Family Medicine 1 Flashcards
(560 cards)
1
Q
coracoid process ant or post to acromioclavicular joint?
A
ant
2
Q
which articulates w clavicle, coracoid or acromion
A
acromion
acromioclavicular joint
3
Q
apley scratch test
A
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
Q
roughly what are the normal limits of full shoulder range of motion
A
flex 180 abduct 180 ext rot 90 int rot 90 apley over down to c7 apley under up to t7
5
Q
empty can jobe test
A
flex humerus
int rot shoulder
pronate forearm
upward against resistance
pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear
6
Q
empty can test aka
A
jobe test
7
Q
jobe test aka
A
empty can test
8
Q
coracoacromio arch formed by
A
coracoacromial ligament
9
Q
neers test
A
empty can position with passive motion 90-180 flexion
pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear
10
Q
empty can test vs neer test
A
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
Q
hawkins-kennedy test
A
shoulder ff 90 int rot bend elbow passive further int rot
drives greater humeral tuberosity under coracoacromial arch, impinging supraspinatus tendon
12
Q
rotator cuff tendons
A
sits supraspinatus infraspinatus teres minor subscapularis
13
Q
speeds test
A
shoulder
ff 90
supinate
resist downwards force
pain suggests biceps tendon or rotator cuff pathology
14
Q
yergason test
A
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
Q
long vs short head biceps tendon relative position
A
long head from supraglenoid tuberosity laterally thru bicipital groove between humeral tuberosities like pulley
short head more anterior and medial from coracoid
16
Q
resisted external rotation of shoulder tests…
A
infraspinatus (more w shoulder neutral) teres minor (more w shoulder abducted 90)
17
Q
posterior liftoff test
A
arm behind back elbow at 90 push away against resistance
tests subscapularis
18
Q
internal rotators of the shoulder
A
Latissimus Dorsi
Pectoralis Major
Subscapularis
Teres Major
19
Q
shoulder ROM tests
A
flex aduct int rot ext rot apley scratch
20
Q
rotator cuff tests
A
empty can / jobe resisted ext rot resisted int rot post liftoff neer hawkins-kennedy
21
Q
biceps tests
A
speed
yergason
22
Q
load and shift test
A
stabilize scap and acromion
shift glenohumeral joint
^50% shift is severely abnorm
23
Q
sulcus sign
A
stabilize scap and ac joint
inf traction down on arm
sulcus appears inf to acromion suggests glenohumeral laxity
24
Q
apprehension test
A
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
