AAFP questions - first 68 sets Flashcards
Patient with no hx of smoking or occupational exposure - now has FEV1/FVCratio of 0.67. CXR shows pan-lobular emphysema. What condition is she likely to have?
α1-Antitrypsin deficiency
Other options: left heart failure, interstitial lung disease, bronchiectasis, and diffuse panbronchiolitis; are not associated with development of COPD or these CXR findings.
CXR findings of each of the following conditions
LHF
ILD
Bronchiectasis
Diffuse panbrnchioltiis
Left heart: pulmonary edema
Bronchiectasis: bronchial dilation and bronchial wall thickening
Interstitial lung disease: reticular/increased interstitial markings.
Diffuse panbronchiolitis: diffuse small centrilobular nodular opacities along with
hyperinflation.
What are pharmacologic treatments for BPH with LUTS?
- α-adrenergic blocker (doxazosin)
- 5-α-reductase inhibitor eg: finasteride (if there is evidence of prostatic enlargement via physical exam or a PSA level >1.5 ng/mL)
- phosphodiesterase-5 inhibitor (eg: tadalafil)
- antimuscarinic therapy (eg: tamsulosin)
57yo male presents with fatigue, erectile dysfunction and low libido. testosterone level is low. Next step?
Check FSH or LH level to rule out primary or secondary hypogonadism. (if low or normal = secondary)
dont forget:
LH acts on the interstitial Leydig cells of the testes, stimulating them to produce testosterone, whereas FSH stimulates spermatogenesis and Sertoli cell function
Treatment for functional constipation?
Polyethylene glycol
Functional constipation is hard, infrequent stools usually occurs in children and adolescents.
Daily use of polyethylene glycol (PEG) solution has been found to be more effective than lactulose, senna, or magnesium hydroxide in head-to-head studies. Evidence does not support the use of fiber supplements in the treatment of functional constipation.
A 2yo child is holding her left arm slightly pronated, flexed, and close to her body. No reported mechanism of injury. No sign of fracture (no erythema swelling bruiding) or abuse. Next step?
Attempted reduction of the subluxed radial head
Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in
children 1–4 years of age, although it can be encountered outside of these ages as well.
The classic history includes a caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is
recalled.
Mariam you chose XRay but no need for XRay as long as there are no outward signs of fracture or abuse)
A patient who uses intravenous drugs and has a fever without a clear source must be evaluated for
……
infectious endocarditis (IE)
IE is usually right sided and tricuspid valve in IV drug users. Right sided endocarditis does not normally show systemic signs like janeway lesions or roth spots.
Order STAT blood cx and TTE
first-line therapy for primary dysmenorrhea
NSAIDs
should be started
at the onset of menses and continued for the first 1–2 days of the menstrual cycle.
combined OCP: lack of high quality randomized control trials demonstrating pain improvement
Jerking movements first in one hand and then the other, but when the patient is distracted the symptom resolves. What type of tremor is it?
- ANSWER: Psychogenic tremor: characterized by an abrupt onset, spontaneous remission, changing characteristics, and extinction with distraction.
- Cerebellar tremor: intention tremor with ipsilateral involvement. Neurologic testing will reveal past-pointing on finger-to-nose testing. CT or MRI of the head is the diagnostic test of choice.
- Parkinsonian tremor is noted at rest, is asymmetric, and decreases with voluntary movement. Bradykinesia, rigidity, and postural instability are generally noted.
- Essential tremor have symmetric, fine tremors that may involve the hands, wrists, head,
voice, or lower extremities. This may improve with ingestion of small amounts of alcohol.No
specific diagnostic test but treated with propranolol or primidone. - Enhanced physiologic tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of caffeine use or anxiety.
Based on CDC guidelines; what induration in 48-72 hours is considered a positive screening test for TB in:
1- Patient with recent exposure, HIV, immunosuppresed: (a)_____ mm
2- For other individuals at increased risk for TB: (b)____mm
3- No known risks for TB infection: > (c) ____ mm
(a) 5
(b) 10
(c) 15
If positive; do a CXR and physcial exam to assess for active infection. If negative»_space; latent infection»_space; tx with isoniazid for 9 months in children, can reduce to 6 months in adults. Can also use combo of rifampin and isoniazid in adults only.
Which of the rotator cuff tendons is responsible for internal rotation?
Subscapularis (goes frominside the scapula, through the joint to the inside of the humerus)
Physical exam to test this:
pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back.
infraspinatus and teres minor: external rotate
supraspinatus and deltoid: abduction
Acute abdominal pain in children- suspicion for appendicitis. First imaging modality?
Ultrasound
Iavoids radiation exposure and is useful for detecting many causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis.
Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history of previous abdominal surgery.
The U.S. Preventive Services Task Force recommends depression screening for all adolescents ___ to ___ years of age.
12-18
Which GLP-1 agonist is shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication?
Liraglutide (victoza)
This does NOT go for dulaglutide (trulicity) and semaglutide (ozempic)
What should sickle cell patients be screened for and with what?
risk of stroke with transcranial Doppler ultrasonography. assesses velocity of blood flow through the BVs
Results:
normal flow: 170cm/s»_space; repeat in one year
greater than 200cm/s»_space; repeat in one week to confirm, if high again, patient may need blood transfusion to reduce viscosity
anything in between: repeat in 6 weeks - 3 months
A chest radiograph, abdominal ultrasonography, a DXA scan, and renal Doppler ultrasonography are not recommended for screening patients with sickle cell disease.
In a newborn, other than a thin upper lip and a flat philtrum - what is the other big sign of Fetal alcohol syndorme?
Curvature of the fifth digit of the hand (clinodactyly)
Plagiocephaly, supernumerary digits, syndactyly, and metatarsus adductus are common in newborns but are not related to fetal alcohol spectrum disorders.
This child has otitis media with effusion, and the recommended course of action is __________
follow up in 3 months.
Medications, including decongestants, antihistamines, antibiotics, and corticosteroids, are not recommended.
Family physicians should be aware of the environmental exposures associated with pulmonary disease.
Stone cutting, sand blasting, mining, and quarrying expose patients to ___(a)___, which is an inorganic dust that causes pulmonary fibrosis.
Occupational exposure to ___(b)___, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic lung disease.
Exposure to ____(c)___ can result in “farmer’s lung,” a hypersensitivity pneumonitis.
(a) silica
(b) berylium
(c) organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens)
Exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD.
Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.
Initial feeding /drinking recs for someone with acute gastroenteritis?
Half-strength apple juice and food on demand
Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks. Water increases the risk of hyponatremia in children. Early refeeding has been shown to decrease the duration of illness.
β-Blockers are the initial therapy for patients with symptomatic hypertrophic cardiomyopathy.
The dietary herbal supplement with the highest risk for drug interactions is
St. John’s wort
It can reduce the effectiveness of multiple medications because it is an inducer of CYP3A4 and P-glycoprotein synthesis. Concurrent use of St. John’s wort with drugs that are metabolized with these systems should be avoided. These include cyclosporine, warfarin, theophylline, and oral contraceptives. St. John’s wort should be avoided in patients taking either over-the-counter or prescription medications.
A Wood’s lamp may assist with the diagnosis of certain skin conditions. What color is revealed with the following conditions?
Erythrasma (Corynebacterium minutissimum): (a)
Pseudomonas: (b)
Tinea infections: (c)
Vitiligo: (d)
(a) coral pink
(b) pale blue
(c) yellow
(d) totally white
A 69-year-old female presents with scaling, redness, and irritation under her breasts for the past several months. She has tried several over-the-counter antifungal creams without any improvement. Next step?
Wood lamps to check for erythrasma (coral pink)
Erythrasma is a common, chronic superficial bacterial infection of the skin (caused by Corynebacterium minutissimum). Often confused with intertrigo because of lboth occur in similar locations (creases).
Visual: plaques sharply demarcated, minimally red, subtle, symmetrical. Intertrigo is more inflammatory, more erythema and serous discharge.
Both can occur together.
Treatment of erythasma?
washing with antibacterial soap, topical 2% clindamycin or 10-20% aluminum chloride
OR oral erythromycin x 5 days
By American society of anesthesiologists; all patients having major surgery should be offered
________________
preoperative laboratory testing, including a CBC and renal function testing.
For patients who are ASA III or IV and have chronic liver disease or take anticoagulants, coagulation testing should be considered. There is no compelling evidence to support either a chest radiograph or an EKG as part of a routine preoperative evaluation.
What is recommended treatment for metatarsal stress ?
No weight bearing for a few days, possibly using a posterior splint»_space; transitioning to a walking boot or short leg cast»_space; and then a rigid-soled shoe in 4–6 weeks.
When can immobilization be discontinued?
Callus formation on a radiograph and a lack of point tenderness signify adequate healing, and immobilization can be discontinued.
Other recommended conservative therapy includes
- modified rest for 6–8 weeks with continuation of activities of daily living and limited walking.
- Normal activity can be resumed after 2–3 weeks with no pain.
- Additionally, the use of NSAIDs, ice, and stretching, as well as cross-training is recommended.
Treatment of the more common second and third metatarsal stress fractures is relatively straightforward.
Fractures of the fifth metatarsal should be carefully investigated to rule out a Jones fracture that may require orthopedic treatment.
On a child with proteinuria (dipstick) x 2 separate visit. Next step?
The pediatric nephrology panel of the National Kidney Foundation reported that a spot protein/creatinine ratio on the first morning urine is a reliable test for ruling out proteinuria.
Repeat always bec it can exercise/stress-induced or orthostatic proteinuria
A specialist referral, blood analysis, and ultrasonography are unnecessary unless persistent proteinuria is identified.
Elevated thyroid peroxidase antibodies are indicative of which disease?
Hashimoto’s thyroiditis
The most
appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8
weeks later. No need for US if there are no palpable nodules.
What is the protocol when individuals travel internationally to areas with high TB prevalence?
The CDC recommends either a TB skin test or an interferon-gamma release assay prior to
leaving the United States.
If the test is negative, the individual should repeat the testing 8–10 weeks after returning.
Elevated TSH and low T4 - no palpable nodules on thyroid examination. Next step?
thyroid peroxidase ab
There is no need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient presents with severe thyroid pain and systemic symptoms.
Trigger finger
versus
Dupuytrens contracture
What is the difference?
Unlike a finger which is bent due to trigger finger, a finger bent by Dupuytren’s contracture is unable to straighten, even with help from the other hand.
Causes?
trigger finger: tendons becomes inflamed and the tendon or the sheath surrounding it can swell and thicken to the point that the tendon can no longer glide smoothly.
In the case of Dupuytren’s contracture, the palmar fascia thickens and draws in which causes the affected finger to bend toward the palm. Small hard knots can form just under the skin at the base of the finger.
Treatment
Trigger finger: conservatively in mild cases, with treatment options including use of an oral anti-inflammatory medication or injection of cortisone. Injection can be used up to 3 times for treatment of a trigger finger, but the issue is resolved after the first injection in 80% of cases.
Dupuytren’s contracture cannot be treated with conservative measures so surgery is often recommended.
medication options for traveler’s diarrhea with international travel?
Azithromycin is preferred to treat severe traveler’s diarrhea.
Traveler’s diarrhea is the most common infection in international travelers. A short course of antibiotics
can be taken after a traveler develops diarrhea and usually shortens the duration of symptoms.
What determines risk of mortality in a patient with community acquired pneumonia?
CURB-65
confusion
BUN >20
RR
BP <90/60
Age >=65
HF or COPD
male sex
Pityriasis rosea - what is it? and how does it affect pregn women?
christmas pattern rash on the back - infectious etiology.
Pregnant women are more susceptible to
pityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate of
spontaneous abortion in the first 15 weeks of gestation.
Unable to conceive after 15 months of trying. Husband had normal semen analysis.
For women who are having regular menstrual cycles, ovulation is very likely.
Ovulation can be
confirmed by a progesterone level ³5 ng/mL on day 21 of the cycle.
If > 5: tubal patency should be confirmed with hysterosalpingography or laparoscopy.
If <5 ng/mL, anovulation should be investigated with TSH, estradiol, FSH, and prolactin levels.
Treat with clomiphene to induce ovulation.
What is the treatment for Diarrhea that develops in patients with Crohn’s disease s/p ileal resection for treatment?
Therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment. Reducing fat intake may also be beneficial.
usually occurs due to increased amounts of bile acid remaining in the stool affecting motility resulting in the development of bile acid diarrhea (BAD).
Best/most sensitvie physical exam test for ACL?
Lachman test (look it up)
sensitivity of 68% for partial ruptures and 96% for complete ruptures
sensitivity for Ant drawer test is only 38%
Treatment of tinnitus that results in improved quality of life?
CBT
No medications, supplements, or herbal
remedies have been shown to substantially reduce the severity of tinnitus.
(mariam you picked ssri)
Donepezil is a __________ inhibitor and therefore not recommended in geriatric patient if they have syncope
cholinesterase inhibitor (anticholnergic)
can cause bradycardia. ironically used for alzheimers
Patients with resistant hypertension - you want to get a aldosterone/renin activity ratio but what medication would you stop 4-6 weeks to avoid interference in the results? (other that acei and arb)
spironolactone
Preop eval - when do you order EKG?
asymptomatic patients undergoing intermediate or high risk surgeries
AND
patients with known heart disease, peripheral artery disease, or cerebrovascular disease who are undergoing intermediate and high-risk surgeries
No further testing prior to a low-risk, nonurgent surgical intervention. A routine preoperative EKG does
not provide any benefit for asymptomatic patients undergoing low-risk surgical procedures.
Constipation treatment in children less than 2 years of age?
Avoid invasive measures like manual disimpaction and enemas.
- Try oral miralax first (oral osmotic agent)
Oral stimulants and bisacodyl rectal suppositories are not recommended for children under 2 years of age. - Enema are second line.
Child is found in day care with head lice. When should the student be permitted to return to class?
Immediately - no isolation required.
AAP recommends that children found to be infested with lice remain in class but be discouraged from close contact with others until treated appropriately with a pediculicide. (head to head transmission)
why?
Visible nits are generally present at the time of diagnosis, confirming that the infestation has been present for some time, so immediate isolation from other children would not be expected to change the natural course of events. The AAP position also recommends abandonment of “no nits” school policies, which prohibit attendance until no visible nits are identified.
Development of which symptoms is concerning in patient with aortic stenosis?
exertional dyspnea, chest pain, or dizziness. (not weight loss)
When symptoms begin to appear in a patient with aortic stenosis the prognosis worsen - this is why it is important to be aware of systolic murmurs in older patients with new sxs. This can be the first presentation of a downward spiral and the need for rapid valve replacement.
Which antihypertensives cause hyperkalemia and hypokalemia resepectively?
Hyper: ACEi and ARB
Hypo: thiazides
_______ a panniculitis that typically affects the subcutaneous fat on the anterior surface of the lower legs, is associated with coccidioidomycosis (valley fever), streptococcal infections and tuberculosis.
Erythema nodosum : rash on the extensor surfaces of his lower legs consisting of painful, subcutaneous, nonulcerated, erythematous nodules.
_____ nerve entrapment results in paresthesia of the first three fingers and can result in thenar muscle atrophy.
____ nerve entrapment (can occur at many different locations): paresthesia and pain in the posterior forearm and dorsal hand as well as weakness in wrist and finger extensors.
_____ nerve entrapment (occurs at wrist): paresthesia of the fourth and fifth fingers and hypothenar eminence, weakness in finger adduction and abduction, and weakness of the pincer mechanism.
Median
Radial
Ulnar
Esophageal varices are identified:
Criteria for initiating prophylaxis to prevent variceal hemorrhage is based on risk of bleeding. Findings associated with a high risk of bleeding are:
a) small varices in patients with ___(a)___
b) small varices with ___(b)___ seen on endoscopy
c) __(c)____ sized varices.
(a) decompensated cirrhosis
(b) red wale signs (thinning of the variceal wall)
(c) medium to large
What about small varices that do not meet the above criteria? They should be rescreened with EGD every 1–2 years.
The recommended first-line therapy for patients with gonococcal urethritis
If patient weight >150kg: ___________
If patient weight <150kg: __________
(a) one dose of ceftriaxone, 1 g intramuscularly
(b)One dose of ceftriaxone, 500 mg intramuscularly
doxy first line for chlamydia, second line is azithro
These criteria require the presence of two out of the following three features: oligomenorrhea, hyperandrogenism, and the presence of polycystic ovaries
According to a 2016 meta-analysis, patients with ___________ were five times more likely than the control group to have adhesive capsulitis.
diabetes mellitus
While unconjugated hyperbilirubinemia is most commonly seen in hemolysis, another common cause is _____ syndrome
gilbert
which stems from a genetic defect that affects how the liver processes bilirubin.
The American Academy of Pediatrics recommends annual blood pressure screening at well child checks beginning at _______ years of age. This recommendation does not differ for children who have a strong family history of hypertension.
3 years old
Hidradenitis suppurativa is associated with ______________________
- obesity, diabetes mellitus, metabolic syndrome, polycystic ovary syndrome
- Crohn’s disease, arthritis
- spondyloarthropathy pyoderma gangrenosum
- trisomy 21.
When can you use biologic agents for asthma?
First step; is to determine the asthma phenotype so..
a) What is the difference between type 2 and non-type 2?
(b) How is type 2 diagnosed?
Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy.
(c) Biologic therapy may only be considered in patients with severe type 2 inflammatory asthma who continue to have significant symptoms despite adherence to optimal therapy which is….
(a) Type 2 asthma includes allergic and eosinophilic asthma. Non–type 2 asthma is driven by neutrophils and is associated with smoking and obesity.
(b) Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy.
(c) high-dose inhaled corticosteroids and a long-acting β-agonist.
what in tumor lysis syndrome can lead to renal failure?
hyperuricemia
. It is caused by the rapid release of intracellular material from lysis of the malignant cells. The breakdown of nucleic acids releases large amounts of uric acid and leads to acute kidney failure, which limits clearance of potassium, phosphorus, and uric acid.
Patients with this condition generally present within 7 days of cancer treatment, including chemotherapy, radiation, or biologic therapies.
A healthy patient would be classified as ASA I, while a patient with mild systemic disease would be classified as ASA II.
All patients who are having major surgery should be offered _____________
preoperative laboratory testing, including a CBC and renal function testing.
For patients who are ASA III or IV and have chronic liver disease or take anticoagulants, coagulation testing should be considered. There is no compelling evidence to support either a chest radiograph or an EKG as part of a routine preoperative evaluation.
What is the treatment for diarrhea that develops after ileal resection in Crohns disease?
A therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment of BAD.
Diarrhea that develops in patients with ileal Crohn’s disease or following ileal resection is usually due to increased amounts of bile acid remaining in the stool. This affects colonic secretion and motility and various protein factors in the gut, resulting in the development of bile acid diarrhea (BAD). Although various tests can be performed to evaluate the stool, gut flora, and bowel function.
Reducing fat intake may also be beneficial.
The American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults 65 years of age states that donepezil use should be avoided in patients with syncope, due to an increased risk of _________.
bradycardia
Donepezil is a cholinesterase inhibitor. Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes. This can cause bradycardia or heart block in patients with or without underlying cardiac conduction abnormalities. Syncope has been reported with these medications.
All pediatric patients with confirmed hypertension should have further evaluation like:
1) labs: BMP, lipid and UA - check for renal dysfunction as well as other cardiac risk factors.
2) renal ultrasonography (for renal disease)
3) echocardiography to evaluate for end-organ damage that would affect treatment goals.
Pharmacologic therapy is usually recommended for pediatric patients with symptomatic hypertension, secondary hypertension, target organ damage, diabetes mellitus, or persistent hypertension in spite of nonpharmacologic treatment.
In asymptomatic patients with sarcoidosis, ________ organ should be examined yearly to detect extrapulmonary manifestations of the disease?
OCULAR/EYE
because it is insidious and asymptomatic and can results in permenant damage.
Skin will show
examine cardiac or neuro only if symptomatic
What is the first line treatment for Immune (idiopathic) thrombocytopenic purpura?
Corticosteroids are considered the first-line therapy (SOR C). Intravenous immunoglobulin and rituximab
have also been used as first-line agents.
ITP is an acquired immune-mediated disorder defined as isolated thrombocytopenia not found to have another cause. Other dx that need to be ruled out are:
EBV, HIV, CMV, graves disease
________ can improve antidepressant-related sexual arousal dysfunction
Buproprion
What are all the options for treating menopausal vasomotor and/or symptoms of sexual dysfunction?
-Black cohosh (Safe)
-Estradiol
-Vaginal estrogen
-Ospemifene - dyspareunia related to vulvar
and vaginal atrophy due to menopause.
-Testosterone (libido only - low evidence)
What is blepharitis and how do you treat it?
Blepharitis - inflammation of the eyelids.
Contributing factor: dry eyes aka Meibomian gland dysfunction due to reduced quality of
tear films. In children, may be staph.
The initial treatment with using warm compresses to remove dried secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization load down.
Sulfonylureas, such ______(a)_______ commonly cause hypoglycemia as an adverse effect.
Biguanides such as ___(b)____ most commonly cause diarrhea, vomiting, and other gastrointestinal symptoms.
Only two thiazolidinediones such as ____(c)_____ most commonly cause include weight gain, salt retention, edema, and, for some patients, cardiovascular complications. They are particular is contraindicated in patients with heart failure, hemodynamic instability, and hepatic dysfunction. Thiazolidinediones may also increase the risk of bone fractures with long-term use.
(a) glipizide, glyburide, and glimepiride
(b) metformin
(c) pioglitazone and rosiglitazone,
The most common adverse effects of DPP-4 inhibitors, which include saxagliptin, sitagliptin, linagliptin, alogliptin, are headache, nasopharyngitis, infections of the urinary tract or upper respiratory tract, and elevated liver enzymes. SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, can cause adverse effects such as urinary tract infections, candidiasis, dehydration, and hypovolemia
The evidence shows that the risk of an opioid overdose increases at the threshold of_______ MME/day.
50
What is an ABI? and less than ____ is diagnostic of occlusive PAD
SBP of ankle divided by SBP of brachial artery.
Less than 0.9
Management of asymptomatic peripheral artery disease (PAD) should initially be conservative and should include a walking program (SOR A), smoking cessation, and a healthy diet. Statins should be started for all patients with PAD regardless of their LDL-cholesterol levels (SOR A). One anti-platelet is recommended.
Patient with Alzheimers disease - what medications help slow the progression of the disease?
Trick qs
There are no currently available medications that have been shown to delay progression of Parkinson’s disease.
The first-line treatment for motor symptoms is carbidopa/levodopa due to its effectiveness for tremors, rigidity, and bradykinesia. You start when sxs begin to affect quality of life.
AMS: acute mountain sickness
1) acute episode
2) prevention
1) acute episode: dexamethasone (first line), acetazolamide (second line)
2) prevention: acetazolamide
For MOST murmurs.. what happens to the sounds with
1) decrease in preload
2) increase in afterload/increase preload
1) decrease murmur (cause less blood flowing through) eg: standing, vasalva
2) increase in murmur (more blood flowing through the heart with increased venous return eg: squatting, handgrip
Plantar fasctitis present as pain in the ____ .
Does the pain get better or worse with activity?
Plantar fasciitis is the most common cause of heel pain.
The pain is typically worst when the patient first gets out of bed and IMPROVES with activity.
______ levels are the most useful predictors of the severity of pancreatitis, reflecting the
degree of intravascular volume depletion
Hematocrit, BUN, and creatinine
Prophylaxis for preeclampsia with aspirin should begin after ____ weeks gestation and continue until delivery.
12
Preeclampsia is diagnosed when the blood pressure is 140/90 mm Hg on two separate occasions after ____ weeks gestation, accompanied by _____
after 20 weeks gestation
+
proteinuria (>300 mg protein in a 24-hour urine collection or 2+ protein on a dipstick).
Two out of three facial features are required to diagnose fetal alcohol syndome.
List the three
smooth philtrum,
shortened palpebral fissures, and a thin vermilion border of the upper lip. T
1) Precocious puberty is the premature development of secondary sexual characteristics in girls age <____ and boys age <___
2) What is premature adrenarche?
8 and 9
First initial test bone radiograph»_space; then LH to determine central or peripheral
R/O premature adrenarche who will only have elevated testosterone levels so - pubic and axillary hair. Bone age is typically normal and no breast development. suspect precocious pubery is there is breast bud enlargement or penile enlargement
Precocious puberty : Elevated estrogen stimulates breast development (thelarche), and elevated androgens account for adult height body odor, acne, and axillary and pubic hair (pubarche). Both estrogen and androgens promote bone maturation, resulting in advanced bone age relative to chronologic age. Most children are also tall for age.
Precocious puberty is subdivided into central and peripheral causes:
● Central precocious puberty is associated with early activation of the hypothalamic pituitary gonadal axis, resulting in increased LH and FSH levels. Most cases are idiopathic but pathologic cases include CNS tumors
● Peripheral precocious puberty is caused by abnormal secretion of sex hormones from other organs (e.g., adrenals, ovaries, testes) and results in suppression of the hypothalamic pituitary gonadal axis and decreased LH and FSH levels.
Which of the following meds increases the risk of kidney stones? lisinopril, metformin, lexapro, topiramate or levothyroxine
Topiramate increases the risk of kidney stones. It is a carbonic anhydrase inhibitor, which induces a
metabolic acidosis that leads to hypercalciuria and the formation of calcium phosphate stones.
Which antidepressants are less likely to worsen the erectile dysfunction? or have less sexual dysfunction side effects?
bupropion, mirtazapine, or fluvoxamine (SSRI used for OCD)
HPV vaccination is recommended through ages ____ to ____
9 to 26
HPV vaccination is not recommended for all adults ages 27 through 45 years. Can discuss. Provides less benefit because more people have already been exposed to the virus.
Define Febrile neutropenia.
Temperature of ____
sustained for ____ hour
with ANC < _____
It usually occurs within 6 weeks of a chemotherapy treatment.
It is defined as a
- single oral temperature of 38.5°C (101.3°F)
- or a sustained temperature of 38°C (100.4°F) for at least 1 hour in patients
- with an absolute neutrophil count (ANC) <500 cells/mm.
TX: give IV abx within an hour of presentation to reduce mortality by 11%
In flu-vaccine NAIVE children (ages ______ ), they must recieve two doses of either trivalent or quadrivalent vaccine separated by 1 month.
ages 6months to 8 years
HIP PAIN - posterior pain ilicited with FABER test indicated what dx?
sacroiliac joint dysfunction
What is first-line treatment for primary focal hyperhidrosis?
topical 20% aluminum chloride.
It should be applied to affected areas nightly for 6–8 hours and works by obstructing the eccrine sweat
glands and destroying secretory cells. Iontophoresis and botulinum toxin are alternative first- or second-line
therapies for palmar and plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or
face.
Topical 2% glycopyrrolate must be compounded by a pharmacy and is indicated only for craniofacial
hyperhidrosis. Oral anticholinergics such as oxybutynin can be considered if other first-line treatments fail.
The classic finding on microscopic
urinalysis for:
1) acute glomerulonephritis
2) pyelonephritis
3) acute interstitial nephritis
1) RBC casts
2) WBC casts
3) eosinp[hils
some one comes to clinic with an acute migraine. Has already tried ibuprofen 800mg and triptan x 2 doses q2h.
Really bad headache, nausea, photophobia. What can you offer next?
IV antiemetics
ideally IV zofran but this isnt available in clinic so give intramuscular prochlorperazine or promethazine.
Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute
migraine beyond their effect on nausea.
1st, 2nd and third line treatments for insomnia?
Extended release-melatonin, doxepin (TCA) and 3rd is Eszopiclone (lunesta-a sedative-hypnotic like zolpidem).
Lunesta has a 1-hour approximate time to peak and a 6-hour half-life.
New guideline came out in 2022 to include a two-dose series of zoster/shingles vaccine for all adults age 19 and older with _____ condition.
HIV
Patients with HIV need bactrim for PJP if their CD4 is < ____
CD4 < 200
A nondisplaced radial head fractures in adults can be managed by primary care physicians. So how do you treat?
Immobilization for 3 days followed by range-of-motion exercises
Cyclic mastalgia/breast pain
treat with first line and second line?
Topical NSAIDs such as diclofenac are the first-line pharmacologic treatment for mastalgia
Danazol (a weak androgen and anabolic steroid, innnhibits production of gonadotropins from pituitary)
is the only drug that is approved by the FDA for treatment of mastalgia, but it is poorly tolerated due to menorrhagia, muscle cramps, weight gain, and other androgenic effects.
Chronic rhinosinusitis as the presence of two of four
cardinal symptoms: ___, ___, ___, ___ , along with objective signs on examination or radiographic studies.
nasal drainage, nasal obstruction, facial pain or pressure, and hyposmia or anosmia
Give me examples of primary, seconday and tertiary prevention
primary: vaccines, condom distribution, fluoride toothpase (interventing to prevent a disease)
secondary: screening for HTN, diabetes or HLD or pap smears. trying to catch an asymptomatic diasease
tertiary: microalbuminuria in a diabetic patient
aUse back up contraception if IUD was inserted more than ____ days after menstrual bleeding starts,
the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next ___ days.
7, 7
if IUD was placed within 7 days AFTER menstrual
bleeding started, back up needed
The annual failure rate of combined oral contraceptive pills with typical use is ____%. Typical failure rates for other contraceptive methods are ___% for the levonorgestrel IUD, ___% for injectable progestin, ___% for male condoms, and ___% for the withdrawal method.
7, 0.2, 4, 13 and 22
The ______is a delirium diagnosis tool/score useful for evaluating ACUTE cognitive changes.
Confusion Assessment Method (CAM)
If there is concern about bleeding risk, particularly in patients older than 65 years of age, the HAS-BLED scoring system has been well validated, with a score of _____ or more indicating that a patient has a high likelihood of hemorrhage.
3
H HTN
A abn liver or kidney fx
S stroke
B bleeding (prior major bleed)
L labile INR
E elderly > 65
D drug (aka alcoholism)
Management of a midclavicular, minimaly dislaced fracture?
treated with just a sling for 2–6 weeks.
Passive range of motion of the shoulder is indicated as soon as the pain allows.
Physical therapy may be started at 4 weeks after the injury.
Referral? no Fractures of the clavicle are common in young individuals, usually from sports injuries or direct trauma. Eighty percent of these fractures occur in the midclavicle. Unless significantly displaced, these fractures do not require referral.
Scoliosis
____° of trunk rotation is assessed by the scoliometer with patient bent to 90degrees warrants a XRay to assess the Cobb angle.
A Cobb angle >___ may signify scoliosis,
5°–7°
20°
______ can bleed with trauma but typically cause pain with thrombosis, independent of bowel movements
If the patient is having pain ONLY with bowel movement - thats likely _____
external hemorrhoids
anal fissure
Patient comes in with a Pulm embolus. When do you consider thrombolysis?
a) hypotension
You do not consider it with RV dysfunction or with hypoxia
Elemental iron supplementation (2 mg/kg per day) should begin at _____ age for exclusively breastfed infants born before 37 weeks gestation and should continue until ______ of age,
1 month
12 month
what is the most effective treatment for Achilles tendinopathy and/or palpable nodule on the tendon?
eccentric calf-strengthening exercises.
Corticosteroid injection is contraindicated due to the risk of tendon rupture. Surgical debridement is considered last option.
Patients with a first degree relative with CRC or adenomatous polyps discovered before age _____, or two or more first degree relatives at any age with CRC or advanced adenoma, should undergo colonoscopy screening starting at age 40 or 10 years diagnosis was made.
The maximum surveillance interval for these patients is _________
60
5 years
HPV vaccine for children ages
How many doses?
How many months apart?
Children in this age group need only two doses of HPV vaccine 6–12 months apart. However, if they received two doses of HPV vaccine less than 5 months apart, they still need to have the third dose.
Pulm nodule less than ___mm are difficult to biopsy (so just monitor)
8mm
Knee pain
Foot orthoses can be helpful for _____ knee pain
Weight loss is recommended for patients with a BMI >_____ kg/m2.
anterior
BMI of 25
Benefits of probiotic
1) shown to prevent the antibiotic-associated diarrhea in children. The number needed to treat to prevent one case of diarrhea is 10.
2) Probiotics reduce the pain associated with irritable bowel syndrome (IBS) but have not been shown to be helpful in reducing diarrhea or constipation
3) In breastfed infants, probiotics reduce daily crying time by up to an hour.
4) prevention of eczema and upper respiratory infections (SOR A). However, their use has not been shown to prevent allergies and asthma.
The following conditions present as
1) Polymyalgia rheumatica
2) polymyositis
3) dermatomyositis
1) bilateral pain and morning STIFFNESS of shoulders, neck and sometimes hip.
2) proximal muscle WEAKNESS
3) proximal muscle weakness + gottrons papules + heliotrope rash (around eye). Linked with malignancy
Children with high fever and no other symptoms, then later develops diffuse rash - diagnosis?
Roseola infantum
Herpesvirus 6
Treatment of Jones fracture?
jones fracture is fracture of fifth toe metatarsal
For someone with increased activity level and needs to get back to work (like dancing) - surgical treatment is the best as it shortens recovery time.
Non-surgical option is also possible but requires 6 weeks in a non-WB cast.
In patients with hypertention, studies show a benefit in reducing sodium levels to less than _____ mg per day
2400mg
Metformin is contraindicated with a creatinine level >______ mg/dL
SGLT2 inhibitors are not as safe or effective if the patient’s estimated glomerular filtration rate (eGFR) is <_______mL/min/1.73 m2, and it is not recommended in patients with an eGFR <_______ mL/min/1.73 m2.
1.5
50 and 30
_________ is characterized by intermittent secretory diarrhea in older patients, only a biopsy from the transverse colon can confirm the diagnosis.
The cause is unknown, but there is some evidence that more than 6 months of NSAID use increases the risk.
Microscopic colitis
A history of an _______ within the past _____ months is an absolute contraindication to fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI),
ischemic stroke
3 months
When do you prescribe abx for acute rhinosinusitis?
acute rhinosinusitis (Sinus pressure, purulent discharge, congestion etc). In the first 3–4 days, viral and bacterial rhinosinusitis are indistinguishable. So watchful waiting…. IF sxs persistent for 7 days or longer, then you can diagnose acute bacterial rhinosinusitis and treat with augmentin.
The most common cause of hypercalcemia is ______________
hyperparathyroidism
Other causes of hypercalcemia include thiazide diuretics, lithium, vitamin D intoxication, hyperthyroidism, milk alkali syndrome from excessive calcium antacid ingestion, adrenal insufficiency, and lymphoma.
The most common causes of chronic cough in children 6–14 years of age are ________
Beyond 14yo, the most common cause is _____
6-14yo : asthma
> 14yo: upper airway cough syndrome aka postnasal drip
Treatment for acute paronychia?
Topical antibiotics
Other options include warm compresses, oral antibiotics, and incision and drainage; however, incision and drainage is not always necessary.
Removal of the proximal nail fold is used to treat chronic paronychia that is not responsive to other treatments
_________ medication is a potent inducer of CYP-450
Phenytoin
Syncope, commonly on exertion, is reported in up to 42% of patients with severe_____________
aortic stenosis.
Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise (or even fall) with exertion.
Light’s criteria: if the following is met - it means exudative fluid
- Pleural fluid protein to serum protein ratio >____,
- pleural fluid LDH to serum LDH ratio >___
- and/or pleural LDH >0.67 times the upper limit of normal for serum LDH
0.5
0.6
the above are 99.5% sensitive for diagnosing exudative effusions and differentiate exudative from
transudative effusions in 93%–96% of cases
Aftr major orthopedic surgery, the American College of Chest Physicians recommends outpatient thromboprophylaxis for a duration of up to ____ days
35
