When is breast cancer risk increased?
If a first-degree relative has had breast cancer
When should a breast self-examination be used?
When the patient chooses to do a breast self-examination and the patient is trained in appropriate technique and follow-up.
What is the evidence surrounding breast self-examination?
The practice of BSE by trained women does not reduce breast cancer-specific or all-cause mortality. Likely increases the number of biopsies performed.
When should a woman get a breast exam according to the USPSTF?
Clinical breast exam should be a part of a periodic health exam, which occurs about every three years for women in their 20's and 30's and every year for women 40 and over.
What are the cervical cancer screening guidelines?
At 21 years of age, cervical cancer screening should begin. Between 21-29, screening should be performed every three years. Between 30-65 years, screening can be done every three years with cytology alone, or every five years if co-tested for HPV. If over 65 and has had adequate screening in the last ten years with normal paps.
When should women get additional screening for cervical cancer?
Women who are immunocompromised, HIV positive, have a history of CIN2-3 or cancer, or have been exposed to DES.
What are the risk factors of cervical cancer?
1) HPV infection (early onset of intercourse, a greater number of lifetime sexual partners) 2) DES exposure in utero 3) cigarette smoking 4) immunosuppression
What is "accuracy"?
High sensitivity and specificity
What is "sensitivity"?
Sensitivity measures the proportion of actual positives that are correctly identified as such (e.g. the percentage of sick people identified as having the condition). The more sensitive the test, the fewer false negative results.
What is "specificity"?
Specificity measures the proportion of negatives that are correctly identified as such (e.g. percentage of well people identified as not having the condition). The more specific the test, the fewer false positives.
What are the endometrial cancer screening recommendations?
At the time of menopause, all women should be informed about the risks and symptoms of endometrial cancer, and strongly encouraged to report any unexpected bleeding or spotting to their doctors. For high risk women (HNPCC for example), endometrial biopsies should be offered starting at age 35.
What are the skin cancer screening recommendations?
Cancer-related checkup should include examination of the skin.
What are the recommendations for breast cancer screening?
Yearly mammograms starting at age 40 per the ACS. USPSTF recommends biennial screening mammography for women aged 50-74 years old.
How do you evaluate a breast lump?
-precise location of the lump -how it was first noticed -how long it has been present -nipple discharge -any change in the size of the lump (esp. during menstrual cycle) Then follow up with a physical exam. If the lump feels cystic, aspiration can be attempted and the fluid sent for cytology. If the lump feels solid, mammography is the next step. US can distinguish a solid mass from a cystic lesion
What are the causes of nipple discharge?
Physiologic: Pregnancy Excessive breast stimulation Pathologic: Prolactinoma Breast cancer -Intraductal papilloma -Mammary duct ectasia -Paget's disease of the breast -Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications use (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)
How do you evaluate nipple discharge?
Color of discharge, then follow up with imaging studies (mammogram, US, bx). Consider hormonal testing to exclude endocrine reasons (PRL). Discontinue medications that may be the cause.
What are the risk factors for breast cancer?
Family history of breast cancer in a first-degree relative (i.e., mother or sister) Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45 Genetic predisposition (BRCA 1 or 2 mutation) Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.) Female sex Increased breast density Advanced age at first pregnancy Exposure to diethylstilbestrol Hormone therapy Therapeutic radiation Obesity
What are the recommendations for osteoporosis prevention?
Premenopausal women need approximately 1000mg of calcium daily while postmenopausal women need 1500 mg of calcium daily. This requires three to four servings of dairy products. Currently recommending against calcium and vitamin D supplementation.
What are the recommendations for osteoporosis screening?
For women >65 years old, screening with DEXA. For women
What are the risk factors for osteoporosis?
-low estrogen states-- early menopause, prolonged premenopausal amenorrhea, and low weight and body mass index -lack of physical activity and inadequate calcium intake Family history of osteoporotic fracture Personal history of previous fracture as an adult Dementia Cigarette smoking White race
What is the Bethesda System for reporting cervical cytology?
Cervical cytology results are given in three categories: specimen adequacy, general categorization of results, and interpretation of results. Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories. Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous. Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress. High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion. Squamous cell carcinoma.
What serotypes of HPV does Gardasil protect against?
Quadravalant DNA vaccine 6,11, 16, and 18. Used in ages 9-25 years
When are breast MRI recommended?
Indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer. May also be used as a diagnostic tool to identify more completely the extent of disease in patients with a breast cancer diagnosis.
What is the RISE mnemonic for preventive visits?
R: risk factors I: immunizations S: screening tests E: education
What are the most frequent causes of death for a 55-year old male in the US?
malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis
What are the risk factors for CVD?
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.
What are the adult immunization recommendations?
-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
What is the controversy surrounding prostate cancer screening recommendations?
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.
What are colon cancer screening options?
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)
What are the indications for exercise stress testing?
Asymptomatic male patients over the age of 45 with one or more risk factors (hypercholesterolemia, hypertension, smoking, orfamily history of premature coronary artery disease)
What are the signs of dyslipidemia and atherosclerosis?
Changes associated with dyslipidemia: corneal arcus, xanthelasmas, acanthosis nigricans Changes associated with atherosclerosis: decreased peripheral pulses, carotid bruit
What are the ECG changes that suggest coronary artery disease?
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)
What are some interventions that improve quit rates for smokers?
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.
How do you manage a high risk for ASCVD event?
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.
What are the recommendations for exercise prescriptions?
-type of exercise or activity -precautions -specific workloads -duration and frequency -intensity guidelines
What are the common causes of insomnia in the elderly?
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
What are the risk factors for completed suicide?
Sex: white male Age: increases with age Previous attempts
What are the major depression diagnostic criteria?
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
Which is better for screening for dementia: the mini-cog exam or the MMSE?
The mini-cog exam is faster and more sensitive and specific than the MMSE
What are some of the side effects of SSRIs/SNRIs?
Headaches, sleep disturbances (drowsiness), GI problems (nausea and diarrhea) Hyponatremia due to SIADH, serotonin syndrome, GI bleeding
What are the medical conditions associated with depression?
-hypothyroidism -Parkinson's disease -dementia
How do you evaluate fatigue or depression?
A CMP screens for electrolyte, renal, and hepatic problems TSH, CBC
What are the treatments for primary insomnia in the elderly?
Sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy Zolpidem and melatonin-receptor agonists
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
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.
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.
Particularly useful in obsessive-compulsive disorder. Greater frequency of emesis compared to other SSRIs.
Most common side effects include nausea, dry mouth, and somnolence
Approved specifically for Generalized Anxiety Disorder. Overall, fewer side effects than citalopram.
What are the signs of limb threatening injury?
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)
What are the important historical features of ankle injury?
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.
What are the grades of ankle sprains?
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.
What is the most common mechanism of injury in ankle sprains?
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.
How do lateral ankle sprains present?
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.
How do peroneal tendon tears present?
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
How do talar dome fractures present?
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.
What are the Ottawa ankle rules?
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.
What is the most effective compression for ankle injury?
Semi-rigid ankle support
What are the signs and symptoms of hyperthyroidism?
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
What is exopthalmos?
(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
What are the causes of enlarged thyroid?
Lack of iodine, Hashimoto's, Grave's, nodules, thyroid cancer, pregnancy, thyroiditis
What is clonus?
A series of abnormal reflex movements of the foot induced by sudden dorsiflexion causing alternate contraction and relaxation of the gastrocnemius and soleus muscles.
What are the primary symptoms of eye manifestations of Grave's disease?
Corneal irritation from eyelid retraction
What are the most common manifestations of Grave's ophthalmopathy?
Eyelid retraction and exophthalmos
What is Grave's disease?
Autoimmune disease in which thyrotroptin receptor antibodies are produced. These antibodies stimulate the thyroid gland to enlarge and produce more thyroid hormone.
What are the symptoms of hypothyroidism?
Weight gain, cold intolerance, pedal edema, heavy periods, and fatigue.
What are the common causes of hyperthyroidism?
Toxic diffuse goiter, toxic nodular goiter, thyroiditis (thyroid hormone leaks from an inflamed thyroid), excessive iodine ingestion
What are the studies to determine the etiology of hyperthyroidism?
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.
How do you treat Grave's disease?
Methimazole is the most commonly used medication to suppress thyroid hormone production. Oral dose of radioactive iodine is the other treatment option.
What is the primary side effect of methimazole?
Agranulocytosis. Requires frequent bloodwork.
What is the primary side effect of radioactive iodine?
Makes most patients hypothyroid. Requires twice yearly bloodwork. Need a pregnancy test before initiation--is teratogenic
What is thyroid replacement therapy?
Thyroxine (1.5-1.8 mcg per kg), increasing until steady TSH
What are the common manifestations of end-organ damage in diabetes?
Cardiovascular disease, retinopathy, neuropathy, nephropathy
What are the acute diabetic decompensations?
IDDM: DKA T2DM: HHS
What are the screening recommendations for diabetes according to the American Diabetes Association?
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
What are the USPSTF recommendations for screening for diabetes?
Asymptomatic adults with sustained blood pressure greater than 135/80
What are the diagnostic criteria for diabetes mellitus?
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%
What do you see on fundoscopic exam with severe, non-proliferative retinopathy?
retinal hemorrhages cotton wool spots microaneurysms neovascularization
How do you distinguish between HHS and DKA?
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
What are the four reasons for ordering lab tests at a diabetes follow-up visit?
Monitoring diabetic control, assessing end organ damage, monitoring side effects of treatment, and uncovering management complications
When do you get A1c levels in a diabetic?
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
How do you screen for diabetic nephropathy?
spot urine albumin-to-creat ratio for microalbuminuria at diagnosis and annually.
What labs do you order with metformin use?
Metformin can cause metabolic acidosis in renal failure. It can also lead to subnormal vitamin B12 levels.
When should TSH levels be ordered in diabetics?
Screening TSH in type 1 diabetics, newly diagnosed dyslipidemia, or women over age 50 as part of a diabetes evaluation
What are the suggested lipid levels for diabetic patients?
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).
When should aspirin be used in diabetics?
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%).
What is the 1st tier for management of T2DM?
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
What are the recommended vaccines for diabetic patients?
influenza vaccine pneumococcal polysaccharide vaccine hepatitis B vaccine if not previously vaccinated
When should diabetics go to the ophthamologist?
Type 1: first annual eye exam five years after diagnosis Type 2: when they are first diagnosed
How long does it take warfarin to reach steady state?
five to seven days
What causes foot ulceration in diabetes?
Impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral arterial disease)
What is the Wagner Grading System for diabetic ulcers?
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
What is the differential of unilateral lower extremity edema?
Lymphedema Cellulitis DVT Venous insufficiency Peripheral artery disease
What is lymphedema on physical exam?
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.
What is cellulitis on physical exam?
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.
What are the symptoms of DVT?
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.
What does venous insufficiency look like on physical exam?
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.
What does peripheral arterial disease look like on physical exam?
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)
What are the Wells criteria for DVT?
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
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.
How do you differentiate between DVT and cellulitis diagnostically?
How do you medically manage ulcers?
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
What are the requirements for treating DVT on an outpatient basis?
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
What are the advantages of LMWH over unfractionated heparin?
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
How do you titrate warfarin?
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.
What are the recommended thromboprophylaxis durations of DVT or PE?
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.
What are the criteria for recommended screening for inherited thrombophilia?
-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
What is the recommended action when goal INR is overshot?
Warfarin should be held, and an oral dose of Vitamin K should be given to reduce INR.
When do you screen for high blood pressure?
Screening for high blood pressure in patients without known hypertension starting at age 18.
What are the classifications of high blood pressure?
What are some of the causes of secondary hypertension?
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.
What are the important elements of the physical exam in patients with hypertension?
-fundoscopic eye exam
-carotid, abdominal, and femoral bruits
-lower extremity exam
-baseline neuro assessment
What tests do you need for a new diagnosis of essential hypertension?
-ECG: look for LVH
-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
How do you initially medically manage HTN in patients under 60?
How do you medically manage patients initially diagnosed with HTN over age 60?
What is the target blood pressure goal?
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
What are the side effects of HCTZ?
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
What is the most effective way to reduce blood pressure through lifestyle?
Weight reduction (5-12 mmHg/10 kg weight loss)
When do you initiate aspirin in hypertensive patients?
Initiate aspirin therapy in men age 45 to 79 years to reduce MI.
What is the stepwise approach to the treatment of hypertension?
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.
What are the side effects of ACEi?
Watch potassium, sodium, and creatinine
First line agent in diabetes and renal disease
Shown to have direct heart remodeling effects
Cough and angioedema are serious side effects
When do you use ARBs?
Reduces microalbuminuria and microalbuminuria.
Shown to have heart remodeling effects.
Avoid in pregnant women.
Less bradykinin production
Calcium channel blockers
Often causes leg edema
Short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies
Monitor electrolytes and creatinine
Aldosterone antagonists and potassium sparing diuretics
May cause hyperkalemia
Low dose aldosterone antagonists reduce morbidity and mortality in CHF but increase sudden death at higher doses.
What are the common causes of back pain?
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
What are the most common causes of back pain?
Mechanical: 97% of back pain.
Lumbar strain/sprain, age-related degenerative joint changes, herniated disc
Remaining 1%: non-mechanical
What are the red flags for serious illness or neurologic impairment with back pain?
Fever, unexplained weight loss, pain at night, bowel or bladder incontinence, neurologic symptoms
What are the symptoms of disc herniation?
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
-muscle weakness, such as foot drop
What are the red flags for serious underlying causes of back pain?
-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
-history of IV drug use
-recent bacterial infection
What are the symptoms for cauda equina syndrome?
-urinary incontinence or retention
-anal spincter tone decreased or fecal incontinence
-bilateral lower extremity weakness or numbness
-progressive neurologic deficits
What are the symptoms of a significant herniated nucleus pulposus?
Major muscle weakness and foot drop
What are the risk factors for vertebral fracture?
-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
What is the prognosis for acute low back pain?
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.
What is the differential for low back pain?
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.
When do you order an Xray for back pain?
-history of trauma
-strenuous lifting in patient with osteoporosis
-prolonged steroid use
-age >20 and >70
-history of cancer
-pain worse when supine or severe at night
-spinal fracture, tumor, or infection
When do you get an MRI for back pain?
-progressive major motor weakness
-cauda equina compression
-suspected systemic disorder (metastatic or infectious disease)
-failed six weeks of conservative
What is conservative therapy for acute low back pain?
Pharmacologic therapy (aspirin/NSAID and/or muscle relaxants)
-physical therapy (slightly more effective than being active at baseline)
What is the type of knee pain seen in children and adults, respectively?
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.
How do you evaluate a suspected infectious process causing knee pain?
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.
What are the side effects of NSAIDS?
-decreasing the effectiveness of hypertension medications
-increasing the effect of sulfonylureas
What is the recommended screening for colorectal cancer?
Recommended yearly FOBT, flex sig every three years, or colonoscopy every 10 years for patients ages 50 to 75 years old.
What screening is recommended for abdominal aortic aneurysm?
A one-time ultrasound to screen for an AAA is recommended in men 65-75 years old who have any history of smoking.
What are the adult immunizations?
-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
What does Lachman's test assess?
Assesses the stability of the ACL
What do the anterior and posterior drawer signs assess?
Assess the anterior cruciate and posterior cruciate ligaments, respectively
What do the valgus and varus stress tests assess?
Assess functioning of the medial and lateral collateral ligaments
What does the McMurray test assess?
Can assess the medial and lateral menisci, though it has low sensitivity and specificity for diagnosing meniscal tears
What is Tinel's sign for carpal tunnel?
Tapping over the median nerve at the wrist to reproduce symptoms
What is Phalen's test for carpal tunnel?
Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms.
What is the differential diagnosis for knee pain?
patellofemoral pain syndrome
iliotibial band tendonitis
What are the major radiographic features of osteoarthritis?
-joint space narrowing
-subchondral sclerosis (hardening of tissue beneath the cartilage)
What is the diagnostic test of choice for carpal tunnel syndrome?
Nerve conduction velocity study
How do you manage pain for osteoarthritis?
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
What are the recommendations on chlamydia screening?
What is the preconception health care checklist?
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
How do you manage an inevitable abortion?
Medical management (800mg misoprostol)
What is a spontaneous aboriton?
The loss of a pregnancy without outside intervention before 20 weeks' gestation.
What are the classifications of alcohol use?
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
What is the psoas sign and the obturator sign?
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
What is the differential of right upper quadrant abdominal pain?
What are the studies to evaluate RUQ abdominal pain?
CBC, electrolytes, UA, LFTs, amylase/lipase
How do you manage biliary colic?
Surgical consultation for cholecystectomy
Can also use a three-month trial of ursodiol
What is the difference between a primary and secondary skin lesion?
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
What are the vocab words used to describe skin lesions?
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
What are the skin cancer screening recommendations?
Annual skin cancer screening by full body skin examination by a health care provider is an "I" recommendation by the USPSTF.
What are the risk factors for nonmelanoma skin cancer?
For melanoma skin cancer?
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
What is the "ABCDE" rule of skin cancer detection?
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.
What are the symptoms of prostatitis?
-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
What is the differential of an oval-shaped, erythematous patch?
eczema, squamous cell carcinomas, actinic keratoses, basal cell carcinomas, melanoma, fungal infection
What do you look for when you are evaluating for BPH?
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
What are the different groups of topical corticosteroids?
Which skin infections do you treat with local vs. systemic antifungal agents?
Systemic therapy: tinea capitis, tinea unguium
Local therapy: tinea pedis, tinea manuum, tinea corporis, tinea cruris
How do you manage BPH?
-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
What screening do you do for women in their 50's without risk factors?
Colon cancer screening
What are the risk factors for endometrial cancer?
-age-- endometrial evaluation should occur in women aged 35 years and older who have abnormal uterine bleeding
-unopposed estrogen therapy
-hypertension, diabetes, and breast or colon cancer
Oral contraceptive use increases progestin levels, providing protection
What are symptoms and findings of atrophic vaginitis?
Symptoms: vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritis
Physical exam findings: smoother vaginal mucosa and cervix
What are risk factors for osteoporosis?
Family history of osteoporosis, especially if a first-degree relative has fractured a hip.
Previous fragility fracture defined as a low-impact fracture
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.
How much calcium and vitamin D should women over 50 consume to prevent osteoporosis?
Most women over 50 should consume an average of 1200 mg of calcium and 600 IU of vitamin D daily.
What DEXA scan indicates osteoporosis?
T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia
T-score less than -2.5 indicates osteoporosis
What is the differential of abnormal uterine bleeding?
cervical polyps (most common in postpartum and perimenopausal women)
hormone-producing ovarian tumors (rare)
What is the treatment for osteoporosis?
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
What are the most effective ways to manage hot flashes?
Hormone therapy for women at low risk for hormone-related diseases
Antidepressants SSRIs and SNRIs
Clonidine and gabapentin
How do you evaluate postmenopausal abnormal bleeding in women?
transvaginal US, endometrial biopsy, CBC, TSH
FSH and LH if menopause needs to be confirmed
What are the common causes of headache? What are the serious causes of headache?
Common types of headache:
What are common etiologies of secondary headaches?
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.
What are important physical exam findings with headache?
Signs of increased ICP:
focal neurologic deficits
What are the differences between migraine headaches, tension headaches, and cluster headaches?
How do you manage tension headaches?
decrease caffeine, aim for 8 hours of sleep each night, try to relieve stress
What are the migraine medications?
non-specific treatments include: aspirin/butalbital/caffeine combos, acetaminophen/butalbital/caffeine combos, acetaminophen/dichloalphenazone combos, and acetaminophen/aspirin/caffeine combos
What medications are used for migraine prophylaxis?
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
What are agents that can cause or contribute to peptic ulcer disease?
-aspirin or NSAIDs
-moderate to severe physiologic stress
How can you distinguish between the symptoms of PUD vs. GERD?
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)
What are the complications of GERD and PUD?
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 .
When is urgent endoscopy warranted?
dysphagia, initial onset of upper GI symptoms occur after age 50, early satiety, hematemesis, hematochezia, iron deficiency anemia, odynophagia, recurrent vomiting, weight loss
How do you manage GERD, gastritis, and PUD?
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
How do you treat H. pylori?
What is the McIsaac Decision Rule?
Used for determining whether a strep test is needed
one point is assigned for:
fever more than 38
absence of cough
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
What are the most common complications of influenza?
Bacterial pneumonia (strep or staph)
How do you treat strep pneumonia?
Amox 90mg/kg/d divided into three dosages for 7-10 days in children 3 months to adolescence
What is metabolic syndrome?
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.
What are pulmonary findings that indicate consolidation?
increased tactile fremitus
dullness to percussion
What is the differential for an acute pediatric cough?
URI, asthma exacerbation, and bronchiolitis
If there is fever, think pneumonia, acute bronchitis, influenza, or GAS
What are antivirals for influenza indicated?
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
How do you manage pediatric pneumonia?
What are the mechansisms of TIAs or possible stroke?
What is AF with rapid ventricular response? How do you treat it?
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
What are the symptoms of a right parietal infarct?
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.
Stroke symptoms of other regions
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.
How do you treat post-stroke depression?
What is the differential of lightheadedness with focal neurologic findings?
Medication side effect
What are the recommended tests for the initial emergency evaluation of a patient with suspected acute ischemic stroke?
CT and MRI
ECG (screen for afib and arrythmias)
Markers for cardiac ischemia (trops and BNP)
CBC and PT/PTT
O2 sat to monitor for hypoxemia
How do you medically prevent stroke?
- adjusted dose warfarin (INR 2-3)
- antiplatelet therapy with aspirin
- dual antiplatelet therapy with clopidogrel and aspirin
How do you medically prevent stroke in patients with a history of stroke or TIA?
- anticoagulation with a vitamin K antagonist
- aspirin alone for patients unable to take oral anticoagulants
What are strategies for secondary stroke prevention?
What are the complications of GABHS pharyngitis?
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
When do you withold vaccinations?
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.
What are the elementary school admission vaccines?
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
When can you diagnose ADHD?
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.
What is the differential for pediatric fever, sore throat, cough, and rash?
Viral pharyngitis and GABHS
-high fever, anterior cervical lymph nodes, tonsilar exudates, absence of cough are highly suggestive of GABHS
How do you treat GABHS pharyngitis?
Penicillin V (FIRST LINE), Penicillin G IM (if patient is unlikely to finish course), amox, first generation ceph, macrolides (PCN allergy)
How do you diagnose and manage acute bacterial/pyogenic infection of a joint or bursa?
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.
What are the likely diagnoses with loss of shoulder range of motion?
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)
What are the rotator cuff muscles?
What is the difference between tendinitis vs. tendinopathy?
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
What is the pathophysiology of shoulder impingement?
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.
What is the order of a joint exam?
Range of motion
(not what Dr. Kapur taught, but what FM Cases states)
What is the differential for subacute right shoulder pain aggravated by movement?
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.
How do you manage rotator cuff tendinopathy/impingement?
pain medication as needed
What is HEEADSSS?
What are the scrotal exam findings?
What are the causes of testicular torsion?
congenital anomaly -- results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis causing the "bell clapper" deformity
recent trauma or vigorous exercise
What are the complications of testicular torsion?
Testicular loss. Surgery needs to occur within the first six hours of onset in order to preserve the testicle
What are the guidelines for adolescent preventive services?
Guidelines for promoting adolescent health and positive behaviors
prevents HTN, hyperlipidemia, use of tobacco and drugs, physical fitness, etc.
What are the symptoms of chlamydia, gonorrhea, and trich and how do you diagnose them?
- 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.
What are the types of testicular tumors?
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
What is the differential of groin pain in an adolescent?
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
How do you diagnose testicular torsion?
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.
How do you manage testicular torsion?
Orchiopexy -- surgical fixation of BOTH testes to prevent retorsion
What is the difference between fatigue and sleepiness?
- 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.
What is the PHQ-2?
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
How can you screen for colon cancer?
Colonoscopy -- once every ten years
Flex sig-- every three years
How do you clinically stage colon cancer?
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.
What is the differential of fatigue?
- Occult malignancy
- Coronary artery disease
- Diabetes mellitus
- Sleep restriction
- Chronic fatigue syndrome
What is the workup of fatigue?
CBC and ESR initially.
Glucose to rule out diabetes.
TSH +/- EBV titers
How do you manage iron deficiency?
Ferrous sulfate 325 mg TID
Docusate sodium 100 mg BID PRN for constipation
What are the recommended immunizations for patients with COPD?
Influenza and pneumococcal vaccines, TdaP
What is the clinical distinction between acute and chronic bronchitis?
Acute bronchitis: productive cough lasting 1-3 weeks
Chronic bronchitis: productive cough for at least three months for the past two years
What are some of the classic findings on physical exam for COPD and CHF?
What are the four items that predict the presence of COPD?
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
What are the major differences between COPD and asthma?
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.
What are the PFTs for COPD?
FEV1/FVC is decreased in COPD. (less than 70%)
What is therapy for moderate and severe COPD?
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
What is the differential of shortness of breath in a middle-aged man who smokes?
How do you define the level of COPD severity?
Measured FEV1 impairment.
FEV1 of >80% is mild.
50-79% is moderate.
30-49% is severe.
What is a COPD exacerbation and how do you manage it?
COPD exacerbation: increased dyspnea, increased sputum volume, and increased sputum purulence
Treatment: inhaled bronchodilators and oral glucocorticosteroids
azithromycin if infection is suspected
How does COPD lead to heart failure?
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.
What are good medications for a patient with both diabetes and hypertension?
What are the physical exam findings for suspected heart failure?
Crackles in the lung bases and dullness to percussion.
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
What is diastolic heart failure?
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.
What is the pathophysiology of diastolic dysfunction?
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.
Can you have systolic dysfunction without diastolic dysfunction?
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.
How do you differentiate heart failure from non-cardiac conditions in patients with dyspnea?
BNP testing can help differentiate heart failure from non-cardiac conditions in patients with dyspnea. A normal BNP effectively rules out CHF.
What is the differential for new onset congestive heart failure?
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
What radiographic findings are associated with congestive heart failure?
- 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
How do you diagnose patients with CAD?
What are the interventions to slow the progression of CAD?
Glucose control, blood pressure control, aspirin, cholesterol control, weight control, immunizations, beta-blockers
How do you manage Stage C heart failure?
Digoxin-- does not improve mortality
Beta-blockers -- metoprolol succinate, carvedolol, bisoprolol
What is primary dysmenorrhea?
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
What are the risk factors for primary dysmenorrhea?
- mood disorders
- tobacco use
- lower state of health or other social stressors
- women who have more children
What are the premenstrual syndrome diagnostic criteria?
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.
What is the differential of secondary dysmenorrhea/menorrhagia?
adenomyosis, chronic PID, endometriosis,uterine leiomyomas
Less likely: cervical stenosis, IBD, IBS, ovarian cysts, mood disorders or adjustment disorders, uterine polyps
How do you evaluate secondary dysmenorrhea/menorrhagia?
CBC, pregnancy test, US, thyroid disorders
How do you treat primary dysmenorrhea?
Mirena IUD, combined OCPs/Depo, hysterectomy, uterine artery embolization
How do you treat PMS?
- 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.
What are the presyncope symptoms, etiologies, and management?
Presyncope-- caused by inadequate cerebral perfusion
+acute blood loss
What is the difference between presyncope, disequilibrium, and vertigo?
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
What is orthostatic hypotension?
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
What are the common causes of vertigo?
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
What is the Dix-Hallpike maneuver?
-one way to confirm the diagnosis of BPPV
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.
What is the differential of dizziness?
Vestibular neuritis, BPPV, vestibular migraine
What is the difference between peripheral and central vertigo?
How do you manage peripheral vertigo?
- 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
What are the important causes of school failure?
Sensory impairment, sleep disorder, mood disorder, learning disability, conduct disorder
What are the "red flags" for risk of learning disability?
- 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
What are the adverse effects of ADHD medications?
Appetite suppression, tic disorders, insomnia, decrease in growth velocity
What is SCFE?
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
What are the guidelines for screening for diabetes mellitus in children?
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.
What are the most common causes of secondary hypertension in children?
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
family history of renal disease
coarctation of the aorta
What is the caloric requirement for 1 to 2 month olds?
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.
When do most babies start to sleep through the night?
4-6 months (around the same time the Moro reflex disappears and infants can start eating rice cereal)
When do most healthy infants double their birth weight?
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.
What are the milestones for a 6-month old?
What are the 12-month development milestones?
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.
What is the differential diagnosis for RUQ mass and pallor in a 9-month-old infant?
neuroblastoma -- most frequently diagnosed neoplasm in infants, most likely
Wilm's tumor -- median age is 3 years
What lab tests would you get for suspected neuroblastoma?
- 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)
What patients are most likely to benefit from statin therapy?
LDL cholesterol > 190
Diabetes age 40-75
estimated 10-year ASCVD risk > 7.5%
When should you screen for lipid disorders?
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
When are high-intensity statins recommended vs. moderate intensity?
- 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
What calorie deficit is necessary to lose 1 pound of weight?