Family Medicine Core Rotation - Acute Complaints_2 Flashcards Preview

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Flashcards in Family Medicine Core Rotation - Acute Complaints_2 Deck (350):
1

what therapy can be a very successful behavioral treatment for nocturnal enuresis?

moisture sensitive alarms

2

how do moisture sensitive alarms for nocturnal enuresis work?

the first drops of urine complete a circuit, activating an alarm that will wake the child and parents, and then the parents help the child complete the voiding in the toilet. over time, a conditioned response develops, and the child awakens voluntarily with the sensation of full bladder

3

what is the gender bias of efficacy of moisture sensitive alarms for nocturnal enuresis?

there is no gender difference in success rates

4

what are the success rates for appropriately used moisture sensitive alarms for nocturnal enuresis?

75-84%

5

how long does a moisture sensitive alarm for nocturnal enuresis take to work?

weeks or months

6

should a child take responsibility for their treatment with a moisture sensitive alarm for nocturnal enuresis?

no. without parental involvement, success rates drop

7

when should you be concerned about a child having failure to thrive?

when a child drops more than 2 percentile brackets on a growth curve and does not maintain at that area

8

in the USA, the vast majority of failure to thrive is secondary to what?

inadequate nutrition

9

how good is albumin at revealing recent undernutrition?

albumin has a long half life and is a poor indicator of recent undernutrition

10

how sensitive is prealbumin for undernutrition?

prealbumin is decreased in acute inflammation and undernutrition and is therefore insensitive

11

organic disease, including hypothyroidism, is found in how many cases of failure to thrive?

<10%

12

how are IgA levels related to undernutrition?

IgA levels are sensitive to undernutrition and would be decreased in failure to thrive

13

in a child with failure to thrive, diarrhea, and recurrent respiratory infections what Dx must be considered?

CF

14

what should you order for a child with failure to thrive, diarrhea, and recurrent respiratory infections?

sweat chloride test

15

what tests may be indicated in the workup of failure to thrive, but only with a reasonable degree of clinical suspicion?

1. mantoux test for TB • 2. HIV test • 3. stool for ova and parasites • 4. RFT

16

what features will you see in a child with esophageal reflux contributing to failure to thrive?

1. wet burps • 2. frequent emesis or cough with eating • 3. occasional wheezing

17

what is the best test to diagnose esophageal reflux causing failure to thrive in a child?

esophageal pH probe

18

if a child has failure to thrive with diarrhea or melena what should you think and order?

think IBD • order hemoccult

19

if a child has failure to thrive and diarrhea, abdominal pain, and foul smelling stools, what do you think and order?

think lactose intolerance • order lactose tolerance test

20

what would cause you to suspect pyloric stenosis in a child?

projectile vomiting • abdominal distention • perhaps palpable mass

21

what do you order on a child in which you suspect pyloric stenosis?

US

22

what do you do for a 9mo child with failure to thrive, signs of minimal smiling and vocalization?

no tests, likely related to infant behavior and/or ineffective maternal-child bonding

23

children with familial short stature have a growth curve that shows what?

simultaneous changes in height and weight

24

what do you see on the growth curve of a child with failure to thrive and constitutional growth delay?

weight decreases first, then height

25

what do you see on the growth chart of a child with hypothyroidism?

height velocity slows first and may plateau before weight changes

26

what do you see on the growth chart of breast fed infants?

weight decreases relative to peers after 4-6 months, but catches up after 12 mo

27

when is hospital admission indicated for failure to thrive?

in the face of hypotension and bradycardia

28

what are the signs of severe malnutrition that necessitate hospital admission for a child with failure to thrive?

hypotension and bradycardia

29

mononucleosis is often mistaken for what?

streptococcal pharyngitis

30

both mononucleosis and streptococcal pharyngitis have which symptoms in common?

sore throat • fatigue • fever • adenopathy

31

what happens if you give ampicillin to a patient with mononucleosis?

diffuse symmetrical erythematous maculopapular rash, not to be confused with penicillin allergy or scarlet fever

32

how does scarlet fever rash compare to what happens when you give ampicillin to a patient with mononucleosis?

the rash of scarlet fever is more confluent, and has a sandpaper like texture

33

what does the rash of measles look like?

erythematous flat papules, first appearing on the face and neck, then spreading to the arms and trunk in 2-3 days

34

fatigue lasting < month is likely what?

result of a physical cause: • infection • endocrine imbalance • CV disease • anemia • medications

35

fatigue lasting >3mo is more likely to be related to what?

psychologic factors: • depression • anxiety • stress • adjustment reactions

36

physiologic fatigue happens because of what?

overwork • lack of sleep • pregnancy

37

how long does fatigue have to be present to diagnose chronic fatigue syndrome and chronic idiopathic fatigue

>6mo

38

what is one of the most common diagnoses in patients presenting with fatigue, especially when denying weakness or hypersomnolence?

depression

39

what should you screen for in a patient complaining of fatigue that has a negative depression screening?

sleep apnea • anemia • hypothyroidism • pregnancy

40

what are the 3 general categories of fatigue?

physiologic • physical • psychologic

41

what historical feature should lead you to look for a physical cause of fatigue lasting >6mo?

progressively worsening

42

initial lab workup for an uncertain diagnosis of fatigue includes what?

CRC • ESR • UA • Chemistry panel • TSH • HCG • age/gender appropriate cancer screening

43

what should you order in a patient with uncertain diagnosis of fatigue if all initial tests are negative?

CXR • ECG • HIV • drug screen

44

what is the second most common cause of lower GI bleeding in children?

intussusception

45

what is the most common cause of significant GI bleeding in children?

Meckel diverticulum

46

do anal fissures, colitis, and juvenile polyposis cause significant bleeding in children?

no

47

what is the best diagnostic testing option in the setting of acute upper GI bleed?

upper endoscopy

48

what is the use of an upper endoscopy in acute upper GI bleed?

localize the source of bleeding • potentially allow therapeutic intervention • allow for tissue diagnosis when necessary

49

how does gastric lavage compare to EGD for acute upper GI bleed?

less useful

50

what is the limitation of using barium study for acute upper GI bleed?

might interfere with subsequent intervention

51

why not order a red cell scan for acute upper GI bleed?

they are better to locate bleeding sources in the lower GIT

52

why not order angiography for acute upper GI bleed?

may miss slower bleed

53

what is the most common congenital abnormality of the GIT?

Meckel diverticulum- 2% of the population

54

how does meckel diverticulum present?

most are asymptomatic, but a common presentation is painless large volume intestinal hemorrhage

55

how is a meckel diverticulum often diagnosed?

incidentally at laparotomy

56

what is the noninvasive diagnostic test for meckel diverticulum?

technetium scan

57

what percentage of patients with colonic diverticulosis develop severe diverticular bleeding?

5-15%

58

can you localize diverticular bleeding using colonoscopy?

yes but it is unusual

59

what is the next step if you can not localize the source of bleeding in diverticulosis on colonoscopy?

tagged RBC scan, which will help guide segemental resection if necessary

60

when is a subtotal colectomy necessary for bleeding diverticulosis?

recurrent severe bleeding with no source identified

61

external hemorrhoids are defined as what?

hemorrhoids arising distal to the dentate line

62

when external hemorrhoids thrombose, they are associated with what?

acute pain and are hard and nodular on physical exam

63

what do you do for thrombosed external hemorrhoids?

the excision can be safely done in the office under local anesthesia

64

what are the advantages of local excision of thrombosed external hemorrhoids under local anesthesia?

it eliminates pain immediately and eliminates the risk of recurrence

65

what is the use of hydrocortisone for thrombosed external hemorrhoids?

not useful

66

what are the indications for rubber band ligation and sclerotherapy for hemorrhoids?

should be reserved for internal hemorrhoids

67

what are the risks of incision and drainage of an external hemorrhoid?

increases the risk of recurrence and can lead to infection of the retained clot

68

what is an anal fissure?

a split in the anoderm of the anal canal

69

when does an anal fissure occur?

generally after the passage of a hard bowel movement

70

how do patients with anal fissure present?

excruciating pain with defecation with blood on the toilet paper--> complaint of ache or spasm that resolves after a couple hours

71

when are internal hemorrhoids painful?

internal hemorrhoids are generally not painful, unless they are thrombosed because of an unreducible prolapse- pain does not resolve

72

would a perianal abscess cause bleeding like anal fissure?

a perianal abscess may not present with bleeding, but would likely be associated with systemic signs of infection

73

what are are the most studied and effective prophylactic agents for migraines?

β blockers

74

what is the only Ca channel blocker that is effective at migraine prophylaxis?

verapamil

75

when are ergotamines used for migraines?

for abortive therapy

76

the goal of prophylactic migraine therapy is what?

to reduce the frequency of headache by 50%

77

of the anti-depressants used for migraine prophylaxis, which has the strongest evidence for efficacy?

amitriptyline

78

what is the dosing of amitriptyline for migraine prophylaxis?

begin with low dose 10mg at night, then titrate up to the most effective dose that does not cause side effects (up to 150mg)

79

what are the red flags in headache necessitating additional workup?

1. onset after age 50yo • 2. very sudden onset • 3. increase in severity or frequency • 4. signs of systemic disease • 5. focal neurologic symptoms (except aura) • 6. papilledema • 7. headache after trauma

80

migraines often occur how?

in a consistent location, are severe and frequent, include a visual aura, and may be associated with severe nausea

81

when is abortive acute therapy for migraines appropriate monotherapy?

if attacks occur less than 2-4x/mo

82

what should be the first choice abortive treatment for migraine?

a triptan (because of receptor specific action)

83

what are good alternatives to triptans in abortive treatment of migraines?

ergot alkaloids

84

what do you do for migraines that fail triptans and ergot alkaloids?

rescue medications (simple analgesics)

85

when should narcotics be used for migraine?

although frequently used in emergency settings, narcotics are rarely needed in the treatment plan for migraines

86

though Ca channel blockers other than verapamil have not been shown to be effective against migraines, they be helpful with which type of headache?

cluster headaches

87

what is the rationale of therapy for cluster headaches?

provide relief from the acute attacks, then use therapy to suppress headaches during the symptomatic period

88

which medications have been shown to be effective against cluster headaches?

nifedipine • prednisone • indomethacin • lithium

89

when is ergotamine good for cluster headache?

generally only helpful in the acute stage, not for prophylaxis

90

cluster headaches characteristically develop how?

rapidly, achieving peak intensity within 10-15 minutes lasting with intense pain for about 2 hours without treatment

91

the mainstay of treatment for cluster headaches is what?

oxygen

92

which parenteral drugs help with cluster headaches?

subQ or intranasal serotonin antagonists • IV/IM ergotamine

93

many physicians diagnose tension type headaches how?

by exclusion

94

what is the most frequent of all headaches encountered in clinical practice?

TTH

95

how long does a TTH episode last?

30 min- several days

96

how often should TTH occur per months?

<15x

97

TTH diagnosis requires which characteristics?

at least 2 of the following: • 1. pressure/tightening • 2. bilateral • 3. mild to moderate • 4. not aggravated by activity

98

what is the relationship between TTH and nausea?

there is generally no nausea

99

what is the relationship between TTH and photophobia/phonophobia?

either photophobia or phonophobia may be present but not both

100

what is the treatment for TTH?

trial of NSAID's with follow up if there is no improvement

101

what is the role of narcotics in TTH treatment?

narcotics should be avoided, since the condition is generally chronic and overuse is likely

102

what is the most common presentation of bladder carcinoma?

painless hematuria without other symptoms

103

what are the risk factors for bladder carcinoma?

1. being male • 2. smoking • 3. working with aromatic amines used in dye, paint, aluminum, textile, and rubber industries

104

acute prostatitis and UTIs are associated with which symptoms?

dysuria • fever • frequency • urgency

105

pseudohematuria can be derived from what?

chemical agents, foods, vaginal bleeding

106

what are the common foods that cause pseudohematuria?

beets • blackberries • certain food dyes

107

what are the medications that discolor the urine?

chloroquine • metronidazole • phenytoin • rifampin • sulfasalazine

108

in patients <40yo with hematuria but a normal IV pyelogram, what is the next step?

urine culture and cytology, periodic monitoring, and reassurance

109

when do you order cystoscopy for hematuria?

any patient >40yo with normal IVP

110

what do you order to diagnose post streptococcal glomerulonephritis?

ASO titer

111

what should you think causes phenomenon where patient falls asleep fast but then wakes up and can't return to sleep despite d/c caffeine use?

alcohol or drugs

112

how does obesity affect quality of sleep?

obesity is a risk factor for sleep apnea, but that generally does not cause inability to return to sleep after waking

113

how does propranolol affect sleep?

propranolol is known to cause nightmares

114

how does HCTZ affect sleep?

can cause nocturia that inhibits sleep

115

how does naproxen affect sleep?

naproxen is not known to interfere with sleep

116

how does alcohol affect sleep?

alcohol is known to cause excessive wakefulness, and often allows people to fall asleep, but interferes with the ability to stay asleep

117

what is essential for treating insomnia?

good sleep hygeine

118

important aspects of sleep hygiene include what?

1. awakening at a regular hour • 2. exercising daily • 3. control of the sleep environment • 4. eat a light snack before bed time (not meal) • 5. limit or eliminate alcohol, caffeine, and nicotine • 6. go to bed when sleepy • 7. use your bed for sleep and intimacy only • 8. get out of bed if you aren't asleep within 15-30 minutes

119

when can pharmacologic agents be used for sleep problems?

in select cases of transient sleep disorders unassociated with more serious problems

120

before using any pharmacologic agents for sleep it is important that the patient maintains what?

excellent sleep hygiene

121

what are the drugs of choice for transient sleep onset problems?

zolpidem (ambien) • eszopiclone (lunesta)

122

what drug can be used for sleep maintenance problems?

zaleplon (Sonata)

123

what is the use of melatonin?

help with adjustments of the sleep wake cycle (jet lag, shift work)

124

what is the use of benadryl for sleep?

can cause excessive somnolence and may help with sleep onset but not sleep maintenance

125

what is the most commonly reported hepatitis virus?

HAV

126

how is HAV spread?

via the fecal-oral route, most commonly through the ingestion of contaminated food or water

127

can HAV cause chronic hepatitis?

causes acute hepatitis only and never results in chronic hepatitis

128

are HAV relapses common?

lifelong immunity is expected for all patients that recover, therefore relapses are uncommon

129

when is a patient with HAV contagious?

fecal shedding of the virus occurs early, and declines once jaundice develops so jaundiced patients are less contagious than those in prodrome

130

symptoms of HAV infection change with what?

age

131

what percentage of patients <5yo infected with HAV are asymptomatic?

90%

132

what percentage of adults infected with HAV are symptomatic?

80%

133

what is the mode of transmission of HBV?

transfer of blood or body fluids, vertically

134

what happens if HBV is acquired early in life?

the infection is silent, but up to 90% of those infected develop chronic disease

135

what type of patients develop chronic hepatitis from HBV easier than others?

immunocompromised patients

136

what is the percentage of adults with HBV that have spontaneous resolution?

95%

137

what percentage of patients with HAV or HBV develop fulminant liver disease?

small percentage

138

HBsAg positivity means what?

either chronic infection or early infection

139

what rules out early infection in the face of positive HBsAg?

negative IgM anti-HBc

140

HBeAg is correlated with what?

replication

141

positivity of anti-HBs indicates what?

either exposure with immunity, recovery phase, vaccination

142

what rules out past exposure or infection in a patient with positive anti-HBs?

negative IgG anti-HBc

143

what stage of disease is a patient with positive HBsAg and positive IgM anti-HBc?

early infection

144

what is the HBsAg finding in a patient in the recovery phase?

negative

145

does asymptomatic bacteriuria cause incontinence?

asymptomatic bacteriuria is common in otherwise well elderly, and does not cause incontinence

146

does a symptomatic urinary infection cause incontinence in the elderly?

it may

147

how does hyperglycemia cause secondary incontinence?

because of polyuria

148

how do you treat incontinence caused by hyperglycemia?

tighter control of blood sugar levels

149

what is the relationship between fecal impaction and urinary incontinence?

stool impaction is thought to be a causative factor in up to 10% of patients

150

can atrophic vaginitis cause urinary incontinence?

yes

151

what is the most common type of incontinence in the elderly?

urge incontinence

152

what causes urge incontinence?

destrusor hyperactivity

153

functional incontinence refers to what?

limitation that does not allow the patient to void in the bathroom

154

what are some causes of functional incontinence?

bed rest • paralysis • severe dementia

155

what is stress incontinence?

loss of urine associated with ↑ intra-abdominal pressure

156

overflow incontinence is due to what?

overdistention of the bladder

157

what is the gender bias of stress incontinence?

much more commonly seen in women than men

158

stress incontinence is most often caused by what?

urethral hypermobility resulting from weakness of the pelvic floor musculature

159

patients with stress incontinence complain of what?

involuntary loss of urine associated with increase in intraabdominal pressure (sneezing, coughing, laughing, exercising)

160

overflow incontinence is primarily what?

a loss of the ability to empty the bladder

161

what are the causes of overflow incontinence?

1. neurogenic bladder • 2. outlet obstruction

162

what are some causes of neurogenic bladder?

longstanding diabetes • alcoholism • disk disease

163

what is a cause of overflow incontinence due to outlet obstruction?

prostatic enlargement

164

in the case of overflow incontinence the patient typically complains of what?

frequent or constant leakage of a small amount

165

what is the interpretation of a postvoid residual less than 50mL?

normal

166

a postvoid residual greater than 200 mL indicates what?

inadequate bladder emptying and is consistent with overflow incontinence

167

what is the volume of an indeterminant postvoid residual?

50-200mL

168

Kegel exercise are designed to do what?

strengthen the pelvic floor musculature

169

how do you instruct a patient to do kegel exercises?

ask the patient to squeeze the muscles in the genital area as if they were trying to stop the flow of urine from the urethra. hold for 10 seconds. repeat many times a day

170

for what types of incontinence are kegel exercises useful?

stress incontinence and mixed incontinence

171

kegel exercises are not useful for what types of incontinence?

functional • urge • overflow

172

when is pharmacologic therapy indicated for incontinence?

if a behavioral approach is ineffective

173

what are the drugs of choice for urge incontinence?

anticholinergic: • oxybutinin (ditropan) • tolterodine (detrol)

174

what drug helps with stress incontinence?

pseudophedrine

175

what drug helps with prostatitis incontinence?

trimethoprim-sulfamethoxazole

176

what drugs help frequent voiding caused by BPH?

finasteride and terazosin

177

which drugs can cause urinary incontinence?

1. α blockers- urethral sphincter relaxation→leakage but not urgency • 2. β blockers- inhibit bladder relaxation →leakage and urgency

178

how do Ca channel blockers affect the urinary system?

cause urinary retention

179

how do diuretics affect the urinary system?

increased frequency and urgency, but usually not leakage

180

what urinary symptoms can alcohol cause?

diuretic effect → polyuria, incontinence

181

what urinary symptoms can decongestants and diet pills cause?

urinary retention if they include α-agonists

182

what urinary symptoms can antihistamines cause?

urinary retention or functional incontinence

183

what urinary symptoms can caffeine cause?

diuretic effect → polyuria

184

does marijuana abuse contribute to urinary symptoms?

no

185

in evaluating childhood jaundice it is important to differentiate between what?

conjugated and unconjugated hyperbilirubinemia

186

if jaundice occurs in childhood and is associated with unconjugated hyperbilirubinemia, what diseases should be considered?

1. hemolytic diseases - G6PD, HS • 2. Gilbert disease • 3. Crigler-Najar

187

if jaundice occurs in childhood and is associated with conjugated hyperbilirubinemia, what should be considered?

1. viral hepatitis- MCC • 2. wilson disease • 3. milder forms of galactosemia

188

viral hepatitis accounts for what percentage of adult jaundice?

75% in pt <30yo • 5% in pt >60yo

189

extrahepatic obstruction accounts for what percentage of jaundice in patients >60yo?

60%

190

what are the cause of conjugated hyperbilirubinemia jaundice due to extrahepatic obstruction in >60yo?

gall stones • strictures • pancreatic cancer

191

CHF accounts for what percentage of jaundice in patients >60yo?

10%

192

metastatic disease accounts for what percentage of jaundice in patients >60yo?

13%

193

when biliary obstruction is suspected, what is the most appropriate initial first test?

US or CT

194

what should you do in a patient with suspected biliary obstruction with findings of dilated ducts?

ERCP or PTC

195

in a patient with suspected biliary obstruction but no dilated ducts, so unlikely obstruction, what should you do?

evaluate for hepatocellular or cholestatic disease

196

what do you do if you still suspect biliary obstruction after negative CT and US?

MRCP

197

what is the advantage of MRCP over ERCP?

no postprocedure pancreatitis

198

primary amenorrhea is defined as what?

absence of menses at age 16 in the presence of normal secondary sex characteristics, or absence of menses at age 14 in the absence of secondary sex characteristics

199

primary amenorrhea is usually the result of what?

genetic or anatomic abnormality

200

what is the most common cause of primary amenorrhea?

gonadal dysgenesis (50% of cases)

201

what is the most well known type of gonadal dysgenesis?

Turner syndrome

202

hypothalamic failure in a girl with amenorrhea is often a result of what?

anorexia nervosa • excessive exercise • chronic or systemic illness • severe stress; • all→suppression of hypothalamic GnRH secretion

203

pituitary failure in a girl with amenorrhea may result from what?

inadequate GnRH stimulation

204

pituitary failure in a girl with amenorrhea is often associated with a history of what?

head trauma • shock • infiltrative process • pituitary adenoma • craniopharyngioma

205

how do you differentiate pituitary from hypothalamic failure in a girl with amenorrhea?

pituitary failure is accompanied by deficiency of other pituitary hormones

206

what is the relationship between PCOS and primary amenorrhea?

PCOS may cause primary amenorrhea, but is generally associated with normal breast development

207

what is the gender prevalence of constitutional delay of puberty?

common in boys, uncommon cause of primary amenorrhea in girls

208

what is the most common cause of secondary amenorrhea?

pregnancy

209

PCOS accounts for what percentage of secondary amenorrhea?

30% of cases

210

PCOS is characterized by what?

androgen excess • irregular/absent menses • hirsutism • acne • virilization

211

functional hypothalamic amenorrhea is usually a result of what?

anorexia • rapid weight loss • rigorous exercise • significant emotional stress

212

what are the less common causes of secondary amenorrhea?

hypothyroidism • hyperprolactinemia

213

anovulatory bleeding is caused by what?

continuous unopposed endometrial estrogen stimulation

214

what is the most common cause of dysfunctional uterine bleeding in women younger than 20yo?

anovulatory bleeding (95%)

215

when is anovulatory bleeding especially common?

when women are within 2 years of menarche

216

what can you do for a young woman with anovulatory bleeding?

1. watch expectantly • or • 2. OCP to regulate periods

217

ovulatory bleeding due to fluctuations in estrogen and progesterone levels accounts for what percentage of abnormal bleeding?

10%

218

what do you need to do for any postmenopausal woman with vaginal bleeding?

she needs an endometrial biopsy to rule out endometrial cancer after examination performing the examination and ruling out STI/anatomic abnormality

219

what are the contraindications for endometrial biopsy?

pregnancy • acute infection • PID • known bleeding disorder

220

primary dysmenorrhea is caused by what?

release of prostaglandin from the endometrium at the time of menstruation

221

treatment of primary dysmenorrhea focuses on what?

reduction of endometrial prostaglandin production

222

how do you reduce endometrial prostaglandin production?

1. inhibition of prostaglandin synthesis by medication • 2. suppressing ovulation

223

what is the first line therapy for dysmenorrhea?

NSAIDs

224

how should NSAIDs be used for primary dysmenorrhea?

start NSAIDs day before menstruation. No benefit of continuous daily use

225

what is the role of SSRIs in menstrual problems?

SSRI therapy is sometimes used for premenstrual dysphoric disorder, but is not a first line therapy for dysmenorrhea

226

what is a second line therapy for primary dysmenorrhea?

OCP

227

what medications can cause hyperprolactinemia leading to amenorrhea?

1. psychotropics- benzodiazepines, SSRI, TCA, phenothiazines, buspirone • 2. neurologic- • sumatriptan, valproate, ergot derivatives • 3. estrogens and contraceptives • 4. cardiovascular drugs- atenolol, verapamil, reserpine, methyldopa

228

what is the purpose of the progestin challenge test?

separates patients with estrogen deficiency from those with normal or excess estrogen

229

any bleeding in the week after the administration of Provera indicates what?

the patient has sufficient estrogen to menstruate, and that amenorrhea is likely due to anovulation as in PCOS

230

would patients with premature ovarian failure have a withdrawal bleed after progestin challenge test?

no

231

patients with amenorrhea and elevated testosterone and DHEA-S levels need what workup?

CT scan of adrenals and US of ovaries to rule out neoplasm

232

hysteroscopy and hysterosalpingogram are involved in workup of what conditions?

menstrual irregularities or infertility

233

when evaluating primary amenorrhea in patients with normal secondary sexual characteristics and normal hcg, TSH, and prolactin, it is appropriate to perform what test?

progestin challenge test

234

what can you use to differentiate between inadequate estrogen and outflow obstruction in a patient with no withdrawal bleeding after a progestin challenge test for primary amenorrhea?

estrogen-progestin challenge

235

no withdrawal bleeding after an estrogen-progestin challenge indicates what?

an outflow tract obstruction or anatomic defect

236

what is a physical exam finding seen in hypertensive encephalopathy

papilledema

237

hyperalert confusion is common with what?

alcohol withdrawal

238

amphetamine withdrawal is associated with what presentation?

psychomotor slowing

239

what is the test you order to diagnose bacterial meningitis?

lumbar puncture

240

what can you give for diabetic gastroparesis?

metoclopramide

241

mild pain followed by the acute onset of distension, nausea, and vomiting is consistent with what?

ileus or obstruction

242

what PE finding can differentiate between obstruction and ileus?

hyperactive bowel sounds → obstruction • absent bowel sounds → ileus

243

when should you suspect psychogenic vomiting?

in patients who are able to maintain adequate nutrition despite chronic symptoms

244

when is psychogenic vomiting seen?

usually during times of social stress or in patients with a past history of psychiatric disorder

245

how do you differentiate psychogenic vomiting from bulimia?

bulimia sufferers usually do not seek medical attention or treatment until concerned others bring the condition to medical attention

246

how do you differentiate psychogenic vomiting from CNS malignancy?

CNS malignancy of vomiting center causes nutritional defecit

247

what are common causes of viral gastroenteritis?

norwalk virus • reoviruses • adenoviruses

248

what is the general course of viral enteritis?

self limited and likely to resolve in 5 days

249

in the presence of pancreatitis, ↑ALT points to what?

gallstone pancreatitis

250

when is ↑ALT less likely in pancreatitis?

when alcohol or ↑TG are the cause

251

when nausea happens before eating in the morning, likely etiologies include what?

pregnancy • uremia • alcohol withdrawal • ↑ICP

252

gastroparesis and pancreatitis cause nausea with what timing?

after eating

253

what is the nature of nausea associated with cholelithiasis?

n/v and pain after eating fatty foods

254

what is the nature of nausea in vestibular disorders?

nausea without any clear association with meals or time of day

255

children with pyloric stenosis typically present how?

with weight loss • dehydration • occasional palpable olive mass in the epigastrium

256

when is pyloric stenosis usually identified?

before 7 weeks of age

257

how do you differentiate pyloric stenosis from reflux?

reflux less likely to be associated with weight loss and dehydration

258

how do you differentiate pyloric stenosis from intussusception?

intussusception is associated with significant abdominal pain and hemoccult positive stools

259

how do you differentiate SBO from pyloric stenosis?

SBO is less likely and is associated with high pitched bowel sounds

260

pancreatitis is associated with the acute onset of what?

significant nausea, vomiting, and epigastric pain

261

what is the timing of the symptoms of pancreatitis?

symptoms occur after eating, and are improved when the patient does not eat

262

what are the typical laboratory findings in pancreatitis?

amylase and lipase are likely to be abnormal, but the CBC is likely to be normal along with hemoccult, AXR, and EGD

263

what is the typical presentation of cholelithiasis?

nausea, vomiting, and pain after eating fatty meals

264

what is the diagnostic test of choice for cholelithiasis?

RUQ U/S

265

when are amylase and lipase elevated in the presence of cholelithiasis?

if the patient develops secondary pancreatitis

266

what are the hemoccult, AXR, and EGD findings in cholelithiasis?

likely normal

267

what are the side effects of the phenothiazines?

drowsiness, • dry mouth • dizziness

268

what are the side effects of tigan?

drowsiness, dry mouth, dizziness as in phenothiazines

269

what are the side effects of zofran?

dizziness and headache

270

what are the side effects of reglan?

diarrhea and extra pyramidal reaction

271

what is the lifetime prevalence of at least one episode of neck pain in the adult population?

40-70%

272

neck pain aggravated by movement, worse after activities, associated with a dull ache and with limited range of motion is consistent with what?

spondylosis or osteoarthritis

273

if neck pain were due to chronic mechanical problems, there would be what?

tenderness to palpation on examination

274

if neck pain were due to cervical nerve root irritation, there would be what?

radiation of symptoms, weakness, numbness, or paresthesias

275

in neck pain from whiplash injury, one would expect a history of what?

an acceleration injury

276

what is the presentation of neck pain due to cervical dystonia (torticollis)

neck would be laterally flexed and rotated

277

what is the presentation of spinal stenosis?

older individual • axial stiffness • paresthesias over several dermatomes

278

what is the best test to order for spinal stenosis?

CT scan

279

when are C-spine radiographs indicated?

after injury, or if there are red flags

280

what is the use of MRI for spine problems?

MRI provides the best anatomic assessment of disk herniation and soft tissue or spinal cord abnormality

281

what is the use of EMG for spine problems?

helps localize radiculopathy

282

what are the 3 questions to ask in the canadian cervical spine rules?

1. is there 1 high risk factor? • 2. is there one low risk factor • 3. is the patient able to voluntarily actively rotate the neck 45 deg to left and right regardless of pain

283

what are the high risk factors in the canadian cervical spine rules for radiographic imaging?

1. >65yo • 2. dangerous mechanism (↑speed MVA) • 3. numbness or tingling in extremities • -- if one yes, then radiography

284

what are the low risk factors in the canadian rules for cervical spine radiography?

1. simple rear end collision • 2. pt ambulatory at the scene • 3. absence of C-spine tenderness on exam • -- one NO requires imaging

285

the Spurling test is also called what?

the neck compression test

286

the spurling test requires what?

patient must bend their head to the side and rotate the head toward the side of pain while the tester exerts downward pressure

287

how do you interpret a neck compression test?

the maneuver reproduces symptoms in the affected upper extremity in the case of nerve root injury

288

what are the sensitivity and specificity of the neck compression test for cervical radiculopathy?

high specificity but low sensitivity

289

how do you interpret a spurling test when the maneuver results in neck discomfort only?

dx: nonspecific mechanical pain

290

what are the ways that torticollis in the adult is managed?

PT • stretching • gentle manipulation • use of cervical collars • ice/heat • botox

291

the most evidence points to efficacy of what treatment for torticollis?

botox injection

292

what are the characteristics of palpitations that can help you determine whether the symptoms are from a cardiac cause?

1. male sex • 2. description as irregular heart beat • 3. personal history of heart disease • 4. event duration >5min

293

when a patient describes their heart beat as rapid and irregular, it suggests what?

either atrial fibrillation or atrial flutter

294

both ectopy and atrial fibrillation can cause what?

irregular pulse

295

how is the pulse in PSVT and stable ventricular tachycardia?

rapid and regular

296

how is the pulse in stimulant abuse?

generally a sinus tachycardia

297

what arrhythmia is caused by hyperthyroidism?

hyperthyroidism may cause Afib, premature beats

298

Ventricular premature beats often occur how?

random, episodic, and instantaneous beats, often described as a flip flopping sensation

299

how do patients describe Afib?

rapid and irregular rate or fluttering in the chest

300

hypertrophic cardiomyopathy can be associated with which arrhythmias?

Afib or Vtach

301

what is the characteristic heart murmur of hypertrophic cardiomyopathy?

systolic ejection murmur worsening with Vasalva maneuver

302

what do you do for a patient with palpitations and normal H&P, 12 lead ECG, labs?

reassure the patient and continue observation

303

what is the likely cause of palpitations in a patient with normal H&P, ECG, and labs?

benign supraventricular or ventricular ectopy

304

what do you order for a patient whose arrhythmia seems to occur with exercise?

stress test

305

when are patients with WPW treated?

if they have symptomatic arrhythmia

306

what is the treatment for WPW?

usually radiofrequency ablation, but also drugs

307

classically, ovarian cysts present with what?

unilateral dull pain that can become diffuse and severe if the cyst ruptures

308

what do you feel on PE of a patient with ovarian cyst?

smooth mobile adnexal mass (with peritoneal signs if it ruptures)

309

how do you differentiate PID from ovarian cyst?

PID is associated with fever and vaginal discharge

310

how do you differentiate ectopic pregnancy from ovarian cyst?

ectopic pregnancy may present with similar symptoms, but menses would not be normal

311

how do you differentiate leiomyoma from ovarian cyst?

uterine leiomyoma are generally asymptomatic if present in this age group, would classically be associated with low midline pressure and menorrhagia or metorrhagia

312

how do you differentiate appendicitis from ovarian cyst?

appendicitis would be associated with fever, nausea, and anorexia

313

PID is classically described as which presentation?

lower abdominal pain that is gradual in onset and bilateral

314

what symptoms may be associated with PID?

fever • vaginal discharge • dysuria • occasionally abnormal vaginal bleeding

315

treatment for PID should provide coverage for what?

N. gonorrhoeae, C. trachomatis, anaerobes, enteric gram negative rods

316

what is the CDC recommended regimen for treatment of PID?

ceftriaxone 250mg IM, + doxycycline 100mg BID x 14 days +/- metronidazole 500mg BID x 14 days

317

when is inpatient treatment for PID indicated?

1. pregnant women • 2. pt w/ severe illness with fever + vomiting • 3. when you can't rule out surgical emergency • 4. those who fail appropriate outpatient therapy

318

pain associated with ectopic pregnancy is often described as what?

colicky, may radiate to the shoulder if there is significant hemoperitoneum

319

what symptom is a diagnostic clue for ectopic pregnancy?

nausea, a sign of pregnancy

320

when should you get a CBC in a suspected case of endometriosis?

if the signs are suggestive of an infectious process

321

how often is ESR elevated in PID?

75% of the time but nonspecific

322

when should you order CA-125 in a patient with symptoms of endometriosis?

if you are concerned about an ovarian mass

323

what imaging should you order for endometriosis?

transvaginal US may be helpful, but MRI is more sensitive for localization of endometriosis

324

what percentage of ovarian masses in girls younger than 15 are malignant?

80%

325

what is the protocol for ovarian mass in a girl <15yo?

bc of high potential for malignancy, any adnexal mass should be evaluated by transvaginal US and referral for surgical removal

326

in many women of child bearing age, adnexal masses are what?

commonly cysts

327

what is the protocol for adnexal mass in adult if the pain is not acute or recurrent, palpable cyst is

monitor with repeat pelvic exam

328

when should you get US for an adnexal mass in an adult?

those masses that do not resolve, or those that increase in size

329

with exudative pharyngitis, palatal petechiae suggest what?

group A streptococcal infection or infectious mononucleosis

330

how do you differentiate infectious mononucleosis from group A streptococcal infection?

posterior cervical adenopathy should point to IM as the correct Dx

331

when associated with pharyngitis and anterior adenopathy, edema swollen uvula is suggestive of what?

group A hemolytic streptococcal infection

332

what is the first line treatment for group A hemolytic streptococcal pharyngitis?

amoxicillin

333

why give liquid amoxicillin for group A hemolytic streptococcal pharyngitis?

penicillin resistance has not been seen in group A β-hemolytic strep, but liquid amoxicillin taste better than liquid penicillin

334

what should you give to a penicillin allergic patient with group A β hemolytic strep pharyngitis?

first generation cephalosporin

335

what percentage of school age children are carriers of group A β hemolytic strep?

20%

336

what is the cause and treatment of laryngitis with pharyngitis?

generally associated with a viral infection, and only supportive care is needed

337

what are the Centor criteria for adults used to determine the probability of group A β hemolytic strep infection?

1 point for each: • 1. tonsillar exudate • 2. tender anterior cervical adenopathy • 3. fever • 4. lack of cough

338

what is the most cost effective approach to treating patients with all 4 Centor criteria for gAβh- strep?

give antibiotics without lab testing

339

how likely is it that someone with 3/4 Centor criteria has strep?

40-60%

340

epididymitis is generally caused by what?

retrograde spread of prostatitis or urethral secretions through the vas

341

in sexually active males <35yo, epididymitis is usually associated with what and caused by what?

associated with urethritis and caused by N gonorrhoeae or C trachomatis

342

what are the less likely causes of epididymitis in sexually active males <35yo?

ureaplasma • mycoplasma

343

what is the more common cause of epididymitis in men >35yo who are monogamous?

enteric gram negative rods (enterobacter) associated with prostatitis

344

what is the protocol for testicular torsion?

requires emergent surgical referral

345

why does testicular torsion require immediate surgical referral?

after 12 hours without treatment, there is only a 20% chance the testicle can be saved

346

what is the nature of the reflex associated with testicular torsion?

the cremasteric reflex is absent

347

how is the cremasteric reflex elicited?

by pinching or brushing the inner thigh which causes the ipsilateral testicle to retract toward the inguinal canal

348

what is a positive prehn sign?

if pain is relieved upon elevation of the testicle when the patient is supine

349

is testicular torsion associated with a positive prehn sign?

no

350

when are the cremasteric reflex and prehn sign present?

epididymitis • hernias • orchitis • cancer