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Flashcards in Family Medicine 2 Deck (207):
1

tf
valvular heart disease can cause palpitations

t

2

tf
palpitations can be atypical presentation of CHD

t
coronary heart disease

3

palpitations affecting sleep or work inc likelihood that they are caused by __

arrhythmia

4

proportion of palpitations caused by

190 pt univ hops study
43% cardiac
31% anxiety/panic
6% prescription or recreational drug

another study found 19% no specific cause

5

another name for menopause

climacteric

6

climacteric means

menopause
(vs critical)

7

some drugs that cause palpitations

caffeine alc tobac cocaine
sympathomimmetics, vasodilators, anticholinergics
BB withdrawal

8

tf
Cushings presents with palpitations

f
it does not

9

DSM-V for panic attack

abrupt surge in fear or discomfort w/in mins
4+ of
palps
sweats
shakes
sob
chokes
chest pain/discomfort
nausea ab discomf
dizzy
chills/heats
paresthesias
derealization depersonalization
fear of losing control / "going crazy"
fear of dying

10

DSM-V for panic disorder

recurrent panic attacks
1+ month of fear of attacks +/- maladaptation

not attributable to drug or another disease

11

most common structural heart abnorm presenting w palpitations
and PE finding

MVP
mid-systolic click w murmur

12

LVH
Q waves in I AVL V456 suggests

HOCM

13

workup palpitation

ekg (dysrrhyth)
24-48hr holter monitor
week-months loop recorder
echo (structural)
cbc (anemia)
tsh (hyperthy)
urine drug screen

14

tf
LDL-c targets dictate statin therapy in 2016

f

15

statin therapy targets what diseases to prevent

stroke
MI

16

what pharmacologic agents are recommended for lowering cholesterol 2016

statins only

17

4 indications for statin

ASCVD (stroke MI UA TIA PVD)
-high intensity statin
40-75y w DM (also consider outside this age)
-Mod intense high if ASCVD risk ^7.5%
^21 w LDL-c ^190 (often genetic)
-high intensity
40-75y w ASCVD risk ^7.5%
-mod or high

18

high intensity statins

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

19

tf
count risk factors to select cholesterol mgmt plan

f
not anymore 2016
based on calculated ASCVD risk

20

tf
angina presentation in women is more likely to be atypical

t
95% F MI report prodrome
only 30% report chest discomfort

21

some characteristics of pain less likely angina

pleuritic - PE PNA pneumothorax pleurisy pleuropericarditis
pulsating
positional - pericarditis pleuritic msk
palpation reproduced - msk

22

prodromal sx of ACS in F

fatigue
dyspnea
neck jaw pain
palps
cough
n/v
indigestion
back pain
dizzy
numb

23

Erikson's stages of human dev

infant - trust / mistrust
toddler - autonomy / shame doubt
preschooler - initiative / guilt
school age - industry / inferiority
adolescent - identity / role confusion
young adult - intimacy / isolation
middle age - generatively / stagnation
elderly - integrity / dispair

24

sandwich generation

caring for children and elderly parents

25

tf
normal keg rules out CAD

f
spec if not symptomatic at exam
may be anginal but not infarct

26

neuro dysreg from stress

noradrenergic
serotonergic probably too

27

when to give baby asa for primary prevention of CAD

50-59y w 10%+ ASCVD risk
not bleed risk
10 year life expectancy
willing to take dose for at least 10 years

28

exercise recommendation for adult

moderate-vigorous 3-4x/wk 40min

29

when is age a risk factor for CAD

45+ men
55+ women

30

when is FH a risk factor for CAD

1st deg relative w CHD
male v55
femal v65

31

35 yo women in good health should be screened for

htn

not CBC TSH CHO HBA1C at this age healthy

32

tf
asa dec risk of ischemic stroke in men

f
ASA prev MI in men, ischemic stroke in women

33

how long does it take for most low back pain to resolve

2-4 weeks

34

low back pain ranks __ for volume of outpatient visits

5th

35

broad differential for low back pain

CT MIIND VV
congenital - scholi kypho spondy
traumatic - strain compress fx
metabolic - OP hyperthy peget osteomalac
infectious - osteomy pyelo discitis herpzos abscess
inflammatory - ank spond sacroiliitis RA
neoplastic - MM mets lymphom leuke osteosarc
degenerative - disc hern OA facet arth spin stenos
vascular - aortic aneur diabetic neurop
visceral - prostatit PID ov cys endometrios kid ston cholecystit pancreatit

36

3 most common causes of low back pain

lumbar strain
disc hern
degenerative joint dz

(all mechanical (97%))
vs far fewer visceral or non-mechanical

37

tf
kidney stones and pyelo are common causes of low back pain

f
most commonly mechanical (strain, disc hern, degen joint)
not visceral

38

red flags for serious low back pain (illness vs neuro compromise)

fever
weight loss
pain at night
bowel bladder incont
neuro sx

39

valsalva can increase low back pain caused by...

herniated disc

40

low back pain improved in supine position suggests

spinal stenosis
disc herniation

41

cauda equina syndrome

always consider in low back pain because perm neuro def possible
large mass effect (disc hern, tumor)
compress cauda equina
pain/numbess radiate down leg
bowblad incont (low on ddx without)

emergent decompression within 72 hours

42

low back pain from mets inc or dec w recumbency?

inc w recumbency
(and cough)

43

ank spondy location

spine and sacroiliiac

44

most common causes of referred lumbar pain men vs women

prostatitis
PID endometriosis

45

order of position for back exam

standing
sitting
supine

46

standing back exam

inspect curvature
check flexion 90, extension 15, side hand to fib
palpate paraspinals
walk heel (L5 disc hern) toe (S1 disc hern)
squat (relieves spinal stenosis)

47

heel walk is difficult with what cause of low back pain

L5 disc hern

48

toe walk is difficult with what cause of low back pain

S1 disk hern

49

squatting relieves back pain assoc w

spinal stenosis

50

side-bend low back pain on same vs opposite side of bend suggests

same side - bone oa or neural compression
op side - muscle strain

51

low back pain w flexion suggest

herniation
oa
muscle spasm

52

low back pain w extension suggest

degen dz
spinal sten

53

seated back exam

CVA tenderness
leg raise
tripod sign
reflexes
motor
sensory

54

grade deep tendon reflexes

0 none
1+ hyporeflexic
2+ normal
3+ hyperreflexic
4+ clonus repeat shortening w one stim

55

nerves of patellar reflex

L3 L4

56

nerves of achilles reflex

L5 S1

57

grade muscle strength

0/5 none
1 flicker not movement
2 movement not antigravity
3 antigravity not resistance
4 overcome some resistance
5/5 normal strength

58

spinal nerves of hip flexion

L234

59

spinal nerves of hip abduction

L45 S1

60

spinal nerves of hip adduction

L234

61

spinal nerves of knee extension

L234

62

spinal nerves of knee flexion

L5 S12

63

spinal nerves of ankle dorsiflexion

L45

64

spinal nerves of ankle plantar flexion

S12

65

spinal nerves of
hip flexion
hip adduction
knee extension
ankle dorsiflexion
hip abduction
knee flexion
ankle plantarflexion

hip flexion L234
hip adduction L234
knee extension L234
ankle dorsiflexion L34
hip abduction L45 S1
knee flexion L5 S12
ankle plantar flexion S12

66

spinal nerve of
great toe sensation
lateral malleolus
posteriolateral foot

great toe sensation L5
lateral malleolus S1
posteriolateral foot S1

67

supine back exam

auscultate bruit AAA
palpate ab/pelv tenderness
rectal exam ONLY in red flags
-masses bleeding (mets) abnorm tone (disc hern cauda equina)
passive SLR
FABER
pelvic compression

68

specify tight hamstrings on SLR

can't SLR to 80 deg
lower slightly, dorsiflex foot - no pain = hamstrings tight
(nerve pain if radiating pain - L5 S1 espec)

69

pain v30deg on SLR suggests

malingering

70

pain opposite of SLR suggests

root compression from central disc hern

71

SLR sn sp compared to MRI

36% sn
74% sp

72

what is "crossed leg raise" pe maneuver

SLR of asymptomatic leg
+ suggests central disc hern
(not sn 25% but highly sp 90% so neg does not rule out but pos virtually diagnostic of disc hern)

73

FABER test

flexion abduction external rotation
(pressure on flexed knee while stabilizing op hip)
hip or si path

74

pelvic compression test

forcibly press hips together
+ causes si pain

75

disc hern pain
exacerbated w
relieved w

inc w sitting or bending
coughing sneezing

dec w lying or standing

76

tf
disc hern can cause foot drop

t
muscle weakeness

77

tf
urinary retention assoc w disc hern

f
cauda equina syndrome

78

pretty comprehensive red flags for low back pain

hx ca
ue wl ^10kg 6 mos
^50 v17 age
persists more than 4-6 wks
night pain rest pain
persistent fever (100.4)
IVDU
UTI PNA cellulitis recently
immunocompromise (DM steroids HIV)
U incont or retent
saddle anesth
anal tone dec fecal incont
bilat le weak numb
progressive FNDs
3/5 muscle weakeness (antigrav not resist)
foot drop
prolongued corticosteroids
mild trauma 50y+, major trauma any age
70y+
OP
prev vert fx

79

cauda equina syndrome red flags

u incont renent
fecal incont dec anal tone
saddle anesth
bilat le numb weak
FNDs progressing

80

cancer low back pain red flags

hx ca
ue wl ^10kg 6 mos
^50 v17 age
persists more than 4-6 wks
night pain rest pain

81

infection low back pain red flags

persistent fever (100.4)
IVDU
UTI PNA cellulitis recently
immunocompromise (DM steroids HIV)
U incont or retent

82

disc hern low back pain red flags

major 3-/5 muscle weakness (not resisted)
foot drop

83

vertebral fx low back pain red flags

prolonged corticosteroids
OP
mild trauma 50y+
major trauma any age
70y+
prev vertebral fx

84

when to get CBC for low back pain

tumor or infection suspected
get ESR too

85

guidelines for low back pain xr

hx trauma
strenuous lifting w OP
prolongued corticosteroids
OP
v20y ^70
hx ca
fever chills wl
pain worse supine night
fx tumor infection suspected

86

MRI indications for low back pain

FND
radiculopathy... not if prob disc hern not progressing?
progressive major motor weakness 3-/5
bowel/bladder cauda equina
suspect mets or infection systemic
failed 6 wks conservative care

87

% hern discs improve w/in 6 wks conservative

75%

88

tf
early MRI assoc w improved outcomes ni pts w acute back pain or radiculopathy

f

89

how to id lumbar vertebra on xr

not rib bearing

90

approach to AP spine xr

count lumbar verts
-non-rib bearing, typically 5 but variable
2 eyes and nose per vert
-pedicles and spinous process
alignment
disc space uniformity
si joint margins
ab/pelv path - kid calcs, vasc calcs, foreign bodies

91

approach to lat spine xr

vert body height uniformity
disk space uniformity (diminish gradually down)
alignment
osteophytes
ab/pelv path - kid calcs, vasc calcs, foreign bodies

92

particular concern in spine xrs

for women ovarian radiation risk equivalent to daily CXR for one year

93

conservative therapy for low back pain

NSAIDs acetaminophen muscle relaxants
moist heat

94

tf
strict bed rest for low back pain

f
encourage to resume normal activities as soon as able

95

tf
physical therapy and spinal manipulation for low back pain

tish
some evidence
safe
but staying active (but avoiding strain) almost as effective

96

manage pt expectation for low back pain treated conservatively

most improve 2-6 wks
(90% resolved 1 mo only 5% persist 3 mo)
recurrence 35-75%
longer recovery time older you get (^45y)
out of work ^6mos only 50% return to work
........^2y ~0% return to work

97

reasonable mgmt options for
low back pain radiculopathy from hern disc progressing slightly after 5 wk conservative mgmt

-refer to surgeon
-continue NSAIDs acetaminophen muscle relaxants moist heat activity not strenuous
-epidural steroid injection

98

lifetime prevalence of low back pain

60-80%

99

L3
reflex
sensation
motor
function

patellar tendon reflex
lateral thigh medial femoral condyle sensation
extend quads
squat/rise

100

L4
reflex
sensation
motor
function

patellar tendon reflex
medial leg and medial ankle sensation
dorsiflex ankle
heel walk

101

L5
reflex
sensation
motor
function

medial hamstring reflex
lateral leg dorsum foot sensation
dorsiflex great toe
heel walk

102

S1
reflex
sensation
motor
function

achilles reflex
post calf foot sole lat ankle sensation
plantarflex ankle
walk on toes

103

point tenderness on spinous process in context of low back pain suggests

vertebral origin
(OP fx, malignancy, etc)

104

male low back pain
malaise chills hesitancy and pain with urination
fever
suggests..
what PE to corroborate

prostatitis
DRE for tenderness over prostate

105

negatively birefringent rods aspirated from joint in

gout

106

positively birefringent rhomboids aspirated from joint in

pseudogout

107

baker's cyst aka

popliteal cyst

108

knee exam
palpate locations
for

patella
quad tendon
patellar tendon
tib tubercle
joint line all around

109

normal knee rom

135 degrees

110

lachman vs ant drawer sign
which tests acl?

both

111

mcmurray test

for meniscal tears (though sn sp questionable)
apply rotation and var/valgus stress while extending knee for pain clunking clicking

112

3 top ddx for peds w knee pain

patellar sublux
tibial apophysitis (osgood schlatter)
patellar tendonitis

113

tf
psoriatic plaques must be present to dx psoriatic arthritis

t
BUT in ~15% cases arthritis appears first so can keep on ddx

114

define oligoarthritis

2-4 joints
(5+ = polyarthritis)

115

synovial wbc in
septic arthritis
vs
gout pseudogout

15k - 200k
vs
3k - 50k

116

popliteal baker cysts often arise in association with

underlying disease such as ra oa

117

ankylosing spondylitis
genotype assoc
joints affected

HLA-B27
lumbar spine, si, hips sometimes

118

accompanying sx to look for in suspected SLE arthritis

fev
rash
raynaud
pleuritis
chest pain

119

to look for in suspected lyme arthritis

prior rash, fever, migratory arthralgia

120

workup of suspected
septic arthritis or
acute inflammatory arthropathy

cbc w diff
ESR
arthrocentesis w cell count diff glue protein cx sns
...polarized light microscopy for crystals

121

ddx arthrocentesis
transudative
hemarthrosis
hemarthrosis w fat globules

transudative - oa degenerative miniscal inj
hemarthrosis - lig ten tear fx
hemarthrosis w fat globules - osteochondral fx

122

ottowa knee rules

xr any of
55y+
isolated patellar tenderness
fibular head tenderness
can't flex 90
can't bear weight immed or ed (4 steps limp ok)

123

when to consider knee MRI

locking popping instability
(cartilage miniscal ligament damage)
but if xr and hx clear oa w js narrowing... can opt out of MRI

124

% US w dxd arthritis

22%

125

tf
exercise improves function and dec pain in OA

t

126

paracetamol generic

acetaminophen
aka tylenol in the UK

127

best 1st choice for short-term mild-mod oa pain

acetaminophen
(tylenol, paracetamol in UK)

toleratbility, low se profile (hepatotox rare if taken approp -- 4gm max/day)

128

intraarticular corticosteroid inj

for inflamed joint (swelling pain)
1/mo max, 3/yr max
long-acting triamcinolone preferred to methylprednisolone
combo 1ml w 3-4ml local anesthetic
rest 24 hr not more
fewer se than nsaids or opiates

129

toradol vs tramadol

toradol = ketorolac = nsaid
tramadol = opioid

130

acupuncture benefit arthritis?

maybe some

131

glucosamine
chondroiotin sulfate
benefit arthritis?

maybe some combined

132

tramadol for joint pain?

opioid
limited by se
modest benefit in older pts moderate-severe pain

133

NSAID cream for joint pain?

better than nothing

134

tf
arthroscopic debridement improves OA pain and function

f
not proven

135

phalen test

press dorsum of hands together 30-60 sec

136

atrophy of thenar eminence in...

long standing untreated carpal tunnel

137

how useful are tinel and phalen when testing for carpal tunnel

somewhat useful
lower sn
high sp
(so will not catch all ct, but if positive likely ct)
nerve conduction velocity study is dx test of choice

138

diagnostic test of choice for carpal tunnel
when to get

nerve conduction velocity study
-expensive uncomfortable
-only do if sx fail conservative tx, motor dysfunction, thenar atrophy

139

PHQ-2
sn
sp

bothered feelling down dep hopeless
bothered little interest or pleasure
+1 = positive
sn 87% sp 78%

f/u w PHQ-9 or other to dx and severity

140

most common se of long acting opioids

constipation
tx w bowel reg lax softeners exercise water fiber

141

what assoc of TCAs makes them CI in pts w CV dz or nerve conduction problems

anticholinergic side effects
dry mouth
urinary reten
constipation
blurred vision

tachyarrhythmias bp changes heart block mi

142

long or short acting opioids higher risk of dependence

short acting

143

tf
anticonvulstants for chronic pain syndromes

f
for trigeminal neuralgia
not other chronic pain evidence lacking

144

what to watch for carbamazepine in young woman

cyp p 450 inducer
OCPs less effective

145

NSAID se's
acute
chronic

GI upset
dec effectiveness of antihtns
inc effect of sulfonylureas

GI ulcers
ESRD
hepatotox, coagulopathy

146

tramadol moa
use
se

centrally acting mu opioid analgesic
stim serotonin release
inhib ne reuptake

control mod severe pain
lower abuse potential than more potent opiods
but still abuse potential

seizures serotonin syndrome resp dep angioedema bronchospasm dependence
constipation nausea dizziness pruritus

147

age range for colorectal cancer screening

50-75

148

stop screening for colorectal cancer at

75

149

age range for screening mammography

50-74 biennially

150

AAA screen recs

men 65-75 smoking hx

151

AAA screening recs in women

none
USPSTF recommend against

152

USPSTF carotid artery stenosis screening in asymptomatic pts

don't screen carotids in asymptomatic pts

153

lipid screening in women

45+ at inc risk for lipid CAD

154

routine thyroid screening?

insuffic ev for or against

155

when to stop cervical cancer screening

65
if adequate screening negative prior

156

best confirmatory test for lyme after joint aspiration

synovial fluid PCR
(not cx, less sensitive for lyme)

157

tf
caution w nsaid use pt on warfarin

t
nsaids can inc effect of anticoagulants

158

tf
caution w nsaid use pt hx h.pylori infection

f
not a CI

159

pt w gout has ci to said and colchicine
next question to guide tx?

number joints involved
1-2 jionts arthrocentesis w intra-articular glucocort inj
polyarticular oral glucocorticoids

160

routine prenatal folic acid dose

400-800mcg
.4-.8mg

1mg DM or epilepsy
4mg prior child w neural tube defect

161

prenatal genetic screen

sickle cell
thalassemia
tay-sachs
cystic fibrosis
non syndromic hearing loss (connexin-26)

162

prenatal ID screen

HIV
syphilis
Hep B immunization
rubella varicella immunization
toxoplasmosis - avoid cat litter, garden soil, raw meat
CMV parvovirus B19 (fifth dz) - hand washing

163

environmental toxins to avoid prenatally

paint thinners pesticides
tobacco smoke
alcoholism drugs

164

medical adjustments prenatally

DM - control, folic acid 1mg, stop ACEI
HTN - avoid ACEI ARB thiazide dour
Epilepsy - control, folic acid 1mg
DVT - switch warfarin to heparin
Depression/Anxiety - avoid BZD

165

lifestyle mod prenatally

regular moderate exercise
avoid hot tubs hyperthermia
caution obesity underweight
screen domestic violence
assess nutritional risk
-- vegan pica milk intol ca fe deficiency
avoid Vit A overuse (2500 - 10000 IU)
avoid Vit D overuse(600 - 4000 IU)
limit caffeine 2 cups coffee

166

goodell's sign

softening of cervix in pregnancy

167

hegar's sign

softening of uterus in pregnancy

168

Chadwick's sign

purpling of cervix and vaginal walls in pregnancy
-hyperemia

169

when is enlarged uterus first palpable by experienced examiner

8 wks gestation on bimanual exam

170

when is uterine funds palpable above pubis symphysis

12 wks gestation

171

when is uterine measurement used to approximate gestational age

20-36wks

172

quickening

fetal movement
detected by mother 18-20wks gestation

173

when are fetal heart tones elicited

hand-held doppler 10-12 wks gestation

174

what is a medical abortion process like

two-step
first pill in office, not usually noticeable
second pill at home 2-3 days later, cramping and heavy bleeding within hours
f/u one week later

175

Naegele's Rule for calculating estimated due date

first day of LNMP
add 1 year
subtract 3 mos
add 1 wk

176

early in prey, which is higher, urine or serum hCG?

serum hCG

177

when to give RhoGAM (RhoD Immune Globulin)

RH- mother any bleeding episode during pregnancy, regardless of gestational age

178

ectropion

turned out
eg eyelid or cervix

179

how many pregnant pts experience vaginal bleeding in first trimester

1/4

180

chance of miscarriage when significantly bleeding in first trimester

25-50%

181

tf
most pregnant pts have mild leukocytosis

t

182

when is progesterone level useful to get in preg

ectopic v5
sustainable intrauterine preg ^25
between not too helpful

so extreme values useful

183

when is hCG secreted by trophoblastic cells

day 7 post ovulation
(early embryonic life)

184

ddx higher than normal vs lower than normal hCG

higher mole multiple test
lower ectopic spontaneous abortion

185

most definitive pregnancy diagnosis

hCG quant
pelvic us

186

3 most common causes of bleeding early in preg

spontaneous abort
ectopic
idiopathic in viable pregnancy

187

cervical os dilated w obvious bleeding early in prey suggests

spontaneous abortion

188

distended acute abdomen w vaginal bleeding early in pregnancy suggests

ruptured ectopic

189

at what b-hCG level can US detect intrauterine pregnancy reliably?

b-hCG ^1500

190

patient becomes unstable w
unstable spontaneous abortion
ruptured ectopic

mgmt

unstable spont abort - d&c

ruptured ectopic - laparoscopy or laparotomy

191

gestational trophoblastic dz aka

molar pregnancy
aka placenta acts like a tumor

192

change EGA or EDD based on LNMP if US findings differ?

1st and 2nd trimester, yes.
3rd trimester, fetal size cannot be used to accurately estimate, do not change due date.

193

accuracy of fetal US in predicting EDD

1st tri +/- 1wk
2nd tri +/- 2wk
3rd tri +/- 3 wk

194

define spontaneous abortion

loss of preg w/o outside intervention v20wk gestation

195

define threatened abortion

bleeding before 20wks gestation

196

define inevitable abortion

dilated cervical os....
as compared to threatened abortion or missed abortion (no dilation)

197

define missed abortion

fetal demise w/o cervical dilation and/or uterine activity (often found incidentally on US w/o presentation of bleeding).

198

what to expect w expectant management of inevitable abortion

-watchful waiting w precautions regarding unusual amounts of bleeding or pain fever
-75% effective
-can take up to 1mo for complete expulsion
-can delay emotional closure
-give RhoGam (rhesus immune globulin) for Rh-

199

mgmt options for inevitable abortion

-expectant: 75% effective, can take 2-6 wks
-surgical D&C vs vacuum for pt pref or heavy bleeding
CI pelvic infection
-medical: off-label vaginal misoprostol 95% effective 3-4 days to 2 wks

RhoGam always for Rh- in all cases!

200

some miscarriage stats

about 1/3 pregnancies end in miscarriage

1/2 of 1st tri miscarriages due to chromosomal abnorm

201

tf
miscarriage indicates fertility problem

fish
not necessarily
many successful pregs after miscarriage

87% miscarriages have subseq normal births

202

tf
stress
physical activity
sex

can cause miscarriage

f
no evidence supporting this

203

labs for initial preg eval

CBC RPR HIV Rub type/scren HepB

204

purpose of CBC in initial pregnancy eval

nutritional anemia
congenital anemia
plt disorders

205

tf
CMP routine initial pregnancy eval

f
only ordered as indicated

206

rate of b-hcg increase

doubles q48hr in first 6-7wks gestation if intrauterine preg

less if ectopic

207

how does b-hcg correspond to ability to detect preg on us?

transvag us detects intrauterine preg w b-hcg 1500-1800

transab w b-hcg ^5000