AAFP Review Questions Flashcards
Infant w/ several week h/o increasing dyspnea, cough, poor feeding. Nontoxic and afebrile. Conjunctivitis. Tachypnea and crackles. CXR: hyperinflation and diffuse interstitial infiltrates. Eosinophilia.
Chlamydia trachomatis
Seen in infants 3-16 weeks of age Prominent cough PE: -diffuse crackles w/ few wheezes -conjunctivitis in 50% CXR -hyperinflation and diffuse interstitial or patchy infiltrates
BPH w/ lower UT sx pharmacological options
- Alpha-adrenergic blocker
- 5-alpha-reductase inhibitor (if evidence of prostatic enlargement or PSA > 1.5)
- PDE-5 inhibitor
- antimuscarinic therapy
First 3 proven as effective monotherapies
Mallet fracture management
Forced flexion injury of DIP resulting in small bone fragment @dorsal surface of proximal distal phalanx
Splint the DIP in extension
Presentation and management of necrotizing fasciitis
Presentation: severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration
Management: Immediate surgical consultation for operative debridement
Nursemaid’s elbow (radial subluxation) presentation and management
Most common ortho condition of elbow in kids 1-4
Arm slightly probated, flexed, and close to body. Tenderness near lateral elbow
Reduce the subluxed radial head (elbow at 90 degrees, hand fully supinated by examiner, elbow brought into full flexion)
Asthma step-up from short-acting bronchodilator
Inhaled medium-dose corticosteroids
Most appropriate first-line therapy for primary dysmenorrhea
NSAIDs
-started @onset of menses and continued for first 1-2 days of menstrual cycle
What to do in an outbreak of Influenza A (H1N1) in a long-term care facility
Chemoprophylaxis w/ appropriate meds for all residents who are asymptomatic, and treatment for all residents who are symptomatic. All staff should be considered for chemoprophylaxis
Neonate w/ flesh-colored papules on an erythematous base on face and trunk containing eosinophils
Dx? Management?
Erythema toxicum neonatorum
Usually resolves in first few weeks of life
SEs of inhaled corticosteroids for COPD
Increased risk of bruising, candidal infection of the oropharynx, and pneumonia.
Decrease risk of COPD exacerbations but have no mortality benefit and do not improve FEV1 consistently.
Polymyalgia rheumatica dx and tx
> 50 y.o., bilateral shoulder pain and stiffness accompanied by upper arm tenderness, soreness about both shoulders, difficulty raising arms above shoulders. Accompanying systemic sx of fatigue, lo-grade fever, weight loss, decreased appetite, depression. Elevated CRP and ESR.
15mg prednisone
Tx of infected diabetic foot ulcer with systemic sx
IV Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)
Drugs that cause SIADH
SSRIs (esp. in >65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, NSAIDs
SIADH = euvolemic pt w/ hyponatremia, decreased serum osmolality, and elevated urine osmolality
Most common cause of unintentional deaths in children
Motor vehicle accidents (58.2% of childhood deaths)
Drowning: 10.9%
Poisoning: 7.7%
Fires: 5.7%
Falls: 1.4%
Treatment of acute mild/mod pericarditis
NSAIDs (glucocorticoids in severe or refractory cases)
Acute, sharp chest pain relieved only by leaning forward. Pericardial friction rub. Diffuse ST-elevations.
First-line tx for previously healthy infants and school-age children w/ mild/mod CAP
Amoxicillin
Most common pathogen: Streptococcus pneumoniae
(Azithromycin would be appropriate in an older child since Mycoplasma pneumoniae is more common)
Tx for non-obese children with obstructive sleep apnea
Adenotonsillectomy
Tx of anemia of CKD
Oral ferrous sulfate or erythropoieten
Signs and sx of hip labral tear
Dull or sharp groin pain which may radiate to lateral hip, anterior thigh, or buttock. Insidious onset or acutely after traumatic event. 50% have mechanical sx like catching or painful clicking w/ activity. FADIR and FABER tests good SN but low SP. MRA is diagnostic.
Which vaccine may cause febrile seizures up to 2 weeks after vax?
MMR (measles component)
Postimmunization seizures are more likely to occur in kids w/ past hx of seizures or 1st degree relative w/ epilepsy.
What is a pathogen more common in corticosteroid-dependent COPD pneumonia than in other patients?
Pseudomonas aureuginosa
Cow’s milk is not recommended for children until the age of?
12 months
Whole cow’s milk doesn’t supply kids with enough vitamin E, iron, and essential fatty acids. It also overburdens them with too much protein, sodium, and potassium. Also fails to provide adequate calories for growth. (Skim and low-fat do the same.)
Tx for acute flare-up of multiple sclerosis
Methylprednisolone (Medrol)
Tx serotonin syndrome
Discontinue offending agent, supportive care, IV benzodiazepine (lorazepam or diazepam). If no response, cyproheptadine
When to give antibiotics in asplenics?
Anytime there is a fever
JNC8 HTN
- In >60, start drugs at >150 or >90 (treat to <150, <90)
- In <60, start drugs at >90 (treat to <90)
- In <60, start drugs >140 (treat to <140)
- In >18 w/ CKD, start drugs at >140 or >90 (treat to <140 and <90)
- In >18 w/ DM, start drugs at >140 or >90 (treat to >140 and >90)
- In nonblacks (including w/ DM), initial drugs include THIAZIDE DIURETICS, CALCIUM CHANNEL BLOCKERS, ACE INHIBITORS, or ARBs.
- In blacks (including w/ DM), begin w/ THIAZIDE DIURETIC or CCB
- In >18 w/ CKD, initial (or add-on) drugs should include an ACE inhibitor or an ARB to improve kidney outcomes. [Regardless of race or DM]
- If BP goal not met w/in 1mo of tx:
-increase dose of initial drug
OR
-add a second drug (thiazide, CCB, ACEi, or ARB)
If BP cannot be attained w/ 2 drugs, add and titrate a third drug
(Do not use ACEi and ARB in same pt)
If goal BP still cannot be reached OR if can’t use one of the drugs from 6 d/t contraindication, antihypertensive drugs from other classes may be used
Refer to HTN specialist
Lifestyle management in pre-diabetes and diabetes
Advise in pre-diabetes and new-onset diabetes
Diet and exercise
May include
- DM education
- frequent individual and group counseling from dieticians, behavior psychologists, exercise specialists
- caloric restriction
- regular exercise
Weight loss strategies
- weekly self-weighing
- regular breakfast consumption
- reduced intake of fast food
Non-insulin DM drugs and MoA
-Alpha glucosidase inhibitors: inhibit enzyme at intestinal brush border; slow absorption of carbohydrates
-Biguanides: decrease hepatic glucose production; increase insulin sensitivity peripherally; and decrease intestinal absorption of carbohydrates
[Metformin]
-DPP4 inhibitors: increase GLP-1; increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas
[Alogliptin, linagliptin, saxagliptin, sitagliptin]
-GLP-1 receptor agonists: increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas; suppress hepatic glucose production; delay gastric emptying
[Albiglutide, dulaglutide, exenatide, liraglutide]
- Meglinitides: close K+ channels in beta-cells; stimulate release of insulin from the pancreas
- SGLT2 inhibitors: lower renal threshold for cluse and reduce reabsorption of filtered glucose from tubular lumen; increase urinary glucose excretion
-Sulfonylureas: bind to K+ channels in beta-cells; stimulate release of insulin from the pancreas
[Glimepiride, glipizide, glyburide]
-Thiazolidinediones: increase hepatic glucose uptake; decrease hepatic glucose production; increase insulin sensitivity in the muscle and adipose tissue
[Pioglitazone, rosiglitazone]
Criteria for type 2 diabetes
A1c > 6.5
OR
Fasting plasma glucose >126
OR
Random plasma glucose >200 w/ sx of hyperglycemia
Two-hour plasma glucose >200 during an oral glucose tolerance test
Management approach to type 2 diabetes
Initial drug monotherapy: METFORMIN
If still not at target A1c [<7] after 3 months:
Two drug combinations w/ metformin (no particular order)
-SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal)
If still not at target A1c after 3 months:
Add a third drug not already part of the patient’s regiment
-SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal)
If still not at target:
-more complex insulin strategies
Diabetes A1c goals
Most diabetics: <7%
<6.5% reasonable for patients w/ short duration of DM, long life expectancy, and no significant CV disease
7.5-8% reasonable for patients w/ short life expectancy, CV disease, 2+ CVD RFs, or duration of disease 10+ yrs
First line therapy for type 2 diabetes
METFORMIN
Glucose monitoring in non-insulin DM?
Self-monitoring of blood glucose levels for patients taking non-insulin therapies does NOT significantly affect glycemic control
Drugs for postherpetic neuralgia
Topical: lidocaine patches, capsaicin cream
Oral: gabapentin, pregabalin, amitriptyline
Risks of PPIs
Fractures of the hip/wrist/spine, CAP, C. diff and other enteric infections, hypomagnesemia, cardiac events if administered w/ clopidogrel
First-line therapy for constipation in kids
Oral osmotic (e.g., PEG)
When can kids with lice return back to school?
Immediately
Recurrent uveitis should raise suspicion for?
Most comon conditions assx w/ uveitis:
- séronégative spondyloarthropathies
- sarcoidosis
- syphilis
- RA
- reactive arthritis
When should red eye be referred to ophtho?
Vision changes (could be glaucoma)
Empiric tx for classic pyelonephritis
Ciprofloxacin (cipro)
Immune thrombocytopenic purpura presentation and treatment
Easy bruising, low platelets, giant platelets
Corticosteroids (IVIG and rituximab have also been used as first-line)
Pertussis treatment
Azithromycin (Zithromax)
TMP/SMX if allergic or intolerant to macrolides
Which diabetes medication does not cause hypoglycemia?
Metformin (but there is risk for lactic acidosis)
Which vessels are present in the newborn umbilicus?
2 arteries and 1 vein
How to avoid kidney injury in rhabdomyolysis?
Rapid large infusions of isotonic saline
How to diagnose fibromyalgia?
Symptoms (NOT tender points)
How to enhance oral absorption of supplemental iron?
Vitamin C (or a meal high in meat protein)
Changes to pharmacokinetics that occur with aging
In older persons there
is a relative increase in body fat and a relative decrease in lean body mass, which causes increased
distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such
medications. The volume of distribution of water-soluble compounds such as digoxin is decreased in older
patients, which means a smaller dose is required to reach a given target plasma concentration. There is also
a predictable reduction in glomerular filtration rate and tubular secretion with aging, which causes
decreased clearance of medications in the geriatric population. The absorption of drugs changes little with
advancing age.
Which NSAID is not associated with an increased risk of MI and thus preferred in patients with cardiovascular risk factors?
Naproxen
NSAIDs cause an elevation of blood pressure due to their salt and water retention properties. This effect
can also lead to edema and worsen underlying heart failure. In addition, all NSAIDs can have a deleterious
effect on kidney function and can worsen underlying chronic kidney disease, in addition to precipitating
acute kidney injury. Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk
of cardiovascular adverse effects and myocardial infarction, compared with placebo. However, naproxen
has not been associated with an increased risk of myocardial infarction and is therefore preferred over
other NSAIDs in patients with underlying coronary artery disease risk factors
Acute laryngitis treatment
Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate.
A Cochrane review concluded that antibiotics appear to have no benefit in treating acute laryngitis.
How to check for hyperaldosteronism?
Peripheral aldosterone concentration
(PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred
screening tests for hyperaldosteronism. A PAC >15 ng/dL and a PAC/PRA ratio >20 suggest an adrenal
cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma.
Tinea capitis treatment
ORAL antigungal (e.g. griseofulvin)
If a patient had shingles, should they get vaccine?
YES
Acne management
Mild: 1-3 topicals
Mod: 2-3 topicals +/- oral
Severe: orals w/ 2-3 topicals
What is a level D recommendation?
A “D” recommendation means the U.S. Preventive Services Task Force (USPSTF) recommends against
the service. There is moderate or high certainty that the service has no net benefit or that the harms
outweigh the benefits.
What is a level I recommendation?
An “I” recommendation means the USPSTF concludes that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
What is a level C recommendation?
A “C” recommendation means the USPSTF recommends selectively offering or providing this service to
individual patients based on professional judgment and patient preferences.
What is a level B recommendation?
A “B” recommendation means the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit
is moderate to substantial.
What is a level A recommendation?
An “A” recommendation means the USPSTF recommends the service and there is high certainty that the net benefit is substantial. The highest levels of evidence and most recent evidence
available are used by the USPSTF in making all of its recommendations.
According to the DSM-5, what is the severity of anorexia nervosa based on?
According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass
index (BMI). Mild is a BMI >17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of
15.0–15.9 kg/m2, and extreme is a BMI <15.0 kg/m2.
First-line therapy for nausea and vomiting of pregnancy
Vitamin B6
Scopolamine is effective for nausea and vomiting of pregnancy but should be avoided in the first trimester
due to the possibility of causing trunk and limb deformities. Likewise, methylprednisolone is also effective
but should be avoided in the first trimester as it is associated with an increased risk of cleft palate if used
before 10 weeks of gestation.
Who should get antibiotics before dental work?
According to the American Heart Association’s 2007 guidelines, prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease.
Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these
recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are
associated with mitral regurgitation. The American Dental Association has endorsed this guideline.
Side effect of methimazole
AGRANULOCYTOSIS
Other rare complications of methimazole include serum sickness, cholestatic
jaundice, alopecia, nephrotic syndrome, hypoglycemia, and loss of taste. It is associated with an increased
risk of fetal anomalies, so propylthiouracil (PTU) is preferred in pregnancy.
Target LDL for diabetes
<100 (but lower is better, so <70 ideally!)
Patients with DM are considered to have known CAD, so 100 is target.
Apart from diabetic medications, what should all DM patients be on?
ACE-inhibitor or ARB for cardiovascular and renal protection
Microalbuminuria is a RF for CVD and progression of renal disease to ESRD and dialysis. ACE-Is/ARBs have been shown to decrease risk EVEN IN NORMOTENSIVE PATIENTS
If new-onset migraine with nuchal rigidity, think…
SUBARACHNOID HEMORRHAGE
Get LP
(If there was a similar headache a few weeks before, think SENTINEL BLEED from an aneurysm)
3-6 week old infant with projectile vomiting, visible peristaltic wave, and olive-like mass
PYLORIC STENOSIS
Hypochloremic, hypokalemic metabolic alkalosis
Acid-base status in pyloric stenosis
Hypochloremic, hypokalemic metabolic alkalosis
Best breast screening for concerning mass in:
<35
>35
<35: Ultrasound (since breast tissue is too dense for mammogram)
> 35: Mammography
Treatment of enterobiasis (pinworm)
Albendazole or mebendazole in ALL HOUSEHOLD MEMBERS
(pyrantel pamoate if pregnant since azoles are teratogenic)
Also wash clothes and bedding, and trim nails (since under nails is most common place for eggs to hide out)
What things are needed to evaluate acute coronary syndrome?
EKG and serial troponins
Unstable angina, NSTEMI, STEMI
Treatment of vulvar candidiasis
Single dose of oral fluconazole or several days of miconazole or clotrimazole vaginal creams
Presentation of vulvar candidiasis
- vulvar pruritis [dominant sx]
- discharge: white with curd-like consistency (“cottage cheese”)
- low vaginal pH (<4.5)
- KOH: budding yeast and hyphae
Other symptoms could include:
- dysuria
- vulvovaginal irritation
- dyspareunia
Alport syndrome
Glomerular hematuria along sensorineural deafness and ocular abnormalities (can’t see, can’t pee, can’t hear). Since this is an inherited disease, there should also be a family history of renal failure and deafness. The primary defect is a genetic mutation in collagen type IV.
Immediate treatment of hyperkalemia
IV calcium gluconate
even if very high and need dialysis, start with IV calcium as a temporizing measure to stabilize the myocardium
Hyperkalemia on EKG
Peaked T waves
Medical emergency: IV calcium to stabilize myocardium
If HTN <30 y.o., think…
secondary HTN (as opposed to essential HTN), such as fibromuscular dysplasia
Drugs for uterine atony
- Carboprost (Hemabate) [contraindicated in asthma]
- Methylergonovine [contraindicated in HTN]
- Misoprostol (Cytotec)
- Oxytocin (Pitocin)
Treatment of acute parotitis
Amoxicillin/clavulanate (Augmentin)
Staphylococcus most common pathogen
Fever in child under 29 days old
Any child younger than 29 days old with a fever and any child who appears toxic, regardless of age,
should undergo a complete sepsis workup and be admitted to the hospital for observation until culture
results are known or the source of the fever is found and treated
Ottawa ankle rules
X-ray only needed if one or more of the following are positive:
- Tenderness of the distal 6 cm POSTERIOR edge of tibia (medial malleolus)
- Tenderness of the distal 6 cm POSTERIOR edge of fibula (lateral malleolus)
- Tenderness of the navicular
- Tenderness of the proximal 5th metatarsal
- Inability to bear weight for four steps immediately after the injury or at examination
Finklestein test
De Quervain tenosynovitis
Place thumb in palm, close fingers around it; maximally deviate in ulnar direction.
+ is pain when maximally ulnar deviated
Phalen test
Carpal tunnel syndrome
Dorsum of hands together with wrists in forced flexion for 30-60 sec
+ is numbness of palmar thumb, index finger, and middle finger
Tinel test
Carpal tunnel syndrome
Lightly tap median nerve at palmar wrist
+ is electric jolt down middle finger
Spurling maneuver
Cervical nerve root pain
Turn head toward affected side with neck extended; exert downward pressure
+ is pain, numbness, weakness down arm
Speed’s test
Tendinitis of long head of the biceps
Arm supinated, elbow extended, resist forward flexion at shoulder
+ is pain in biceps groove
Empty can test
Supaspinatus tendon
Arms extended at 30 degrees, thumbs pointing down, resist upward motion
+ is weakness or pain
Drop arm test
Supraspinatus tendon tear
Passively hold arm extended at shoulder level and release; allow patient to slowly lower arm to waist
+ is instability to control maneuver to waist
Lift off test
Subscapularis
Dorsum of hands in lumbar area, resist straight lift off
+ is pain or weakness
External rotation test (arm)
Infraspinatus and teres minor
Arm against ribs, elbows flexed at 90 degrees, resist external rotation
+ is pain or weakness
Neer test
Rotator cuff impingement
Arm extended and pronated, examiner passively lifts arm up past head
+ is pain
McMurray test
Meniscus
Patient supine, thumb and fingers in knee joint line, grasp heel, fully flex and extend knee while exerting valgus stress while externally rotating knee; repeat with varus stress while internally rotating knee
+ is catching
Cross arm test
AC joint
Arm at shoulder level, elbow 90 degrees, examiner brings across to touch other shoulder
+ is pain at AC joint
Apprehension test
Subluxation of the glenohumeral joint
Arm at shoulder level, elbow at 90 degrees, hand toward ceiling; anterior pressure on humerus
+ is apprehension of joint dislocating or pain
Straight leg raise test
Lumbar nerve root compression
Leg extended, hip at 90 degrees
+ is radiation pain or numbness down past knee
FABER test
SI joint
Hip in flexion, abduction, and external rotation (“figure 4”)
+ is pain
Trendelenburg test
Hip abductor weakness
Patient stands on affected leg and lifts other leg
+ is pelvic drop to contralateral side
Colles fracture
Fracture of distal radius/ulna
Usually from fall onto an outstretched hand
Lachman test
ACL
Patient supine, knee flexed at 30 degrees, stabilize femur (hold it), pull tibia anteriorly
+ is lack of clear endpoint of displacement of tibia
Posterior drawer test
PCL
Patient supine, knee flexed at 90 degrees, fix foot (sit on it), push tibia posteriorly
+ is posterior displacement of tibia
Valgus stress test
LCL
Patient supine, leg slightly abducted at the hip, knee 30 degrees flexed, stabilize tibia, push knee inward
+ is laxity
Varus stress test
MCL
Patient supine, leg slightly abducted at the hip, knee 30 degrees flexed, stabilize tibia, push knee outward
+ is laxity
McMurray test
Meniscus
Patient supine, thumb and fingers in knee joint line, grasp heel, fully flex and extend knee while exerting valgus stress while externally rotating knee; repeat with varus stress while internally rotating knee
+ is catching
Gout treatment
Acute flare: NSAIDs + low dose colchicine
Maintenance: allopurinol (xanthine oxidase inhibitor), probenecid (increases uric acid excretion in the urine)
Target serum uric acid level in gout
<6
Most common joints involved in gout and pseudogout
Gout: first MTP
Pseudogout: knee
CASPAR criteria for psoriatic arthritis
3 or more out of 6 is positive
-psoriasis of the skin
present (2 pts)
past (1 pt)
FHx (1 pt)
-nail lesions (1 pt)
-dactylitis (1 pt)
-negative RF (1 pt)
-juxtaarticular bone formation on XR (1 pt)
Management of stable COPD
inhaled beta agonists (albuterol) and anticholinergic bronchodilators (tiotropium or ipratropium).
Oral steroids may be need for patients with more severe disease.
Supplemental oxygen has clearly been shown to prolong life in COPD patients – the only other intervention that does so is smoking cessation!
Colles fracture
Fracture of distal radius/ulna
Usually from fall onto an outstretched hand
Gonorrhea treatment
Ceftriaxone and azithromycin
Want to treat both chlamydia and gonorrhea to avoid development of PID which can lead to infertility
(G is much less common than C, and patients infected with G are likely to also be infected with C- the reverse is not true since C is so common/easy to acquire statistically)
If a patient tests + for chlamydia or gonorrhea, should the partner be treated?
Yes, or the patient will become reinfected
Combined OCP vs. progestin-only
Progestin only pills (a.k.a. “POPs” or “the mini pill”) are associated with more break-through bleeding and slightly higher failure rates than the combination pill that contains both estrogen and progesterone. Progestin only pills are more difficult to take, because they must be taken at the same time every day to maintain their efficacy. They are usually reserved for women who have a compelling reason avoid estrogen. Such patients might include women with migraine headaches, smokers over age 35, patients in the postpartum period, or women with clotting disease, cardiovascular disease, uncontrolled HTN, SLE, or hypertriglyceridemia
If a patient has myasthenia gravis, what conditions need to be considered?
Do a CT for thymic pathology. 75% will have thymic hyperplasia, and 15% will have an overt thymoma (removal of the thymus can be curative in some patients who fail medical therapy)
Also in younger females, consider autoimmune (SLE, RA, hyperthyroidism)
Mitral valve prolapse murmur
Midsystolic click followed by a late systolic murmur heard best at the apex of the heart
Atrial septal defect physical exam findings
Buzzword: fixed splitting of S2
Loud S1 with a fixed and widely split S2. Soft, midsystolic ejection murmur heard best at L 2nd ICS MCL.
ASDs are silent! The murmur heard is a systolic ejection flow murmur out of the pulmonic valve due to increased flow.
ASDs can remain asymptomatic for a long time, but eventually get pulmonary hypertension and shunt can reverse –> Eisenmenger syndrome
Medications beneficial in acute COPD exacerbations
corticosteroids, antibiotics (amoxicillin, trimethoprim/sulfamethoxazole, and doxycycline), and inhaled bronchodilators
Antibiotics used in COPD exacerbations
amoxicillin, trimethoprim/sulfamethoxazole, and doxycycline
Classic COPD x-ray
hyper-inflated lungs, flattened diaphragms, and a narrow cardiac silhouette
Management of stable COPD
inhaled beta agonists (albuterol) and anticholinergic bronchodilators (tiotropium or ipratropium).
Oral steroids may be need for patients with more severe disease.
Supplemental oxygen has clearly been shown to prolong life in COPD patients – the only other intervention that does so is smoking cessation!
X-ray appearance of coarctation of the aorta
Rib notching (d/t collateral circulation formation)
Hallmark lab finding in polymyalgia rheumatics
Markedly elevated ESR
OCPs and cancer
Prevent ovarian cancer and may cause breast cancer
Combined OCP vs. progestin-only
Progestin only pills (a.k.a. “POPs” or “the mini pill”) are associated with more break-through bleeding and slightly higher failure rates than the combination pill that contains both estrogen and progesterone. Progestin only pills are more difficult to take, because they must be taken at the same time every day to maintain their efficacy. They are usually reserved for women who have a compelling reason avoid estrogen. Such patients might include women with migraine headaches, smokers over age 35, patients in the postpartum period, or women with clotting disease, cardiovascular disease, uncontrolled HTN, SLE, or hypertriglyceridemia
First step in evaluating short stature
Growth velocity
- if normal:
- familial short stature
- constitutional delay of growth
- if abnormal:
- endocrinopathies
- GH deficiency
- malnutrition
- abuse
- malignancy
Distinguish between familial short stature and constitutional delay of growth
Bone age (X-ray of hand and wrist)
- FSS: bone age matches chronological age
- CDG: bone age lags behind chronological age
(both have normal growth velocity)
Do we treat bacteruria of pregnancy?
YES (EVEN IF ASYMPTOMATIC), to prevent pyelonephritis
From UpToDate:
- Without treatment, as many as 30 to 40 percent of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection (UTI).
- We screen all pregnant women at least once for asymptomatic bacteriuria. Screening for asymptomatic bacteriuria is performed at 12 to 16 weeks gestation with a midstream urine for culture. The diagnosis is made by finding high-level bacterial growth (≥105 colony forming units [cfu]/mL or, for group B Streptococcus, ≥104 cfu/mL) on urine culture in the absence of symptoms consistent with UTI.
- Management of asymptomatic bacteriuria in pregnant women includes antibiotic therapy tailored to culture results, which reduces the risk of subsequent pyelonephritis and is associated with improved pregnancy outcomes. Potential options include beta-lactams, nitrofurantoin, and fosfomycin
Treatment of bacteruria in pregnancy
[common bugs: E. coli, Klebsiella, GBS]
cephalexin, amoxicillin, amoxicillin/clavulanate, nitrofurantoin, and sulfonamides (but NO sulfonamides in 1st trimester d/t causing hyperbilirubinemia of the newborn]
Kawasaki disease
At least 5d
At least 4 of:
- peripheral edema
- desquamation (esp. of fingertips, palms, and soles)
- bilateral conjunctivitis
- polymorphous, nonvesicular rash
- cervical lymphadenopathy (often unilateral)
- dry or fissured lips
- “strawberry tongue” [Ddx: scarlet fever or Kawasaki disease]
DO-NOT-MISS DIAGNOSIS d/t life-threatening coronary artery aneurysms
Patients need serial echos to monitor aneurysms.
Treatment of Kawasaki disease includes intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis
Treatment of Kawasaki disease
Patients need serial echos to monitor aneurysms.
Intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis
How to choose allopurinol vs. probenecid
24 hour urine collection for uric acid
<600 mg: underexcreter –> probenecid
>600 mg: overproducer –> allopurinol
Two most common nonpathological reasons for high alfa-fetoprotein
- Multiple gestations
2. Inaccurate gestational date
Blood on dipstick but no RBCs
Myoglobinuria (myoglobin cross reacts w/ hemoglobin on dipstick)
Prevent myoglobin-induced ATN in rhabdomyolysis
IV saline
Hypertensive urgency
> 200 / >120 in the absence of symptoms
Hypertensive emergency
increased blood pressure with signs and symptoms of end-organ damage such as papilledema, stroke, hematuria, headache, altered mental status, acute coronary syndrome, etc.
Treatment of hypertensive emergency
IV antihypertensive
Treatment of hypertensive urgency
Oral antihypertensives (e.g., labetalol)
How to begin a new-onset eneuresis workup
Urinalysis
This single test will allow screening for urinary tract infection, a common cause of new-onset enuresis, as well as diabetic ketoacidosis, diabetes insipidus, and water intoxication. Imaging and referrals are reserved for patients with histories and physical exams that suggest a structural cause.
Intusussusception presentation
The patient (usually 6 mo - 36 mo) usually presents with a history of sudden onset severe, crampy abdominal pain that is accompanied by drawing the legs up toward the abdomen and inconsolable crying. These episodes usually last 20 minutes and pain-free periods can follow. Usually the episodes become more severe and spaced closer together over time. Non-bilious vomiting can become bilious as the obstruction worsens. “Currant jelly” stool is a common description of the blood and mucus mixed stool that can occur with intussusception. Palpation of a “sausage-shaped” mass is also classic, but is not always appreciated on physical exam. Ultrasound imaging is not mandatory for diagnosis, but if performed, it may reveal pathognomonic “bull’s eye” or “coiled spring” lesions. Prompt treatment is necessary to avoid irreversible intestinal ischemia or bowel perforation. Air contrast enema is diagnostic and therapeutic.
Congenital rubella findings
Deafness and cataracts as well as numerous purpuric skin lesions, (“blueberry muffin” baby).
Congenital rubella syndrome occurs when the mother contracts rubella early on in her pregnancy – the risk of congenital rubella syndrome is very low after 20 weeks. Since the MMR vaccine contains a live attenuated virus, there is at least a theoretical risk of causing congenital rubella syndrome, and for this reason the vaccine is avoided in pregnant women.
HIV patient w/ CD4 < 200 needs what?
TMP/SMX for prophylaxis of pneumocystis jirovecii pneumonia
HIV patient w/ CD4 < 100 needs what?
TMP/SMX for prophylaxis of toxoplasma gondii
HIV patient w/ CD4 < 50 needs what?
Azithromycin or clarithromycin for prophylaxis of MAC
What is a positive PPD in a high risk patient?
> 5 mm induration
HIV/AIDS, immunocompromised/suppressed, close TB contact
What is a positive PPD in a moderate risk patient?
> 10 mm induration
homeless, comes from a country with high TB rates, or is an i.v. drug user
What is a positive PPD in a low risk patient?
> 15 mm induration
no major TB RFs
Management of shoulder dystocia
- Fundal pressure (sufficient in most cases)
- Corkscrew maneuver: delivery of the posterior arm and shoulder, flexion of the maternal hips, and rotation of the infant
- fracturing the fetal clavicles or maternal symphysi
(RFs for shoulder dystocia:
Fetal macrosomia, gestational diabetes, maternal obesity, postdate pregnancy, and prolonged second stage of labor)
Most common complication of shoulder dystocia
Erb palsy
Damage to C5-C6 –> waiter’s tip
Congenital syphilis findings
Rash involving palms and soles, blood-tinged purulent nasal discharge (“the snuffles”), lymphadenopathy, organomegaly
Classic triad of congenital toxoplasmosis
Hydrocephalus, chorioretinitis, intracranial calcifications
Congenital rubella findings
Deafness and cataracts as well as numerous purpuric skin lesions, (“blueberry muffin” baby).
Congenital rubella syndrome occurs when the mother contracts rubella early on in her pregnancy – the risk of congenital rubella syndrome is very low after 20 weeks. Since the MMR vaccine contains a live attenuated virus, there is at least a theoretical risk of causing congenital rubella syndrome, and for this reason the vaccine is avoided in pregnant women.
Most common causes of hypercalcemia
Malignancy and hyperparathyroidism
CHIMPANZEES
- calcium supplementation
- hyperparathyroidism
- immobility // iatrogenic (from thiazide diuretics)
- milk alkali syndrome
- Paget’s disease
- Acromegaly // Addison’s disease
- Neoplasm
- Zollinger-Ellison syndrome (when associated w/ MEN-1)
- Excess vitamin D
- Excess vitamin A
- Sarcoidosis
Signs of hypercalcemia
Bones, stones, abdominal groans, psychiatric overtones
bone fractures, kidney stones, vomiting and constipation, and weakness, fatigue, and altered mental status
Hypercalcemic crisis
MEDICAL EMERGENCY d/t heart conduction abnormalities
Calcium > 14 or severe symptoms
Check EKG and begin IV fluids and furosemide (lose Ca++)
Charcot’s triad
of acute cholecystitis
RUQ pain, jaundice, and fever/chills
Reynold’s pentad
of acute cholecystitis
Charcot’s triad (RUQ pain, jaundice, and fever/chills) plus shock and mental status changes
Treatment of isolated chlamydia infection
Azithromycin (single dose) or doxycycline (1 wk)
(1 wk of erythromycin also reasonable but causes GI upset)
(Fluoroquinolones like ofloxacin and levofloxacin are more expensive alternatives)
(Pregnant: azithromycin or erythromycin)
Treatment of acute dystonia
Benztropine or diphenhydramine
What is leukoria and what does it signify?
Leukoria is a white pupillary reflex (as opposed to the normal red reflex).
It can indicate
- disorders of the lens (e.g., cataracts)
- disorders of the vitreous (e.g., hemorrhage)
- disorders of the retina (e.g., retinoblastoma)
Isolated elevated opening pressure
Cryptococcal meningitis
also see lymphocytosis in CSF
Treatment of cryptococcal meningitis
amphotericin B and flucytosine
If early pregnancy loss, think:
cytogenetic abnormalities (abnormalities of chromosome number or structure)
Elevated BUN/Cr ratio
Pre-renal azotemia
Causes of late pregnancy loss
- cervical incompetence
- uterine anomalies
- leiomyoma
- intrauterine synechiae
PANDAS
pediatric autoimmune neuropsychiatric disorder associated with group A streptococci
- pediatric onset
- presence of obsessive compulsive disorder and/or a tic disorder
- abrupt onset with episodic symptom course
- associated with group A strep infections
- association with neurological abnormalities like motoric hyperactivity, choreiform movements and tics
Superficial thrombophlebitis treatment
rest, elevation, NSAIDs, heat
NO NEED FOR ANTICOAGULATION
SVT vs. DVT
Palpable cords: superficial vs. deep
Both cause swelling, pain, and warmth
Only DVT can cause PE
The saphenous vein is a superficial vein; the femoral (and superficial femoral) and popliteal veins are deep veins!
What antibodies are found in primary biliary cholangitis?
Anti-mitochondrial
What antibodies are found in celiac sprue?
Anti-TTG (most SN + SP), anti-gliadin, anti-endomysial
What is leukoria and what does it signify?
Leukoria is a white pupillary reflex (as opposed to the normal red reflex).
It can indicate
- disorders of the lens (e.g., cataracts)
- disorders of the vitreous (e.g., hemorrhage)
- disorders of the retina (e.g., retinoblastoma)
Treatment of mild comedonal acne
topical retinoid and/or other topical agents such as salicylic acid, azelaic acid, glycolic acid, and benzoyl peroxide
Test for primary adrenal insufficiency (Addison’s disease)
Cosyntropin (synthetic ACTH) stimulation test, along with a measurement of plasma cortisol
If adrenals are functioning: cortisol should rise upon stimulation
Symptoms of Addison’s disease
fatigue, weight loss, hypotension, hyponatremia, and hypoglycemia
Elevated BUN/Cr ratio
Pre-renal azotemia
Otitis media antibiotic guidelines
The American Academy of Pediatrics (AAP) recommends antibiotic therapy for children 6 months of age
or older with severe signs and symptoms of acute otitis media (AOM), including moderate or severe otalgia
or otalgia for more than 48 hours, or a temperature ³39°C (102°F), whether the AOM is unilateral or
bilateral (SOR B). Children younger than 24 months without severe symptoms should receive antibiotic
therapy for bilateral AOM, whereas older children or those with unilateral AOM can be offered the option
of observation and follow-up.
The usual treatment for AOM is amoxicillin, but an antibiotic with additional beta-lactamase coverage, such
as amoxicillin/clavulanate, should be given if the child has received amoxicillin within the past 30 days,
has concurrent purulent conjunctivitis, or has a history of AOM unresponsive to amoxicillin (SOR C).
Penicillin-allergic patients should be treated with an alternative antibiotic such as cefdinir, cefuroxime,
cefpodoxime, or ceftriaxone.
Treatment of salmonella infection
NOTHING
The recommended management for patients who have non-severe Salmonella infection and are otherwise
healthy is no treatment. Patients with high-risk conditions that predispose to bacteremia, and those with
severe diarrhea, fever, and systemic toxicity or positive blood cultures should be treated with levofloxacin,
500 mg once daily for 7–10 days (or another fluoroquinolone in an equivalent dosage), or with a slow
intravenous infusion of ceftriaxone, 1–2 g once daily for 7–10 days (14 days in patients with
immunosuppression).
Treatment of cervical lymphadenitis
Systemic symptoms, unilateral lymphadenopathy,
skin erythema, node tenderness, and a node that is 2–3 cm in size. The most common organisms associated
with lymphadenitis are Staphylococcus aureus and group A Streptococcus. Empiric antibiotic therapy with
observation for 4 weeks is acceptable for children with presumed reactive lymphadenopathy (SOR C). If
symptoms do not resolve, or if the mass increases in size during antibiotic treatment, further evaluation
is appropriate.
What needs to be tested before beginning PrEP w/ Truvada (emtricitabine/tenofovir disoproxil )
HIV antibody test
Need to make sure they’re HIV negative since Truvada is insufficient for treating HIV
What is recommended in all patients w/ croup, even with mild disease?
Single dose of po dexamethasone
Most common cause of toxic megacolon
IBD (esp. UC)
CSF of bacterial meningitis
Elevated white count w/ neutrophilic predominance, increased protein, decreased glucose
Key feature distinguishing DKA from HONK
ACIDOSIS
DKA will have an ELEVATED ANION GAP
What things can precipitate DKA or HONK?
Stress- infections, dehydration, drug use
Increased stress hormones and glucagon increase the patient’s blood sugar and begin the pathological cascade
Pseudohyponatremia
Pseudohyponatremia occurs whenever there is a high concentration of glucose, triglycerides, or ketones in the blood. Though the relationship between glucose increase and sodium decrease is nonlinear, a useful rule of thumb is that the sodium concentration will drop 2.5 mEq/L for every 100 mg/dL of glucose rise above normal.
Colon cancer screening
Colon cancer screening should begin at age 50 in normal patients (and even younger for high-risk patients) with flexible sigmoidoscopy or colonoscopy
or FOBT (with abnormal referral to colonoscopy or normal repeat every year)
Cervical cancer screening
Annually once a woman is >18 years old or becomes sexually active. However, if a woman has had no new sexual partners and three normal Pap smears in a row, you can safely screen her once every three years instead of annually
