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
Breast cancer screening
every year or two at age 35 or 40, and then annually after age 50
What does a rising pCO2 indicate in asthma attack?
A rising pCO2 in an asthma attack signals impending respiratory failure, not improvement! It is important to recognize that this patient is getting worse, not better. Typically, in an acute asthma attack, the patient’s tachypnea causes them to “blow off” CO2, resulting in a primary, uncompensated respiratory alkalosis. Rising CO2 in the face of sustained tachypnea is a very ominous sign - it shows that the patient’s airways are so constricted that he is no longer able to get rid of CO2!
Management of grade II-III vesicoureteral reflux
Medical management: TMP/SMX or nitrofurantoin until documentation that VUR has disappeared
How to classify ascites fluid
SAAG
If the difference between the serum albumin and the ascites albumin is greater than 1.1, then the ascites is caused by portal hypertension [TRANSUDATE] (cirrhosis, right sided CHF, and Budd-Chiari syndrome).
If the SAAG is less than 1.1, then the ascites is NOT caused by portal hypertension [EXUDATE] (pancreatitis, peritonitis, and peritoneal carcinomatosis).
Spontaneous bacterial peritonitis ascitic finding
> 250 PMNs in the ascitic fluid
Lab finding to confirm menopause
Elevated FSH
Ddx for non-AG metabolic acidosis
Renal tubular acidosis and GI bicarbonate loss (diarrhea)
CV screening recommendations
- HTN: >18
- lipids: M > 35, F > 45, patients > 20 w/ hi risk
- AAA: M never smokers 65-75
- obesity: BMI for all
CAD screening NOT recommended in low-risk individuals
Cancer screening recommendations
- colon cancer: > 50 (FOBT annually, flexible sigmoidoscopy every 3-5 yrs, or colonoscopy every 10 yrs)
- lung cancer: M 50-80 w/ 30+ pack-year hx who continue to smoke or who quit less than 15 yrs ago- annual low-dose CT
Routine PSA screening or DRE NOT recommended
Screening for pancreatic cancer or testicular cancer NOT recommended in asymptomatic individuals
Tobacco and alcohol screening
Tobacco: Grade A
Alcohol: Grade B
Tdap booster
All 19-65
Influenza vaccination
Everyone over 6 months
Pneumococal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13)
All 65+
Select younger (e.g., immunocompromised)
Hep B vaccination
health care workers, people exposed to blood or blood products, dialysis patients, IV drug users, individuals with multiple sexual partners or recent STDs, MSM, DM
Hep A vaccination
chronic liver disease, use clotting factors, occupational exposure to Hep A, IV drug users, MSM, travel to endemic Hep A areas
Meningococcal vaccine
high-risk groups, college dorm residents, military recruits, certain complement deficiencies, functional or anatomic asplenia, travel to endemic countries
If emphysema <45 y.o. and/or nonsmoker, think:
alpha-1-antitrypsin deficiency
PFTs in COPD
Decreased FVC and FEV1
FEV1/FVC < 0.7 –> OBSTRUCTION
Management of stage I COPD
prn short-acting bronchodilators
these include:
- beta-2 agonists (albuterol)
- anticholinergics (ipratropium)
Inhaled > po d/t fewer SEs
Management of stage II COPD
long-acting bronchodilator
these include:
- beta-2 agonists (salmeterol)
- anticholinergics (tiotropium)
po methylxanthines (aminophylline, theophylline) are options but have narrow therapeutic windows and multiple DDIs
Management of stage III-IV COPD with complications
inhaled steroids (fluticasone, triamcinolone, mometasone)
DO NOT AFFECT RATE OF DECLINE OF LUNG FUNCTION but do reduce the frequency of exacerbations
OXYGEN therapy also recommended in stage IV if there is evidence of hypoxemia [DECREASES MORTALITY if at least 15h/d]
No benefit of oral steroids and many complications
Continuous Abx is controversial- decreases exacerbations but not mortality
What precipitates COPD exacerbations?
Bacterial and viral infections, air pollutants
Which type of drug is known to precipitate gout attacks?
Thiazide diuretics, since they increase urinary urate reabsorption, causing hyperuricemia
Loop diuretics and chemotherapeutic agents also may cause gout attacks
Gout crystal
Monosudium urate (MSU): Needle-shaped, with strong negative birefringence
Pseudogout crystals
CPPD: rod shaped, rhomboid, weakly positive birefringence
Indications for ultrasound in pregnancy
Not mandatory in routine pregnancy.
Indicated for:
- evaluation of uncertain gestational age
- size/date discrepancies
- vaginal bleeding
- multiple gestations
- other high-risk situations
Advanced maternal age
Pregnant women who will be 35 or beyond at the estimated date of delivery
Women considering conception should take what?
Folic acid (400-800 μg if low risk, 4 mg if previous child w/ NTD, 1 mg if DM or epilepsy)
Naegele’s rule
Subtract 3 months from the first day of the LMP and add 7 days to date the pregnancy
Screening for gestational diabetes
Between weeks 24-28
1-hour 50 g glucose challenge test
If positive, 3-hour 100 g GGT after overnight fast. Assess fasting, 1 hr, 2 hr, and 3 hr postload serum glucose samples.
-2 out of 4 positive values indicate GDM
Women diagnosed with GDM should be screened for T II DM at 12 weeks postpartum
Group B streptococcus screening
Between 35-37 weeks
Colonized women should be treated w/ IV abx at the time of labor or rupture of membranes
Late-term pregnancy
41 weeks, 0 days - 41 weeks, 6 days
Post-term pregnancy
Beyond 42 weeks or 294 days
Pre-term pregnancy
Birth before 37 weeks
If h/o pre-term, women should be given progesterone injections weekly from 16-37 weeks
Vaccinations during pregnancy
- prenatal visit: influenza
- 27-36 weeks: tetanus toxoid, diphtheria, Tdap
Varicella, rubella, and live attenuated influenza NOT recommended
What to do if woman is Rh negative
Assess antibody screen or do indirect Coomb’s
If Ab screen is negative, no isoimmunization –> give RhoGAM at 28 weeks and again at delivery if baby is determined to be Rh +
If Ab screen is positive, and the identity of the Ab is confirmed to be Rh (anti-D), check titer
- low titer: observe
- high titer: US +/- amniocentesis
BMI in children
Underweight: <5 percentile
Healthy weight: 5-85 percentile
Overweight: 85-95 percentile
Obese: >95 percentile
Pediatric failure to thrive
Weight below the 3rd or 5th percentile
OR
Decelerations of growth that have crossed two major growth percentiles in a short period of time
Mandatory newborn screens
PKU and congenital hypothyroidism
Hearing is almost always tested too
Lead testing
Between 12-24 months OR at 36 and 72 months
Screen for strabismus
Cover-uncover test
Positive: uncovered eye deviates to focus on the object
If positive, refer to ophtho immediately
Rear-facing car seat
Until 2 y.o. or until child has reached the maximum height or weight limit of the rear-facing seat
> 40 lbs: booster seat
Top three causes of death in infants < 1
- congenital abnormalities
- short gestation
- sudden infant death syndrome (SIDS) [babies should sleep on their BACK]
2 month vaccinations
RV #1 DTaP #1 Hib #1 PCV #1 IPV #1
4 month vaccinations
RV #2 DTaP #2 Hib #2 PCV #1 IPV #2
6 month vaccinations
DTaP #3
PCV #3
IPV #3
12 month vaccinations
MMR #1
Varicella #1
HepA #1
Treatment of allergic rhinitis
- antihistamines
- first gen: diphenhydramine, chlorpheniramine, hydroxizine [SE: sedation, dry mouth, dry eyes, blurred vision, urinary retention; careful in elderly]
- second gen: loratadine, desloratadine, fexofenadine, azelastine, cetirizine
- intranasal corticosteroids
- decongestants (alpha agonists)
- leukotriene inhibitors
- zafirlukast, montelukast, zileuton
- systemic corticosteroids (in severe cases)
- desensitization therapy
Non-nicotine smoking cessation therapy
Bupropion (Zyban) and Varenicline (Chantix)
Bupropion (Zyban)
- NDRI
- contraindications: eating disorders, seizures, MAO-I, careful in heart disease
- 7-12 weeks, can be used up to 6 mo
- SE: insomnia, dry mouth
- pregnancy category C
Varenicline (Chantix)
- partial nicotinic receptor agonist
- SE: neuropsychiatric symptoms including behavior changes, agitation, depression, SI; nausea, insomnia, abnormal/vivid/strange dreams
- CI: h/o depression, heart disease
- pregnancy category C
Principles of medical ethics
- Autonomy
- Benificence
- Nonmaleficence
- Justice
MMA and homocysteine levels
High MMA: B12 deficiency
High homocysteine: folate deficiency
Anemia of chronic disease
- Normal ferritin
- TIBC decreased
Iron deficiency anemia iron studies
- Serum iron: low
- TIBC: high
- Transferrin saturation: low
- Serum ferritin: low
Common bugs causing traveler’s diarrhea
Bacteria
- E. coli
- Salmonella
- Shigella
- Vibrio (non-cholerae)
- Campylobacter
Viruses
- Rotavirus
- Norovirus
Parasites
- Giardia lamblia
- E. histolytica
- Cryptosporidium parvum
Mammograms
Starting at 50: every 2 years
D/c after 75
Pap smears
Begin at 21 and do every 3 years
For women over 30, can do every 5 years by co-testing with HPV cytology
Stop at 65 if had 3 consecutive negative Paps or two consecutive negative HPV results within the last 10 years
If cervix has been removed, testing is no longer necessary
Osteoporosis diagnosis
DXA T-score at or below -2.5
Osteopenia: -1 - -2.5
DXA scan
65 and over, and under 65 with high risk
Calcium and vitamin D for primary prevention of fractures in osteoporosis
Level D
Ottowa knee rules
Perform X-ray if any one:
- > 55
- isolated patella tenderness
- tenderness of the head of the fibula
- inability to flex the knee to 90 degrees
- inability to bear weight for 4 steps immediately and in the exam room (regardless of limping)
Management of most acute sprains
PRICE
- protection
- rest
- ice
- compression
- elevation
NSAIDs or acetaminophen for pain control
Early mobilization of injured ligaments promotes healing and recovery
-begin ROM exercises 48-72 hours after injury
Excision borders of melanoma in situ
5mm
Superficial spreading melanoma location
Men: torso
Women: legs
Acral lentiginous melanoma
More common in blacks and Asian
Under nails, soles of feet, palms
ABCDEs of melanoma
Asymmetry Borders (irregular) Color (variegated) Diameter (>6 mm) Elevation/Evolving
Excision margins for lesion concerning for melanoma
2-3mm
If biopsy confirms malignancy, want 5mm margins
What factor is most important in the prognosis of melanoma?
Breslow factor (depth): <1 mm thick have a low rate of metastasis
First-time microscopic hematuria
Follow up with repeat UA and microscopy in 6 weeks before any other management is done
Graves disease finding on radionucleotide scan
Diffuse increased uptake
Graves disease treatment
Radioactive iodine (in non-pregnant patients- don’t use in children or breastfeeding mothers)
In adolescents:
- antithyroid drugs: PTU, methimazole, carbimazole (inhibit organification of iodine; PTU also inhibits peripheral conversion)
- may go into spontaneous remission after 6-18 months of therapy
PTU vs. methimazole
Methimazole is first-line unless pregnant (PTU preferred for 1st trimester)
PTU: black box warning for HEPATOTOXICITY
Watch for agranulocytosis
Evaluation of thyroid nodule
TSH and ultrasound
Nodules >1 cm on US require biopsy (FNA)
Stages of labor
- onset of labor until cervix is completely dilated
- latent phase: contractions become stronger, longer lasting, and more coordinated
- active phase: usually starts at 3-4 cm of dilation; rate of cervical dilation at its maximum; contractions usually strong and regular [INDICATION FOR ADMISSION TO BIRTHING UNIT] - complete cervical dilation (10 cm) through delivery of fetus
- normal < 2 hrs in nulliparous woman and < 1 hr in parious woman
- epidural can prolong by up to 1 hr - delivery of baby until delivery of placenta and membranes
- prolonged if > 30 min
Determinants of the progress of labor
- Power
- strength of uterine contractions
- strength of maternal pushing efforts - Passenger
- fetus size, lie, presentation, position within birth canal - Pelvis
- size, shape
Confirm rupture of membranes
Exam:
- fluid leaking from cervical os (either spontaneously or w/ Valsalva)
- presence of amniotic fluid pooling in the posterior vaginal fornix
Amniotic fluid:
- Nitrazine test: pH > 6.5 (normal vaginal secretions < 5.5)
- ferning (under microscope)
Fetal cardinal movements
- Flexion
- Internal rotation
- Extension
- External rotation
Treatment of maternal GBS
penicillin (or ampicillin)
Hypovolemic hyponatremia etiologies and treatment
Cerebral salt wasting, skin loss, diuretic use, GI losses, mineralocorticoid deficiency, third-spacing
See signs of volume depletion
Tx: normal saline and treat underlying condition
Severe symptomatic: <125
- confusion, seizures, coma
- urgent treatment with 3% (hypertonic saline)
- but go slow d/t risk of osmotic demyelination (“from low to high your pons will die”)
Hypervolenic hyponatremia etiologies and treatment
Heart failure, cirrhosis, nephrosis
Exhibit signs of volume overload
Tx: diuretics and restriction of sodium and water intake
Euvolemic hyponatremia etiologies and treatment
SIADH (d/t infections, malignancy, drugs, CNS disorders), primary polydipsia, water intoxication, hypothyroidism, low solute intake (“tea and toast syndrome”)
Tx: fluid restriction and treat underlying cause
Pseudohyponatremia
Low plasma [Na+] in the setting of hyperglycemia, hypertriglyceridemia, hyperproteinemia, laboratory errors, or mannitol use
Usually have normal volume status with normal osmolality
Management plan for hyperkalemia
- stabilize myocardium w/ IV calcium gluconate
- shift K+ intracellularly with insulin and glucose
- lower total body K+ with Kayexalate, loop diuretics, or dialysis
- Address underlying cause
Centor criteria
For suspicion of GAS
Points given for:
- absence of cough
- enlarged/tender anterior cervical adenopathy
- fever of 100.4 or higher
- tonsillar swelling/exudates
0-1: no further testing or abx warranted
2-3: perform rapid strep or throat culture and treat w/ abx if positive
4+: consider empiric abx treatment
GAS treatment
Penicillin
IM penicillin G or 10-day course of po penicillin V
Swimmer’s ear bug
Pseudomonas aureuginosa
Malignant otitis externa
Patients w/ DM at risk
Pseudomonas aureuginosa
Most common presentation of Hodgkin’s lymphoma
Asymptomatic lymphadenopathy or an incidentally found widened mediastinum
Presence of symptoms generally indicates a worse prognosis
Typicaly symptoms include B symptoms (fever, night sweats, chills)
More rarely:
- pruritis (esp. after a hot shower)
- severe pain after ingesting alcohol
Ann Arbor staging for Hodgkin’s lymphoma
Stage I: involves only a single lymph node region
Stage II: involves two or more lymph node regions on the same side of the diaphragm
Stage III: involves lymph node regions on both sides of the diaphragm
Stage IV describes disseminated disease.
In addition to the stage, the designations “A” and “B” are used to describe the absence (A) or presence (B) of the “B symptoms”
Acute bronchitis features and treatment
Cough with purulent sputum in the setting of other findings suggestive of a URI
Tx: pseudephedrin and acetaminophen [NO ABX- IT IS ALMOST ALWAYS VIRAL]
What constitutes controlled asthma?
If a patient’s asthma is controlled, then he or she should require their rescue inhaler less than 2 times per week in the day and less than 2 times per month at night.
Appearance of basal cell carcinoma
smooth, pearly, with telangiectasias
Impetigo d/t MRSA resistant to cephalosporins
clindamycin or TMP/SMX
Migraine prophylaxis
- beta blockers (propranolol, timolol)
- anticonvulsants (valproic acid, topiramate)
- TCAs (amitriptyline)
Lab results most indicative of pancreatitis
Elevated lipase
What is alprostadil?
INIJECTABLE prostaglandin analog for ED
What class of drugs is contraindicated with nitrites?
Phosphodiesterase inhibitors (sildenafil, vardenafil, or tadalafil)
In patients on nitrites who have ED, consider injectable PG analog alprostadil
Most common cause of isolated bloody nipple discharge in healthy young woman
Intraductal papilloma
Normal pressure hydrocephalus symptoms and CT findings
dementia, gait disturbance, and urinary incontinence (wet, wobbly, wacky)
CT: ventricular enlargement (hydrocephalus) WITHOUT cerebral atrophy
Antibiotics for acute mastitis
dicloxacillin and cloxacillin, amoxicillin/clavulanate, cephalexin
Incision and drainage is indicated for breast abscesses, which are a common complication of mastitis
Consideration about breast development
Breast development often begins asymmetrically, and breasts can differ by as much as two Tanner stages before such development is considered abnormal
Signs and symptoms of endometriosis
fixed, retroverted uterus or blue spots in the posterior fornix
Other clues include dyspareunia (especially with deep thrusting), rectal pain during menstruation, pain with defection, or tender bilateral adnexal masses palpable during menstruation.
Though you may suspect endometriosis clinically, to confirm the diagnosis, you need to directly visualize the endometrial implants surgically, by laparoscopy or laparotomy. (The lesions will appear as dark red, blue, or purple lesions, frequently called “powder burns,” “mulberry lesions,” or “chocolate cysts.”
Endometriosis treatment
Endometriosis can be treated either medically (with OCPs, Depo-Provera injections, danazol, or GnRH agonists like leuprolide) or surgically (by hysterectomy, lysis of adhesions, or removal of endometrial implants).
MEN1 syndrome
Parathyroid hyperplasia, pancreatic islet tumors, and pituitary tumors in addition to gastrinomas and ZES
MEN-2A syndrome
“2 MPH”
medullary thyroid cancer, phenochromocytomas, and hyperparathyroidism
MEN-2B syndrome
“2 PM”
medullary thyroid carcinoma and pheochromocytoma
What to do with postmenopausal bleeding
Endometrial biopsy
Postmenopausal bleeding is NEVER normal
Surruptitious insulin use (factitious disorder) labs
High insulin, low c-peptide
Treatment of acute bacterial prostatitis
ciprofloxacin or levofloxacin or TMP/SMX
Stages of kidney failure
Normal GFR: 90-120 Stage 1: GFR > 90 w/ proteinuria, hematuria, or abnormal renal structure Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: GFR 15-29 Stage 5: GFR < 15 or dialysis
Strawberry cervix
Trichomonas vaginalis
po metronidazole (also treat partner to prevent reinfection)
Atypicals
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Legionella pneumophilia
- viruses
Tend to cause bilateral, diffuse infiltrates (cf focal, lobar infiltrates)
Clues for legionella pneumonia
Pneumonia with diarrhea, hyponatremia, and elevated liver enzymes
X-ray appearance of pneumocystis pneumonia
Bilateral ground glass infiltrate
Empiric therapy for community acquired pneumonia
Clarithromycin or azithromycin, or doxycycline
If DM or heart/lung disease: fluoroquinolones (levofloxacin, moxifloxacin), or combo beta-lactam plus macrolide
Hospitalized treatment of CAP (non-ICU)
IV beta-lactam (cefoxatime, ceftriaxone, or ampicillin/sulbactam) and an IV macrolide (erythromycin or azithromycin). Or IV fluoroquinolone
Post-influenza pneumonia is most commonly caused by
staph aureus
Hypertension in pregnancy after 37 weeks
Admit and induce
What medication may reduce the risk of preeclampsia?
Aspirin
Preferred narcotic in kidney disease
Fentanyl (99% hepatic metabolism)
Test for hereditary hemochromatosis
random measurement of serum ferritin and
calculation of transferrin saturation.
If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is 45% the HFE gene should be checked
What is most helpful for narrow-complex supraventricular tachycardias
IV adenosine and vagal maneuvers
Causes of postpartum hemorrhage
The 4 Ts:
- Tone: uterine atony (70%)
- Trauma: cervical, vaginal, or perineal lacerations; uterine inversion (20%)
- Tissue: retained placenta or membranes (10%)
- Thrombin: coagulopathies (1%)
Endometritis
Postpartum fever associated with uterine tenderness and foul-smelling lochia
Treat w/ broad-spectrum abx that cover vaginal and gastrointestinal flora (e.g., combo gentamicin and ampicillin). For C-section must also cover anaerobes (eg., combo gentamycin and clindamycin)
When does postpartum blues resolve?
Typically by 10th postpartum day
Tearfulness, sadness, emotional lability
Contraindications to breast feeding
HIV infection, miliary TB, acute hepatitis B, herpetic breast lesions, chemotherapy
Abuse of cocaine, heroin, PCP, alcohol
Women who have had breast reduction surgery with nipple transplantation will be unable to breast feed
What type of birth control pill is preferred in breast feeding women?
Mini-pill (progesterone only) since combined OCP can reduce lactation
Wait until 6 weeks postpartum
Depo Provera injection also ok
Non-breast feeding women should wait 3 weeks after delivery to start contraception d/t increased risk of thromboembolic disease
Early CHF CXR finding
Cephalization of the pulmonary vasculature (upper lobe pulmonary vein dilation with lower lobe pulmonary vein constriction)
Indicates increased preload
CHF CXR findings
Interstitial pulmonary edema can be seen as perihilar infiltrates, often in a butterfly pattern
Kerly lines (spindle-shaped linear opacities in the periphery of the lung bases)
Pleural effusions (often bilateral, but if unilateral, R > L)
Drugs for heart failure
ACE-i/ARBs, beta-blockers (carvedilol, metoprolol, bisoprolol), loop diuretics (furosemide, bumetanide, torsemide, ethacrynic acid), aldosterone antagonists (spironolactone, eplerenone)
African-American: hydralazine + nitrates (in combo with ACE-is, beta blockers, and spironolactone)
CCBs increase mortality
Digoxin may help symptoms but has no mortality benefit
Progression of vascular dementia
Stepwise degeneration
Features of metabolic syndrome
- waist circumference > 102 cm (M) or 88 cm (F)
- hypertriglyceridemia (> 150)
- low HDL (<40 (M) or <50 (F))
- HTN (>130/>85)
- Fasting plasma glucose (>100, or previously diganosed T2DM)
BMI
Underweight: <18.5
Normal: 18.5-24.9
Overweight: 25-29.9
Obese:
I: 30-34.9
II: 35-39.9
III (morbid obesity): >40
IV (super obesity): >50Candidates for bariatric surgery
-BMI > 40 who have failed diet and exercise
or
-BMI >35 with serious comorbid conditions
Migraine features
Repeated attacks lasting 4 hours to 3 days At least 2: -unilateral pain -throbbing pain -aggravation by movement -moderate or severe intensity Plus at least 1: -nausea/vomiting -photophobia and phonophobia
Who needs a statin?
- Patients under 75 w/ clinical CVDa
- Patients w/ LDL >190
- Patients 40-75 with DM and LDL >70
- Patients 40-75 w/ 10-yr CVD risk >7.5% and LDL >70
Monitor LFTs
If statin is contraindicated or not tolerated, offer exetimibe
Kocher criteria for septic arthritis in children
- fever >101.3 (38.5)
- non-weight bearing
- ESR >40
- WBC >12,000
Legg-Calvé-Perthes disease
avascular necrosis of femoral head in kids 4-8
- boys>girls
- gradual onset of hip, thigh, or knee pain, and limping over a few months
- treatment is conservative
Slipped capital femoral epiphysis
separation of the growth plate, which results in the femoral head being medially and posteriorly displaced
- most common in adolescent overweight boys
- pain in hip, thigh, or knee along with a limp
- limited internal rotation and obligate external rotation when hip is passively flexed
- treatment is surgical pinning of the femoral head
Transient synovitis
self-limited inflammatory response that is a common cause of hip pain in children 3-10
- boys>girls
- often follows viral infection
- gradually increasing hip pain that results in a limp or refusal to walk
Most common causes of postoperative fever by frequency
5Ws
- wind (pneumonia)
- water (UTI)
- would (surgical site infection)
- walking (DVT)
- wonder drugs (drug fever)
Croup
- barking cough
- “steeple sign”
- glucocorticoids and nebulized epinephrine
Treat cat bites
Amoxicillin/clavulanate (10-14d)
Also for dog and human bites (5-7d)
First step in evaluation of acute stroke
Non-contrast CT
May not show ischemia for up to 72h
Who should get tPA
Ischemic stroke patients whose strokes began <3 hrs ago
Contraindications:
- recent surgery
- trauma
- GI bleed
- MI
- certain anticoagulant meds
- uncontrolled HTN
Diagnosis of hepatitis A
Conjugated hyperbilirubinemia, elevated serum transaminases, and positive antibody titers
Acute: anti-HAV IgM
Previous infection: elevated HAV IgG, negative IgM
Diagnosis of hepatitis B
- HBsAg present in acute and chronic infections
- HBeAg is a marker of HBV replication and infectivity
- anti-HBcAg IgM is diagnostic of an acute infection [only marker present during window period of seroconversion]
- Anti-HBs Ab is seen in resolved infections and is the marker produced by the HBV vaccine
Chronic: HBsAg without anti-HBcAg IgM
Diagnosis of hepatitis C
HCV RNA
Liver enzymes in alcohol abuse
> 2:1 ratio of AST to ALT
GGT elevated
Most common cause of peptic ulcer disease
Helicobacter pylori
Gold standard diagnosis: EGD w/ mucosal biopsy
Roseola
- HHV6
- prodromal illness with mild respiratory symptoms and high fever for up to 5 days, then defervescence
- followed by characteristic erythematous maculopapular rash that appears suddenly on the trunk and spreads rapidly to the extremities, with sparing of the face
- rash disappears 1-2d
- no treatment
Varicella
- varicella zoster virus
- chicken pox in kids
- development of rash (papules or vesicles on an erythematous base = “dewdrops on a rose petal”) in clusters followed by malaise, fever, and anorexia
- the vesicles then progress to shallow, crusted erosions and ulcerations
- may also develop enanthems, with lesions on the oral, nasal, or GI mucosa
- common complication: superinfection of vesicles w/ GAS and staph aureus
- rare serious complications: encephalitis, meningitis, pneumonitis
- treatment in patients >2: acyclovir, valacyclovir, or famcyclovir (if start w/in 24 hours of exanthem)
- varicalle vaccine (live attenuated) at 12 and 15 months, booster at 4 yrs
Shingles (herpes zoster) is reactivation of VZV which remains dormant in dorsal root ganglia
- vesicular eruption along a dermatome
- extremely painful
- may cause posterherpetic neuralgia
- vaccine in >60
Erythema infectiosum
aka fifth disease or slapped cheek disease
- parvovirus B19
- prodrome of mild fever and upper respiratory symptoms
- rash that lasts 4-14d: confluent erythematous macules on the face, which usually spares nose and periorbital regions (slapped cheek appearance)
- facial rash lasts 2-4d, followed by lacy, pruritic exanthem on the trunk and extremities that lasts 1-2wks
Parvovirus B19 in older adolescents and adults can caue more serious illness
-rheumatic complaints including arthralgias
In sickle cell disease, parvovirus B19 can cause aplastic anemia
In pregnancy can cause hydrops fetalis
Complications of group A beta-hemolytic streptococcus
- streptococcal pharyngitis
- scarlet fever
- rheumatic fever
- postinfectious glomerulonephritis
- impetigo, erysipelas, cellulitis, necrotizing fasciitis
Scarlet fever
- complication of GAS
- rash starts 2d after sore throat and fever
- rash: punctuate, raised, erythematous eruptions that can become confluent (Pastia lines) and feel like sandpaper
- rash starts on upper trunk and spreads to rest of trunk and to the extremities
- enanthem can cause “strawberry tongue”
- rash fades and desquamation typically occurs 4-5d after appearance of rash
GAS treatment
Penicillin (cephalosporin or macrolide if allergic)
Rocky Mountain Spotted Fever
- d/t rickettsia rickettsii
- early: fever, headache, myalgias, arthralgias, fatigue
- kids may complain of abdominal pain
- exanthem: macular, papular, or petichial eruption that starts on the wrists and ankles and spreads both centrally and to the palms and soles
- low WBC, low platelets, hyponatremia, elevated liver enzymes
- doxycycline
Causes of breast pain
- cyclic mastalgia (diffuse, bilateral, often radiates to axilla and upper arm, related to menstrual cycle)
- noncyclic mastalgia (continuous or intermittent, not related to menstrual cycle)
- extra-mammary pain
Common causes
- pregnancy
- mastitis
- thrombophlebitis
- cyst
- benign tumors
- cancer
- musculoskeletal cause
- stretching of Cooper ligaments
- pressure from bra
- fat necrosis from trauma
- hidradenitis suppurativa
- meds (OCPs, ADs, antipsychotics, anti-hypertensives)
Breast pain is NOT a common presentation of breast cancer
Chronic paroxysmal hemicrania
These resembles cluster headache but have some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.
Electrolyte disturbance side effect of carbamazepine + hydrochlorothiazide
hyponatremia (esp. elderly)
Treat hypoglycemia in an unconscious patient
IM glucagon
Grapefruit
Inhibits P450
Cauda equina syndrome
Increasing neurologic deficits and leg weakness, bowel and/or urinary incontinence, anesthesia or paresthesia in a saddle distribution, and bilateral sciatica
Pain on straight leg test, reduction in anal sphincter tone, decreased bilateral ankle reflexes
Need immediate eval w/ MRI, corticosteroids, and commonly immediate surgical decompression
L4, L5, and S1
L4: knee strength and reflex
L5: great toe and foot dorsiflexion
S1: plantar flexion and ankle reflexes
Symptoms of Parkinson disease
Distal resting tremor, micrographia, cogwheel rigidity, bradykinesia, postural instability, shuffling gait, asymmetric onset
First-line therapy for osteoporosis
Bisphosponates (alendronate, risendronate, ibandronate)
Empty stomach with full glass of water, upright for 30 min
SE: osteonecrosis of jaw
In patients w/ hemoglobinopathies, recent blood loss, or recent drastic changes in diet, what level is better to get than HbA1c?
Serum FRUCTOSAMINE (gives you 2-3 wk)
Long QT syndrome
- autosomal dominant
- M >470 ms, F >480 ms
Any QT >500 is at risk for dangerous dysrhythmias
When should labor be induced?
41 weeks
Which vaccine should not be started after 15 weeks?
Rotavirus
Rotterdam criteria for PCOS
2 or more:
- Hyperandrogenism, as evidenced by hirsutism or elevated serum androgen levels
- Oligomonorrhea with cycle length greater than or equal to 35d
- Multifollicular ovaries on pelvic US, defined as 12 or greater small follicles in an ovary
First-line treatment for aspirin-sensitive asthma
Leukotriene receptor antagonists
Treatment of tropical sprue
ANTIBIOTICS
Not gluten avoidance
What type of immunization is rotavirus and when is it contraindicated?
Oral
CI if ever had intuscusseption
Treatment of postpartum endometritis
Gentamicin + clindamycin
Typical use failure rate for OCPs, IUDs, injectable progestin, condoms, and withdrawal
The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method.
H. pylori and drug dosing
H. pylori infection cam impair absorption, requiring higher doses of certain drugs
Uncomplicated UTI treatment
3 days of trimethoprim/sulfamethoxazole
Best antipsychotic for aggression in dementia
Aripiprazole
What type of medication hastens the passage of ureteral stones?
Alpha-1 blockers (doxazosin, prazosin, and tamsulosin)
Impaired fasting glucose
100-125
Treatment for lupus arthritis
Hydroxychloroquine
Treat M vs. F hair loss
Female pattern hair loss is categorized as diffuse and nonscarring. It presents with parietal hair thinning with preservation of the frontal hairline. Minoxidil 2% produces regrowth of hair in female pattern hair loss (SOR B). Oral finasteride is appropriate only for men with male pattern hair loss
Osgood-Schlatter disease
Osgood-Schlatter disease is seen in skeletally immature patients. Rapid growth of the femur can cause tight musculature in the quadriceps across the knee joint. It typically appears between the ages of 10 and 15, during periods of rapid growth. Pain and tenderness over the tibial tubercle and the distal patellar tendon is the most common presentation. The pain is aggravated by sports participation, but also occurs with normal daily activities and even at rest.
Patellofemoral pain syndrome
Patellofemoral pain syndrome is one of the most common causes of knee pain in children, particularly adolescent girls. Pain beneath the patella is the most common symptom. Squatting, running, and other vigorous activities exacerbate the pain. Walking up and down stairs is a classic cause of the pain, and pain with sitting for an extended period is also common. The physical examination reveals isolated tenderness with palpation at the medial and lateral aspects of the knee, and the grind test is also positive. Can also see lateral tracking of the patella. on extension of the knee
First sign of SIADH
Hyponatremia
Inappropriate release of ADH increases free water reabsorption, which increases circulating blood volume, dilutes sodium, and lowers hematocrit and hemoglobin. Urine output is often lowered because of this reabsorption, and the urine is more concentrated (urine osmolality > plasma osmolality) with sodium levels >20 mEq/L
Urine in SIADH
Inappropriate release of ADH increases free water reabsorption, which increases circulating blood volume, dilutes sodium, and lowers hematocrit and hemoglobin. Urine output is often lowered because of this reabsorption, and the urine is more concentrated (urine osmolality > plasma osmolality) with sodium levels >20 mEq/L
FSH and LH in PCOS
Polycystic ovary syndrome usually results in normal to slightly elevated LH levels and tonically low FSH levels.
LH and FSH in primary ovarian failure
Elevated FSH and LH
Diabetes medications that cause weight loss
GLP-1 receptor agonists, metformin, amylin mimetics, and SGLT-2 inhibitors.
Lung cancer screening recommendation
The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose
computed tomography (LDCT) in adults 55–80 years of age who have a 30-pack-year smoking history and
currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has
not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability
or willingness to have lung surgery
Treatment of smoldering multiple myeloma
Nothing
Occlusion of the circumflex artery is most likely to cause EKG changes in
I and AVL (and possibly V5 and V6 too)
Left anterior descending coronary artery occlusion causes changes in
V1-V6
Right coronary occlusion causes changes in
II, III, and AVF
Telogen effluvium
A nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.
Anagen effluvium
the diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair.
Contraception in breast-feeding vs. non-breast-feeding women
Non-breast feeding: wait 3 weeks, and then combined OCP
Breast-feeding: wait 6 weeks, and then progestin-only (Mini Pill), Depo Provera, or IUD
Effectiveness of lactation-induced amenorrhea as birth control
99% effective for 6 months
What to do if pregnant woman is positive for HBsAg
Treat newborn with HepB Ig and vaccination
Most common cause of hospitalizations in >65
CHF
Stool gap
measured osm - calculated osm
(290) - 2(Na + K)
<50: secretory
>100: osmotic
When should we get stool cultures for acute diarrhea?
- bloody diarrhea
- diarrhea lasting more than 3-7d
- immunocompromised
- evidence of systemic disease or severe dehydration
Step up treatment of asthma
I: SABA prn II: SABA + ICS III: SABA + LABA + ICS IV: increase dose of ICS + SABA + LABA V: po steroids
(Can use LTA for ICS)
Weight loss drugs
- orlistat
- locaserin
- phentermine/topiramate
Sprain vs. strain
Sprain: stretching or tearing injury of a LIGAMENT
Strain: stretching or tearing injury of a MUSCLE or TENDON
Complications of CKD
- Anemia of CKD
- Secondary hyperparathyroidism and marrow bone disease
- Volume overload
- Acidosis
When does nausea of pregnancy typically resolve?
~22 wks
Dieulafoy lesion
- a dilated aberrant submucosal vessel that erodes the overlying epithelium in the absence of a primary ulcer
- brisk painless bleeding
- patients typically men with comorbidities including cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse; NSAID use also common
- dx: EGD [a raised nipple or visible vessel without an associated ulcer; however, the aberrant vessel may not be seen unless there is active bleeding from the site]
- tx: resection
Common causes of microscopic hematuria
Exercise, sex, recent DRE, urologic procedures, contamination by menses, meds
AAA screening
Men 65-75 who have ever smoked
Prostate cancer screening
55-69: shared decision making about PSA
>70: no
HDL
> 40
> 60 is high
Antibiotics or not? Which?
- shigella
- salmonella
- campylobacter
- EHEC
- ETEC
- shigella: fluoroquinolone (or TMP/SMX if sensitive)
- salmonella: none (unless severe)
- campylobacter: erythromycin or fluoroquinolone
- EHEC: fluoroquinolone or TMP/SMX
- ETEC: fluoroquinolone or TMP/SMX
[if pregnant or kid or quinolone resistant, use azithromycin]
IBS meds
- abdominal pain
- antispasmodics (dicyclomine and hyosycamine prn)
- low dose TCAs (careful in patients with constipation)
- SSRIs if comorbid depression and anxiety
- rifaximin (if diarrhea)
- probiotics and peppermint oil - constipation
- solube fiber (psyllium)
- polyethylene glycol
- lubiprostone (activates intestinal Cl- channels, inducing secretion)
- linaclotide (stimulates cGMP production) - diarrhea
- loperamide
- alosetron (only for severe, SE is ischemic colitis)
- rifaximin
If Rh-
May be susceptible to Rh disease.
If Ab screen negative, give RhoGAM at 28 weeks, after any trauma, obstetrical complication, or invasive procedure, and also after delivery if baby is Rh+
Mesenteric ischemia
“gut attack”
Patient usually a vasculopath or has a reason for emboli formation (e.g., recent angiography, A-fib). Pain out of proportion to exam. Pain with eating, so avoids eating –> weight loss.
Dx: angiogram
Tx: revascularization or resection
If patient can’t tolerate statin
Ezetimibe
HPV vaccine
All boys and girls 9-26
Child w/ nasal polyps
Any child 12 years or younger who presents with nasal polyps should be suspected of having cystic fibrosis until proven otherwise.
Antibiotics for diverticulitis
Metronidazole or amoxicillin/clavulanate
SCFE physical exam finding
limited internal rotation of the hip
Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°
ALT > 3x AST
gallstone pancreatitis
Behçet syndrome
recurring genital and oral ulcerations and relapsing uveitis (can lead to blindness)
Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations. This disease is also associated with cutaneous hypersensitivity
more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults
Erythrasma
tender erythematous plaque with mild scaling found in skin folds (e.g., groin)
coral-red fluorescence under a Wood’s light
Corynebacterium infection
Erythromycin (topical or systemic)
Orthostatic proteinuria
This benign condition occurs in about 3%–5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections
Rapid strep test specificity and sensitivity
High specificity, low sensitivity
Treatment of lateral epicondylitis (tennis elbow)
- activity modification and NSAIDs
- use of brace
- stretching/strengthening
- steroid injection
- surgical debridement of tendon
Consideration when prescribing topical retinoids for acne
Avoid sun (PHOTOSENSITIVITY)
Same with tetracycline
Management of recurrent UTI
Prophylactic post-coital antibiotics (TMP/SMX, nitrofurantoin, cephalexin)
Pleurodynia
aka “the devil’s grip”
Often caused by coxsackie virus.
Symptoms may include fever and headache, but most characteristic is attacks of severe pain in the lower chest, often on one side
Metformin contraindication
Renal insufficiency (Cr >1.7)
Nicotine patch contraindications
Angina pectoris, CAD
Prevention of swimmer’s ear
Daily use of alcohol-acetic acid ear drops
What causes hyponatremia in heart failure?
Decreased cardiac output –> decreased baroreceptor stretch and renal perfusion –> RAAS –> ADH secretion
Positive PPD + negative CXR
Latent TB (9 mo INH + B6)
Tinea versicolor treatment
Topical selenium sulfide
Shingles vaccine
Shingrix everyone after 50 regardless of whether they’ve had singles or Zostavax
Pap smear
Every 3 years
Every 3 years with cervical cytology alone in women aged 21 to 29 years.
For women aged 30 to 65 years, screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).
Lipid guidelines
F: >45 unless RFs (start 20)
M: >35 unless RFs (start 20)
Routine asymptomatic CBC and electrolytes?
NO
What vaccine should asthma patients get?
PPSV 23 (Pneumovax)
DM screening
40-70 y.o. who are overweight
A1c
Hep C screen
High risk (injection drugs users, transfusions before 1992, long term hemodialysis, incarceration), born 1945-1965
ASCUS + HPV+
Colposcopy
ASCUS + HPV-
Pap in 4-6 mo or 1 year or colposcopy
Low risk, 1 yr
Low grade SIL on Pap
Colposcopy
Atypical glandular cells on Pap
Colposcopy or endometrial biopsy (if of endometrial origin)
RDW in iron deficiency anemia
Elevated
How to clinically distinguish folate from B12 deficiency
Neurologic symptoms are only present in B12 deficiency
Lyme disease treatment
Early localized: oral doxycycline or amoxicillin
Late disseminated: IV ceftriaxone
Lice treatment
Permethrin 1%
Palpable breast mass that is mammogram negative
US and biopsy
Acoustic neuroma symptoms
Unilateral tinnitus and hearing loss
Eventually may have vertigo, facial weakness, and ataxia
Menière disease symptoms
Discrete attacks of vertigo lasting several hours, associated with nausea, vomiting, hearing loss, and tinnitus
Distinguish central vs. peripheral vertigo
Dix-Hallpike maneuver is negative in central
First-line therapy for peripheral vestibular disorders
Antihistamines (meclizine, diphenhydramine)
BNP measurement
Can rule out CHF (has 99% NPV)
Low vs high D-dimer
Low: high NPV –> no PE
High: low PPV –> confirmatory spiral CT (or pulmonary angiogram which is the gold standard)
Interstitial cystitis symptoms
Dysuria and hematuria without pyuria
Dx: cystoscopy
Sleep onset vs sleep maintenance pharmacotherapy
Onset: zolpidem (Ambien) or eszopiclone (Lunesta)
Maintenance: zaleplon (Sonata)
Most common cause of primary amenorrhrea
(Def: absence of menses at 16)
Gonadal dysgenesis (e.g., Turner syndrome)
Palpable preauricular lymph node
Viral conjunctivitis
Short acting insulin
Aspart (Novolog), lispro (Humalog), glulisine (Apidra): onset between 15-30 min, peak between 30-60 min, last 3-5 hrs
Intermediate acting insulin
Regular insulin: onset between 30-16 min, peaks 2-3 hrs, last 4-12 hrs
Long acting insulin
NPH: onset between 1-2 hours, peak 4-8 hours, lasts 10-20 hrs
glargine (Lantus), detemir (Levemir): onset between 1-2 hours, peak unpredictable, and last ~24 hrs
What type of hearing loss is presbyacusis?
Presbyacusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and sensorineural
Most common cause of erythema multiforme
Herpes simplex virus
Treatment of cocaine-associated chest pain
Aspirin, nitroglycerin, IV benzodiazepines
NOT beta-blockers, which can worsen coronary vasospasm d/t unopposed alpha action
How to diagnose Duchenne muscular dystrophy in kids who have not started walking yet
Elevated CK
Bowel rest after acute pancreatitis?
NO
Bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from te gut
So: Early initiation of a low-fat diet
Most common cause of wheezing in infants
Gastroesophageal reflux
Skin tags are associated with
Diabetes and obesity
Which fluoroquinolone should not be used in UTIs?
Moxifloxacin
Doesn’t attain high enough urinary concentrations
Treatment of shingles
ORAL antivirals (acyclovir, valacyclovir, famcyclovir)
Prevent renal failure induced by contrast
adequate hydration and the use of N-acetylcysteine
Most effective treatment of lice
Malathion
Which tocolytic also causes respiratory depression?
Magnesium sulfate
What does it mean if mother is anti-D antibody positive?
The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive
TNF inhibitor black box warning
All drugs in this class carry an FDA black-box warning
about the potential for developing primary tuberculosis or reactivating latent tuberculosis. These drugs are
also associated with an increased risk for invasive fungal infections and opportunistic bacterial and viral
diseases. The FDA also warns of reports of lymphomas and other malignancies in children and adolescents
taking these drugs.
Antidote to respiratory depression from magnesium
Calcium
