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
