

when is breast MRI indicated

screen if ^20% lifetime risk (gene testing, pedigree, radiation for hodgkin)
further dx of brca dx
w contrast for implants -- mammo difficult

106

indications for breast US

eval abnorms
not for aymptx screening

107

tf
breast us used for screening

f
eval abnorms
not for asympx screen

108

brca risks

FH
prolongued E v12 ^45yo, late first preg
genes BRCA 1 or 2
age
female
inc breast density
DHE in utero
radiation
obesity
excess alcohol

109

is high or low breast density a risk for brca

high density

110

dec brca risk assoc

late menarche
early menopause
early preg
high parity
SERMs NSAIDs ASA

111

what dietary intervention prevents brca

dec alc
that's it

112

avg age, range menopause

51 (40-60)

113

confirm menopause

no menstuation 12 consec mos

114

duration of perimenopause

2-8 yrs

115

perimenopauseal sympx

irregular menst
hot flashes
vaginal dryness
mood swings

116

how long do perimenopausal hot flashes last

30sec-10min

117

most common mood swing perimenopause

depression

118

calcium for women

1000mg pre menopause
1200mg postmenopause

ideally thru 3-4 servings dairy

119

inc calcium intake risks...

atherosclerosis
kidney stones

120

osteoporosis screening USPSTF 2016

^65 DEXA dual energy xr absorptiometry
v65 use fx risk tool, screen equivalent risk to 65 yo women no risks (9.3% in 10 years)

121

OP risks

vE (eraly menopause)
sedentary
prev adult fx
FH OP fx
smoking
white

122

tf
black is risk for OP

f
white

123

tf
obesity is risk for OP

f
obesity high E actually protective

but inc risk for OA

124

tf
best to limit both saturated and trans fats

t
but sat worse
pack together

125

recommendation for healthy breakfast

whole grain
fruit
dairy or lean protein

126

6 stages of change

precontemplation
contemplation
preparation
action
maintenance
relapse

127

when is mammo's earliest detection relative to brca sympx?

1-2 years prior to mass palpable

128

USPSTF when to screen for DM

vs ADA

htn ^ 135/80

BMI ^25

129

tf
cluster ha rare in peds

t
1/10,000

130

what route of admin of triptans is most effective in peds

intranasal or dissolving tablet
preferred to po tablet
(possibly due to migraine assoc w GI absorptive issues...)

131

combined OCPs are CI in what kind of migraine

migraine w aura (estrogen is a problem..)

132

rhinosinusitis on diff for what kind of h/a syndrome

cluster headache

133

Flonase
generic
moa
use

fluticasone
corticosteroid nasal spray - antiinflammatory
allergic rhinitis

134

tf
eye strain (refractive error) is a common cause of primary headache syndrome

f
evidence not good
maybe triggers, but not a Cause...
don't hang your hat on it

135

tf
obesity is a risk factor for breast cancer

t

136

Gardasil is a vaccination against

HPV

137

HPV vaccination approved for ages

9-26

138

HPV vaccination names, strain coverage, how many shots, recommended age, approved age

Gardasil 6 11 16 18
Cervarix 16 18 31 45
3 shots both
recommended for females 11-18 ideally before sexual debut but approved for M & F 9-26 regardless of sexual activity

139

tf
sexual activity is a contraindication to HPV vaccination

f
optimally before or shortly after debut, but not a CI

140

4 letter mnemonic for preventive visits

RISE
risk immunize screen ed
risk factors
immunizations
screening tests
education

141

6 most freq causes of death for 55 yo M in no order

cancer
heart disease
injury
Dm
chronic lung
chronic liver

142

tf
travel history is important to obtain when working up an adult for CV disease

f

143

guidelines for freq of ASCVD risk factor assessment in pts free of ASCVD

q6-7 yrs in adult 20-79yo free of ASCVD

144

tf
recommendation for an annual preventive visit and physical exam is evidence-based

f
no RCTs
but 65% primary care agrees annual physical is necessary

periodic exams, not necessarily annually, for younger healthy adults, is reasonable -- pts w chronic illness should also schedule periodic PREVENTIVE visits, not just disease management

145

tf
heart auscultation and routine labs are recommended for annual well-exams

tf
no evidence
but pts expect
physicians often provide

146

info for pt who does not wear seatbelt

don't want to preach, but
MVA common cause of death
restraints can save life
can be a good driver and get hit by a bad driver
most accidents occur within 25 miles of home -- frequent territory

147

three C's of addiction

compulsion
control lacked
continue despite adversity

148

5 a's of counseling behavior change

ask about the behavior
assess interest
advise - give options
assist motivation
arrange f/u

149

wellbutrin generic moa

buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion

150

zyban generic moa

buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion

151

budeprion generic moa

buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion

152

3 antidepressants commercial for buproprion used for smoking cessation

wellbutrin, zyban, budeprion
block NE and D reuptake
(antidepressant)
NuDoprion

153

Chantix generic moa

varenicline
partial neuronal a4 B2 receptor agonist that blocks nicotine stim of mesolimbic dopaminergic pathway, less dopa stim than nicotine, decreased craving and withdrawal

some S (serotonin) agonism of unknown sig as well

154

2 common oral pharm aids for smoking cessation

buproprion (wellbutrin = zyban = budeprion) NE D reup antag

verenicline (Chantix) partial nicotinic agonist

155

how helpful are oral meds such as buproprion (wellbutrin zyban budeprion) and varenicline (Chantix) for smoking cessation?

1.5-3x success of placebo for 12 month quit rate

fyi 2-3% quit rate wo med intervention

meds best in combo w group or on-on-one problem solving skills, social support, relaxation techniques etc

156

1st line pharm for smoking cessation

budoprion
varenicline has more SEs and reserved for budoprion failure or specific request

157

good types of questions to assess alcohol misuse, beyond quantifying

CAGE
felt need to Cut down?
Annoyed at critics?
Guilty feelings ever?
Eye opener ever?

diff folks diff susceptibility to alcoholism. best advice, don't do it

also
friends fam ever express concern?
ever miss work because drinking?

158

is a glass of red wine good for you?

speculative
cultural studies confounded by lifestyle, exercise, diet, etc

mod alcohol known to raise HDL, but exercise or niacin (B3) can do that better

alc and resveratol may reduce platelet stickiness, but aspirin can do that better

research merited, consumption not recommended now, especially if taking other meds

159

mnemonic for dietary assessment

WAVE
weight, activity, variety (pyramid/groups), excess - salt, sugar (carbs), fat, cholesterol

160

tf
important to include sat and sun in food diary

t
often eat different on weekends

161

casual 3 q screen for intimate partner violence

f/u w 4q screen if concern

tell me about living situation
how are you getting along
do you feel safe at home

SAFE
Stress/safe do you feel
Afraid/abused have you ever
Friends/fam are they aware/supportive
Emergency plan do you have one, place to go, resources

162

2016 USA adult obesity rate

25%

163

BMI is used clinically as a surrogate for

% body fat

164

high total body fat is a risk for

DM
HTN
DLD dislipidemia
CVD

165

what body fat distribution is higher risk for CAD

abdominal
so measure waist and waist/hip circumference ratio

166

physical exam findings of dyslipidemia

-corneal arcus aka arcus senilis = ch dep in corneal stroma anterior to border of iris, white, gray, or blue, opaque
-xanthelasma =ch dep in skin typ around eye
-acanthosis nigracans = hyperpig of skin typ body folds

167

pe findings of atherosclerosis

carotid bruit
dec peripheral pulse

168

mnemonic for suspicious skin lesions

ABCDE
assym
border irreg
color non-uniform
diam ^6mm
evolution

169

tf
zoster vaccine recommended for elderly

t
one does at 60yo

170

are varicella and zoster the same thing?

f
varicella = chicken pox kids
zoster = herpes zoster = shingles elderly

both caused by varicella-zoster virus

171

vaccines CI in immunocompromise, close contacts, and pregnant women

live attenuated ones
VZV
MMR
OPV (oral polio vacc)

172

strategy for keeping up with literature in family med

follow guidelines
read up on changes, see if you agree

173

USPSTF grading system

A - substantial benefit
B - high certainty of moderate-substantial benefit
C - benefit negligible
D - No benefit or risks outweigh benefit
I - insufficient evidence

A & B recommended

174

sti screen for sexually active men

HIV
syphilis
chlamydia
gonorrhea

consider hep B and C

175

tf
genital herpes screen routine for sexually active male

f
only if symptomatic

176

opt-out HIV testing recommended by

the CDC

177

tf
HIV testing requires informed consent

tf
only in some states
otherwise opt-out -- tell pt it is routine and do it unless they refuse it

178

USPSTF grade for PSA screening

D - harms outweigh benefit
in average risk male
no demonstrated reduction in prostate ca deaths;
ED, bowel and bladder incont, false positive psych effect

societies suggest informed decision w doc

large RCT US and EU pending

one study suggested 1 prevented death takes 1055 screens and 37 treated cancers

179

patient practical concerns w colonoscopy

laxative prep
ride home (sedated)

180

CRC screen guide

50-75 yo
w
FOBT
sigmoidoscopy or colonoscopy

181

reasonable to check fasting lipids in adults over 21 how often

q4-6y
fasting = 8 hours after last meal

182

when to screen well adult for OSA

obese

183

when to screen well adult for CKD

htn
with BMP

184

when to screen well adult for DM

age 45
or overweight BMI ^25

185

interpret EKG

RRAHI
rate
rhythm segments intervals
axis r wave progress
Q waves STD STE IT

186

tf
can consider exercise stress test in asymptomatic male

t
^45yo plus one of
DLD
HTN
smoking
FH early CAD

good prognosticinfo

187

ischemia EKG

STD

188

acute MI EKG

STE

189

prior infarct EKG

q wave
^ 25% R wave
^ 0.04 seconds

190

ischemia vs
acute MI vs
prior MI
on ekg

STD
STE
Q waves

191

instructions for buproprion smoking cess

set quit date
start bup 1 week prior
1 qd 3 days, then 1bid morn and eve
stop smoking on date
add nicotine gum for bad cravings
after 2 mos on pills, gradually stop

1800 quit now
smokefree.gov
try partnering up

192

how to handle "door handle" situation

quickly assess whether issue is life-threatening or requiring early follow-up. If not, at least ask a brief question to acknowledge the concern. Can have appropriate conversation at next visit.

193

patient has one or two v1cm tubular adenoma polyps with low-grade dysplasia on colonoscopy, recommend fu

colonoscopy in 5-10 years

194

what is a "small" polyp on colonoscopy

v1cm

195

manage high risk for ASCVD

asa 81mg
statin med-high dose

196

tf
location is a predictive factor for melanoma

f
ABCDE
assym
border irreg
color not same throughout
diameter ^6mm
evolving changing

197

chloraseptic sore throat spray generic and moa

phenol
depresses cutaneous receptors -- local anesthesia

198

metaxalone moa

general depression of CNS
centrally acting muscle relaxant

199

metolazone class moa

thiazide diuretic
inhib distal tub na k resorb
leads to h secretion in cd I think

200

elidel generic moa uses

pimecrolimus
topical calcineurin inhibitor
(blocks proinflammatory cytokine transcription)
atopic dermatitis
off label lichen planus, psoriasis, vitiligo

201

triamcinolone topical moa uses

corticosteroid-responsive dermatoses
topical corticosteroid
induces PLA2 inhibitory proteins and thus inhibs release of AA and multiple inflammatory mediators kinins, histamines, pg.
antiinflam, aintipuritic, vasoconstrictive

202

ivermecitn use

antihelminthic

203

phymatous

sebaceous gland overgrowth

204

what is rosacea

skin disorder of various manifestations primarily localized over central face
4 types -- erythematotelangiectatic, papulopustular, phymatous, ocular

205

centor criteria

tonsilar exudates
tender anterior cervical LAN
fever by history
absence of cough
modified - +1 age 3-14, -1 age ^45

likelihood of GAS group A strep inc w number of criteria (v3 unlikely GAS and should not get abx or dx testing)
Big study of 200,000, 1 crit 7% GAS, 2 21%, 3 38%, 4 57% GAS

206

Afrin generic moa

oxymetazoline
stims a, vasoconstriction

207

% presenting acute pharyngitis that gets abx for GAS vs % presenting acute pharyngitis that is GAS

70%
5-15%

208

RADT in context of strep

rapid antigen detecting test
rapid strep test

209

tessalon generic moa and use

benzonatate
antitussive
via topical anesthesia of airway stretch receptors

210

mucinex generic use moa

guaifenesin
expectorant +- antitussive
via hydration and decreased viscosity of resp mucus facilitating clearance but maintaining sol lyer for ciliary clearance

also inhib cough reflex hypersensitivity in URTI prob via sputum volum barrier to cough receptors

211

spell the word for frequent loose stool

diarrhea

212

augmentin generic

amoxicillin clavalunate

213

what is a neti pot

container to use home saltwater solution to drain in one nostril out the other ew

214

valium generic class

diazepam
benzodiazepine

215

Percocet generic

oxycodone acetaminophen

216

medicalese for breast pain

mastalgia

217

tf
it is common for brca to cause breast pain

f
uncommon, unless inflammatory breast cancer -- visually obvious

218

1st line tx mastalgia

analgesics
supportive bra

219

7 causes of non-cyclical mastalgia

large pendulous
diet lifestyle nonspecific
post MP HRT
ductal ectasia
mastitis
inflammatory brca
hidradentitis suppurativa (acne inversa, occlusive follicular)

220

ductal ectasia
define
sx
tx

distended subareolar ducts due to inflammation not infection
-fev local pain tenderness from lipid penetration of duct wall
-Tylenol, ibuprof advil motrin prn, maybe try abx, sg and option but rarely necessary

221

how long pre bedtime to avoid alc and caffeine for good sleep

4-6 hours

222

how common is sleep apnea in the elderly

20-70%
common

223

breif definition rem sleep behavior disorder

sleep enactment behaviors from loss of REM atonia

224

what demo w hyperthyroidism frequently do not present w typical sx tachycardia weight loss and may require lab studies to detect the problem

elderly

225

advanced sleep phase syndrome define
typical demo

circadian rhythm progresses forward till drowsy 6-7pm waking 3-4am

common in elderly

226

tf
alc is an effective sleep aid

tf
initial sleep-inducing, few hours later stimulant/wake-up effect as levels fall

227

how to regulate diet for sleep hygiene

avoid heavy, spicy, sugary foods 4-6 hours before bedtime

a light milk or banana snack before bed may help (tryptophan)

228

tf
exercise helps deepen sleep

tf
can
but careful, within 2 hours of bed can impair sleep

229

what to do if can't sleep

if can't sleep in 15-20 min or wake up and can't get back to sleep in 15-20 min
leave bedroom
tryptophan snack milk banana
quiet reading, bath, other quiet, not challenging

230

Ambien generic moa use

zolpidem
BZD1/GABA receptor agonist (not BZD class)
sedative hypnotic
(not anxiolytic, myorelaxant, anticonvulsant... BZD2 for those)

insomnia

231

define cognitive restructuring

psychotherapeutic learning to id and dispute irrational or maladaptive thoughts (cognitive distortions) eg splitting magical thinking over-generalization, magnification, emotional reasoning

232

define emotional reasoning

cognitive distortion in which person concludes that their emotional reaction proves something is true -- amplifies other cognitive distortions

233

define magnification type cognitive distortion

mountain of molehill
over-reactive
histrionic

234

sleep restriction vs
sleep compression
therapy for insomnia

restrict in-bed time to recent average sleep time, no more. As sleep efficiency inc q5d can inc in-bed time by 15-20min till optimal sleep time

dec time in bed gradually to match total sleep time

235

safest most efficacious hypnotic drugs for elderly insomnia

zolpidem Ambien (non-BZD)
melatonin-r agonists

antihist, antidep, anticonv, antipsych BEERS more risk than bene in elderly

236

common insomnia causes

environment not conducive
drugs alc caf
osa
parasomnias (restles leg, periodic leg, rem sleep behavior)
sleep-wake disturb jetlag night shift
psych anx dep
CP CHF COPD asthma
pain pruritus
GERD
hyperthy
adv sleep phase synd

237

tylenol pm generic moa uses

acetaminophen
diphenhydramine
-competitive H1 antagonist GI blood vessels resp tract... anticholinergic and sedative too

occasional insomnia
allergies
antitussive
motion sickness
parkinsonism
common cold rhinitis/snz

238

% US w hypothyroid

5%

239

tf
htn
asthma
associated w depression

f
not more than genpop

240

% Parkinson disease that gets depression sx

60%

241

quick assessment of cognitive skill in pt w dimentia

mini cog > mmse
-orientation, mem, attn., naming, commands, write sentence, copy shape)

242

define hematochezia

brbpr
bright red blood per rectum

vs melena

243

gender more likely to attempt suicide

F

244

gender more likely to complete suicide

M

245

how do we know that physicians need to proactively ask about suicidal ideations in elderly?

75% of elderly suicides visited a PCP within the preceding month

246

tf
poverty is a risk factor for suicide

f
not by itself
rich folks get suicidal all the time

247

tf
ethnic minority is a risk for suicide

f
just no
but low socioeconomic status a risk for depression

248

MDD diagnostic criteria

5/9 sigecaps nearly every day ^2wks
sleep insom hypersom
interest anhedonia
guilt inappropriate worthless
energy down fatigue
concentration down
appetite change
psychomotor retardation
suicidal ideation recurrent or attempt

^ 2 mos grief loss

249

female
isolation
widowed divorced separated
low socioec
chronic disease
uncontrolled pain
insomnia
functional impairment
cognitive impairment
risks for...

depression

250

tf
bringing up suicide topic may increase suicidality

f
allows opportunity to intervene

251

mnemonic for assessing suicide risk
and intervention needed

SAD PERSONS
sex male
age v19 ^45
depression
previous attempt
ethanol/substance abuse
rational think impaired psychosis etc
social support lack
organized plan
no sig other
sickness

4-6 outpt tx, 7-10 hospitalize

252

6 SSRIs generic and comm

citalopram Celexa
escitalopram Lexapro
fluoxetine Prozac
fluvoxamine Luvox
paroxetine Paxil
sertraline Zoloft

253

TCA moa
4 generic and comm

snri
nortriptyline Pamelor
amitriptyline
clomipramine Anafranil
doxepin Sinequan

254

MAOI moa
2 generic and comm

block sn catab
phenelzine Nardil
tranylcypromine Parnate

255

2 SNRIs generic comm

venlafaxine Effexor
Duloxetine Cymbalta

256

4 classes of antidepressants

SSRIs
TCAs
MAOIs
SNRIs
some random others

257

common SEs of SSRIs SNRIs

headaches
sleep disturbance drowsy vs insom
GI naus vom
serotonin syndrome (leth, restles, hypertonic, rhabdo, renal failure, death risk)
GI bleeding
SIADH - hyponatremiasex dysfunc
falls in elderly
cit escit can cause QT prolong but not usually symptomatic

258

antidepressant class known to cause arrhythmias

TCAs
notrip amitrip clomip doxep

259

tf
ssris snris cause arthralgias

f
but depressed often complain of arthralgias

260

optimal approach to mgmt. major depresson

biopsychosocial
bio psycho social
pharm ssri or snri (9-12 mos initial, 2-3y recurrent, continuous multiple recurrences or elderly)
psychother CBT or interpersonal
id stressors, exercise

combo med and counsel best

ECT safe and effective, for psychotic depression or refractory nonpsychotic depression

261

how do antidepressants cause drug-drug interactions

through p450 system

262

ssri preg cat D

Paxil paroxetine
evidence of human fetal risk

most other ssris are preg cat C no human evidence but animal evidence however can use if benefit may outweigh risk

263

antidepressant discontinuation syndrome

20% pts after abrupt discont after at least 6 wks on, more likely w longer
flu-like sx
insom
naus
imbalance
sens disturb
hyperarousal

mild 1-2 wks, rapid extinguish w restart antidep

264

screen for medical causes of depression

CBC - anemia, vit defic
CMP - e-, renal, hepatic
TSH - hypothyroid

optional:
ESR - rheum
EKG - certain drugs eg TCAs QT prolong

265

common drug classes that can cause depression as SE

cv drugs
chemo
antiPD
antipsychotic
antianxiety/sedatives
anticonvulsant
antiinflam / antiinfect
stimulants
hormones
others others others`

266

model for eliciting pt perspective on illness

ESFT
Explanatory model of illness from pt perspective
Social and financial barriers to adherence
Fears and concerns about illness or recommended treatment
Therapeutic contracting and playback

267

tf
immigrant Hispanics higher rates of depression than US-born hispanics

f
US born higher rates -- comparable to other ethnic groups

Immigrants lower rates

268

define sandwich generation

caring for both parents and children

269

tf
dementia is a risk factor for abuse

t

270

tf
elder's dependency is a risk for abuse

f
but Caregiver's dependence on elder Is a risk

271

onset of effect of SSRI

perhaps as soon as 1 wk, full effects not till about 2 mos

272

adherence rate of elderly to antidepressant med

50%
so discuss challenges to adherence up front, answer questions, educate, etc

273

how do these differ in grief vs depression
guilt
thoughts of death
worthlessness
psychomotor retard
functional impairment
hallucinations

guilt - just actions taken or not at time of death
thoughts of death - just better of dead or wishing died with other
worthlessness - morbid preoccupation in MDD
psychomotor retard - marked in MDD
functional impairment - marked and prolongued in MDD
hallucinations - just voice/image of deceased

274

tf
suicidal behaviors increase with age

f
behaviors don't
but completions do
increase w age

275

most common means of suicide in elderly

medication od

276

what etiologies of depression fatigue does CBC screen for

anemia
nutrition deficiencies

277

define "fully weight-bearing" eg in acute ankle inj pt

can take 4 steps independently

278

tf
hearing a snap or tear is diagnostically significant in an acute ankle injury

f
acute knee
not acute ankle

279

6 p's of limb threatening injury

pain
pallor
pulseless
paresthesia
perishing cold (inability to reg own body temp)
paralysis

280

how long post injury can acute pain and swelling limit physical exam?

48 hours

281

tf
acute ankle injury is one of most common MSK injuries in athletes and sedentary

T
20% of all sports injuries

282

this comprises 20% of all sports injuries in the US

acute ankle injury

283

next on diff after lateral ankle sprain?

peroneal tendon tear
also due to inversion injury often occurs w lat ank sprain

284

peroneus muscles and tendons
origin
course
insertion
function
nerve
a
compartments

peroneus aka fibularis
-longus: fibular head, along fib, tendon post lat malleolus across bottom of foot to 1st cune and 1st met
-brevis: mid and dist 2/3 fib, joins long tendon post lat malle insert lat tuberosity of prox 5th met
-tertius: dist med fib joins ext pol longus tendon along dorsum to dorsal prox 5th met

long brev lat comp sup fib/pero n fib a evert plantarflex

tert ant comp deep fib n ant tib a evert dorsiflex

285

peroneal in the leg aka

fubular

286

diff fibular fracture from lat ankle sprain or peroneal tendon tear

more inability to walk, more pain, more deformity, xr

287

big concern w talar dome fx

avascular necrosis from interruption of blood supply -- can miss on first xr repeat imaging if sx persist

288

instability in acute ankle sprain suggests...
maneuvers to test...

ATFL + CFL tears
PTFL is strongest lateral lig and rarely injured in inversion sprain

anterior drawer ATFL
inversion stress CFL

289

medial ligament of ankle aka

deltoid ligament 4 parts
PTTL
TCL
TNL
ATTL

290

what stabilizes medial ankle

DL (PTTL TCL TNL ATTL)
bony mortise

291

define mortise

recess cut into a part (mortise) to receive a corresponding projection (tenon)

aka the ankle joint

292

factors in grading ankle sprain

lig tear
loss of function
pain severity
swelling severity
ecchymosis
weight bearing

293

grade ankle sprain

I - stretch/small tear, mild tend swell, slight to no funct imp, no instability
II - incomplete tear, mod funct imp, mod tend swell ecchymosis, mildmod instability
III - complete tear, severe swell (^4cm) ecchymosis, no weight bear, instability (no definite stopping point)

294

% ankle injuries to ed turn out to be significant fractures

15%

295

indications to image acute ankle or foot

ottowa rules (evidence based)
ankle xr if malleolar pain And one:
-bone tend post edge lat malle (med or lat)
-non-weight bearing immediate and ED

foot xr if midfoot pain And one:
-bone tend prox 5th met or navicular
-non-weight bearing immediate and ED

296

how sensitive are the ottowa rules

97-100%
for adults 18 and up
recently for 5 and up too

297

name midfoot bones

navicular w 3 wise cuneiforms distal
cuboid the retard laterally

298

test for high ankle sprain

cross leg test
(tests tib-fib syndesposis... AITFL PITFL)

299

tf
ankle sprains can take as long as fractures to heal

t

300

RICE for most MSK injuries stands for

rest
ice
elevation
compression

also ibuprofen with food (NSAIDS > placebo)

301

how long to Rice in ankle sprain

72 hours or less
may help with reduction of swelling and healing, then stretch, move, use
-too much rest dec ROM, persistent pain, swelling, chronic instability

302

best ankle support for sprain

aircast - semirigid for flex ext but limited inv ev

better than tape, elastic wrape

soft lace-up brace less support but good for mild w prev sprain or returning to sports

303

what exercises in particular help reduce reinjury of ankle

proprioceptive exercises

304

in for referral of acute ankle from fam med

fx disloc sublux
tendon rupt
syndesmotic inj
nv comp
wound pene
locking
sx disproport to traum
unclear dx

305

rule out vaginal infection

pelvic exam and wet prep

306

what is a vaginal wet prep

vaginal discharge observed w wet mount microscopy

307

tf
in young f w typical sx of LUTI an no signs of UUTI you want + LE and + nitrates in UA before give abx

f
can treat empirically, uncomplicated UTIs common in young F

308

demo for acute achilles tendon rupture

middle-aged males
(weekend warriors)

309

how does acute achilles tendon rupture present differently from lateral ankle sprain

no inversion or trauma
e.g. middle-aged weekend warrior lands on ball of foot after taking shot, hears pop and immediate posterior pain

310

next step in mgmt. when compartment syndrome suspected

emergent fasciotomy
(maybe manometry if not so so concerning...)
DON'T WAIT can lose limb to ischemia

311

what has more weight in treating for UTI, constellation of sx or UA

constellation of sx
empiric tmp/smx 1tab bid 3d

312

cv causes of palpitations

arrhythmia
cardiomyopathy
hypovolemia

313

psych causes of palpitations

anxiety
panic attack

314

medication causes of palpitations

caffeine
stimulants
theophylline
albuterol

315

substance causes of palpitations

tobacco
caffeine
alcohol intox or withdraw
cocaine

316

endocrine causes of palpitations

hyperthy
pheo
hypogly

317

hematologic causes of palpitations

anemia

318

infectious causes of palpitations

febrile illness

319

heart beating
fast vs
hard

likely etiologies

fast more likely path (espec irregular) - anxiety, arrhythmia... but most folks w arrhythmia don't complain of palps

hard - strong emotion, caffeine or other stimulant

320

tf
most folks w arrhythmia complain of palpitations

f
most do not
more anxiety (fast) or emotion/stimulant (hard)... but arrhythmia prob if irregular
but KEEP ON DIFFERENTIAL for fast

321

2 quickest q's to screen for depression

bothered by feeling
down depressed hopless?
little interest or pleasure in doing things?

0 not at all 1 several days 2 more than half the days 3 nearly every day
score 0-6 w ppv 0 15% 6 79%

that's PHQ-2, if 2+ complete full PHQ-9

322


PHQ in context of PHQ2 or PHQ9 stands for

patient health questionnaire - for MDD

323

diff hyperthyroid from anxiety
as cause of palpitations

both
tachy, tremulous, irritable, weak, fatige

hyperthy only
weight loss change stools (freq loose) change menses (light)

324

pts w anemia severe enough to cause tachycardia typically also report...

positional diziness

325

assoc signs and sx that suggest intoxication as cause of palpitations

dilated pupils
inc energy
inc bp
erratic behavior

326

tf
constipation is a sx of hyperthyroid

f
freq loose stools

327

tf heavy periods are a sx of hyperthyroid

f
lighter periods

328

hyperthyroid
7 common sx
4 less common but possible

heat intol
tachyc
fatig
weight los
tremor
sweating
exertional dyspnea

depression hyperreflexia freq loose stool light periods

329

lid lag

eyelid lags to adjust to eye movement eg look down have to blink to get eyelid down too
sign of hyperthyroidism

330

how does hyperthyroidism cause dyspnea

inc catab inc O2 consumption

331

7 causes of goiter

lack of idoine (#1 cause ww)
hypothy (e.g. hashimoto)
hyperthy (e.g. graves)
nodules
thyroid ca
pregnancy (slight enlargement)
thyroiditis (tender or nontender)

332

tendon in gentle ___ to elicit reflex

gentle extension (stretched slightly)

333

most common cause of hyperthyroidism in adults and children

toxic diffuse goiter (graves) - 60-80% majority
5% toxic nodular goiter
less thyroiditis, excess iodine (diet, amiodarone) causing thyroiditis

334

toxic diffuse goiter
aka
pathogenesis
findings

graves
ai ab to TSH-R
stims excess TH synth and release
hyperthyroidism
exopthalmos
pretibial myxedema (dep of hyaluronic acid in dermis and sub-cu)

335

multi vs solitary nodular goiter demos freq

multi common ^40yo usually asymptomatic only 5% ca

single younger e.g. iodine deficiency

336

thyroiditis pathogenesis

viral illness, pregnancy, excess iodine (diet med amiodarone)
inflamed thyroid hormone leaks out

337

main objective in eval thyroid nodules
red flags

exclude malig (US and FNA)
(5% malig)

M, v20 ^65yo, rapid growth, dysphag neck pain hoarse (local invasion), hx rad to head neck, fh thy ca polyposis (gardener's - FAP var AD gi polyps, osteomas, skin soft tiss benign tumors)

338

Gardener syndrome

FAP familial adenomatous polyposis variant
AD
GI polyps, osteomas, skin soft tiss tumors

339

FAP familial adenomatous polyposis variant
AD
GI polyps, osteomas, skin soft tiss tumors

Gardener syndrome

340

causes of tender vs nontender thyroiditis

tender
infarct radiation trauma

nontender
ai med idiopathic fibrotic

341

drugs of drug-induced thyroiditis

amiodarone
IFN-a
IL-2
Li+

342

tf
thyroiditis always causes hyperthyroidism

f
eu hyper or hypo

343

how is radioactive iodine uptake affected in thyroiditis

usually reduced uptake
but can be eu hyper hypo thyroid

344

tf
TSH is usually sufficient to dx hyperthyroid or hypothyroid

t
but if primary pit path does not reflect circulating th so need to get T4 as well

345

TSH mildly elevated (5-10)
serum free T4 normal
dx

subclinical hypothyroidism

346

TSH normal
free T4 increased
dx

pit adenoma or
TH resistance

347

TSH inc
free T4 dec
dx

hypothyroidism

348

TSH dec
free T4 inc
dx

hyperthyroidism

349

TSH dec
free T4 dec
dx

central pit hypothyroidism
aka TSH or TRH deficiency

350

TSH dec
free T4 normal
T3 inc
dx

T3 toxicosis

351

TSH dec T4 inc, sx of hyperthy
next step?

propanalol (BB) for sx relief
radioactive I uptake test and scan (inc graves hot nodule, dec thyroiditis cold nodule)
antithyrotropin releasing abs (graves)

352

normal RAIU

radioactive iodine uptake
15-30% ingested dose

353

difference between TRAb vs TPOAb in graves vs hashimoto

TRAb anti thyrotropin (receptor) releasing antibody
97%sn 99%sp for graves

TPOAb anti TPO ab
elevated in 90% hashimoto 75% graves

354

when to get thyroid US

thryoid nodules
enlargement

NOT hyperthyroid -- RAIU TRAb for that

355

why RAIU inc in graves

synth more th need more i

356

TRAb stands for
signifies

anti thyrotropin releasing antibiody
ab against TSH receptor stims TH synth and release

357

gender predom
age predom
graves

F 5-10x
(AI duh) - stress, high I intake, recent preg
40-60yo
anti thyrotropin releasing antibiody
ab against TSH receptor stims TH synth and release

358

most common manifestations of graves opthalmopathy are

eyelid retraction
exopthalmos

359

primary sx of eye manifestations of graves, when they occur, are related to

corneal irritation from eyelid retraction

360

tf
eye signs and sx of graves always bilateral

f
Mostly bilateral
but can be unilateral

361

tf
tx of hyperthyroidism improves eye manifestations of graves

f
does not cure eyes
some worsen after radioactive iodine... ppx w oral steroids after tx

362

tf
more than 50% graves pts have clinically sig eye problems

f
50% eye involv on MRI
only 20-30% clinically relevant

363

graves
mgmt

1st line (but pt pref.. euro med, us radio)
methimazole blocks ox of i and thereby T4 T3
1% agranulocytosis watch out
some improv 1 mo, 3 mos to full effect
stay on, dose fluctuates so freq bloodwork to check

2nd line
oral RAI - localized
few se... possible slight vasc mort or thy ca (preg breast feed CI absolute - damage to fetal infant thyroid -- no preg 6 mos post tx no fathering 4 mos post tx)... stay away from v3yo kids and pregs 21 days post tx... flush toilet 2x excrete urine and sweat
eventual thyroid supplement w 1-2x/y bloodwork for dosing, but easy to manage usually

3rd line - sx

364

methimazole moa

blocks oxidation of iodine and thereby T4 T3

365

RAI radioactive iodine
tx
f/u

preg test
1m from v3yo preggos 21 days post dose
avoid in general don't share bathrooms urine stool excr
transient soreness of neck or worsening sx resolve few days, some worsening eye sx

f/u remove propanolol if prescribed, q2-3mos blood draws till level stabilizes then q6mos+, alert to hypothy sx (weight gain cold intol pedal edema heavy periods fatigue) as will need supplementation at some point

366

common hypothyroid sx

fatigue
cold intol
weight gain
pedal edema
heavy periods

367

thryoxine aka

T4

368

start thyroid replacement

typical starting dose levothyroxine 1.5-1.8 mcg/kg
inc dose slowly, repeat TSH 6 wks
when TSH stable can check 1-2x annually

369

tf
gynecomastia is seen in graves

t
10-40% pts
inc sex hormone binding globulins we think

370

what % hyperthyroidism due to nodules

5%
usually asymptomatic

371

tf
most thyroid nodules are asymptomatic

t

372

tf
PaO2 is impacted in blood loss

f

373

tf
platelet count is impacted in blood loss

f

374

tf
LDH is elevated in gi blood loss anemia

f
elevated in hemolytic anemia

375

symptomatic hyperglycemia =

polyuria
polydipsia

376

relevant hx in diabetic

age and characteristics at onset
-polyu polyd, dka, hhs, retinopathy on exam
tx prev current response
nutrition exercise
DM education
hypergly hypogly episodes awareness
microvasc compx retinop nephrop neurop
-sensory, foot lesions, ans dysfunc sexual gastroparesis
psychosocial depression
dental

377

diabetic exam and labs

bp
dilated eye exam
foot exam
a1c
ldl
urine screen for nephropathy

378

tf
DM 1 and 2 both cause the same end damage and complications

t

379

organs to think about in DM

blood vessels

eyes heart brain nerves sensation autonomics

380

diabetics __ times more likely to suffer heart disease or stroke

2-4 times

381

tf
diabetes considered equivalent risk to prev MI

t
2-4 times more likely to have heart disease
worse outcomes after MI

382

most common cause of blindness among adults of working age

diabetes

383

prevalence of retinopathy in DM

40% pts requiring insulin
25% on oral agents

384

how long w DM does retinopathy dev

15 years
all T1DM
67% T2DM

385

tf
by the time vision is affected in DM substantial retinal damage may have already occurred

t

386

classifications of neuropathy

focal
diffuse
sensory
motor
autonomic

387

prevalence of neuropathy in DM
define

loss of ankle jerk reflex
7% 1 year
50% 25 years

for both T1 and T2 DM

388

% DM develop diabetic nephropathy

20-40%

389

most common cause of ESRD

DM
44% of cases in 2005

390

what type of DM more often develops
DKA
vs
HHS

T1DM - DKA
T2DM - HHS... but DKA possible when B cells exhausted insulin deficient eg elderly w longstanding T2DM acutely ill w pneumonia

391

HHS vs DKA which is life-threatening requiring prompt mgmt

both

392

mortality rate w HHS vs DKA

HHS 15% but up to 30% w serious infection
DKA 2% u65yo up to 22% ^65yo

393

tf
HHS in T2DM causes metabolic acidosis

f
pH ^7.3

DKA causes met ac

394

plasma glucose levels in HHS vs DKA

^600 HHS
~250 DKA

395

ketones in HHS vs DKA

absent or mild HHS
ketosis DKA

396

physical findings in HHS

severe dehydration
-excess 9L fluid deficit w serum osmolality ^320mOsm/kg

fluid replacement is key

397

most common cause of HHS in T2DM
and some other ones

infection aka pna uti w dec fluid intake

also stroke MI PE

398

who to screen for DM

ADA
overweight or obese + 1 other risk factor
or 45 yo regardless
q3 years afterward if 1st negative

USPSTF
sustained bp ^135/80 (B)
insufficient evidence if normotensive (I)

399

routine dx of DM

-randome gluc 200mg/dl + sx polyu polyd unexplained weight loss etc
-fasting gluc 126 repeat unless obvious sx
-hba1c 6.5 repeat unless obvious sx
-OGTT more sns more spec than fasting but difficult and poorly reproducible, not recommended for routine clinical use

400

% US pop w DM in 2011
raw US total w DM
% ^20yo w DM
% ^65yo w DM

8%
26 Million (19dxd 7undxd)
11%
26%

401

racial/ethnic risk factors for DM

native americans
african americans
latin americans
pacific islanders

402

dx prediabetes aka
why important to ID

impaired fasting glucose
fasting gluc 100-126
OGGT 2h 140-200

end-organ damage already occurring
can delay or prevent progression w lifestyle mod (lesser degree w medicine)

403

DM risk reduction in prediabetics after
intensive lifestyle mod
vs
info and metformin

58% risk reduction (11 year delay)
vs
31% risk reduction

404

5 biggies on physical exam for diabetes

eyes
thyroid (dz can contribute to DM, HLD)
heart
lungs
feet

405

tx diabetic retinopathy

laser photocoagulation
slows progression
does not restore lost vision

406

fundascopic findings in diabetic retinopathy

retinal hemorrhages (partial obstruction and infarct)
cotton wool spots (prior infarct)
microaneurysms (vascular dilation)
neovascularization = proliferative retinopathy = very bad

407

JNC 7 and 8 HTN classes

v120/80 normo
v140/90 pre
v160/100 stage 1 HTN
^160/100 stage 2 HTN

408

diabetic foot exam

inspect color hair loss scaling
inspect abrasions calluses ulcers infection
inspect bony abnorms
inspect footwear abnorm wear patterns and sizing
sense touch monofilament pinprick vibratory temp changes
pulses dorsalis pedis post tibial
achilles reflex

409

monofilament exam for DM

start by demonstrated on pt arm, observe buckling, sensation
close eyes
say now when feels pressure
test big toe 1st 3rd 5th metatarsal heads randomly on both feet

410

vibratory sns exam for DM

toe
then wrist, compare
can also compare sides

411

what to consider for abnorm vib or sense exam in DM

protective footwear
in addition to meds and lifestyle

412

hba1c represents

4-12 wk plasma gluc conc (via hb glycoscylation)

413

how often to get HbA1c in DM

2x/y pt stable meeting a1c goal v7
4x/y pt therapy changing or not meeting goal

414

why
how often
and how
to screen for diabetic nephropathy in DM

assess renal insuff, possible need to adjust renally excreted drugs to avoid tox (eg met ac from metformin)

annually

spot urine alb/cr ratio for microalbuminuria
serum cr and calculated GFR for monitor/stage CKD

415

when to get fingerstick glucose for DM in family med

if pt acutely complaining of hypergly or hypogly sx
(not useful for assessing glycemic control... a1c for that)

416

SE to monitor in metformin

tox from progressing renal insufficiency altering appropriate dose

B12 deficiency (unknown cause.. just data)

417

when to order TSH screen in DM

T1DM wo TSH in past year
new dx DLD
F ^50yo

418

tf
fasting lipid profile is important to obtain in DM family med

t
DLD common in DM

419

normal serum cholesterol

v200 mg/dl

420

normal fasting glucose

74-100 mg/dl

421

normal TSH

.4-4.2 microIU/ml

422

tf
controlling glucose as close to normal 4-6% a1c as possible has evidence of improving CVD outcomes that matter to pts

f
prevents microvascular retinopathy nephropathy
unclear if macrovascular benefit
(so goal is close to or less than 7% and tailor to pt aviod hypoglycemia and weight gain)
but lowering blood pressure v140/90 does macrovasc MI stroke mortality benefit

423

leading cause of death in DM

ASCVD

424

when to give statin in DM
what intensity

mod-intense statin for DM age 40-75

high-intense statin for DM age 40-75 and 7.5% 10 year ASCVD risk score

^21yo w LDL ^190 with or without DM

425

when to consider aspirin for DM

same as non DM
hx CVD
inc risk (men^50 F^60 w +1 other risk)

(dec chance MI or stroke should outweigh inc chance of GI bleed)

426

baby aspirin
dose
alternative if allergic

81mg aspirin
75mg clopidogrel

427

ADA algorithm for mgmt of T2DM

at dx a1c^6.5 = lifestyle + metformin
at assessment a1c^8 = add sulfonylurea (glyburide glipizide glemipiride) or basal insulin (insulin glargine [Lantus] insulin detemir [Levemir]) on intermediate-acting insulin (NPH)
at reassessment a1c^8 = add insulin if not already or intensify insulin; consider discont sulfonylurea to avoid hypoglycemia

then time to explore other tx options

428

tf
initiation of insulin should be viewed as a failure by physician or pt

f
course of disease that b cells function dec
that would be setting up for failure
can create barrier to insulin initiation

429

tf
dental care is important in DM

t
inc gluc in saliva
immunosuppression
periodontal disease can inc heart disease

430

vaccs for DM

flu like urbody else
pneumococcus for everyone, revacc if neprhotic, CKD, immunocompromise and at age 65 if last more than 5 years ago
Hep B for DM HIV other immunocompromise liver dz

431

yearly dilated retinal exam sensitive for detecting

retinal thickening from
macular edema or
early neovascularization

432

when to get optho consult for dilated retinal exam in DM

annually starting 5y post dx for T1DM
annually starting at time of dx for T2DM
(20% already getting retinopathy)

433

factors that contribute to hyperglycemia

overeating
missed med
dehydration
infection
illness
stress

434

dx DM by OGTT

^200 2h post 75g glucose load

435

blurry vision in DM due to...

macular edema

436

transient dark spots in vision in DM due to...

retinal vessel hemorrhage

437

tf
glaucoma more likely in people w DM

t
40% more likely
assoc w nausea headache narrow vision halos around lights

438

AMS ddx in T2DM

HHS - dehydration gluc ^600 phv7.0
korsakoff syndrome - thiamine def alcoholic malnutrition
stroke - FND

439

1st line antihtn in DM
goal bp JNC8

ACEI renoprotective
v140/90

440

of htn dm obesity smoking
which causes the most deaths in us

smoking
single greatest contributor to death in US
450,000 annual premature smoking and 2nd hand smoke deaths
(lung cancer, MI, COPD)

300,000 Obesity (dec life expect mean6y R2-20y)
213,000 DM (CVD CKD)
20,000 HTN (uncontrolled dec LE 20y) (CAD, hypertensive cardiomyopathy, CVD, CKD)

441

key difference between leg swelling from
cellulitis lymphedema DVT
vs
venous insufficiency PAD

unilateral
vs
bilateral

442

tf
lymphedema can be unilateral
but
venous insufficiency is usually bilateral

t

443

tf
cellulitis always has fever

f
can be localized w/o fever

444

general diff b/tw strep and staph cellulitis

strep small breaks of skin
staph large wounds ulcers abscesses

445

tf
DVT is palpable

tf
sometimes cord of thrombosed vein palpable

446

Homan's sign

pain on passive dorsiflexion foot
classic sign of DVT
but low predictive value - msk inj, cellulitis, venous insuff too

447

PAD what area does it describe

anything distal to arch of aorta

448

ankle brachial index consistent w PAD

v0.9

449

greatest modifiable risk factor for PAD

cigarette smoking
odds inc 1.4 q10cigs/day

450

rate of PAD in DM

half of pts w DM 20+ ys
usually below knees

451

how is d-dimer used in context of dvt

best to r/o dvt if pretest probability low
eg by Well's criteria
-ca w/in 6 mos
-paralysis paresis -immobilization
-bed ridden 3 days recently (within 4 wks)
-entire leg swollen
-calf swelling ^3cm measured 10cm below tibial tuberosity vs contralat
-pitting edema
-collateral superficial (not varicose) veins
-alternative dx not more likely

low prob 0, mod prob 1-2, hi prob 3+

452

DVT
reflex cxr?

f
not without respiratory sx

453

precedes diabetic foot ulcer

pressure callus

454

grade diabetic foot ulcer by wegner system
and manage each

1 - skin - outpt deb care pres rel
2 - soft tissue - outpt deb care pres rel
3 - bone/abscess - eval osteomy PAD hospit
4 - forefoot gangrene - hosp, sg consx
5 - extensive gangrene - hosp, sg consx

455

% PE from DVT VTE

95%

456

deaths due to PE occur in what timeframe

within 1-2 hours usually

457

to treat DVT on outpt basis

pt must
hemodynamically stable
good kidney function
low bleed risk
stable supportive home env
access to daily INR monitoring

458

tf
pt must not be on home O2 for outpt dvt mgmt

f
can be on home O2

459

tf
pt must not be diabetic for outpt dvt mgmt

f
can be diabetic

460

goals of DVT therapy
treat

stop clot
resolve clot
prevent clot

heparin or LMWH

461

advantages of LMWH vs unfractionated heparin

LMWH
longer t1/2 so qd or bid sq
no lab monitoring
less thrombocytopenia
dosing fixed
can use outpt

462

tf
dosing is fixed w heparin

f
that's LMWH

463

tf
lab monitoring is required with heparin

t
but not w LMWH

464

tf
heparin may be used in outpt

f
LMWH can

465

how is heparin administered

iv
"heparin drip"

466

dose warfarin in an adult

5-10mg qd
titrate to INR 2-3 q3-7d

467

how long to anticoagulate first idiopathic (unprovoked) DVT VTE PE in low risk pt

6 months at least

468

how long to anticoagulate first DVT/PE provoked by sx or transient factor

what if bleeding risk is moderate?

3 mos

still 3 mos
for low to mod bleed risk

469

how long to anticoagulate first DVT/PE unprovoked

6+ mos if low mod bleed risk
3 mos if bleed risk high

470

how long to anticoagulate first DVT/PE if assoc w active ca

6+ mos

471

what does it mean that LMWH dosing is fixed

once adjusted for body weight,
no further adjusting based on lab monitoring

472

tf
fixed dosing means everyone gets same dose

f
same dose/body weight
and then no adjusting based on labs necessary

473

how are pts w inherited coagulation disorders managed diff from others after first DVT/PE

indefinite anticoagulation

474

when to screen for inherited thrombophilia

1st thrombosis v50yo wo risk factor IDd
FH VTE
recurrent thrombosis
thrombosis in unusual vascular beds

475

tf
colon cancer is a risk of obesity

t

476

tf
gallbladder dz is a risk of obesity

t

477

tf
stroke is a risk of obesity

t

478

how many days for warfarin to reach steady state

5-7 days
(t1/2 40 hours.... x4 = 6.6 days)

479

when to check INR after starting?

~3 days
before steady state (5-7 days... t1/2 40 hours)
to make sure not supratherapeutic
but if subtherapeutic give more time

480

INR 11
what to do re warfarin regimen?

stop
give vit K 5mg orally to reduce INR (if INR^9)

significant bleed risk

481

what to do if warfarin INR supratherapeutic but not bleeding

5-9 no other bleed risk factors omit 1-2 doses
5-9 w other bleed risk factors omit 1-2 doses
---and give oral vit K 1-2.5mg)
9-20 omit several doses, give oral vit K 3-5mg
---monitor repeat K prn restart warf when down
^20 treat as bleed refer to ED

482

what to bridge to warfarin
when to stop bridge

UFH LMWH fondaparinux
5 days And INR therapeutic ^24h

483

when can steroid injections help OA

when there is joint inflammation

484

when to start screening for htn per USPSTF 2016

age 18

485

define htn

140/90 v60yo
150/90 ^60yo

486

end-organ damage in htn

stroke TIA
retinopathy
LVH angina MI HF
CKD
PAD

487

how does smoking contribute to CV disease

inc BP
interacts w CV drugs

488

what recreational drugs commonly affect bp

cocaine ketamine
narcotic withdrawal
smoking
alcohol

489

renal CV risk factors

microalbuminuria
GFR v60

490

how does stress contribute to bp

stim release of NE and AT II

491

tf
hx glaucoma is essential info in new htn dx

f

492

% US htn
essential (primary, idiopathic)
vs
secondary (identifiable cause)

95-98% essential

493

dx htn

2 elevated measurements 5 min apart
one each arm (r/o aortic anomaly)
two or more visits
not ill
beware whitecoat htn, get home measurements maybs

494

standardized BP measurement

seated quietly w back supported 5+ min
arm supported at heart level
cuff bladder length 80+% arm circ
width cuff 40+% arm circ

495

tf
for standardized BP measurement most adults should get adult-sized cuff

f
most adults now fat
may require xl or thigh-sized cuff

496

funduscopic findings to watch for in htn
which is a hypertensive emergency

a-v nicking
cotton wool spots (infarct)
flame hemorrhage
exudates (fatty dep)
papilledema (htn emergency)

497

panniculus

fat jelly rolls

498

medical for fat jelly roles

panniculus

499

manage htn in adult
(^18yo)

LIFESTYLE +
non-black v60yo
-ACEI ARB CCB or thiazide goal v140/90
black v60yo
-CCB or thiazide goal v140/90
^60yo
-ACEI ARB CCB or thiazide goal v150/90
w CKD
-ACEI or ARB goal v140/90
w DM
-ACEI ARB CCB or thiazide goal v140/90

500

tf
can consider BB AB loop hydralazine (vasodilator) clonidine (central a2 agonist) for initial mgmt of htn

f
ACEI ARB CCB or thiazide initial mgmt.

BB AB worse outcomes in studies
loops, vasodilators, central a2ag not sufficient data

501

tf
CKD or DM elevates the target BP in htn mgmt

f
just age (v60y 140/90 ^60y 150/90)

502

most cost-effective antihtn drug

hydrochlorothiazide HCTZ $4.30/mo

503

joint dz to watch for w thiazide diuretic

gout (hyperuricemia)

504

hydrochlorothiazide is what class of drug

thiazide diuretic antihtn

505

how does age influence urinary incontinence

dec bladder capacity
dec awareness to void
dec detrusor and pelvic floor muscle strength
incomplete emptying
atrophic urethra changes

506

tf
50mg HCTZ dec BP m and m more than 25mg

f
not per evidence

507

starting dose for HCTZ in elderly

6.25-12.5mg low does avoid hypotension
most other adults can start at 25mg

508

when is HCTZ not the antihtn of choice

in CKD
(ACEI ARB)

509

second best prognostic factor for death in all people

LVH
all people with or without htn

(age is #1 duh)

510

labs to get at dx of htn

EKG for arrhythmia IHD LVH
UA for protein glucose alb/cr raio
blood glucose
hematocrit for low can make ischemia risk
K+ ele for CI to ACEI ARB KSD
----- cushing hyperaldo
Cr
9-12h fasting lipid panel for metabolic syndrome
serum Ca for nephrolithiasis hyperPTH

511

antihtns that cause hyperkalemia

ACEI ARB KSD

512

lifestyle mod to dec BP most

weight loss

513

fascia lata of the thigh

deep fascia of thigh
encloses thigh muscles
separates with intermuscular septa
thickened laterally into IT band

514

IT band

iliotibial band / tract
fibrous thickening of latral aspect of fascia lata
associated with muscles that extend abduct externally rotate hip and laterally stabilize knee
origin anterolat iliac tub
imsert lat tib gerdy cond w glut max and tens fasc lat

515

normal fasting glucose range

65-100

516

normal plasma sodium

135-145

517

normal plasma K

3.5-5

518

normal plasma Cl

95-105

519

normal BUN

7-21

520

normal Cr

.8-1.3

521

normal total cholesterol

120-200

522

normal triglycerides

70-150

523

normal HDL

45-100

524

normal LDL

v100

525

normal lipid panel

T CH 120-200
TAG 70-150
HDL 45-100
LDL v100

526

tf
two arms needed for HTN monitoring

f
not for monitoring
but for SCREENING for HTN and aortic anom

527

what is considered an "elevated" 10 year ASCVD risk

^7.5%

528

in 2016, on what do we base cholesterol management

ASCVD risk score
(pooled data from large cohort studies)

529

USPTF aspirin recommendation

start in
men 45-79 to reduce MI
women 55-79 to reduce ischemic stroke

530

tf
according to JNC8
you can manage htn by
maximizing 1 med before starting another or
starting another before 1st maxed
starting 2 at the same time

t
all acceptable
but maximize double combo before starting 3rd

531

tf
doses of HCTZ above 25mg demonstrate improvement in BP and morb mort

f
25mg max useful dose per evidence

532

what to watch for in HCTZ pts

hyponatremia
gout

533

tf
BBs mask hypoglycemic strokes so avoid in DM pts

f
evidence not there in real world clinical situations

534

antihtn med to avoid in asthmatics

BB

535

to check before starting BB

EKG
pulse

536

BBs especially good antihtn in context of

tachyarrhythmia/fib
migraine
essential tremor
periop htn

537

tf
avoid BB in heart block

tish
3rd degree heart block

538

what degree is complete heart block

3rd degree

539

to watch in ACEI

K Na Cr (Cr up 35% allowed)
bradykinin cough in 15-20%
angioedema
avoid in pregnancy

540

first line antihtn in DM and kidney disease

ACEI

541

antihtn w heart remodeling effects

ACEI ARB

542

antihtn reduce albuminuria

ACEI ARB

543

to watch in ARB

avoid in pregnancy

544

tf
ARB causes bradykinin cough in 15-20%

f
ARB much less so than ACEI

545

antihtn potentially useful in raynauds

CCBs

546

to watch in CCB

leg edema (15-30%)
CI short acting CCBs in essential htn and rug emerg

547

to watch in aldo antag

hyperkalemia
avoid in K^5 prior to start
(goes for K sparing diuretics too)

548

a-blocker use as antihtn

only as adjunct for refractory bp
possibly BPH but not first line

549

tf
prev and sev of htn is inc in AAs

t

550

special antihtn consideratin in AAs

less responsive to BB ACEI ARB
and more (2-4x) angioedema from ACEI
so prefer CCB and diuretics
unless CKD or 3rd or 4th line needed

551

ethnic groups w lowest BP control rates

mexican american
native american

552

when to consider referral to specialist for htn

can consider when
lifestyle mods appropriately adjusted and
not controlled to goal after 2 meds maxed
or CHF htnnephropathy or other end-organ damage

553

tf
htn = elevated blood pressure

f
htn is a diagnosis that requires 2 separate readings ^140/90 at least 1 wk apart

elevated bp is what you call one high read

554

preferred antihtn if known CAD or previous MI

BB thiazide

555

pt drinks 1-2 beers 5 days/week
will alc chess improve bp?

f
mod alc actually improves bp 2-4mmhg

but don't encourage non-drinker to drink... could get problematic

556

DASH diet stands for

dietary approaches to stop hypertension
(NIH-sponsored)

557

tf
avoid ACEI in AAs, even those w DM

t
htn in AAs may not be ATII dependent
as it is in others
and AAs 2-4x more angioedema w ACEI

558

mnemonic for symptom characterization

OPQRSTA
onset
provocation palliation
wuality
radiation
severity
temporal elements
associated sx

559

where can anginal pain radiate

neck throat jaw teeth
UE shoulder

560

tf
wide radiation of chest pain increases chances it is MI related

t