Family Medicine Cases Flashcards

Question

What are the most frequent causes of death for a 55-year old male in the US?

Answer 1

malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis

Answer 2

sedentary lifestyle stress premature family history excess alcohol use and many more...? Recommended to be assessed major risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.

Answer 3

-yearly flu vaccine -one-time dose of Tdap for Td booster for ages 11-64 to provide additional pertussis protection, then boost with Td every 10 years -one dose of zoster vaccine at 60

Answer 4

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA based screening in average risk males results in little or no reduction in prostate cancer related deaths and is associated with harms related to tests, procedures and treatment of the condition, some of which may be unnecessary. Other organizations, such as the American Cancer Society (ACS) recommended that physicians should have a discussion of the potential benefits and harms of screening with a PSA test.

Answer 5

Screening colonoscopy every 10 years. Annual testing of three stools for blood and a flex sig test every 5 years. Double contrast enemas every 5 years. CT colography (experimental)

Answer 6

Asymptomatic male patients over the age of 45 with one or more risk factors (hypercholesterolemia, hypertension, smoking, orfamily history of premature coronary artery disease)

Answer 7

Changes associated with dyslipidemia: corneal arcus, xanthelasmas, acanthosis nigricans Changes associated with atherosclerosis: decreased peripheral pulses, carotid bruit

Answer 8

Horizontal ST segment depression or downsloping ST segment (suggests cardiac ischemia) Convex ST segment elevation (suggests acute myocardial injury) Q waves that are greater than 25% of succeeding R wave and greater than 0.04 seconds (indicates infarction)

Answer 9

Quit rates are highest when patients are engaged in a group setting. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 - 3 times the placebo quit rate. When combined with medication, a series of one-on-one counseling sessions (as in a physician's office), enhances quit rates.

Answer 10

Start aspirin and begin a moderate-to-high intensity statin. An exercise stress test can be considered to further evaluate for the presence of coronary atherosclerosis in a high risk man.

Answer 11

-type of exercise or activity -precautions -specific workloads -duration and frequency -intensity guidelines

Answer 12

Environment not conducive to sleep Sleep apnea Restless leg syndrome Periodic leg movement and REM sleep behavior disorder (the patient experiences involuntary leg movements while falling asleep and during sleep respectively) Disturbances in the sleep-wake cycle Depression and anxiety Shortness of breath due to cardiorespiratory disorders Pain or pruritis GERD Hyperthyroidism Advanced sleep phase syndrome

Answer 13

Sex: white male Age: increases with age Previous attempts

Answer 14

Must have at least five of the following for a minimum of two weeks: SIG E CAPS Sleep or insomnia Interest (loss of) Guilt Energy (decreased) Concentration (decreased) Appetite (either increased or decreased) Psychomotor retardation Suicidal ideation

Answer 15

The mini-cog exam is faster and more sensitive and specific than the MMSE

Answer 16

Headaches, sleep disturbances (drowsiness), GI problems (nausea and diarrhea) Hyponatremia due to SIADH, serotonin syndrome, GI bleeding

Answer 17

-hypothyroidism -Parkinson's disease -dementia

Answer 18

A CMP screens for electrolyte, renal, and hepatic problems TSH, CBC

Answer 19

Sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy Zolpidem and melatonin-receptor agonists

Answer 20

Unusually long half life (two to four days), so effects can last for weeks after discontinuation. Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia

Answer 21

In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders. More gastrointestinal side effects than the other SSRIs.

Answer 22

Strong antianxiety effects. Best studied SSRI in children. Side effects can include significant weight gain, impotence, sedation, and constipation. Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

Answer 23

Particularly useful in obsessive-compulsive disorder. Greater frequency of emesis compared to other SSRIs.

Answer 24

Most common side effects include nausea, dry mouth, and somnolence

Answer 25

Approved specifically for Generalized Anxiety Disorder. Overall, fewer side effects than citalopram.

Answer 26

Pain Pallor Pulselessness Paresthesia Poikilothermia Paralysis Pain (esp disproportionate pain) is often the earliest sign and clinical hallmark of compartment syndrome. However, the loss of normal neurologic sensation (paresthesia) is the most reliable sign)

Answer 27

A patient who seeks help immediately, and is non-weight bearing is more likely to have a severe injury than one who presents a few days after an incident and is fully weight bearing (the ability to take four steps independently). A history of previous ankle sprain is a common risk factor for ankle injury. While hearing a snap or tear is diagnostically significant in an acute knee injury, it is not in an acute ankle injury.

Answer 28

Grading of ankle sprains takes into consideration: the presence/absence of a ligament tear, loss of functional ability, severity of pain, presence and or severity of swelling, presence of ecchymosis, difficulty bearing weight (the ability to take four steps independently) Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress. Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point. Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.

Answer 29

Combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular, and posterior talofibular ligaments are most often damaged. The anterior talofibular ligament is the most easily damaged.

Answer 30

Lateral ankle sprains generally present acutely (after trauma) with pain, warmth, and some swelling. Ankle sprains do not create a deformity. If there is a large amount of swelling present, however, it may appear to be a deformity.

Answer 31

Peroneal tendon tear is typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain. Patient may complain of persistent pain posterior to the lateral malleolus. Swelling may or may not be present. Repetitive trauma may cause injury to the peroneal tendons

Answer 32

Talar dome fracture is usually due to acute injury. Overall prognosis is related to potential for interruption of the blood supply. Talar dome fracture may occur in conjunction with an ankle sprain, and initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis after talar dome fracture.

Answer 33

The rules suggest that radiographs of the ankle are needed if: There is pain in the malleolar zone AND either bony tenderness along the distal 6 cm of the posterior edge of either malleolus OR inability to bear weight 4 steps both immediately after the injury and in the emergency department. Radiographs of the foot are needed if: There is pain in the midfoot region AND one of the following: (a) bony tenderness at either the navicular bone or base of the 5th metatarsal OR (b) inability to bear weight four steps immediately after the injury and in the emergency department.

Answer 34

Semi-rigid ankle support

Answer 35

heat intolerance tachycardia due to increased adrenergic tone and heightened conduction fatigue weight loss due to increased calorigenesis and gut motility causing hyperdefecation and malabsorption tremor increased sweating

Answer 36

(also called proptosis) is the forward projection or bulging of the eye out of the orbit. Most commonly seen in Graves' disease and can be either bilateral or unilateral

Answer 37

Lack of iodine, Hashimoto's, Grave's, nodules, thyroid cancer, pregnancy, thyroiditis

Answer 38

A series of abnormal reflex movements of the foot induced by sudden dorsiflexion causing alternate contraction and relaxation of the gastrocnemius and soleus muscles.

Answer 39

Corneal irritation from eyelid retraction

Answer 40

Eyelid retraction and exophthalmos

Answer 41

Autoimmune disease in which thyrotroptin receptor antibodies are produced. These antibodies stimulate the thyroid gland to enlarge and produce more thyroid hormone.

Answer 42

Weight gain, cold intolerance, pedal edema, heavy periods, and fatigue.

Answer 43

Toxic diffuse goiter, toxic nodular goiter, thyroiditis (thyroid hormone leaks from an inflamed thyroid), excessive iodine ingestion

Answer 44

Radioactive iodine uptake test and scan. Measures the amount and pattern of radioactive iodine taken up by the thyroid in the 24 hours following ingestion of a set dose.

Answer 45

Methimazole is the most commonly used medication to suppress thyroid hormone production. Oral dose of radioactive iodine is the other treatment option.

Answer 46

Agranulocytosis. Requires frequent bloodwork.

Answer 47

Makes most patients hypothyroid. Requires twice yearly bloodwork. Need a pregnancy test before initiation--is teratogenic

Answer 48

Thyroxine (1.5-1.8 mcg per kg), increasing until steady TSH

Answer 49

Cardiovascular disease, retinopathy, neuropathy, nephropathy

Answer 50

IDDM: DKA T2DM: HHS

Answer 51

overweight or obese patients who have one or more of the following risk factors: -physical inactivity -race/ethnicity -first degree relative with diabetes -previously diagnosed impaired fasting flucose (100-125) or impaired glucose tolerance -PCOS -history of gestational diabetes or delivering a baby \>9lbs -A1c \>5.7% -history of cardiovascular disease In the absence of the above risk factors, screening should begin at 45 years of age Repeated at three-year intervals

Answer 52

Asymptomatic adults with sustained blood pressure greater than 135/80

Answer 53

1) random glucose of 200 or above plus symptoms of hyperglycemia like polyuria 2) fasting plasma glucose of greater than or equal to 126 3) A1c greater than or equal to 6.5%

Answer 54

retinal hemorrhages cotton wool spots microaneurysms neovascularization

Answer 55

HHS: not a metabolic acidosis, serum pH is generally 7.3 with a bicarb \> 15, plasma glucose is usually \>600, ketones are absent or only mildly elevated. Severe dehydration with serum osmolality over 320 mOsm DKA: metabolic gap acidosis with a pH

Answer 56

Monitoring diabetic control, assessing end organ damage, monitoring side effects of treatment, and uncovering management complications

Answer 57

A1c levels should be taken at diagnosis, with follow-up testing at least two times per year in patients who are stable and meeting a goal of A1c

Answer 58

spot urine albumin-to-creat ratio for microalbuminuria at diagnosis and annually.

Answer 59

Metformin can cause metabolic acidosis in renal failure. It can also lead to subnormal vitamin B12 levels.

Answer 60

Screening TSH in type 1 diabetics, newly diagnosed dyslipidemia, or women over age 50 as part of a diabetes evaluation

Answer 61

Measurement of fasting lipids is recommended at the time of diagnosis of diabetes and annually for patients on statins. The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following blood cholesterol treatment for patients with diabetes and LDL-c 70-189 mg/dL: · Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (Level of Evidence A). High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated. (Level of Evidence B)· In adults with diabetes mellitus, who are 75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (Level of Evidence C). Note, the ACC/AHA recommends all patients \> 21 years old (with or without diabetes) who have an LDL-c \>190 should be started on statin therapy (Level of Evidence B).

Answer 62

Use aspirin as secondary prevention in diabetes patients with a history of CVD or as a primary prevention strategy in diabetics at increased cardiovascular risk (10-year risk \>10%).

Answer 63

step 1: Diagnosis = HbA1c \>6.5% = lifestyle changes plus Metformin step 2: Assessment. If HbA1c \>8, continue lifestyle changes and metformin plus either add a sulfonylurea or basal insulin step 3: if HbA1c\>8, continue lifestyle changes and Metformin + add basal insulin or intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia

Answer 64

influenza vaccine pneumococcal polysaccharide vaccine hepatitis B vaccine if not previously vaccinated

Answer 65

Type 1: first annual eye exam five years after diagnosis Type 2: when they are first diagnosed

Answer 66

five to seven days

Answer 67

Impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral arterial disease)

Answer 68

Grade 1: diabetic ulcer (superficial) Grade 2: ulcer extension (involving ligament, tendon, joint capsule, or fascia) Grade 3: deep ulcer with abscess or osteomyelitis Grade 4: gangrene forefoot (partial) Grade 5: extensive gangrene of foot

Answer 69

Lymphedema Cellulitis DVT Venous insufficiency Peripheral artery disease

Answer 70

Generally painless, but patients may experience a chronic dull, heavy sensation in the leg. In the early stages, edema is pitting. In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic.

Answer 71

Cellulitis is an acute inflammatory condition of the skin characterized by localized pain erythema, swelling, and heat. Small breaks of skin are associated with strep infection, whereas staph is commonly associated with larger wounds, ulcers, or abscesses.

Answer 72

Swelling, pain, and discoloration in the affected extremity. Physical exam may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation. Classic signs include Homan's sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth. Chronic venous insufficiency may result from DVT and/or valvular incompetence.

Answer 73

Edema of venous insufficiency can be differentiated from chronic lymphadema as venous insufficiency edema is softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli.

Answer 74

PAD is the presence of systemic atherosclerosis in arteries distal to the arch of the aorta. As a result of the atherosclerotic process, patients with PAD develop narrowing of these arteries. PAD patients have a history of claudication. Use ABI to diagnose (\<0.9)

Answer 75

Wells score or criteria: (possible score −2 to 9) ``` Active cancer (treatment within last 6 months or palliative): +1 point Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point Unilateral pitting edema (in symptomatic leg): +1 point Previous documented DVT: +1 point Swelling of entire leg: +1 point Localized tenderness along the deep venous system: +1 point Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point Alternative diagnosis at least as likely: −2 points[4] ``` Those with Wells scores of two or more have a 28% chance of having DVT, those with a lower score have 6% odds. Alternatively, Wells scores can be categorized as high if greater than two, moderate if one or two, and low if less than one, with likelihoods of 53%, 17%, and 5% respectively.

Answer 76

Venous doppler

Answer 77

Grade 1-2: ulcer management can be done as an outpatient and should include extensive debridement, local wound care, and relief of pressure. Treat for infection as needed. Grade 3: require evaluation for possible osteomyelitis as well as peripheral arterial disease Grade 5: require emergent hospitalization and surgical consultation, often resulting in amputation

Answer 78

Patient must be: hemodynamically stable, with good kidney function, and at low risk for bleeding Home enviroment must be stable and supportive, capable of providing the patient with daily access to INR monitoring

Answer 79

LMWH: longer biologic half-life so it can be administered subcutaneously once or twice daily, laboratory monitoring is not required, thrombocytopenia is less likely, dosing is fixed

Answer 80

Monitor warfarin dose by measuring the INR and titrate the warfarin dose every three to seven days to an INR of 2.0-3.0.

Answer 81

For DVT prophylaxis, the recommended method for at-risk patients is LMWH. For those who cannot be anticoagulated, or another agent is recommended, mechanical prophylaxis is an option. Duration is usually until the patient is ambulatory or discharged from the hospital, unless high risk.

Answer 82

- Initial thrombosis occurring prior to age 50 without an immediately identified risk factor - a family history of venous thromboembolism - recurrent venous thrombosis - thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins

Answer 83

Warfarin should be held, and an oral dose of Vitamin K should be given to reduce INR.

Answer 84

Screening for high blood pressure in patients without known hypertension starting at age 18.

Answer 85

Sleep apnea, chronic renal disease, renovascular causes, drug-induced causes, pheochromocytoma, primary aldosteronism, chronic steroid use, Cushing's syndrome, thyroid and parathyroid disease, and coarctation of the aorta.

Answer 86

- BMI - fundoscopic eye exam - carotid, abdominal, and femoral bruits - thyroid gland - lung exam - heart exam - lower extremity exam - baseline neuro assessment

Answer 87

- ECG: look for LVH - urinalysis: proteinuria - blood glucose: for diabetes - hematocrit: anemia may be a product of target organ damage in ESRD - serum potassium: need a baseline before ACE/ARB/diuretic prescription. Also look for Cushing's or primary hyperaldo GFR/creatinine: looking for ESRD Lipid panel: looking for lipid co-morbidities as part of metabolic syndrome Serum calcium: looking for renal parenchymal damage due to nephrolithiasis. Increased calcium in hyperparathyroidism raises blood pressure

Answer 88

In the general population over 60, the goal BP is \<150/90. In the population aged \>18 with CKD, lower the blood pressure to \<140/90 In the population aged \>18 with diabetes, lower the blood pressure to \<140/90

Answer 89

Can cause hyponatremia Can precipitate gout flares Can cause elderly patients to become incontinent of urine Low dose are superior to high dose in effectiveness

Answer 90

Weight reduction (5-12 mmHg/10 kg weight loss)

Answer 91

Initiate aspirin therapy in men age 45 to 79 years to reduce MI.

Answer 92

Implement lifestyle interventions. Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and CKD. If the blood pressure is still not at goal, maximize first medication before adding second. If at maximum doses of the double combination of medications and the blood pressure is still not at goal, continue adding agents from other classes. Always avoid combined use of ACEI and ARB.

Answer 93

Watch potassium, sodium, and creatinine Renal protective Reduces microalbuminuria First line agent in diabetes and renal disease Shown to have direct heart remodeling effects Cough and angioedema are serious side effects

Answer 94

Reduces microalbuminuria and microalbuminuria. Shown to have heart remodeling effects. Avoid in pregnant women. Less bradykinin production

Answer 95

Often causes leg edema Short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies

Answer 96

Monitor electrolytes and creatinine

Answer 97

May cause hyperkalemia Low dose aldosterone antagonists reduce morbidity and mortality in CHF but increase sudden death at higher doses.

Answer 98

Congenital: scoliosis, kyphosis, spondylolysis Traumatic: lumbar strain, compression fracture Metabolic: osteoporosis, hyperparathyroidism, Paget's disease, osteomalacia Infectious: pyelonephritis, osteomyelitis, discitis, herpes zoster, spinal or epidural abscess Inflammatory: ankylosing spondylitis, sacroilitis, rheumatoid arthritis Neoplastic: multiple myeloma, metastatic disease, lymphoma/leukemia, osteosarcoma Degenerative: disc herniation, osteoarthritis, facet arthropathy, spinal stenosis Vascular: aortic aneurysm, diabetic neuropathy Visceral: prostatitis, PID, ovarian cyst, endometriosis, kidney stones, cholecystitis, pancreatitis

Answer 99

Mechanical: 97% of back pain. Lumbar strain/sprain, age-related degenerative joint changes, herniated disc Visceral: 2% Remaining 1%: non-mechanical

Answer 100

Fever, unexplained weight loss, pain at night, bowel or bladder incontinence, neurologic symptoms

Answer 101

Exacerbation when sitting or bending, relief when lying or standing - increased pain with coughing and sneezing - pain radiating down the leg and sometimes the foot - paresthesias - muscle weakness, such as foot drop

Answer 102

- history of cancer - unexplained weight loss \>10 kg within 6 months - age over 50 or under 17 years old - failure to improve with therapy - pain persists for more than 4-6 weeks - night pain or pain at rest - persistent fever - history of IV drug use - recent bacterial infection - immune compromise

Answer 103

- urinary incontinence or retention - saddle anesthesia - anal spincter tone decreased or fecal incontinence - bilateral lower extremity weakness or numbness - progressive neurologic deficits

Answer 104

Major muscle weakness and foot drop

Answer 105

- prolonged use of corticosteroids - mild trauma over age 50 years - age greater than 70 years - history of osteoporosis - recent significant trauma at any age - previous vertebral fracture

Answer 106

Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three months.

Answer 107

Lumbar strain, disc herniation, spinal stenosis, and degenerative arthritis Pain worse with movement and sitting is suggestive of a mechanical cause of back pain, such as a lumbar strain, disc herniation, or degenerative arthritis. Pain radiating down the leg and numbness indicate nerve involvement, such as in disc herniation. Pain that improves with the supine position suggests spinal stenosis and disc herniation.

Answer 108

- history of trauma - strenuous lifting in patient with osteoporosis - prolonged steroid use - osteoporosis - age \>20 and \>70 - history of cancer - fever/chills/weight loss - pain worse when supine or severe at night - spinal fracture, tumor, or infection

Answer 109

- neurological deficit - radiculopathy - progressive major motor weakness - cauda equina compression - suspected systemic disorder (metastatic or infectious disease) - failed six weeks of conservative

Answer 110

Pharmacologic therapy (aspirin/NSAID and/or muscle relaxants) - local therapy - physical therapy (slightly more effective than being active at baseline)

Answer 111

Children and adolescents who present with knee pain are likely to have patellar subluxation, tibial apophysitis (Osgood-Schlatter), or patellar tendonitis). Adults are more prone to patellofemoral syndrome (a clinical diagnosis of exclusion for anterior knee pain), overuse syndromes (such as pes anserine bursitis), traumatic injuries (ligamentous sprains - anterior cruciate, medial collateral, lateral collateral - and meniscal tears) and inflammatory arthropaties, such as rheumatoid arthritis, septic arthritis, and Reiter's syndrome.

Answer 112

If concerned about septic arthritis or an acute inflammatory arthropathy, check a CBC with differential and ESR. Perform an arthrocentesis and send the fluid for cell count with differential, glucose and protein, bacterial culture and sensitivity, and polarized light microscopy for crystals.

Answer 113

- GI upset - decreasing the effectiveness of hypertension medications - increasing the effect of sulfonylureas

Answer 114

Recommended yearly FOBT, flex sig every three years, or colonoscopy every 10 years for patients ages 50 to 75 years old.

Answer 115

A one-time ultrasound to screen for an AAA is recommended in men 65-75 years old who have any history of smoking.

Answer 116

- tetanus: substitute one-time dose of Tdap for Td booster, then boost with Td every 10 years - Pneumococcal polysaccharide: if \>65 years, one dose - flu: one dose annually - zoster: if \>60 years, one dose

Answer 117

Assesses the stability of the ACL

Answer 118

Assess the anterior cruciate and posterior cruciate ligaments, respectively

Answer 119

Assess functioning of the medial and lateral collateral ligaments

Answer 120

Can assess the medial and lateral menisci, though it has low sensitivity and specificity for diagnosing meniscal tears

Answer 121

Tapping over the median nerve at the wrist to reproduce symptoms

Answer 122

Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms.

Answer 123

patellofemoral pain syndrome iliotibial band tendonitis ACL sprain MCL sprain LCL sprain Meniscal tear Septic arthritis Osteoarthritis Gout/pseudogout Popliteal cysts

Answer 124

- joint space narrowing - subchondral sclerosis (hardening of tissue beneath the cartilage) - osteophytes - subchondral cysts

Answer 125

Nerve conduction velocity study

Answer 126

exercise, acetaminophen (first line, 4 g/d in divided doses), NSAIDS, intra-articular corticosteroid injections, tramadol, hyaluronic acid injections (superior in the long term to corticosteroids), long-acting opiods, tricyclic antidepressants

Answer 127

Folic acid supplement (400 mcg) Carrier screening (sickle cell, Tay-Sachs, CF) Screen for infectious diseases : HIV, syphilis, Hep B, rubella, varicella, toxoplasmosis-avoid cat litter, CMV For diabetics, optimize control, folic acid 1 mg, off ACEi HTN: avoid ACEi, angiotensin II receptor antagonists, thiazide diuretics

Answer 128

Expectant management D&C Medical management (800mg misoprostol) Give RhoGam

Answer 129

The loss of a pregnancy without outside intervention before 20 weeks' gestation.

Answer 130

risky/hazardous drinking: patient's alcohol consuption exceeds the National Insititute on Alcohol Abuse and Alcoholism per occasion threshold for men of 4 drinks per occasion problem drinking: significant physical, social, or psychological harm from drinking alcohol abuse: requires a maladaptive pattern of use with failure to fulfill obligations alcohol dependence: requires tolerance, withdrawal, physical and pscyhological problems

Answer 131

Psoas sign: Passive extension of patient's thigh as s/he lies on his/her side with knees extended, or asking the patient to actively flex his/her thigh and hip causes abdominal pain, often indicative of appendicitis Obturator sign: examiner has patient supine with right hip flexed to 90 degrees- takes patient's right ankle in his right hand as he uses his left hand to externally/internally rotate patient's hip by moving th knee back and forth. Elicitation of pain in the abdomen implies acute appendicitis

Answer 132

- biliary colic/cholecystitis - duodenal ulcer - hepatitis - acute pancreatitis

Answer 133

CBC, electrolytes, UA, LFTs, amylase/lipase Abdominal US

Answer 134

Surgical consultation for cholecystectomy Can also use a three-month trial of ursodiol

Answer 135

Primary skin lesion: uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy. Secondary skin lesions: changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions

Answer 136

Macule: flat lesion less than 1 cm in diameter Patch: macule greater than 1 cm in diameter Papule: solid raised lesion that has distinct borders and is less than 1 cm in diameter Plaque: solid, raised, flat-topped lesion greater than 1 cm in diameter Nodule: raised solid lesion and may be in the epidermis, dermis, or subcutaneous tissue Tumor: solid mass of the skin or subcutaneous tissue, larger than a nodule Vesicle: raised lesion less than 1 cm in diameter and is filled with clear fluid Bulla: circumscribed fluid-filled lesion that is greater than 1 cm in diameter Pustule: circumscribed elevated lesion that contains pus Wheal: area of elevated edema in the upper epidermis

Answer 137

Annual skin cancer screening by full body skin examination by a health care provider is an "I" recommendation by the USPSTF.

Answer 138

Non melanoma skin cancer: • 80 percent of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor) • Episodic sun exposure "probably does not increase risk" • White race • Celtic ancestry • Fair complexions • People who burn easily • People who tan poorly and freckle • Red, blonde or light brown hair • Increasing age • Use of coal-tar products • Tobacco use • Psoralen use (PUVA therapy) • No significant Family History • Male \>\>\> female • Whites near equator (UV exposure) • Outdoor work • Chronic osteomyelitis sinus tracts • Burn scars • Chronic skin ulcers • Xeroderma pigmentosum • Human papillomavirus infection • Previous skin cancer of any type gives 36-52% 5-year risk of second skin cancer For melanoma skin cancer: • White race • Celtic ancestry • Fair complexions • People who burn easily • People who tan poorly and freckle • Red, blonde or light brown hair • Early adulthood and later in life • Cumulative sun exposure "probably does not increase risk" • "Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk" 3/18 • Radiation exposure • Melanoma in 1st or 2nd degree relative • Familial atypical mole-melanoma syndrome (FAMMS) • Male \> female (slight) • Whites near equator (UV exposure) • Indoor work • Higher incidence in those with more education and/or income • Nonfamilial dysplastic nevi • Large number of benign pigmented nevi • Giant pigmented congenital nevi • Nondysplastic nevi (markers for risk, not precursor lesions) • Xeroderma pigmentosum • Immunosuppression • Previous nonmelanoma skin cancer • Other malignancies • Previous melanoma

Answer 139

Asymmetry: asymmetry in two or more axes Border: irregular border Color: two or more colors Diameter: six millimeters or greater Enlargement: enlargement of the surface of the lesion When a hyperpigmented skin lesion shows asymmetry, irregular borders, mixed colors, a diameter of six millimeters or larger, or recent growth in size, there is a higher suspicion of melanoma.

Answer 140

- tends to occur in young and middle aged men - pain in the perineum, lower abdomen, testicles and penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen

Answer 141

eczema, squamous cell carcinomas, actinic keratoses, basal cell carcinomas, melanoma, fungal infection

Answer 142

lower urinary tract symptoms (increased frequency of urination, nocturia, hesitancy, urgency, weak urinary stream), urinary tract infections, obstructive nephropathy need to perform DRE, PSA, UA maximal urinary flow rates and post-void residual urine volume are useful in most men suspected of BPH

Answer 143

Systemic therapy: tinea capitis, tinea unguium Local therapy: tinea pedis, tinea manuum, tinea corporis, tinea cruris

Answer 144

- behavior modifications: avoiding fluids before bedtime or going out, reducing caffeine and alcohol intake, use of salts and spices, etc. - alpha-adrenergic antagonists: decrease urinary symptoms in most men with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin, and doxazosin. - 5-alpha-reductase inhibitors: more effective in men with larger prostates. - don't take decongestants or antihistamines

Answer 145

Mammogram Colon cancer screening Pap smear

Answer 146

- age-- endometrial evaluation should occur in women aged 35 years and older who have abnormal uterine bleeding - unopposed estrogen therapy - tamoxifen - obesity - anovulatory cycles - early menarche - late menopause - nulliparity - hypertension, diabetes, and breast or colon cancer Oral contraceptive use increases progestin levels, providing protection

Answer 147

Symptoms: vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritis Physical exam findings: smoother vaginal mucosa and cervix

Answer 148

Corticosteroid use Family history of osteoporosis, especially if a first-degree relative has fractured a hip. Previous fragility fracture defined as a low-impact fracture Smoking Heavy alcohol use Lower body weight (weight \< 70 kg) is the single best predictor of low bone mineral density. Caucasian race - At any given age, African-American women on average have higher bone mineral density (BMD) than white women.

Answer 149

Most women over 50 should consume an average of 1200 mg of calcium and 600 IU of vitamin D daily.

Answer 150

T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia T-score less than -2.5 indicates osteoporosis

Answer 151

cervical polyps (most common in postpartum and perimenopausal women) endometrial hyperplasia hormone-producing ovarian tumors (rare) endometrial cancer proliferative endometrium

Answer 152

Bisphosphonates: potent inhibitors of bone resorption and reducing bone turnover, increasing bone mineral density. Look for Alendronate and risedronate Parathyroid hormone: anabolic drug for those with osteoporosis at high risk for fracture Estrogen replacement therapy: used short term only Calcitonin: shown to reduce vertebral fractures only

Answer 153

Hormone therapy for women at low risk for hormone-related diseases Antidepressants SSRIs and SNRIs Clonidine and gabapentin

Answer 154

transvaginal US, endometrial biopsy, CBC, TSH FSH and LH if menopause needs to be confirmed

Answer 155

Common types of headache: - tension type - migraine - medication overuse Serious causes: - meningitis - brain tumor - intracranial hemorrhage

Answer 156

1) headache due to depression and anxiety 2) medication overuse headache mild to moderate in severity diffuse, bilateral headaches that occur almost daily and are often present on first waking up in the morning Can often be aggravated by mild physical or mental exertion May improve slightly with analgesics but worsen when the medication wears off. Tolerance develops. Requires more than 15 headaches per month to make the diagnosis, with regular overuse of an analgesic for more than three months.

Answer 157

Signs of increased ICP: papilledema AMS meningeal irritation focal neurologic deficits

Answer 158

decrease caffeine, aim for 8 hours of sleep each night, try to relieve stress

Answer 159

triptans ergot alkaloids non-specific treatments include: aspirin/butalbital/caffeine combos, acetaminophen/butalbital/caffeine combos, acetaminophen/dichloalphenazone combos, and acetaminophen/aspirin/caffeine combos

Answer 160

Beta-blockers (propranolol and timolol)-- best because excellent and cheap Neurostabilizers (divalproex sodium, topiramate, gabapentin)-- good but expensive Tricyclic antidepressants (amitriptyline) -- off-label, but good results Calcium channel blocker (verapamil) -- off-label, fair effectiveness, expensive

Answer 161

- aspirin or NSAIDs - moderate to severe physiologic stress - H.pylori

Answer 162

PUD: usually characterized by episodic or recurrent epigastric "aching", "gnawing", or "hunger-like" pain or discomfort, symptoms occur on an empty stomach and are commonly relieved by meals GERD: classic symptoms of heartburn and regurgitation, likely to occur when gastric volume is increased (after large meals)

Answer 163

GERD: Esophagitis develops when the mucosal defenses that normally counteract the effect of injurious agents are overwhelmed by refluxed acid, pepsin, or bile. Peptic strictures from fibrosis and constriction occur in about 10% of patients with reflux esophagitis. Replacement of the squamous epithelium of the esophagus by columnar epithelium ( Barrett's esophagus ) may result from reflux esophagitis. Two to five percent of cases of Barrett's esophagus may be further complicated by adenocarcinoma . PUD: Hemorrhage or perforation into the peritoneal cavity or adjacent organs (causing severe, persistent abdominal pain). Ulcer scar healing or inflammation can impair gastric emptying leading to gastric outlet obstruction syndrome .

Answer 164

dysphagia, initial onset of upper GI symptoms occur after age 50, early satiety, hematemesis, hematochezia, iron deficiency anemia, odynophagia, recurrent vomiting, weight loss

Answer 165

Empiric therapy with PPIs If unresponsive to PPIs, check for contributing agents, test for H. pylori (IgG serology test at first, followed by urea breath test and stool antigen test) Need to rule out GI bleeding

Answer 166

Used for determining whether a strep test is needed one point is assigned for: fever more than 38 absence of cough tonsilar exudates anterior cervical lymphadenopathy age less than 15 one point is taken away if more than 45 years old if 2 or 3 points, order a rapid strep if 4 points, order a throat culture and empirically treat

Answer 167

Bacterial pneumonia (strep or staph) Otitis media

Answer 168

Amox 90mg/kg/d divided into three dosages for 7-10 days in children 3 months to adolescence

Answer 169

Defined in adults as having at least three of the following, hypertriglyceridemia, low HDL, elevated fasting blood glucose levels, excessive waist circumference, or hypertension, affects 20 percent of adults ages 20 to 40, and 40 percent older than 40 years of age. They are at increased risk for cardiovascular disease and diabetes. While there is no agreed upon definition for metabolic syndrome in children, if we apply the diagnostic criteria to children, substituting elevated BMI for waist circumference, we have started to see increased rates in adolescents. Seven percent of overweight adolescents, 29 percent of obese adolescents, and 50 percent of severely obese adolescents meet the criteria for metabolic syndrome and will have increased health risks. Smoking also increases the risk of metabolic syndrome.

Answer 170

egophany increased tactile fremitus dullness to percussion crackles whispered pectoriloquy

Answer 171

URI, asthma exacerbation, and bronchiolitis If there is fever, think pneumonia, acute bronchitis, influenza, or GAS

Answer 172

If given within the first 48 hours of illness or if the patient has moderate to severe CAP with influenza or if the patient is clinically worsening at the time of the initial outpatient visit

Answer 173

AF with RVR is the presence of physiologic or non-physiologic ventricular tachycardia in the presence of AF. Can be caused by fever, myocarditis, pericarditis, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction. Treat with rate control-- IV diltiazem, beta blockers, or verapamil Rhythm control-- cardioversion

Answer 174

Right hand dominant patients with strokes in the area of the brain are likely to have left hemiplegia. Patients with right middle cerebral infarcts affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distance, or they may attempt to read holding books upside down. They may ignore people or objects in their left visual feild or not pay attention to that area of the room. They may also not recognize their functional impairments.

Answer 175

Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness. Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke. A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because there is bilateral central control of this portion of the facial nerve. A peripheral injury to the facial nerve (such as Bell's Palsy) causes facial weakness of the forehead.

Answer 176

Seizure Stroke TIA CAD Medication side effect

Answer 177

CT and MRI Renal function/electrolytes ECG (screen for afib and arrythmias) Markers for cardiac ischemia (trops and BNP) CBC and PT/PTT O2 sat to monitor for hypoxemia

Answer 178

* adjusted dose warfarin (INR 2-3) * antiplatelet therapy with aspirin * dual antiplatelet therapy with clopidogrel and aspirin

Answer 179

* anticoagulation with a vitamin K antagonist * aspirin alone for patients unable to take oral anticoagulants

Answer 180

Scarlet fever presents as punctate, erythematous, blanching, sandpaper-like exanthem. Rash is found in the neck, groin, axillae. The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue). Complications: rheumatic fever and post-streptococcal glomerulonephritis, peritonsilar abscess, mastoiditis, meningitis, bacteremia

Answer 181

Patients with recent exposure to infectious diseases, or patients who have a mild illness should receive their vaccines. However, if a patient has moderate to severe illness (including high fever, otitis, diarrhea, and vomiting), then vaccines should be postponed until they are recovering and no longer acutely ill. Also contraindicated when there is an allergy, or patient is immunocompromised.

Answer 182

Between four and six years of age, a child needs a booster of DTaP, IPV, MMR, and varicella. * Three hepatitis B * Five DTaP * Five polio * Two MMR * Two varicella

Answer 183

Children must be at least six years old. Symptoms must be more frequent or severe compared to other children the same age. The behaviors must be present in at least two settings.

Answer 184

Viral pharyngitis and GABHS -high fever, anterior cervical lymph nodes, tonsilar exudates, absence of cough are highly suggestive of GABHS

Answer 185

Penicillin V (FIRST LINE), Penicillin G IM (if patient is unlikely to finish course), amox, first generation ceph, macrolides (PCN allergy)

Answer 186

urgent recognition is necessary because septic joints may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone or more distinct sites by way of bacteremia "red flags" include local complaints such as redness or swelling and/or systemic complaints such as fever, chills, and myalgias. Predisposing factors include diabetes, alcoholism, or other immune-compromising conditions Definitive evaluation includes aspiration and culture of related fluid. Commonly staph.

Answer 187

A patient with loss of active and passive ROM is more likely to have joint disease A patient with loss of only active ROM is more likely to have an issue with muscle tissue. The following joint diseases will produce restricted active and passive ROM of the shoulder: - adhesive capsulitis: a condition common in patients with metabolic diseases in which there is contracture of the joint capsule - glenohumeral arthritis: much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity - Rotator cuff injuries will compromise only ACTIVE ROM (rotator cuff tear and impingement)

Answer 188

tendinitis: inflammatory etiology that occurs only in the first days after an acute tendon injury; not appropriate unless injury is very acute tendinopathy: more general term that may imply a degenerative pathology. It is a chronic condition that is characterized by a fibroblastic response, lack of acute phase reactants, and collagenous degeneration

Answer 189

The supraspinatus tendon, and possibly other rotator cuff tendons, are being impinged upon by the roof of the subacromial space, which is formed by the acromion and the coracoacromial ligament. Processes that decrease the subacromial space, such as the weakened rotator cuff muscles or weakened scapularr stabilizers will promote this process.

Answer 190

Inspection Palpation Range of motion Strength testing Special maneuvers (not what Dr. Kapur taught, but what FM Cases states)

Answer 191

Rotator cuff tendinopathy -- weakness and pain with empty can testing, limited active ROM Torn rotator cuff --limited ROM with significant pain, significant weakness with strength testing Impingement syndrome with bursitis-- limited ROM, Neer and Hawkins-Kennedy tests rule out Labral tear--may occur through repetitive damage from glenohumeral joint instability or secondary to frank dislocations or other trauma. Often a diagnosis of exclusion.

Answer 192

physical therapy pain medication as needed relative rest

Answer 193

Home Education Eating Activities Drugs Sexuality Suicide/Depression Safety

Answer 194

congenital anomaly -- results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis causing the "bell clapper" deformity undescended testicle recent trauma or vigorous exercise

Answer 195

Testicular loss. Surgery needs to occur within the first six hours of onset in order to preserve the testicle

Answer 196

Guidelines for promoting adolescent health and positive behaviors prevents HTN, hyperlipidemia, use of tobacco and drugs, physical fitness, etc.

Answer 197

* Patients with chlamydia present with dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, breakthrough bleeding or can be asymptomatic. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample. * Patients with gonorrhea can be either asymptomatic, or have dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, or breakthrough bleeding. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample; gonococcal culture for rectal or pharyngeal specimens. * Presenting symptoms of trichomonas include vaginal discharge with odor or itching, so testing for T. vaginalis should be performed in women seeking care for vaginal discharge. But trichomonas can also be asymptomatic and screening for T. vaginalis can be considered in those at high risk for infection, such as women who have new or multiple partners (the situation presented in this question), have a history of STIs, exchange sex for payment, and use injection drugs. Diagnosis is made by either saline wet mount or rapid antigen testing.

Answer 198

Germ cell tumors (seminomatous or nonseminomatous)-- most common primary testicular tumors. Usually seminomatous. Non-seminomatous are usually embyronal cell tumors, teratomas, or yolk sac tumors. Other causes include non-germ cell tumors (Leydig cell and Sertoli cell tumors) and extragonadal tumors

Answer 199

testicular torsion: physical findings include a swollen, tender scrotum and the cremasteric reflex is typically absent. Testicular torsion causes the orientation of the testis to change, causing a "transverse lie". Torsion of the testicular appendages: Appendix testis is a small vestigial structure (embryonic remnant of the Mullerian duct) located on the anterosuperior aspect of the testis. Pain is usually less severe than in testicular torsion and is localized to the region of the appendix testis without any tenderness in the remaining areas of the testis. Bluish coloration in the scrotum at the upper pole of the testis is seen. Epididymitis: Most common cause. Symptoms are slowly progressive over several days. Caused by bacterial infection of the epididymis (UTI or STD), severe swelling and exquisite pain on the involved side with fever, rigors, and irritative voiding symptoms. On exam, scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex is usually present, and the testis is in its normal location and position. Other less ilkely things: trauma, inguinal hernia, HSP, hydrocele, tumor, varicocele

Answer 200

Color Doppler US-- if testicular torsion is present, intratesticular blood flow is either decreased or absent when appears as decreased echogenicity, as compared with the asymptomatic testis. Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion. Radionuclide scintigraphy is more sensitive, but US is faster and easier.

Answer 201

Orchiopexy -- surgical fixation of BOTH testes to prevent retorsion

Answer 202

* fatigue - A feeling of exhaustion or tiredness that is pervasive, not relieved by rest, and often worsened by exertion. * sleepiness - A feeling of tiredness that gives a patient the tendency to fall asleep, and is often relieved by either rest or exertion.

Answer 203

The PHQ-2 involves asking patients, "Over the last two weeks, how often have you been bothered by any of the following problems?" (1) "Little interest or pleasure in doing things." (2) "Feeling down, depressed, or hopeless." For each question, the patient can answer: "not at all" (0 points) "several days" (1 point) "more than half the days" (2 points), "nearly every day" (3 points). Screens for depression

Answer 204

Colonoscopy -- once every ten years FOBT yearly Flex sig-- every three years

Answer 205

Clinical staging of colorectal cancer is the depth of the invasion of the bowel wall. For colon cancers, this cannot be determined until the cancer is surgically removed (pathologic staging). In the case of rectal cancers, endorectal US provides oncologists with failry accurate estimates of the depth of invasion and may guide therapy. Metastasis - pelvic lymph nodes, liver, and lung CEA - elevated in many colorectal cancers. Elevation above 5 ng/m is associated with worse prognosis at each stage.

Answer 206

* Depression * OSA * Anemia * Occult malignancy * Coronary artery disease * Diabetes mellitus * Sleep restriction * Hypothyroidism * Chronic fatigue syndrome

Answer 207

CBC and ESR initially. Glucose to rule out diabetes. TSH +/- EBV titers

Answer 208

Ferrous sulfate 325 mg TID Docusate sodium 100 mg BID PRN for constipation

Answer 209

Influenza and pneumococcal vaccines, TdaP

Answer 210

Acute bronchitis: productive cough lasting 1-3 weeks Chronic bronchitis: productive cough for at least three months for the past two years

Answer 211

Smoking more than 40 pack-years Self-reported history of COPD Maximum laryngeal height of 4 cm or less Age of at least 45 years

Answer 212

COPD is not reversible via bronchodilator therapy and asthma is. COPD symptoms slowly progress, while asthma symptoms vary day to day. COPD has more symptoms during exertion, while for asthma the symptoms are more common at night or early morning Cigarette smoke is more of a causal agent in COPD. Mast cells, helper T cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma. Macrophages, T killer cells, and neutrophils play a role in an inflmmatory and destructive process in COPD. Post-bronchodilator FEV1/FVC ratio \>12% after bronchodilator.

Answer 213

FEV1/FVC is decreased in COPD. (less than 70%)

Answer 214

Therapy for moderate COPD: FEV1 is between 50 and 80% of predicted. Maintenance therapy of inhaled anticholinergics (ipratroprium or tiotroprium) alone or in combination with short-acting beta agonists. Therapy for severe COPD: Symptomatic patients whose FEV1 is Risks of overuse of beta agonists include: tachycardia, exaggerated somatic tremor, and hypkalemia

Answer 215

Measured FEV1 impairment. FEV1 of \>80% is mild. 50-79% is moderate. 30-49% is severe.

Answer 216

COPD exacerbation: increased dyspnea, increased sputum volume, and increased sputum purulence Treatment: inhaled bronchodilators and oral glucocorticosteroids azithromycin if infection is suspected

Answer 217

Chronic hypoxia causes pulmonary vasoconstriction, which increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased JVD.

Answer 218

Crackles in the lung bases and dullness to percussion. JVD PMI that is laterally displaced from the mid-clavicular line towards the axillary line S3 from rapid ventricular filling or poor left ventricular functioning. Enlarged liver, hepato-jugular reflux, and distention and shifting dullness indicating ascites Lower extremity edema Sacral edema

Answer 219

Diastolic heart failure occures when signs and symptoms of heart failure are present, but left ventricular function is preserved (ejection fraction \>45%). It is caused by impaired LV filling and abnormal LV relaxation and is most commonly related to uncontrolled hypertension. The incidence of diastolic heart failure increases with age and is more common in older women.

Answer 220

The left ventricle develops an abnormality of filling and becomes stiffer and noncompliant as the disease progresses. Then there is increased pulmonary vessel pressure during exercise, increased filling pressure, and, as left atrial pressure and size increase, congestion. At this point, exercise intolerance increases and clinical signs of failure, particularly dyspnea on exertion, appear. Pulmonary congestion, hepatic congestion, and peripheral edema appear.

Answer 221

No, all patients with systolic dysfunction also have diastolic dysfunction. A patient cannot have pure systolic heart failure. However, certain cardiovascular diseases such as hypertension may lead to diastolic dysfunction without concomitant systolic dysfunction.

Answer 222

BNP testing can help differentiate heart failure from non-cardiac conditions in patients with dyspnea. A normal BNP effectively rules out CHF.

Answer 223

MI, arrythmias (such as a fib/flutter with rapid ventricular response. Without the atrial kick, the ventricle does not fill as well, a problem that is exacerbated by the decreased filling time that occurs with tachycardia), ischemic cardiomyopathy, uncontrolled HTN

Answer 224

* Cardiomegaly: Defined when the width of the heart is more than half of the width of the thorax. * Central vascular congestion and hilar fullness: Patients in failure frequently have hilar fullness on a PA chest film. Individual vessels may appear enlarged. * Pleural effusions: Identified by a blunting of the costophrenic angles. This can be seen posteriorly on a lateral film as well. Occasionally, prominent fluid in the horizontal fissure will be seen in the right lung. * Cephalization of pulmonary vasculature: Typically, pulmonary vessels are not well seen in the upper lung fields. In CHF, however, they become engorged and can be seen extending from the hilum. * Kerley B lines: These are small linear densities 2-3 cm in length seen in the periphery of the lung fields on the PA view. They represent interstitial fluid in the lung tissue

Answer 225

Glucose control, blood pressure control, aspirin, cholesterol control, weight control, immunizations, beta-blockers

Answer 226

ACEi ARBs Digoxin-- does not improve mortality Loop diuretics Beta-blockers -- metoprolol succinate, carvedolol, bisoprolol Eplerenone

Answer 227

Primary dysmenorrhea-- painful menses without pelvic pathology. Usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours Secondary dysmenorrhea--painful menses secondary to some pelvic pathology

Answer 228

* mood disorders * tobacco use * lower state of health or other social stressors * women who have more children

Answer 229

Premenstrual dysphoric disorder is a complex disorder that occurs at a specific time in a woman's cycle during multiple menstrual cycles in a year. A minimum of five symptoms need to begin the week prior to menses, start to improve during menses and then become minimal the week after menses. The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess. The patient must also have one of the following: food cravings, changes in sleep, being "out of control", decreased energy, anhedonia, and some physical symptoms. The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms for the woman. It may be helpful to get the perspective of other close contacts of the patient.

Answer 230

adenomyosis, chronic PID, endometriosis,uterine leiomyomas Less likely: cervical stenosis, IBD, IBS, ovarian cysts, mood disorders or adjustment disorders, uterine polyps

Answer 231

CBC, pregnancy test, US, thyroid disorders

Answer 232

Ibuprofen Mirena IUD, combined OCPs/Depo, hysterectomy, uterine artery embolization

Answer 233

* Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular. * Oral contraceptives are effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. While not always effective for premenstrual syndrome, they are a good place to start. It would be appropriate to try this in a woman also needing birth control. The most favorable pill is the formulation containing ethinyl estradiol and drospirenone. One study demonstrates potential improved effectiveness by decreasing the placebo pills to four days from seven. * Selective serotonin reuptake inhibitors during menses are an effective treatment of premenstrual syndrome, especially if severe or mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as daily treatment for decreasing both psychologic and physical symptoms. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a woman has symptoms and continue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine can be used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior to considering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost. * Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in women. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in women done with childrearing. Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies the effectiveness is inconsistent. If this were to be tried on a patient, the dosing would be during luteal phase. You must be cautious about causing potential electrolyte abnormalities with this drug. * Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity. Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been evaluated with mild results. These are all worth discussing with patients, although true efficacy is not proven.

Answer 234

Presyncope-- caused by inadequate cerebral perfusion +acute blood loss

Answer 235

presyncope- feeling light-headed or faint dysequilibrium- a feeling of being off balance vertigo- a sensation of the room spinning Cardiac arrhythmias/valvular heart disease can cause syncope

Answer 236

A drop in systolic blood pressure of \>20 mmHg or a drop in diastolic blood pressure of \>10 mmHg when changing position from supine to standing accompanied by feelings of dizziness or light-headedness

Answer 237

benign paroxysmal positional vertigo vestibular neuritis-- results when a viral infection of the inner ear causes inflammation of the vestibular branch of the eighth cranial nerve acute labyrinthitis-- occurs when an infection affects both branches of the nerve resulting in tinnitus and/or hearing loss as well as vertigo

Answer 238

-one way to confirm the diagnosis of BPPV ## Footnote Turn the patient's head to 45 degrees and quickly lay him down supine with his head just over the end of the exam table. Then turn the head to the side which should reproduce the symptoms of dizziness and produce nystagmus. Observe for 20 to 30 seconds. If present, the nystagmus will have the fast component in the direction of the pathology. Next, sit the patient up and observe again for nystagmus.

Answer 239

Vestibular neuritis, BPPV, vestibular migraine

Answer 240

* diuretics and a low salt diet for Meniere's disease (decrease the endolymphatic pressure and abate symptoms) * Epley maneuver * vestibular rehabilitation * vestibular suppressant medications -- anticholinergic vestibular suppressants such as meclizine and dimenhydrinate

Answer 241

Sensory impairment, sleep disorder, mood disorder, learning disability, conduct disorder

Answer 242

* history of maternal illness or substance abuse during pregnancy * complications at the time of delivery * history of meningitis or other serious illness * history of serious head trauma * parental history of learning disabilities or difficulty at school

Answer 243

Appetite suppression, tic disorders, insomnia, decrease in growth velocity

Answer 244

Displacement of the femoral head from the femoral neck through the physeal plate. Most commonly, it occurs at the onset of puberty in obese patients with delayed sexual maturation. Typical symptoms include an antalgic gait due to pain referred to the hip, thigh, and/or knee, with limited ROM on examination of the hip

Answer 245

Children should be screened if the are overweight (BMI \>85th %ile) plus any two of the following risk factors: - family history of Type 2 DM in a first or second degree relative - race/ethnicity of a high-risk group - signs of insulin resisitance or conditions associated with insulin resistance (acanthosis nigricans, PCOS, etc.) - maternal history of diabetes or gestational diabetes during the child's gestation Should be started at 10 years of age or at the onset of puberty, whichever is earlier. Screening should occur every three years with the same criteria as for diabetes in adults.

Answer 246

umbilical arterial or venous access: placement of an umbilical arterial or venous line during the perinatal period may predispose to renal vascular disease UTI-- due to renal scarring catecholamine excess family history of renal disease coarctation of the aorta

Answer 247

Adequate growth for a term infant require approximately 100 to 120 cal/kg/day. Average daily weight gain for a term infant is 20 to 30 g.

Answer 248

4-6 months (around the same time the Moro reflex disappears and infants can start eating rice cereal)

Answer 249

By 4-5 months, and will triple their birth weight by 1 year of age. Most children will reach double their birth length by 4 years.

Answer 250

Gross motor: Stands alone (many can walk well). Fine motor: Has a well developed, "neat" pincer grasp. Language: Says "mama" and "dada" (specific) and 1 or 2 other words. Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner.

Answer 251

hepatic neoplasm hydronephrosis neuroblastoma -- most frequently diagnosed neoplasm in infants, most likely teratoma Wilm's tumor -- median age is 3 years

Answer 252

* CBC with Differential The CBC with differential is helpful in identifying the extent of anemia and to look for cytopenia that may be associated with bone marrow infiltration. This test is not specific for any one diagnosis. * Catecholamine Metabolites (VMA and HVA) Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma. This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection. * Chest X-ray A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray. * Skeletal Survey A skeletal survey can identify metastases to the bone * Abdominal ultrasound: will identify a mass, showt he organ of origin, and determine if the mass is solid, cystic, or combined (first choice of imaging)

Answer 253

LDL cholesterol \> 190 Diabetes age 40-75 estimated 10-year ASCVD risk \> 7.5%

Answer 254

The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening: men \> 35 years old women \> 45 years old if they are at increased risk for coronary heart disease. The U.S. Preventive Services Task Force (USPSTF) recommends screening: men 20 - 35 years old if they are at increased risk for heart disease women 20 - 45 years old if they are at increased risk for heart disease

Answer 255

* Dosages that lower LDL cholesterol by 30- 50% are considered high intensity statins. * High intensity therapy is recommended for: patients \> 75 years of age with clinical ASCVD * those with LDL cholesterol \> 190 mg/dL * diabetics aged 40-75 with estimated 10-year ASCVD risk of \> 7.5% * Moderate intensity therapy is recommended for: patients

Answer 256

3500 calories

Family Medicine Cases Flashcards

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