The Review Course Flashcards
(384 cards)
1
Q
Cough:
list acute, subacute and chronic cough ddx
A
Acute <3wks:
- Something fatal? pneumonia, HF, neoplasia, foreign body, PTX
- Medication: ACe inhibitors
Subacute 3-8 wks:
- Post-viral
- Infectious : bacterial, viral
- Early chronic: asthma, reflux, upper airway cough syndrome (post nasal drip), covid 19
Chronic >8 weeks:
- COPD
- Infectious (ascaris?)
- Refractory or unexplained cough
- Less common: cystic fibrosis, bronchiectasis, eosinophilic bronchitis
Always ask travel, occupation, contacts, critters
2
Q
Cancer:
- Prostate
- Testicular
- Lung
- Ovarian
- Cervical
- Melanoma
- Colon
- Breast
- Pancreatic
-
A
- Prostate cancer : no screening for average risk
- Testicular cancer : screen if cryptorchidism, FMHx, PMHx (screen with BHCG, alpha-fetoprotein). Tx Lop it off surgery.
- Lung cancer: Low dose CT 55-74yo if 30pk/yr smoker (smoking now or in last 15 years). Annually x 3 max. No CXR. Think Radon gas 2nd leading cause of lung cancer, recommend home radon test kit.
- Ovarian: do not screen if asx low risk. High risk (BRCA positive) then screen.
- Cervical: screen 25-69 q3years (DO not screen: never sexually active, weakened immune system, HIV is every year no q3yrs, sx cervical cancer, previous abnormal screening, does not have a cervix)
- Melanoma: refer if high risk (older, male, previous skin cancer, FMHx, # nevi (low risk <15), light skin, red hair, multiple sunburns, actinic skin damage)
- Colon cancer: FIT test 50-74yrs q2yrs, not affected by NSAIDs, OACs or ASA (or flex sig q10yrs)
- Breast cancer: 50-74yrs q2-3years if average risk (otherwise shared decision making)
- Pancreatic cancer: only if high risk (BRCA1 +, FMHx, Peutz-Jeghers syndrome).
3
Q
Febrile neutropenia
DOs/DONTs
A
DOs: look in mouth for mucositis, look for source (consider fungal)
Early abx: cipro + amox if low risk, tazo if high risk. consider antifungals.
DONTs: rectal exam/temperature
4
Q
Unexplained weight loss
Investigations
A
Weight, height
Serum Hemoglobin
Serum sodium, potassium, eGFR
Serum urea, creatinine
Serum PSA
Fecal Occult Blood
Chest x-ray
Chest, abdomen, pelvis CT (with contrast!!!! for cancer)
CAREFUL IF THEY ASK FOR SERUM
5
Q
Shortness of breath
- r/o PE with
A
- Wells first, if low risk then PERC
- pregnant: YEARS rule –> signs DVT, hemoptysis, PE most likely (1pt each) –> d-dimers : r/o PE if <500 (1-2-3pts), <1000 (0pt)
6
Q
SOB:
investigations
A
ECG
Echocardiogram
Troponin
Arterial blood gas (if acute)
Chest x-ray
Pulmonary function
CT chest if no clear diagnosis
7
Q
Shortness of breath
Zebra causes lung and heart
Extra pulm/cardiac causes:
Life threatening
A
Lung: recurrent fungal pneumonia, fibrosis, post-COVID 19 sequelae, pleural effusion
Heart: occasional arrhythmia, cardiomyopathy, malignancy, mycobacterial, aortic stenosis
Other: anxiety, abnormal thyroid, altitude, anemia, acid reflux, allergy, deconditioning
Life threatening: foreign body, anaphylaxis, pneumothorax
8
Q
Pneumothorax primary spontaneous <2cm on xray: dos and donts
A
Do: observe 4 hours, d/c if well tolerated and stable on xray, offer needle drainage instead of chest tube (less pain, higher failure rate) but 85% DO NOT require drainage
Don’t: CT/POCUS (not necessary)
9
Q
COPD
Ddx:
Does oxygen therapy change time to death/hospitalisation?
Non-pharmaco tx to think about
When can you consider opioids?
A
Ddx: think pre-COPD (resp sx but normal lungs)
No
Acupuncture, active mind-body therapy, yoga, tai chi
In palliative context
10
Q
COPD:
3 elements to consider with treatment
A
- Daily macrolides (reduce exacerbations)
- Action plan (reduce hospital use)
- CPAP if COPD + OSA (reduce mortality + admission)
11
Q
COPD:
Explain treatment for COPD mild vs mod/severe
A
Mild: LAMA or LABA (no longer SABD x 2023)
Moderate to severe:
- if lo AECOPD: LAMA + LABA + ACS
- if Hi risk AECOPD: triple + oral (roflumilast/pde-4 inhibitor, n-acetylcysteine, daily azithromycine)
ALWAYS SABD PRN
Mild = COPD Assesment test (CAT) <10, FEV1>=80%
Mod/severe = CAT>=10, FEV1<80%, mMRC scale >=2
12
Q
What other one test would you order for COPD?
A
Blood eosinophils –> if >=300 change to ICS + LABA instead of LAMA/LABA
13
Q
Can you diagnose COPD in non-smoker?
A
It could be second-hand but think about other causes:
- Alpha-1 anti-trypsin (if dx <65yo or <20pk/yr)
- Bronchiectasis
- Infectious
- Cardiac
- Mass
14
Q
COPD:
acute exacerbation vs chronic worsening
Treatment for both
Treatment for AE
A
AE: days
Chronic worsening: over months
For both : stop smoking, optimize inhalers + review technic
Treatment for AE:
- Steroids
- Antibiotics if CRP >40 or 2/3 winnipeg symptoms (sputum purulence, sputum volume, dyspnea)
—> treat as per local resistance pattern
15
Q
COPD:
common pathogens
A
Ear bugs: H.influenzae, S. pneumonia, M. catarrhalis
Complicated: ear bugs + Klebsiella, pseudomonas, gram negatives
16
Q
COPD: prevention, refer, start
A
Prevention:
- Vaccination: influenze, pneumococcal vaccines, covid-19
- Exercise to prevent exacerbations
- smoking cessation
Refer early: respiratory therapy, pulmonary rehabilitation, respirology, smoking consellor, palliative
Start: short-acting beta-agonists if mild + intermittent sx, long-acting muscarinic antagonist if regular mild sx.
17
Q
How do you mange COPD/Asthma overlap syndrome
A
ICS/LABA (fluticasone propionate + salmeterol) +/- LAMA (tiotropium)
Refer +/- biologic medications
18
Q
Asthma:
diagnosis in pediatric population
A
<6 years old: reverse with salbutamol, wheezes, r/o other causes (croup, foreign body, asthma can overlap with bronchiolotis or virus induced wheeze)
> = 6 years old : PFT
19
Q
Main cause of bronchiolitis:
- diagnosis
- cause
- management
- prevention
A
RSV bronchiolitis
- Investigation = NONE if uncomplicated. Nenonates may present with apnea or cyanosis only.
- Cause = RSV 80%, mycoplasma, pertussis
- Management = supportive (admit if needed to maintain saO2 >90%
- Prevention = vaccine
20
Q
How can you assess asthma severity at ER?
A
PRAM score:
- <4 mild
- 2-7 mod
- >7 severe
Asses: O2 sat, retractions/indrawing, air entry, wheeze
21
Q
Asthma:
what environment exposition increases risk in children?
A
Frequent use of cleaning products
Antibiotics without being breastfed in 1st year of life
22
Q
Asthma:
3 elements of hx with adult
A
- triggers
- past severity
- current control
23
Q
Asthma control if:
A
PER WEEK:
=<2 days with symptoms
<1 day night symptoms
=<2 doses of reliever
NO interference with work/school/exercise
Mild infrequent exacerbations
24
Q
ASTHMA diagnostic PFT values:
A
25
ASTHMA : management
Safety : how many relievers used? (normally 1 puffer every year, 1 puffer = 200 doses. If 2 puffers <6 months, review plan. if >=3 puffers/yr consider ICS as PRN)
Next visit: when to FU, in-person for complete physical exam
Offer: PFT, chest xray
26
Asthma : regularly reassess
Control
Risk of exacerbation
Spirometry or PEF
Inhaler technique
Adhrence
Triggers
Comorbidities
27
Asthma: pharmacological
1st line: ICS PRN or (ICS + SABA)PRN (asthma should always have ICS even if mild asthma, otherwise just ventolin might increase exacerbations)
2nd line: daily low dose ICS + ICS-formoterol PRN
(other: daily leukotriene receptor antagonist)
3rd line: low dose ICS+LABA or medium dose ICS with ICS-formoterol PRN (other low dose ICS + leuko)
4th step: medium dose ICS + LABA or high dose ICS + LAMA or LTRA
5th step: high dose ICS-LABA +/- anti-IgE, anti-IL5, anti-IL4 (monoclonal biologic therapy)
28
What is the one test you should think of in abdominal pain?
Beta-HCG in any woman in age to procreate
29
Abdo pain:
List 5 alarm features other than weight loss, palpable mass or hematochezia/melena
Age > 55
Severe pain
Melena
Weight loss
Abnormal labs (Hb, CRP, Na, K)
Vomitting
Dysphagia
Mass
Family history
Previous history
Bilious vomit
BHCG
30
Dyspepsia: how do you treat pylori
14 days quadruple therapy:
clarithromycine, amoxicillin, metronidazole, PPI
31
Dyspepsia: Barrett's esophagus
Risk factor
Management
Reflux = greatest risk factor
Management:
- Lifestyle for reflux (caffein, ETOH, smoking, weight loss)
- High dose PPI
- ASA (reduces the risk for adenocarcinoma)
32
When should you screen for esophageal cancer?
Never, even if high risk
33
What are PPIs side effects? (important cause prescribed very often in the past and now we realise there are important side effects)
- B12 deficiency
- Gastric cancer
- Fractures
- Dementia
- C. difficile
34
Abdo pain: non-abdo causes
- Think pelvic exam/B-HCG
- Herpes Zoster (skin exam)
- Testicular torsion? (mostly if younger male)
- PE/MI/endocarditis
35
Imaging 1st modality for ureteral stones?
Kidney Ultrasound
Can add Kidney Ureter Bladder Xray
36
What risk for pancreatitis
Rx: septra, flagyl, HCTZ, ACEi, progesterone/estrogen, atorvastatin
Medical condition: gallstones
Habitus: ETOH
37
Risk factors for gallstone
Female, forty, fertile, obese, OCP
38
Insomnia: explain types
20 sleep disorders on DSM-5
Narcolepsy
Restless leg syndrome
Sleep terrors
Sleep walking
Insomnia disorder
OSA
Hypersomnolence Disorder
Circadian rythm sleep-wake Disorders
39
insomnia: what are the other causes
It's never JUST insmonia
Medications
Drugs (cocaine most days)
Drink 2 bottles of wine each day
Has a history of ADHD
Cushing (facial & neck fat prominence)
Hyperthyroidism/Hypothyroidism
Depression (YES to PHQ2 : 1) down/depressed/hopeless 2) little interest/pleasure)
Parkinson (resting tremor?)
40
insomnia: pharmacological consideration (deprescribe/new medication)
Deprescribe in insomnia: benzo (harm>benefit), trazodone (risk of falls + ineffective), antipsychotics (ineffective)
New medication: dayvigo (lemborexant) or lunesta (eszopiclone --> non-benzo sedative hypnotic)
41
Insomnia: SNOPQRST
Safety: verify if noding off at the wheel or if sleeping >10hours a day, or falling during conversation. No driving.
Next visit: physical exam + interview partner
Quit: naps, caffein (at least 6 hours before bedtime, some people very sensitive 8-10hours)
Refer: sleep medicine, level 3 sleep study, psychiatry, auricular acupuncture, CBT-INSOMNIA (dont forget the insomnia!!!!)
Teach: avoid screen time before bed, sleep diary (medication taken).
42
Deprescribing benzodiazepines
43
Deprescribing antipsychotics
44
restless legs syndrom
non-prescription vs prescription
Non-prescription: iron, magnesium, stretch calves, avoid caffeine, massage/heat, exercise
Prescription:
- Non-ergot dopamine agonists (pramipexole)
- Alpha-2-delta calcium channel ligand (gapapentin, pregabalin)
45
sleep apnea
Diagnosis: STOP questions (Snore, tired, observed apnea, High BP)
Treatment: positive airway pressure (c-pap), mandibular advancement device
46
family issues: how to management isolation/loneliness
Social facilitation
Animal Therapy
Psychological therapies
Skill development
47
FIFE +
Feelings + Ideas
Function/Fears + Expectations
Domains of Impact = MRS SWELP$
- Mental
- Relationship
- Spiritual
- Sex
- Work
- Emotional
- Legal
- Physical
- $ Financial
More relational :
- Spouse (how long together/married, risk domestic abuse, supportive?)
- Parents, siblings, children (in the same city?)
- Roommate?
- Mistress?
- If relation mentionned in SOO (my wife/children told me to consult, assess impact/expectations/fears they have and offer to talk to them) --> CAREGIVER BURNOUT?
BE CONVERSATIONAL
"it's sound like you're expecting" "what are you hoping we can accomplish today?" "what do you think is going on"
48
How can you help caregiver burnout
by staying CALM
Counselling
Appointment (separate visit)
Lifestyle advice
Mental health support
49
CBT tricks name 4
- Goalification (help pt find goal in each complaint - complaining about exam : you have studied for this for years, you have a plan, you did questions)
- Viewpointing (how would -insert relation- see this?)
- Scalification (1-10, why not worse)
- Reward chart (link effort and reward)
- Pathogenic beliefs (identify by listening/acting/guessing)
- Cognitive illusions (identigy thinking traps "i'll never find...")
- Mood Pie with 2 slices (good vs bad luck, bad luck = excuse for self-compassion)
- Thoughts record: write thoughts and associate to feelings/illusions
- Persuasion (help patients drop pathogenic beliefs)
- Systematic desensitization (increase exposure to fears)
50
Acute diarrhea (length, always do what?, antibiotics causing )
<14 days
Always assess if HD stable (hypovolemia) + consider BHCG
Antibiotics-associated diarrhea: clinda, cipro/levo
- prevent with probiotics
- "Antibiotics Can Trigger Loose C.Diff" : amox, clinda, tetra, levo/ciprofloxacin, cephalosporines
- if recent abx use think C.diff (treat with vanco, not metronidazole anymore)
51
Dehydration : fluids for peds + consideration if formula-fed in context of diarrhea
Bolus 20cc/kg
Rule 4-2-1 for maintenance (4cc/kg x 10, 2cc/kg x 10, then 1cc/kg)
Continue breastfeeding if diarrhea
Formula-fed : temporary lactose-free formula
52
What are direct objective measures to direct management of severe dehydration?
LAB measures: serum glucose/sodium/urea/creatinine/potassium/eGFR
Other: weight
53
Investigation mild gastroentritis?
None, avoid overinvestigating
54
Don't always assume gastroenteritis also think of:
Infectious : meningitis, pneumonia, cholera, sepsis
Non-GI
Abuse/neglect
Medication
Diabetic ketoacidosis
55
Always think of how different the management could be in special populations. Special populations are:
Pregnant, infant, elderly
56
In a patient with shortness of breath, new rash or diarrhea, you should always ask if?
Recent travel/immigration
57
Diarrhea in elderly causes
- Acute ischemic bowel
- Obstruction
- Diverticulitis
- Appendicitis
- Neoplasm
Gastroenteritis = LOW on the list
58
Diverticulitis management complicated vs uncomplicated
Uncomplicated : no abx, treat OP, non-opioid analgesia
Complicated (perforation/abscess): antibiotics +/- surgery
59
C.difficile risks (5) + treatment
Healthcare-associated (recent hospit)
Older age
Immunocompromised
Previous c.diff infx
Recent antibiotics (clinda, cipro, clavulin) --> "C" antibiotics can cause "C" difficile
Treatment: first line = fidaxomicin, others (vancomycin, metronidazole), rare (fecal transplant)
+ dont forget supportive care (IVF)
60
What should you always assess in a chronic condition? (chronic diarrhea, chronic SOB, chronic pain, etc.)
New sx/pattern?
Exacerbation?
Complication?
61
Chronic diarrhea : length + investigations
>4 weeks
Common:
- Hb, ferritin, TSH, anti-TTG (tissue transglutaminase antibody), calprotectin (IBD), FIT test, C.diff, ova& parasites stool culture
If altered bowel habits : straight to colonoscopy
Other:
- Hydrogen breath test (lactose intolerance)
- Fecal elastase (fat malabsorption)
- MRI abdomen (chronic pancreatitis)
62
In patients with chronic diarrhea you should always look for 3 categories of etiology (think GI and non GI sx):
1. Inflammatory bowel disease (IBD):
- GI: Look for blood in stools, abdominal pain, weight loss
- Non-GI: joint pain, skin manifestations, and eye inflammation.
2. Malabsorption syndromes:
- GI steatorrhea, bloating
- Non GI malnutrition, vitamin deficiencies, anemia, and neurological symptoms.
3. Compromised immune system:
- GI: recto/melena, recurrent GI infections
- Non-GI : fever/constitutional sx, lymphadenopathy, and opportunistic infections causing persistent diarrhea.
63
What are therapies that should now be avoided for Crohn's according to 2019 guidelines?
Avoid the As
- 5-ASA po --> prescribe only per rectum (not orally)
- Antibiotics
- Alternative treatments (marijuana, probiotics, omega-3, naltrexone)
64
Pharmacological management of Crohn's
1st line : sulfasalazine
Steroids (not in high risk pts)
Thiopurines (not for induction)
Methotrexate
Biologics (anti-TNF therapy)
65
DOs for IBS
- TTG or endomysial IgA
- FODMAP diet trial
- Psyllium, prune juice
- Peppermint oil, probiotics
- CBT
- colonoscopy if >50yr or alarm features
66
DONTS IBS
67
Pharmacotherapy for IBS-D:
Dont loperamide, cholestyramine, osmotic laxatives
68
What would be the diagnosis for a prodound fatigue NOT improved by rest or with post-exertional malaise?
Myalgic encephalomyelitis
69
Fibromyalgia diagnosis + treatment
Diagnosis : diffuse body pain x 3 months with no other explanation with WPI>=7 + SS>=5 or WPI 3-6 and SS>=9 (7+5 = 12, 3+9 = 12)
- Widespread Pain Index: /19 (jaw, neck, chest, shoulders, U arms, L arms, abdomen, buttocks/hips, U legs, L legs) --> 1 pt for each side except chest/neck/abdo
- Symptom Severity: /12 (0-3 fatigue, 0-3 waking unrefreshed, 0-3 cognitive sx, 0-3 systemic sx)
Treatment: exervise, psychological (CBT), themal baths, massage
70
Myasthenis Gravis symptoms + tests
Masticulation difficult
Ocular (diplopia/ptosis)
Phonation (weak voice with long convo)
Test: Acetylcholine receptor antibody, tensilon test
71
What's the new name for hypochrondiasis
Somatic symptom disorder (SSD-PAIN subtype if pain is a sx)
72
What is the investigation for somatic symptom disorder?
None
73
When can you diagnose somatic symptom disorder (SSD)?
After
- complete hx + PE
- thorough workup
- Referrals
- Rule out other causes: rx side effects, myasthenia gravis, abuse/trauma, DVT, necrotizing fasciitis, osteomyelitis
74
When a patient presents with dyscopia (inability to cope) you should think of what ddx?
Somatic symptoms, Anxiety, Depression (SAD - always think of the others when thinking of one)
Chronic pain
Sleeping disorder
Substance use disorder
Side effects
75
How do you manage somatic symptom disorder?
Start: PT, massage, acupuncture, naturopathy
Search: life-threatening causes
Team: PT, CBT, important to have only one primary care provider (in SOO, offer to be family doctor)
Teach: support groups, online resources & apps
Time: regular long-term follow up (building an alliance)
76
How do you manage thyroid storm?
BLOCK Bs
Block TSH synthesis (methimazole, PTU)
Block Conversion of T4 --> T3 (propranolol, PTU)
Block TSH release (iodine)
Beta-blockers (propranolol)
Block bile (cholestyramine)
Thyroid storm is a severe form of hyperthyroidism (like myxedma coma is the severe form of hypothyroidism) --> therefore you want to start with thionamides to decrease TSH synthesis, PTU is preferred because it also decreases conversion T4 to T3 (as T3 is more potent/active in the body ). Just after thionamide you give iodine to help decrease TSH release and finally, BB propranol helps with blocking both conversion + control sx palpit/tremors/anxiety. You can also add cholestyramine who binds TSH and is excreted in poop)
77
Explain management of grave disease
Same first 4 Bs:
- Block TSH synthesis (thionamides)
- Block T4 conversion (propranolol)
- Block TSH release (iodine, used less frequently)
- Beta-blockers
Radioactive iodine ablation
Thyroidectomy
78
Modifiable/non-modifiable risk factors of thyroid disease:
medication
sedentary
alcohol
smoking
obesity
pregnancy
Non-modifiable: FMHx, PMHx
79
When do you screen ASYMPTOMATIC for hypothyroidism?
At risk : pregnancy, previous thyroid disease, previous radiation, pituitary/hypothalamus disorder
Taking thyroid replacement
80
When do you do radioactive iodine uptake? When do you avoid RAIU?
When high TSH is confirmed (do hx + PE and px BBs while sending to scintigraphy) to r/o hot nodule(s).
You DONT for: pregnant or breastfeeding women. (also if 1000% graves like pt has exophtalmia, avoid doing it)
81
What do you do if there is a thyroid nodule on scintgraphy?
Hot nodule (multigoiter, toxic adenoma) : then surgery
Cold nodule: r/o neo so thyroid ultrasound and per features on US to fine needle aspiration for cytology
IF thyroid nodule
1) TSH + Thyroid US:
2) FNA if:
- >=1cm if hypoechogenic or solid (mostly if irreg, taller than wide, calcifications, extend extra-thyroid)
->=1.5 if isoechogenic or part. cystic with other worrisome features (irreg borders, microcalcifications)
- >=2 if spongiform or part. cystic without worrisome features
No FNA is completely cystic
82
Differential neck mass diagnosis (acute, subacute, chronic)
Acute: sialadenitis, hematoma, vascular, lymph node
Subacute: sialadenitis, neo
Chronic: carotid body tumor, congenital cyst, goiter, thyroid nodule, goiter, layngocele, lipoma
Next steo = US neck or CT Neck + CT angiography neck (add PET scan of PMHx cancer)
83
Suicide Risk assessment
- Ask about access to firearms
- SCARED screening tools in adolescent
84
What is the first thing you should do in a new presentation for anxiety?
Cardiac
Resp
Hormonal
infectious
drug (use or withdrawal)
Other psy: psychosis, bipolar, depression
85
Risk factors for anxiety
FMHx
PMHX (mood disorder or anxiety)
Adverse childhood experiences
Female
Chronic medical illness
Behavioural inhibition
86
Management of anxiety (pharmaco)
Anxiety drug classes : benzodiazepines (PRN mostly for panic disorder), SSRIs, SNRIs, buspirone
Also effective for GAD: mirtazapine, sertaline, fluoxetine, buspirone
Off label: MAOI, TCAs, atypical anti-psychotics, anticonvulsants
87
What are the 5 rules when prescribing benzodiazepines?
Dont combine with opioids
Avoid in high doses
Address fear - always talk about safe storage of medication if pt has children!!!
Consider dependence
Avoid in elderly
88
Non pharmaco for anxiety
CBT, Mindfulness-based , meditation, aerobic exercise, yoga, tai chi
89
PST management
SSRI, SNRI
mirtazapine, amitryptiline
CBT
Trauma-focused therapy
Group therapy
INsomnia: prazosin
debriefing of all trauma victims NOT recommended
90
OCD management
SSRI
CBT
Exposure with response prevention
91
Trichotillomania and excoriation
SSRI or antipsychotic
N-acetylcysteine
Treat the wound (abx if infx)
92
Tourette
similar to movements disorder
Risperidone or tetrabenazine
Botox
Habit reversal training
93
PICA
methylphenidate, olanzapine
treat complications (xray, bezoar?)
94
Diabetes: DKA 3 sx/signs
Hyperglycemia, ketosis +/- ketonuria, acidosis with anion gap
95
How do you manage
IVF
Insulin
Potassium
96
Etiology of DKA
Infection
Infant
Illegal drugs (cocaine)
Iatrogenic (medical like corticosteroids)
Insulin problem (defect, left in hot temperatures)
Ischemia/infarct
Idiopathic
97
DKA management post resolution
Prevention : vaccination (pneumovax)
Refer: nurse educator, dietitian, endocrinology
Teach: written information
98
What should you always questions in someone that was newly diagnose or with suspicion of diabetes that you see for the first time?
Symptoms : polyphagia, polyuria, polydypsia, weight loss
End organs: paresthesia, blurry vision, urine changes (polyuria)
99
Examination and investigation for diagnosis of Db2
Assess retinopathy, renal disease, cardiovascular, neuropathy
HbA1C (individualize target)
Arrange diabetes education (nurse educator, dietitian)
100
MODY : list 4 elements on history that would make you think of MODY
Onset <30
Not obese
Metformin doesnt help
Hypoglycemias with sulfonylureas
In Db1: weight loss, ketonuria, onset in weeks/days
101
Explain type 2 diabetes management in stepwise approach
Diagnosis
Lifestyle +/- metformin
2nd OHA (GLP1, SGTL2i, DPP4, sulfonylureas)
- NEW : GIP/GLP1R agonist (tirzepatide)
qHS Basal insulin (10u NPH qHS)
qAM basal insulin
bolus insulin
102
When is SGLT2 inhibitor contra-indicated?
Type 1 Diabetes
103
What are side effects SGLT2i
- Normoglycemic DKA
- Drop GFR (10-15% x 3 months)
- Yeast vaginitis/balanitis is common
104
Benefits of continuous glucose monitoring
type 1: decrease 2% severe hypoglycemia
no benefits type 2
no meaningful improvement in A1C
105
106
How do you advise patient who will be driving long hours with their risk of hypoglycemia?
RULE 2-4-6:
1) If pt is hypoglycemia unaware: check gluco q2hrs
otherwise check ever 4hours
2) If low: treat and wait 40min
3) Keep 6 lifesavers candies in the car for hypoglycemias
107
Name 3 neurological complication of diabetes and their management
Diabetic neuropathy:
- 1st line = TCA, SNRI, NA channel blocker (lidocaine, class IB), gabenpitnoids
- Prevent ulcers/falls
Diabetic amyotrophy:
- Severe neuropathic pain with motor weakness and proximal muscle atrophy + weight loss
- Analgesia, physiotherapy
Gastroparesis
- Prokinetics (mtoclopramide, domperidone), antiemetics
- Stop GLP1
- Look for other diabetic autonomic neuropathies (cardiac, erectile, vaginal dysfunction)
108
Hepatits: what are the other causes for elevated LFTs?
109
Investigation for hepatitis:
Hepatic cause:
- HIV, HBV, HCV, syphilis
- Liver Ultrasound
Extrahepatic:
- TSH, anti-TTG (celiac), troponin, cortisol (adrenal insufficiency), CK (myopathy), alpha1 antitrypsin
110
Explain steatotic liver disease
SLD (previously fatty liver) = umbrella terms for the different ETIOLOGIES:
1) Steatohepatitis (inflammation)
2) Metabolic associated (inflam + cardiometabolic)
3) Metabolic dysfunction associated steatotic liver disease (cardiometabolic risk factors)
4) Metabolic Alcohol associated liver disease (alcohol + cardiometabolic risk factors)
5) Alcohol associated liver disease (alcohol)
SLD is also a spectrum for the evolution of fatty liver disease:
1) Healthy liver
2) SLD (steatosis/fat accumulation) --> reversible
3) Steatohepatitis (steatosis + inflam) --> reversible
4) Cirrhosis (fibrotic scarring)
5) HCC (tumor) --> straight from steatohepatitis too
111
What is the best treatment for SLD?
Lifestyle
- Exercise
- Weight loss
Uncertain evidence GLP1, SGLT2i, bariatric etc
Not helpful = metformin
112
How do you manage SLD?
Fib4
- intermediate score = elastography (fibroscan)
- high score = refer
113
Hepatitis serologies for HBV
- Hepatitis B: HbsAb (anti-HBs), HbcAb (anti-HBc IgM), HbsAg
- anti-HBe present when infectivity is very high
114
Hepatitis C serologies
anti-HCV, serum HCV RNA, genotype & subtype
115
Resolution rate of Hep C
Spontaneous recovery in 20-45%
116
Management Hepatitis
A : supportive care + refer
B: refer hepatology, treat if severe (HBV DNA >2000), tenofovir/entecavir, monitor
C: hepatology, treat if sevre, interferon for treatment
117
How do you monitor hep B or hep C
hepatocellular cancer: liver US q6-12months
Varices: gastroscopy q1-3years
ETOH: monitor hx
Labs: ALT q 6months
Cirrhosis/fibrosis: fibroscan
118
Post-exposure prophylaxis hepatitis
119
Imaging for low back pain?
Not reuired
120
Management LBP non-pharmaco vs pharmaco
manage mostly with non-pharmaco
meds small benefit
steroids can help if radicular
121
Non-inflammatory vs inflammatory
Non-inflammatory : AM stiff<30min, worse at the end of the day
Inflammatory: AM stiffnes >30min, better at the end of the day
122
What are the non MSK causes of LBP you need to think of? Name 3
Stone
Aneurysm
Vascular
123
Myotomes L1/L2 and L3/4
124
Myotomes C5/C6 and C7/C8
125
Dermatomes LBP
126
Nonpharmaco options for LBP
osteopathy
CBT (chronic)
yoga (strong evidence)
Small benefit of acupuncture
127
Explain approach monoarthritis
128
Explain approach to polyarthritis
129
Explain the 5 common mistakes made during joint disorders investigation/diagnosis
1) Don't miss alarm features:
- HOT (fever, warm joint)
- BOG (soft, boggy joint)
- AM : stiff >30min
- pain at night
2) don't miss other causes: lupus, angina, systemic vasculitis, genital infx, TB, epicondylitis
---> in children acute lower extremity pain not due to trauma THINK INFECTION mostly if fever. Do blood culture
3) don't xray everybody
4) ont mistake/ignore referred pain (knee pain could be because of hip fx)
5) don't forget to treat the pain while investigating/referring
130
Four things to remember in autism:
1) review tools: modified checklist for autism in toddlers (revised, with follow up)
2) Refer early: HEARING/VISION assessment, autism clinic, OT, psychology, speech language pathology, pediatrics
3) Rx as needed: melatonin for sleep, could consider pharmacological for constipation or anxiety/depression
4. Rule-out:
- global dev delay/intellectual disability
- social communication disorder
- developmental language disorder
- hearing impairment
- epilepsy
- genetic disorder
- anxiety disorder
- OCD
131
Behavioural Problems
NOT JUST ADOLESCENCE
- Depression/anxiety
- A medical problem
- Bullying
- Abuse
- Witnessing violence
- Substance use
- Peer issues
- Home stressors
132
Dx of:
- Violation of basic rights of othrs or age appropriate societal norms
- Violence against people/animals
- Running away, rule breaking
- Repetitive and persistent
Conduct Disorder
133
Dx of:
irritable, defiant, vindictive
Explain treatment
Oppositional defiant disorder
Tx: CBT, family therapy, parent training, social skills training
134
Do children in oppositional defiant disorder:
- show aggression towards people/animal?
- destroy property?
- habitually lie and steal?
No x 3
135
Enuresis dos and dont
DO:
- make toilet accessible
- pee before bed
- include morning clean up
- training pants
DONT:
- caffeine/chocolate
- fluid before bed
- punish child
- diapers
136
What is the management for enuresis (bed wetting) ?
Bedwetting alarms
Desmopressin (short term)
Imipramine (last line)
Look for other causes
137
management adolescent behaviour change
refer to adolescent psychiatry
138
List 6 things you can counsel parents when they visit for their toddlers well-baby care visit
HONEY'N'GUNS
HONEY
- No honey before 12 months
- Choking hazards (avoid grapes)
- Vit D for baby and mom
- Button battery (can give honey to slow down injury)
GUNS
- Guns
- Carbon monoxide
- Electric plugs
- Hot water heater
- Car seats
- Medication storage and to know poison control number (1-844-POISON-x)
139
Couselling stuttering
Males 4x more
90% recover --> reassure
Meds limited evidence
Speech language therapy
140
Counselling on circumcision, foreskin hygiene, phimosis mangement
No routine circumcision
Don't force the foreskin, if adherent gently pull back
Phimosis management : 8-10yo topical steroids (bethmetasone), avoid sx
141
Milestones tricks:
- 2 months "coo coo"
- 4 : months (head steady), years (one fit steady). 4 months grasping object (with 4 fingers)
- 6 : sit at six
- 8 months : pincer grasp (8 la two pincers)
- 1 year: walk, one word
- 2 years: run, 2 word sentence, 2 step direction
- 3 years: 3 step directions, 3 words sentence
142
Pregnancy immunisation:
- TDaP each pregnancy (27-32wks)
143
3 vaccines cannot do during breastfeeding
BCG, japanese encephalitis, yellow fever
144
Who needs meningitis c vaccine?
Travelers (Hajj = mandatory, belt of africa)
Military recruits
Asplenia & sickle cell
ALL canadian adolescents (12yrs)
145
Who should receive flu vaccine?
>6 months in children
>65yo
High risk adults (neuro/neurodev conditions, work in health care, working with poultry, withing 30 days of MI)
WITHIN 30 DAYS OF MI
146
Counselling anti-vaccine
Dont: find another doc
DO: emphasize safe to vaccinate, danger in not vaccinating, pain can be reduced
147
How to prevent pain during vaccine for kids:
Dont aspirate
Most painful LAST
Breastfeed, hold babies (skin to skin)
topical anesthetic
oral sugar
Manage fear with CARD
Comfort
Ask questions
Relax
Distract
148
Managing vaccine fears and phobias
Comfort
Ask questions
relax
distract
149
Explain contraindications to vaccines
MIld illness is not a contrindication.
Nasal congestion then delay Live Attenuated Intranasal Vaccine
150
At the end of my exam, I should take a moment to remember if I forgot anything like:
HIV
Pain
Abuse
BHCG
Bugs
Suicide
Tetanus
Harm
Guns
151
Manage common cold:
zinc sulfate IS NOT INTRANASAL
152
PHARYNGITIS hx/score
CENTOR SCORE
153
Sinusitis
PODS
Pain - facial pain/pressure/fullness
Obstruction (Nasal)
Discharge
Smell (lack of)
154
Sinusitis bacteria
think of ear bug
H. influenzae
S.pneumonia
M.catarrhalis
155
Sinus alarm features + DOs/DONts
Do: if bacterial tx with amoxicillin 5-7days, nasal rinse, intranasal steroids, decongestants, analgesics, anti-inflammatories
DONT: nasal culture, dont treat if suspicion viral, NO IMAGING UNLESS RED FLAGS
156
Recognize MONONUCLEOSIS
ELEVATED LYMPHOCYTE COUNT not WBC so for investigation say Lymphocyte Count
NO SPORT at least 3 WEEKS --> splenomegaly in 50%, can last up to 8 weeks
157
Neonatal resuscitation first steps
1) tone, tears, term then
2) Dry, stimulate, warm, limit suction. Consider skin to skin.
3) PPV (20-30breaths/min) if apnea/gasping/HR<100 / CPAP if just cyanosis/laboured breathing + O2 monitoring for both, consider ECG monitoring if HR<100
4) Reassess after 30s
A) if HR<100, go through MR SOPA:
- Mask adjustment
- Reposition airway
- Suction
- Opening mouth
- Pressure (increase)
- Advanced airways
B) if HR<60, intubate then compression (3 compression for 1 ventilation)
- consider urgent UCV access
5) Reassess after 60 seconds, if HR still <60 then IV epinephrine (0.01mg/kg IV)
158
If risk of opioids consumption by mother, what should you consider during resusc of baby?
Naloxone.
159
Sepsis risk factors
Chorioamnionitis
Fever
<37weeks
Rupture>18hrs
GBS+
160
Sepsis pathogens in neonates
Listeria
E.Coli
GBS
161
Hypoglycemia signs in newborns
Jittery
Lethargic
Hypotonic
Sweating
Weak Cry
Tachypnea
Seizures
162
Managing hypoglycemia in newborn
Hourly D10W if ill/cannot feed, bolus if symptomatic
163
Hyperbilirubinemia should last max how long?
Jaundice should last 2 weeks
If longer get a serum conjugated bili
164
Hyperbilirubinemia investigation
Hemoglobin
Group and screen
Conjugated bilirubin
Coomb's (DIRECT - does BABY have mother's antigens on his RBCs, INDIRECT - does MOM have antibodies against baby's RBCs )
Peripheral smear
165
Don't miss on baby exam:
166
Undescended testes complicateds in
torsion (if twist 0, no imaging)
(- TWIST score : absent cremasteri reflex, nausea/vomitting, high riding teste, teste swelling, hard testicle)
trauma
tumor
inguinal hernia
infertility
167
Signs down syndrome:
Rule of 1s:
- 1 palmar crease
- 1% recurrence (if sibling with down)
- 1st toe web space
168
Risk factors hips dysplasia
Firstborn
Female
Family history
Feet first (breech)
Fluid (oligo)
169
Babies: four Fs for Follow Up
Fever >24-48hrs
Fluid (2 wet diapers die)
Fatigued/listless
Fearful symptoms
170
Acetaminophen after or before vaccines?
After
171
What can you do for teething?
Teething rings
Avoid numbing gel
172
How long do you have to avoid bottles in bed?
15 months
173
When do you start allergens
4-6 months (feed a few times a week)
ex: peanuts, eggs, etc
174
What are the screen time limits?
None but monitor & model meaningful screen use
Video chat OK
Increased screen time increases conduct problems and depression
175
What antibiotic causes teeth stain?
Tetracycline and only at doses we dont usually use.
Doxycycline is ok.
176
Pediatric LIMPS etiologies
Never forget abuse
177
INjuries suggestive of abuse
Remember to look for PATTERNED BRUISING
Bruising on torso, ears, neck is suspicious
4 months or younger is suspicious
178
Constipation management
r/o abuse
179
Reflux in infants - management
180
Reflux in children
181
HEADSS
Home (who do you live with, smoke detector? CO2 detector?)
Education/employment (bullying? favourite class)
Activity (safety: helmet)
Drugs (px and illicit)
Sexuality/gender
Suicide/Mood
182
What are the red flags of puberty onset?
183
Red flags in fever
THINK KAWASAKI
- mucocutaneous lymph node syndrome
- major complication (coronary artery aneurysm --> if you CRASH, call the CAA)
- Treat with ASA, IVIG, Steroids
184
Travel medicine counselling
1) prevention - vaccination:
- General: Hep A&B, rabbies PRN
- Country-specific: typhoid, meningitis, yellow fever, encephalitis
- Routine vaccines: flu, shingrix, pneumococcal, tetanus, pertussis, COVID-19
2) Prevention - medication:
- Before: antimalarials --> atovaquone-proguanil (malarone), chloroquine has a lot of resistance CHECK FOR RESISTANCE
- During: antimalarials, anti-diarrheals (lopramide/imodium), insect precautions
- after: antimalarials, zika precautions
3) Traveller's diarrhea: loperamide, azythromycine, bismuth subsalicylate, oral rehydration solution
- avoid: ice cubes, salad, uncooked veggies, used bottle wate (drinking, brushing teeth). Boil/peel it/cook it. Wash/sanitize hands ++
- take abx/loperamide only if functional impairment (mostly if bloody, take azythro++)
- bloody diarrhea/dysentry (no loperamide/imodium)
4) Cholera - prevention: doxycyline
5) Pregnancy - dont travel
185
Name 3 diseases a patient can contract as a returning traveller.
- Malaria
- Traveller's diarrhea
- Resp infx (usual ddx, dont forget the usual conditions just because hx of travel)
186
Medication for altitude sickness prophylaxis
Acetazolamide (diamox) --> makes kidney secretes bic, helping with lower O2 in high altitude zones
Dexamethasone (for severe cases or cannot take diamox)
Nifedipine (prevent pulm edema)
Sildenafil (prevent pulm edema)
Prophylactic salmeterol
187
Counselling on medication storage during travel?
keep in hand luggage --> temperature changes in plate luggage section can make medication ineffective
188
What is the main cause of mortality in travellers?
High risk activity
(including ETOH, unprotected sex)
189
Name the 6 complications in palliative care
1) Hypercalcemia
- hydrate, bisphosphonates, calcitonin/steroids
2) Massive Bleed
- dark towels, midazolam
3) Seizure
-benzo or phenobarbital (barbiturate)
4) Superior vena cava SVC obstruction (lung, NH lymphoma)
- dexamethasone, elevate head, opioids, benzo for SOB, stent vs chemo/RT
5) Cord Compression
- prostate/breast/lung
- dexa, RT, sx
6) Opioid Toxicity
- hydrate, rotate, treat sx (nausea, constipation)
- SAFETY STORAGE if children
190
What can you say instead of "do not resuscitate"?
Allow natural death
191
Name common palliative concerns
192
Should you prescribe ASA for PRIMARY prevention of cardiovascular disease?
No
193
Should you screen for hepatitis C if average risk?
No
194
Abdominal aortic aneurysm screening
65-80years, one time abdominal ultrasound in MEN
195
When should you start screening for smoking?
Starting age 5yo for smoking/vaping.
196
Calculate sensitivity, specitiy, PPV, NPV
SPecificity rules IN (SPIN)
SeNsitivity rules OUT (SNOUT)
197
Elderly in yearly preventive visit you should do 3 things
FALLS
Pain medication (review)
Medication (review)
198
First step in assessing learning disabilities
- Vision/hearing impairment to r/o
then educational issue? intelluctal disability, TBI, neurocutaneous disorders, seizures, trauma
199
What is the age onset to diagnose ADHD?
12 yo
200
Symptoms required to diagnose ADHD?
Children = 6
Adults = 5
201
Do stimulants help with ADHD?
Yes, improvement within 2 weeks
202
ADHD med classes
EKG before starting
Consider atomoxetine or guanfacine is worried about diversion (non-psychostimulant)
Consider DATR before changing dose
Dose - increase
All- try all 1st line
Time - give enough time to response + side effects to resolve
Examine - what are the targets what standardized measures
Review - comorbidity, lifestyle
203
Non-pharmaco management ADHD
patient and family education
behavioural and occupational interventions
psychological treatment
educational accomodations (offer to talk to school)
video game (endeavor rx)
204
In the education of patients/family, discuss higher risk.
DRIVING SAFETY
- 2-4x as many motor vehicle accidents
-minimize road rage/impulsivity, mobile phone
- recommend manual transmission to decrease risk of accident
Also medication/monitoring side effects/weight.
205
Immigrants health
1) Screen BP, DLPD, Db2, anemia (iron test), dental/eye, lead poisoning
-2) Infectious disease:
- Test first HBV, varicella (if >13yo), HIV/HCV/TB if from high risk area
- Test strongyloides and schistosomiasis
- Do not test malaria
3) Vaccination
- Vaccination : in doubt give Tdap-IPV (inactivate polio vaccine) + MMR
4) Women's health: discuss contraception
206
How do you diagnose TB?
- Mantoux skin test (intradermal not subcutaneous) --> not to dx for active TB!!
- Newer test: = IGRA (95% for LATENT TB) --> use if pediatric or past BCG vacine.
- If high risk Combine IGRA with Tuberculin skin test + xray
- does NOT dx active tb
207
Treatment for latent TB
rifapentine + isoniazid
208
Active tb treatment
RIPE - until sensitivity
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
then treat per sensitivity
avoid monotherapy
209
What should you NOT screen in immigrants?
Maltreatment of children
Domestic violence
PTSD
ONLY SCREEN: depression cause the others we will make them relive traumatic things and we dont have anything to help
210
2 traditional medication treatment to discuss:
Cupping may have benefit for acne, pain, facial paralysis
211
What are key history elements in schizophrenia
- Evaluate function (MRS SWELP$)
- Sexual function
- Wants to get pregnant? Plans for having children?
212
Medical management of schizophrenia
1) 1st episode = 2nd generation antipsychotic for 18months
2) Oral or depot per pt's preference
3) treat comorbid depression (SSRI/SNRI)
213
What is the most morbid adverse effect?
Neuroleptic malignant syndrome
214
Symptoms neuroleptic malignant
215
Treatment
benzo + dantrolene + bromocriptine
216
Non-pharmaco: management schizophrenia SOS
S = safety first (suicide, homicide (check for firearms) are family, health care team safe? or do they have delusions that could put them at risk?)
O= offer (housing, family counselling, vocational rehab, financial support, admission, detox, SW)
S= start monitoring (adhreance, pregnancy status, sx, ETOH/drugs, side effects)
217
Explain approach to aggressive patient (BATS)
Bring down the energy (calming techniques)
ASK how can I help?
Think of other causes (see pictures)
Safety first (suicide/homicide, weapons access?? do they have kids?)
218
Pneumonias DOs and DONTs
DOs:
- PSI score
- Test influenza
- Treat with antiviral if influenza positive / abx if pnmia suspected
DONTs:
- use CURB-65
- order procalcitonin (PCT)
- order sputum staining & culture / blood culture unless sick ++
- prescribe steroids for pnmia
- order chest x-ray if pneumonia resolves in 7 days
219
What could explain a non-resolving pneumonia in an adult?
Wrong drug
Wrong bug
Wrong diagnosis
220
Name 5 ddx for pneumonia
Pneumocystis Jirovecii Pneumonia --> ALWAYS THINK HIV
IF THINK HIV then think HCV and TB
221
Name four factors thar can affect antibiotic choice
- Allergy
- Interactions (warfarin interacts with everything)
- COPD Co-tx
- Aspiration coverage
222
Think of 3 outbreaks that could explain pneumonias in a population
1) Legionnaires (lower respiratory sample for culture & urine legionnaires antigen test, but only if symptomatic)
2) Influenca
3) COVID-19
223
Pathogens in pneumonia
Always think EAR bugs: H. influenzae, S pneumonia, M. catarrhalis (S.pneumo no1 in no comorbidity
If comorbidity H. inf/ M. catar. and S.aureus = 1st cause
If no comorbidites think: mycoplasma, chlamydophila
224
Treatment pneumonia
High dose amoxicillin x 5 days
225
Should you do an xray after treatment of pneumonia in kids?
No if normal vitals + normal exam
226
Hypertension - secondary causes
227
Hypertension - lifestyle management
228
Hypertension - treshold and target
High risk = CAD or risk >=15%, CKD, >=75
229
Hypertension treat = ACDs and avoid the ABCs
ACDS : ACEi/ARB, CCB, Diuretics, 4th line = Spironolactone
ABCs : alpha-blockers alone, BBs if >=60, ACE if black/pregnant (also chlorthalidone)
230
Hypertension work uo
Lipid panel (non-fasting is ok)
Ka, Na, creat, UA
HbA1C
ECG
BhCG (women)
231
Advice for sodium, weight, alcohol exercise, diet, relaxation:
232
Which anti-hypertensive should you not prescribe and why?
Chlortalidone (including indapamide), increases risk of diabetes + renal electroly abnormalities
233
What major risk does hydrochlorothiazide causes?
Increases x 4 the risk of non-melanoma skin cancer after 3 years --> consider switching if at high risk (light skin, PMH/FMH, immunosuppressed)
234
What substances could impeded the action of anti-hypertensive medications?
235
Hypertensive urgency vs emergency
Emergency also if asymptomatic but dBP>=130
Also consider pheochromocytoma and pre-eclampsia as hypertensive emergency
236
Treatment for hypertensive emergency
Nifedipine, labetalol, captopril, clonidone, hydralazine, nitrates
237
Hypertension in pregnancy - avoid, aim and acceptable rx in breastfeeding
238
Hypertension in children:
when do you measure?
Which arm should you check and why?
Workup if BP elevated?
HTN if >99percentile
239
Explain approach to dizziness
TiTrATE
Timing
Triggers
A Thorough Exam
1) Timing
episodic vs acute vestibular syndrom
2) Trigger:
Episodic
- triggered : BPPV, OTH
- No trigger: arrhythmia, stroke/tia, hypoglycemia, meniere's, migraine
Acute
- triggered: head trauma, barotrauma, medications, illicit drugs
- not triggered: vestibular neuritis, thiamine deficiency, Listeria encephalitis, stroke/TIA
240
Associated sx of vertigo
240
4 symptoms migraine vertigo
- Scintillating scotoma
- Aura
- Headaches
- Dizziness
Also: nausea, photophobia
240
If you have headache with vertigo you need to r/o something before thing of migraine
aneurysm
241
Vertigo + headaches in young people, dont jump to migraine, r/o
vertebral artery dissection
242
When vertigo is worse with head movement, the cause is peripheral. True or False.
False.
can happen with stroke too.
243
What blood test should you do in vertigo?
BHCG
244
Name 4 elements on the vertigo exam
Head Impulse, Nystagmus, Test of Skew PLUS hearing loss
but ONLY for ongoing constant vertigo and nystagmus at rest NOT for BPPV
Dix-Hallpike if vertigo <2min & no nystagmus at rest
245
Management BPPV
epley + betahistine (better than epley alone, betahistine better then benzo)
Self Epley: look to one side, bend over, and while your head still on that side, bend the other way.
Self semont PLUS : bend on the side more to be horizontal with the bed.
246
5 DONT in hyperlipidemia guidelines
Lipoprotein A once in a lifetime for everyone
- non-HDL C or apo-B preferred over LDL-C when TG>=1.5
247
Risk calculator (2)
Framingham
Cardiovascular Life Expectancy Modem (CLEM)
248
Framingham risk score elements
calculate q5yrs
249
Non-pharmaco management
250
Pharmaco management
Statins then exetimibe
251
Statins in the elderly, should you give them?
252
What can you give instead of statins to reduce MACE?
Bempedoic acid pill
253
When are omega-3 fatty acids 1st line?
Hypertriglyceridemia
254
Algorithm to diagnose CKD
255
How do you manage CKD
256
When do you refer to nephrology
eGFR < 30 and/or ACR > 60
Kidney failure risk equation > 5%
257
If you don't refer, how do you monitor CKD?
eGFR + ACR q6months
AND: Na, Cl, UA (routine + microscopy)
you also do the investigation before referring and until seen/monitored by nephro
258
What are the 3 pillars of CKD management
259
What medication should a pt with CKD stop during a sick day/risk dehydration?
260
3 types of AKI
261
Explain the AKI spectrum (RIFLE)
AKI = eGFR decreasing otherwise AKD
262
First steps in managing AKI stop + star
263
What is the emergency in patient with CKD?
Fever in peritoneal dialysis patients:
SPONTANEOUS BACTERIAL PERITONITIS
Do paracentesis. + tx w/ pip tazo and albumin
264
How do you manage every acute situation?
usually ABC already done in SAMPs/SOOs so need to do something else
if not sure what to do rpt (serial) abc/vitals/ecg
265
How do you deprescribe PPI
1) Discontinue/taper down
2) Step down to histamine-2 receptor antagonist (ranitidine, famotidine)
3) Reduce: switch to PRN or lower the dose
266
When should you transfuse for a GI bleed?
ONLY IF:
1) Symptomatic
2) Fluids aren't working
3) Hb <70-80 (usually <80 preferred, mostly if they have CAD).
If all 3 transfuse, but stick to 1 packed RBC transfusion if not actively bleeding and stable.
267
How do you manage acute UPPER GI bleed
You want to decrease the stomach content by:
1) Decrease acid --> PPI bolus (for non-variceal bleeding, since variceal bleed are due to hepatic portal hypertension and not to stomach erosion/ulcers like nv bleeding)
2) Decrease the blood out of the stomach --> causing diarrhea helps stomach emptying --> ERYTHROMYCINE
3) If variceal bleed: ceftriaxone + somatostatin
4) No benefit of tranexamic acid and might increast VTE
268
What other things can mimic lower GI?
Beets, iron, pepto-bismol (bismuth salicylates)
269
Management of anal fissure
270
New suicide risk factors
THINK OF SANTA CLAUSE
PRECIPITATING FACTORS:
- drugs/ETOH (snow moutain cocaine)
- Access to means (toy guns)
- Life events (Mrs clause left him)
- New terminal/chronic disease (travels everywhere has all tropical disease)
- Media effects
PREDISPOSING FACTORS
- neuropsych disorders (talks to rudolph)
- FMHx (previous santas)
- previous attempt (always on the roof)
- Adverse childhood experiences (never had toys himself)
- Socioeconomic status (how does he afford making all the toys)
271
Depression management
1st line = CBT, interpersonal therapy, Behavioural activation
Recommended CBT or IP + antidepressant (escitalopram, mirtazapine, paroxetine, venlafaxine, amitriptyline = most effective)
2nd line = SSRIs, SNRIs or TCA aaaannd alpha-2 antagonist (mirtazapine, trazodone)
272
How do you choose the correct antidepressant for your patient?
Adverse effects, cost and other considertions
273
Antidepressant if smoking cessation
bupropion
274
Antidepressant if ETOH use disorder
sertraline or mirtazapine
275
Antidepressant in ADHD
bupropion or duloxetine
276
Antidepressant in:
- HF
- ACS
HF: sertraline
ACS: escitalopram, sertraline
277
Antidepressant if IBS
paroxetine, fluoxetine, citalopram
278
Antidepressant if loss of libido in WOMEN
bupropion
279
Antidepressant if stress incontinence
duloxetine
280
Antidepressant if CKD:
- non-dialysis CKD
- dialysis ESRD
- ESRD associted pruritus
sertraline for all
mirtazapine for pruritus
281
Antidepressant if chronic pain:
- OA
- Db neuropathy
- Fibromyalgia
- Chemotx induced pain
Only duloxetin for chemo-induced pain
Otherwise duloxetin + venlafaxine for all (limited effects in fibro though)
Fibro: also consider SSRI and mirtazapine
282
Antidepressant in patient who would also benefit for migraine prophylaxis
venlafaxine or duloxetine
283
What antidepressants are most likely vs least likely to cause headaches?
284
What antidepressants are most likely to cause dysrhythmia?
citalopram, escitalopram, mirtazapine
285
What antidepressants are most likely to cause blood pressure/HR changes?
Which are BP/HR neutral?
BP/HR changes: bupropion, SNRIs
Neutral: SSRI, mirtazapine, vortioxetine
286
What antidepressants are most likely to cause sedation?
Which one is activating?
Most sedating: mirtazapine
Activating: bupropion
287
What antidepressants are most likely to cause nausea/vomiting?
all, but duloxetine/vortioxetine the most
288
What antidepressants are most likely to cause constipation?
mostly SNRIs, paroxetine and sertraline
289
What antidepressants are most likely vs least likely to cause sexual dysfunction?
SSRIs/SNRIs
Least likely = bupropion (might actually improve it)
290
What antidepressants are most likely likely to cause seizure? Least likely?
bupropion (activating)
least likely: SSRIs, SNRIs, mirtazapine
291
What antidepressants are most likely vs least likely to cause weight gain?
Most: mirtazapine, citalopram
Least: bupropion (might lose weight)
292
What antidepressants are most likely vs least likely to cause withdrawal sx?
Most likely: paroxetine, venlafaxine, desvenlafaxine
Potentially none: mirtazapine, bupropion
293
How long do you wait before increasing/changing?
294
Risk factors of self-harm in teenagers
increases risk suicide
295
Question to quickly rule out anxiety
mania
OC
delusion
hallucinations
dont forget to ask for SI/plan
296
Medical causes of depression?
think of them always, r/o first mostly if acute change!!
hormones: TSH, cortisol, vitamin D
Grief/adjustment
Drug use
Bipolar
tumour
delirium
297
Bipolar II first line therapy
298
Pharmacology for bipolar disease acute vs maintenance
299
Elements in history that should orient you towards bipola
300
Non-pharmacological management
always think of counselling and support groups
301
Investigation in anemia
Always :
1) Serum hemoglobin
2) MCV
3) Iron profile : ferritin, iron, total iron binding capacity
Also very important:
- Beta-HCG
Can also consider: peripheral blood smear
Think: colonoscopy
DUB/AUB? Need for pelvic ultrasound vs endometrial biopsy?
302
When do you transfuse in case of anemia and what should you do next?
HB<70 (80 if CAD) and symptomatic
Don't just treat, FIND THE CAUSE
303
Thalassemia: region at risk, when to test and how to test
Region: africa, middle east, mediterranean, south east asia, caribbean/south america
When to test: in case of microcytic anemia without evidence of iron deficiency, especially if pregnant/trying to conceive
Test with : Hb, MCV, RDW, ferritin/iron/total iron binding capacity, HB ELECTROPHORESIS, peripheral smear
304
What are the risk factors for B12 deficiency?
Gastric surgery
Strict vegans
Breastfed children of vegans
Elderly >60
Psychiatric
305
Investigation of B12 deficiency
Vitamin B12 level
If low confirm PERNICIOUS ANEMIA with --> anti-intrisic factor antibody (confirms if positive)
could also consider methymalonyl acid (MMA) and homocysteine levels
306
What kind of iron has highest iron content?
Which one is best for children?
Highest = ferrous fumarate (fu for full)
Children: ferrous sulfate (s for small ones)
307
Ferrous sulfate is best absorbed if taken every 2 days. True or False?
True-ish. Suggest taking it q2days if cannot tolerate daily. Almost same absorption but way less side effects
Consider IV iron if iron po not enough.
308
To aid iron absoprtion take iron with vitamin C.
False.
But still recommend to avoid tea.
309
Polysaccharide iron is more effective than the other options. true or false?
False.
310
How to break bad news?
S - Setting Up
P - Perception
I - Invitation
K - Knowledge
E - Emotion
S - Strategy
311
Acronym for empathetic statements
312
Key topics to discuss when announcing bad news
goals, strength, abilities, family
313
Management of bad news
Safety : avoid driving after receiving bad news
Next visit : plan it, offer to have family next time
Refer: oncology, palliative, social work, grief counselor
Teach: advance directives (CPR' feeding tubes, intubation), estate planning, will, how to break news to relatives (offer to help)
314
Name 3 types of pain:
nociceptive, neuropathic, psychogenic
315
Which analgesic should be used to reduce acute MSK pain?
ibuprofen (avoid duplication with OTC NSAIDs + px NSAIDs)
316
What is the maximum start for opioids in non-cancer patient?
Max 50mg morphine equivalent per day (MED)
317
When should you use opioids?
If you've exhausted all the other options:
- TCAs
- Nabilone
- NSAIDs
- non-rx: CBT, exercise, PT, self-management
318
To what level should you taper down opioids if someone if already on high doses of opioids?
90mg MED
319
In elderly what would be the optimal length of opioids treatment in treating acute pain?
=<3days (rarely >7 days)
320
How do you taper in outpatient?
Slowly (5% drop over 2-8wks) with taper rest periods.
321
What can you think of for monitoring opioid strategy?
Establish a contract with your patient before starting opioids about tapering and stopping opioids eventually.
322
Managing symptoms of withdrawal
323
When can you consider cannabis? Name 3
in REFRACTORY:
- neuropathic, palliative pain
- spasticity
- chemotherapy-induce nausea & vomiting
324
If you prescribe cannabis what do you need to monitor?
- Assess mood, anxiety, abuse
- Manage pt's pain not the marijuana request
325
Safety measures if prescribed cannabis
- Avoid in pregnancy
- Avoid driving (<6hrs after inhalation, <8hours after oral ingestion
326
Name 3 contra-indication for cannabis
327
Management chronic pain
Safety - driving with the medications, abuse of medication
Offer - resources like power over pain portal, to be their family doctor
328
What should you limit in difficult patient?
329
Describe cluster A personality and treatment for each
shizotypal (willy wonka)
schizoid (gollum)
330
Describe cluster B personality and treatment for each
antisocial (hannibal, joker)
331
Describe cluster C personality and treatment for each
332
What shouldn't you forget to investigate in patients with PD?
r/o medical cause mostly in schizotypal PD (CT, TSH)
333
Treatment of alopecia areata
Social consequence: hairpiece, wigs
Immunotherapy
New tx : jak inhibitors
334
For EVERY skin condition, there is a non-pharmaco intervention you should ALWAYS be doing. What is it?
Address the psychosocial impact and offer solutions:
- wigs, hair piece
- tattoos, cammouflage
335
Explain Eczema coxsackieum
in differential, try to always name a new red flag
336
Treatment rosacea
If persistent try oxymetazoline, brimonidine gel, paroxetine
Persistent w/ telangiectasia --> laser
337
Eczema
Non-pharmaco tx, suggest more frequent showers = 30% improvement.
338
NEVER MISS THIS RASH --> what is the one question you should ask?
Travel history --> tick bite eschar
339
340
Nail fungal tx
ONYCHOMYCOSIS
CONFIRM it's fungal before treating as fungal
Tx : terbinafine x 12 weeks --> monitor liver function with AST/ALT/ALP/GGT/bilirubin
341
Seborrhea treatment
342
General risk factors to think of for any condition.
Obesity is protective for osteoporosis
343
Risk factors for osteoporosis
Rx: COC (depoprovera)
344
New guidelines screening by CTFPHC
We are basically screening who needs more than vitD + calcium, therefore:
1) Assess FRAX
2) BMD if patient interested in receiving medication if high risk.
345
Osteoporosis Canada guidelines (differ from CTFPHC)
1) Non-pharmaco prevention of osteporosis for every man >=50yo and post-menopausal women : balance, muscle strenghtening >=2/wk, Diet rich in calcium and protein and vit D 400IU daily
2) Screen risk factors + signs possible vertebral Fx
Offer BMD to everyone >=7o regardless of risk fathers, otherwise:
- 50-64 need >=2 RF
- 65-69 need 1 RF
Then NO rx if 10yr fx risk <15%, 15-19.9% <70yo SUGGEST rx, >=20% >=70yo RECOMMEND rx
3) If previous hip/spine Fx or PMHx >=2 Fx --> recommend Rx
346
List Risk factors of osteoporosis
- age>65
- fragility fracture age > 40
- prolonged used of glucocorticoids
- rheumatoid arthritis
- hypogonadism / early menopause before 45yo
- malabsorption (IBD, celiac, etc) /eating disorder
347
How can you assess for vertebral risk? How do you investigate?
Height yearly:
- loss 2cm PROSPECTIVE (in our office measure)
- loss 6cm (from peak self-reported adult height)
- occiput-to-wall distance >5cm
Lombo-thoraco xray
348
What blood test should you order if you find a vertebral fracture?
SPEP (r/o multiple myeloma)
349
Investigation in osteporosis
Goal is to look for 2nd causes
350
Management of osteoporosis
Start: BCDEFG
- Biphosphonates
- Calcium
- vit D
- Exercise twice weekly (progressive resistance/ balance and function training. AVOID rapid/rptive sustaines, weighted or end ROM twisting/flexion spine)
- prevent FALLS
- Hip Guards
Refer: fall clinic, geriatric, rheumatology, OT, PT, home care
351
What are side effects for 1st line treatment of osteoporosis
Bisphophonates (1st line unless high risk) : esophageal ulcer, jaw osteonecrosis, increased atypical fractures
Raloxifene : VTE, PE
HRT: PE, DVT, stroke, breast cancer, liver disorder
352
What do you suggest if biphosphonates is contra-indicated or intolerated?
Denosumab (prolia)
Risk: hypocalcemia, join/muscle pain, atypical fx, jaw osteonecrosis.
CI in pregnancy
Best a fracture prevention
353
How do you manage high risk patients?
HI risk = recent severe vertebral fx or >=2 vertebral fx + t-scor =<-2.5
Consider anabolic therapy at diagnosis (teriparatide an analog parathyroid hormone and romosozumab a monoclonal antibody)
After consulting specialist.
Then biphosphonates
354
When should you stop the bisphosphonates?
Consider "drug holiday after 3 years then r/a (BMD + FRAX)
Consider stopping after 3-6 years
Stop if lo risk of fx
Continue if still high risk
355
Name disability supports
1) Disability tax benefit
2) Canada pension plan-disability (mental or physical, prolonged and prevents ANY work)
3) registered disability savings (only if eligible disability tax credi, max ag 59, not taxed on withdrawal(
356
What should you think of if some patient asks for a little time off? SOOs/SAMPs
What is the reason underlying the time off
357
What should you look for in development disease?
Ensure capacity for voluntary & informed consent + vision/hearing impairment + dental disease
358
HIV is not considered a chronic disease because of the high mortality rate. True or false?
False.
359
What are the medication complications of HIV medication?
360
What other chronic conditions should you screen for in HIV?
361
Name 2 anti-retrovirals used in HIV./
362
What are the 3 questions you should ask for in context of chronic disease mostly in SOOs?
Also ask:
is there complaint related to the disease or the medication (side effect, adverse rx, compliance) ?
ALSO THINK SANTA - lots of chronic disease (db, ETOH, etc) = suicide risk
363
What are the main geriatrics complaints?
Frailty
Sarcopenia
Anorexia of aging
Cognitive impairment
that can lead to : falls, hip fx, depression, dementia & delirium
364
Name the safety R.I.S.K.S
365
CFP Frail elderly check list (name 6) and what is missing on this list (name 6)
Cognition
Mobility
Ulcers
Pain
Med check
Rx monitoring (lithium)
366
Management of nocturia per underlying cause
367
What are the 5 ways to suddenly improve function in elderly
Glasses dont screen in your clinic, do annual optometry screening
368
In elderly, questions function beyond MRS SWELP$, think D.E.A.T.H for ADLs
very important to know Activities of daily living (ADL)
369
List independent ADL (iADLs), think SHAFT
independant activities of daily living
370
Anytime you assess medication what should you question?
371
What is the one medication you should be wary of in elderly?
benzodiazepines
372
Identify the 4 types of elder abuse
373
A man presents with a history of gradually worsening pain on is left leg. Reports it is more heavy and swollen in the last year. He is worried he has another DVT like he was treated for one year prior.
He was seen by his specialist last week who told him there were no masses.
What is your diagnosis?
Post-phlebitic syndrom
374
Management of post-phlebitic syndrome using SNO-PQRST
SNO-PQRST:
- Offer: Venous duplex doppler ultrasound of affected leg (assess reflux)
- Prevent: compression stockings (might help)
- Start: elevation, exercise, topical meds for skin changes (horse chestnut seeds extract efficacious and safe)
- Refer : vascular surgery for vein ablation/excision
375
A woman presents with acute unilateral leg swelling and pain. You suspect DVT. While investigating her condition, how do you assess if you should start her on VTE prophylaxis?
Improve VTE calculator
376
What is the virchow triad
**1) Stasis:**
- immobilisation (long flight, bed rest)
- CHF
**2) Endothelial injury:**
- trauma
- iatrogenic: sx, central line, pacemake, ortho sx, COC
- inflammation (IBD)
**3) Hypercoagulable state:**
- Thrombophilia (factor V leidan mutation)
- Physiologic: pregnancy
- Chronic disease: cancer, IBD, CHF, nephrotic kidney disease
Nephrotic syndrome causes loss of protein (so loss of anticoagulation proteins like antithrombin II and proteins C+S) and loss of water (increasing blood hyperviscosity),
377
Blood diathesis vs thrombophilia
Blood diatheses = tendency to bleed
- inherited: von Willebrand, hemophilia A and B
- acquired: disseminated intravascular coagulation (DIC), liver disease, vit K deficiency (basically recreating effect of coumadin)
Thrombophilia = tendency to form clots
- inherited: factor V leidan, protein C or S deficiency, antithrombin III, prothrombin mutation
- acquired: antiphospholipid syndrome, immobilisation, hormone therapy/COC (estrogen), cancer
378
Main causes blood diathesis
379
Main causes thrombophilia
380
What is disseminated intravascular coagulation (DIC)?
Underlying condition (sepsis, trauma, cancer) triggering widespread clotting causing a decrease in platelet factors and thus inducing a bleeding disorder 2nd lack of available resources to form clots.
Called a consumptive coagulopathy (Plt and clotting factors are consummed).
381
Name 4 conditions causing pupura in adults and 4 conditions causing purpura in children.
Meningoccemia : N meningitis creates purpura by releases endotoxins targeting endothelial walls + can trigger DIC.
382
Explain
