Hearing loss - Conductive
- causes
- Weber + Rinne tests
External ear
- ear wax
- otitis externa
- exostoses
Tympanic membrane perf
Middle ear
- otitis media
- otosclerosis
- neoplasm
- congenital malforation
Sx:
- OK loud noises
- decreased perception of Sound
Weber –> sound to affected side
Rinne –> abnormal; bone > air
Hearing loss - Sensorineural
- causes
- Weber + Rinne tests
Presbycusis
- symmetrica, gradual degen sensory cells and nerve fibers at base of cochlea
Noise induced damage
- hair cells in organ of corti damaged
Infection
Drugs
- aminoglycosides
- furosemide, ethracyrinc acid
- cisplatin
- vancomycin
- wuinidine
- ASA –> tinnitus + reversible hearing impairment
TORCH infections
MEniere’s dz
- fluctuating, unilateral
CNS
- acoustic neuroma
- meningitis
- meningioma
Sx:
hard to hear loud noises
- trouble w/ high freq
- + tinnitus
Weber –> sound to unaffected side
Rinne –> normal; bone < air
Tx OSA
mild - moderate = wt loss, no alcohol, prop up during sleep
Severe = > 20 apneic episodes = CPAP, uvulopalatopharyngoplasty, trache
Tx narcolepsy
Methylphenidate
Planned naps
Tx insomnia
Tx underlying cause
Psych eval if suspected
When use bariatric surgery for obesity?
If BMI > 40
CAGE for EtOH
Cut down
Annoyed
Guilty
Eye opener
Tx EtOH addiction
AA is best
Disulfiram
Naltrexone***
Acamprosate
Diazepam for w/d
Thiamine, folate, MV
Tx smoking cessation
Buproprion
Varenicline
How often reposition pt to prevent ulcers at bony prominces?
2 h
Tx uncomplicated acute otitis media
1st line = amoxicillin
When tx dental infection?
With what?
If it becomes cellulitis
- do not tx gingivitis, periodontitis, periapical abscesses
Tx w/ oral penicillin G
- if pcn allergy, clindamycin
leading cause of congenital hearing loss
CMV
Which opioid is contraindicated in elderly?
meperidine should not be used in the elderly because its metabolite can accumulate and cause seizures
Domestic violence demographic associations
Domestic violence cuts across all racial, socioeconomic, religious, and ethnic lines.
The only consistent risk factor for being a victim of domestic violence is female gender
Child is jehova’s witness, parents refuse tx, the pt is rapidly deteriorating and needs blood transfusion. What do you do?
Western courts have deemed that parents cannot refuse emergency, life-saving treatment to children based on these principles:
(1) the child’s interests and those of the state outweigh parental rights to refuse medical treatment;
(2) parental rights do not give parents life and death authority over their children; and
(3) parents do not have an absolute right to refuse medical treatment for their children, if that refusal is regarded as unreasonable.
When can physician bill for time spent with patient?
When counseling or coordination of care accounts for more than 50% of the face-to-face time of the encounter
Opiates in terminally ill pts used to relieve….?
pain
fatigue
dyspnea
When should babies start dada or mama
6-9mo
Leading cause of death on child > 1 yo
Accidents and injuries
How long should child sit in rear facing car seat
Until both 1 yo and weighs at least 20lb
The diagnosis of multiple myeloma is based on
evidence of myeloma-related end-organ impairment in the presence of M protein,
monoclonal plasma cells, or both.
This evidence may include hypercalcemia, renal failure, anemia, or skeletal lesions.
Patients should be screened for tuberculosis and hepatitis B and C before starting these drugs
TNF inhibitors
infliximab, adalimumab, certolizumab pegol, and golimumab.
If baby had mild hypochromatic anemia with elevated RDW, what would you do next?
Oral iron - see if there is a response to therapy
Most are Fe-deficient
A patient with chronic kidney disease presents with chronic normocytic anemia with a hemoglobin level of 7.8 g/dL. The best outcome is predicted if you raise the hemoglobin level to: (check one) A. 8–10 g/dL B. 10–12 g/dL C. 12–14 g/dL D. >14 g/dL
10-12
Sudden infant death syndrome (SIDS) is
the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2–4 months of age and a quick dropoff by the age of 6 months
Tx alcohol w/d
Benzodiazepine
Stray cat bite….infection in bite…what pathogen do you suspect?
Pasteurella species are isolated from up to 50% of dog bite wounds and up to 75% of cat bite wounds, and the hand is considered a high-risk area for infection
In a baby: itching and a beefy redness around the anus and/or vulva and will not clear with medications used to treat candidal infections.
What is it caused by?
Group A Strep infection
Foods that have the highest association with latex allergy include
avocados, bananas, chestnuts, and kiwi
Which S/E of opioids does not diminish with time?
Constipation
miosis
End stage Alzheimer’s disease and hospice care - how does this work?
Patients with end-stage Alzheimer’s disease are eligible for the Medicare hospice benefit if they meet criteria for hospice.
If the patient lacks decision-making capacity, a family member or guardian may elect the Medicare hospice benefit for the patient.
The patient must be certified by the hospice medical director and primary physician to have a life expectancy of less than 6 months to qualify for hospice services.
Tx otitis media 1st line
Amoxicillin x 10d
Tx cat scratch disease - what is the pathogen?
1 = Azithromycin
Bartonella henselae
Also: Rifampin Cipro TMP/SMX gentamicin
A 3-year-old male is brought to your office by his parents because they are concerned about three “spells” he has had in the past month. In each case, the child started crying when he was prevented by a parent from doing something he wished to do. While crying, he suddenly stopped breathing and his face and lips began to turn blue. After 30–45 seconds he resumed crying, his color returned to normal, and he showed no evidence of impairment. A physical examination today is normal and the child is developmentally appropriate for his age. A recent hemoglobin level was in the normal range.
Which one of the following should you do now? (check one)
A. Teach the parents age-appropriate disciplinary procedures to implement when the child behaves in this manner
B. Reassure the parents that this is a benign condition and will resolve as the child gets older
C. Order an EEG
D. Obtain appropriate laboratory studies to confirm the most likely diagnosis
E. Initiate treatment with valproic acid (Depakene)
B
This child is experiencing simple breath-holding spells, a relatively common and benign condition that usually begins in children between the ages of 6 months and 6 years. The cause is uncertain but seems to be related to overactivity of the autonomic nervous system in association with emotions such as fear, anger, and frustration. The episodes are self-limited and may be associated with pallor, cyanosis, and loss of conciousness if prolonged. There may be an association with iron deficiency anemia, but this child had a recent normal hemoglobin level.
These events are not volitional, so disciplinary methods are neither effective nor warranted. While children may experience a loss of consciousness and even exhibit some twitching behavior, the episodes are not seizures so neither EEG evaluation nor anticonvulsant therapy is indicated. No additional laboratory studies are indicated. Parents should be reassured that the episodes are benign and will resolve without treatment.
The threshold for prophylactic platelet transfusion is
10,000/μL
< 50,000/μL is an indication for platelet transfusion in patients undergoing an invasive procedure
effective for single-dose prophylaxis against Lyme disease
doxycycline
Types of prevention (primary, etc)
Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex).
Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia).
Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin).
The laws regarding clinician reporting of partner violence
vary from state to state.
Many states do not require contacting legal authorities if the victim of the abuse is a com- petent adult.
All states require docs report suspected child abuse. What if there tuns out to be no abuse?
Any health-care provider who makes a good-faith report of suspected abuse or neglect is immune from any legal action, even if the investigation reveals that no abuse occurred.
Elder abuse needs to be recorded too
the anterior fontanel closes between
4-26 months of age (avg. 13.8 months)
A spiral fracture of the tibia is known as a “toddler’s fracture”. Is this abuse?
is a common injury that is often confused with abuse, but not often caused by abuse
Common medications associated with drug fever include
cephalosporins, fluoroquinolones, sulfonamides, and penicillins
Nosocomial and post op fever
Pulmonary complications, especially atelectasis, are the largest single cause of postoperative morbidity.
➤ Pneumonia is currently the leading cause of mortality from nonsurgical postoperative nosocomial infection. Mortality rate is 20% to 50%. Mechanical ventilation is the most important risk factor.
➤ UTI is the most common cause of nonsurgical postoperative nosocomial infection.
➤ The most common noninfectious cause of postoperative fever is drug fever.
Child tuning around with food all of a sudden can’t breathe. What do you do?
Since no foreign object is visualized, a series of abdominal thrusts (Heimlich maneuver) should be the next step to try to expel the foreign body.
In infants, back blows and chest thrusts are performed instead of abdominal thrusts, which could cause iatrogenic trauma to the liver and stomach, which are not protected by the rib cage at that age.
Consequence of alcohol w/d
generalized tonic-clonic seizures (within 6-48 hours),
hallucinations (within 12-48 hours; typically visual but can be auditory or tactile),
delirium tremens (DTs; within 48-72 hours), which is characterized by hallucinations, agitation, tremor, sleeplessness, and sympa- thetic hyperactivity.
How should you remove a stinger from a bee?
Scrape with credit card
May risk injecting more venom if you grasp it by the stinger
Bee sting treatment if it is a local rxn
Local faction is histamine like rxn. Local reactions can be treated with ice and anti- histamines for itching.
Tetanus prophylaxis should be provided for those who have not been vaccinated.
Bee sting tx if it is a LARGE local rxn
Large local allergic reactions are mediated by immunoglobulin (Ig) E reactive to the hymenoptera venom.
best treated with oral steroids
Bee sting tx if anaphylaxis
assessment and management of the ABCs (airway, breathing, and circulation), with intubation, if necessary, IV access, and fluid resuscitation at 10 to 20 mg/kg (usually 500-1000 cc) as soon as possible.
Subcutaneous or intramuscular injection of 0.3 to 0.5 mL of 1:1000 solution of epinephrine should be given as quickly as possible and repeated in 10 to 15 minutes if needed.
Antihistamines, steroids (if severe), and bronchodilators may be required as well.
Anyone with an anaphylactic reaction should be observed in a hospital setting for 12 to 24 hours, as the symptoms can recur.
Abx for animal bites?
Although clear evidence of efficacy is lacking for dog and cat bites, current recommendations are for antibiotic prophylaxis for 5 to 7 days for patients with moderate to severe wounds from dog, cat, or human bites.
When cellulitis is present, longer courses of antibiotic, usually 7 to 14 days, are required
Amoxicillin-clavulanate (Augmentin) is choice
most common infection in closed fist injuries with human bite
Eikenella species
standard screening test for HIV infection is
ELISA
Samples that are repeatedly positive on ELISA testing must be confirmed by Western blot testing
When Ppx in HIV pts for
PCP
MAC?
Prophylaxis against P jiroveci pneumonia should be instituted using TMP- SMX when the CD4 count falls to less than 200 cells/μL
Mycobacterium avium–intracellulare complex prophylaxis, using azithromycin or clarithromycin, is recommended if the CD4 count falls to less than 75 cells/μL.
association of sexual abuse with a lifelong history of
functional gastrointestinal disorders
toddler has a history of fever, and rash that is diffuse, erythematous papules. This is most likely due to
roseola, caused by human herpes virus 6 (HHV-6).
HHV-6 is a ubiquitous virus that infects most children before the age of 3
Tx meningococcal meningitis
Ppx
Tx 1st choice = penicillin G.
Ppx = ciprofloxacin or rifampin.
Age by which a child should use single words:
Most children will say “mama/dada” indiscriminately by 9 months of age
use two words other than mama/dada by 12 months of age.
No single words by 16 months of age are a red flag for the presence of an autism spectrum disorder (ASD).
Other red flags:
• No babbling or pointing by1 2months
• No single words by 16months
• No 2-word phrases by 24months
• Loss of language or social skills at any age
Which one of the following is a physiologic difference between males and females that can affect the pharmacokinetics of medications with a narrow therapeutic index? (check one)
A. A consistently higher glomerular filtration rate in women
B. The typically higher BMI in women
C. Smaller fat stores in women
D. Greater gastric acid secretion in women
E. Slower gastrointestinal transit times in women
There are key physiologic differences between women and men that can have important implications for drug activity. Gastrointestinal transit times are slower in women than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.
Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole. Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions. Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action. Women also have lower glomerular filtration rates than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.
Bacterial infections more commonly result in an increase in what cell type?
neutrophils.
One exception to this is Bordetella pertussis, which has been known to cause absolute lymphocyte counts of up to 70,000/μL
A 5-year-old female is seen for a kindergarten physical and is noted to be below the 3rd percentile for height. A review of her chart shows that her height curve has progressively fallen further below the 3rd percentile over the past year. She was previously at the 50th percentile for height. The physical examination is otherwise normal, but your workup shows that her bone age is delayed. Of the following conditions, which one is the most likely cause of her short stature? (check one) A. Constitutional growth delay B. Growth hormone deficiency C. Genetic short stature D. Turner syndrome E. Skeletal dysplasia
This patient has delayed bone age coupled with a reduced growth velocity, which suggests an underlying systemic cause. Growth hormone deficiency is one possible cause for this. Although bone age can be delayed with constitutional growth delay, after 24 months of age growth curves are parallel to the 3rd percentile. Bone age would be normal with genetic short stature. Patients with Turner syndrome or skeletal dysplasia have dysmorphic features, and bone age would be normal.
Tx chronic insomnia
Cognitive behavioral therapy
The best predictor of vancomycin efficacy is
the trough serum concentration, which should be over 10 mg/L to prevent development of bacterial resistance
Otitis Media causes
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media.
Penicillin-resistant S. pneumoniae is the most common cause of recurrent and persistent acute otitis media.
The statistics that are clinically useful for evaluating diagnostic tests include
the positive predictive value,
negative predictive value,
likelihood ratios.
- Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease
There is strong evidence that physical activity will prevent what in the elderly?
Falls
When obtaining informed consent from a patient, which one of the following is NOT required for a patient to legally have decision-making capacity? (check one)
A. The absence of mental illness
B. The ability to express choice
C. The ability to understand relevant information
D. The ability to engage in reasoning
E. The ability to appreciate the significance of information and its consequences
Patients with mental illness may have decision-making capacity if they are able to understand and communicate a rational decision. The key factors to consider in determining decision-making capacity include whether the patient can express a choice, understand relevant information, appreciate the significance of the information and its consequences, and engage in reasoning as it relates to medical treatment.
Lab values in iron deficiency anemia
Ferritin and serum iron levels fall with iron deficiency.
Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the plasma protein that binds to iron for transport throughout the body) when iron levels are low.
Tx medication ingestion
A single dose of activated charcoal is the decontamination treatment of choice for most medication ingestions.
It should be used within 1 hour of ingestion of a potentially toxic amount of medication
Gastric lavage, cathartics, or whole bowel irrigation is best for ingestion of medications that are poorly absorbed by activated charcoal (iron, lithium) or medications in sustained-release or enteric-coated formulations
When do you do immediate bx if lymph node?
Immediate biopsy is warranted if the patient does not have inflammatory symptoms and the lymph node is >3 cm,
if the node is in the supraclavicular area,
if the patient has coexistent constitutional symptoms such as night sweats or weight loss.
Immediate evaluation is also indicated if the patient has risk factors for malignancy.
In a child with a microcytic anemia who does not respond to iron therapy, what is appropriate to diagnose thalassemia.
hemoglobin electrophoresis
The most useful findings for identifying dehydration are
prolonged capillary refill time,
abnormal skin turgor,
abnormal respiratory pattern
Unlike in adults, calculation of the BUN/creatinine ratio is not useful in children.
Tx smoldering multiple myeloma vs multiple myelooma
This means pt does not have any organ or tissue damage related to this disease and has no symptoms.
Early treatment of these patients does not improve mortality and may increase the likelihood of developing acute leukemia.
The standard treatment for symptomatic patients under age 65 is autologous stem cell transplantation.
Patients over 65 who are healthy enough to undergo transplantation would also be appropriate candidates.
Patients who are not candidates for autologous stem cell transplantation generally receive melphalan and prednisolone with or without thalidomide
In patients with fatigue, family physicians should complete an appropriate history and physical examination…including…
erythrocyte sedimentation rate, a complete metabolic panel, TSH level, CBC urinalysis. A pregnancy test should be ordered for women of childbearing age.
Characteristic vital signs in patients with severe anorexia nervosa include
hypotension, bradycardia, and hypothermia.
Criteria for hospital admission include a heart rate <36°C (97°F).
Increased cardiac vagal hyperactivity is thought to cause the bradycardia
CYP inducers
Momma Barb Steals Phenphen and Refuses Greasy Carbs Chronically
Modafinil Barbituates St Johns wort Phenytoin Rifampin Griseofulvin Carbamazepine Chronic EtOH
CYP inhibitors
MAGIC RACKS in GQ
Macrolides Amiodarone Grapefruit joice INH Cimetidine Ritonavir Acute EtOH abuse Cipro Ketoconazole Sulfonamides Gemfibrozil Quinidine
Hemolytic anemia is established by
reticulocytosis, increased unconjugated bilirubin, elevated lactate dehydrogenase (LDH), decreased haptoglobin, and peripheral blood smear findings
Pediatric pre-op indications on food
Stop X hrs prior to surgery: 8 hours for solid food, 6 hours for formula, 4 hours for breast milk, 2 hours for clear liquids.
Waldenström’s macroglobulinemia
- Cause
- Sx/PE
- uncontrolled proliferation of lymphocytes and plasma cells, which produce IgM proteins with kappa light chains.
Sx:
Weakness, fatigue, weight loss, bleeding, and recurrent infections are common presenting symptoms.
Physical findings include pallor, hepatosplenomegaly, and lymphadenopathy.
Typical laboratory findings include moderate anemia and monoclonal IgM peaks on serum electrophoresis. Bence-Jones protein is seen in 80% of cases, but is typically absent in monoclonal gammopathy of undetermined significance.
Unlike in multiple myeloma, lytic bone lesions are not seen, and marrow biopsy reveals mostly lymphocytes.
In kids with fever, when do you:
- admit to hospital for observation
- observe w/ close f/u
- send home w/ f/u in 24 hrs
Hospital admit –> for complete sepsis w/u
- Any child younger than 29 days old with a fever
- any child who appears toxic, regardless of age
Observe w/ close f/u:
- 3-36 mo that look NONtoxic + temp < 102.2 F
Send home w/ f/u in 24 hrs:
- 29-90 days that look NONtoxic + negative screening lab studies (CBC, UA)
A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If the usual incidence of this complication were 1% per year, how many patients with this disease would have to be treated with this medication for 1 year to prevent one occurrence of this complication? (check one) A. 20 B. 50 C. 100 D. 200 E. 500
Considering relative risk reduction without also considering the absolute rate can distort the importance of a therapy. A useful way to assess the importance of a therapy is to determine the number-needed-to-treat for that therapy. To calculate this number, the percentage of absolute risk reduction of a particular therapy is divided into 100. In the case in question, the absolute risk reduction would be 0.5% (0.5x.01). Thus, the number-needed-to-treat for the example cited would be 200 (100/0.5).
You are considering how useful a new treatment might be in preventing stroke. A well designed study is reported with 200 patients in the treated group and 200 patients in the untreated group. The study finds a 5-year risk of stroke of 3% in the treated group versus 5% in the untreated group. Assuming this study is valid and applicable to your patient population, how many patients would you have to treat for 5 years to prevent one stroke (number needed to treat, or NNT)? (check one) A. 400 B. 200 C. 100 D. 50 E. 25
The relative risk reduction (RRR) is the proportional decrease in disease incidence in the treated group relative to the incidence in the control group. In this example the 3% incidence in the treated group is 40% less than the 5% incidence in the control group: (5%–3%)/5% = 40%. The absolute risk reduction (ARR) is the difference between the incidence of disease in the treatment group and the incidence in the control group. In this example the ARR is 5% minus 3% = 2%.
The number needed to treat (NNT) equals the reciprocal of the ARR: 1/.02 = 50.
use of what in patients with severe sepsis and a high risk for death does improve survival
recombinant activated protein C
