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Family Medicine Clerkship > Aquifer 5 > Flashcards

Aquifer 5 Flashcards

1
Q

Reasons to do neuroimaging for a headache?

A

Migraine with atypical pattern or unexplained abnormalities on neuro exam

Higher risk of a significant abnormality

Result of the study would alter management

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2
Q

Symptoms increasing the odds of positive neuroimaging results for headache

A

Rapidly increasing frequency of headaches
Abrupt onset of severe headache
Marked change in headache pattern
History of poor coordination, focal neuro signs/symptoms, and a headache that awakens the patient from sleep
Headache worsened with use of Valsalva
Persistent headache following head trauma
New onset of headache in a person 35+
History of cancer or HIV

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3
Q

Physical or environmental triggers for tension and migraine headaches

A

Intense or strenuous exercise, sleep disturbances, menses, ovulation, pregnancy (for many women, headaches actually improve during pregnancy), acute illness, fasting, bright or flickering lights, emotional stress

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4
Q

Medications or substances that trigger tension and migraine headaches

A

Estrogen, tobacco, caffeine, alcohol, aspartame, and phenylalanine

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5
Q

Contraindications to triptan use for migraines?

A

Concurrent use of ergotamine MAOIs, history of hemiplegic or basilar migraine, significant cardio/cerebro/peripheral vascular disease, severe hypertension, pregnancy, in combo with SSRIs (serotonin syndrome)

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6
Q

When should opioid/butalbital be used in treating migraines?

A

Only as a last result; frequent use of these meds can worsen headaches

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7
Q

Who should be treated for migraines prophylactically?

A

At least 6 headache days/month +

At least 4 headache days with some impairment +

At least 3 headache days with severe impairment or requiring bed rest

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8
Q

Prophylactic migraine treatment?

A
  1. Beta-blockers (metop, propran, tim - first line; aten, nad - second line)
  2. TCAs (amitripytline)
  3. Neurostabilizers (second line - VPA, topiramate)
  4. Herbal - butterbur
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9
Q

What else can amitriptyline treat besides migraines?

A

Fibromyalgia, tension-type headaches

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10
Q

Increased TSH, Decreased T4

A

Hypothyroidism

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11
Q

Mildly elevated (5-10) TSH, normal T4

A

Subclinical hypothyroidism

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12
Q

Inappropriately normal TSH, increased T4

A

Pituitary adenoma or thyroid hormone resistance

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13
Q

Decreased TSH, Increased T4

A

Hyperthyroidism

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14
Q

Decreased (or normal or increased) TSH, decreased T4

A

Central or pituitary hypothyroidism

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15
Q

Decreased TSH, normal T4, increased T3

A

T3 toxicosis

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16
Q

Many of the typical symptoms of hyperthyroidism are absent in patients >70. How might they present?

A

Sinus tach, fatigue, AFib, weight loss, no other symptoms

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17
Q

Causes of enlarged thyroid?

A

Lack of iodine, hypothyroidism (Hashimoto), hypertyroidism (Graves), nodules, thyroid cancer, pregnancy (slight enlargement), thyroiditis (often tender)

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18
Q

DDx - hyperthyroidism

A

Toxic diffuse goiter (Graces)
Toxic nodular goiter
Thyroiditis
Excessive iodine ingestion or drug-induced (amiodarone)

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19
Q

Toxic nodular goiters cause ___% of cases of hyperthyroidism. They are common but most are not ___. Only ___% are cancerous. They are more common in patients >___ (age).

A

5; symptomatic; 4-5; 40

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20
Q

Causes of thyroiditis?

A

Viral illness or pregnancy

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21
Q

Causes of high radioactive iodine uptake (>30%)?

A

Graves, multi-nodular goiter, toxic solitary nodule, TSH-secreting, pituitary tumor, hcg secreting tumor (increases thyroid hormone production)

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22
Q

Causes of low radioactive iodine uptake (<15%)?

A 
Subacute thyroidits
Silent thyroiditis
Iodine induced
Exogenous L-thyroxine
Struma ovarii
Amiodarone
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23
Q

Dx Graves?

A

Anti-thyrotropin releasing antibiodies (TRAb)

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24
Q

Discuss the presence of anti-thyroid peroxidase antibodies (TPO).

A

Elevated in 90% of patients with Hashimoto and 75% of patients with Graves

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25
Q

When is thyroid U/S used?

A

Evaluate nodules and enlargement, not hyperthyroidism

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26
Q

Peak incidence of Graves disease?

A

40-60 y/o

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27
Q

Unique signs of Graves disease

A

Bruit or thrill upon auscultation of the thyroid (hypervascularity), pretibial myxedema (deposition of hyaluronic acid in the dermis and subcutaneous tissue), Graves opthalmopathy (eyelid retration and exophthalmos)

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28
Q

True or false - treatment of hyperthryoidism also treats eye manifestations.

A

False - it does not affect the eye manifestations; radioactive iodine treatment may make it worse

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29
Q

Rx - hyperthyroidism

A
  1. Methimazole (most commonly used med) - notice improvements after 1 month, takes up to 3 months to suppress production
  2. Oral dose of radioactive iodine - few side effects, brief worsening of side effects; most people will need thyroid replacement eventually; pregnancy test before treatment, avoid pregnant women and young children for several days after treatment
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30
Q

Rare AE of methimazole?

A

Agranulocytosis

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31
Q

Symptoms of hypothyroidism?

A

Weight gain, cold intolerance, pedal edema, heavy periods, fatigue

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32
Q

Rx - hypotyroidism

A

Thyroxine (starting dose 1.5-1.8 mcg/kg); repeat TSH in 6 weeks; when stable check 1-2x/year

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33
Q

2 signs to evaluate appendicitis

A

Psoas and obturator

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34
Q

AUDIT-C questions

A
  1. How often did you have a drink containing alcohol in the past year?
  2. How many drinks did you have on a typical day when you were drinking in the past year?
  3. How often did you have 6+ drinks on one occasion?
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35
Q

Positive AUDIT-C?

A

4+ for men, 3+ for women

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36
Q

DDx - RUQ pain

A

Biliary colic, cholecystitis, duodenal ulcer, hepatitis, acute pancreatitis, pneumonia/pleurisy, MI, renal pain/colic, pyelonephritis, herpes zoster, appendictis

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37
Q

Presentation of biliary colic?

A

Constant RUQ/epigastric/chest pain, often radiating to the back lasting 4-6 hours or less; follows a heavy, fatty meal, associated with N/V

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38
Q

Classically radiates under the R shoulder blade?

A

Biliary colic

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39
Q

Hallmark of biliary colic?

A

Resumption of normal gallbladder function and resolution of symptoms within 4-6 hours (when stone moves away from the outlet)

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40
Q

Presentation of cholecystitis?

A

Severe persistent RUQ pain;

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41
Q

Compare the severity of pain in biliary colic and cholecystitis

A

Cholecystitis is more severe than biliary colic; associated with N/V, fever; occurs after a large fatty meal

Positive Murphy’s sign

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42
Q

Classically occurs after a large fatty meal

A

Cholecystitis (but biliary colic does too)

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43
Q

Specificity and sensitivity of Murphy’s sign for cholecystitis?

A

High specificity

Low sensitivity

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44
Q

Compare the cause of biliary colic and cholecystitis

A

Cholecystitis - stone does not dislodge from the duct

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45
Q

Presentation of duodenal ulcer?

A

Typically epigastric pain, RUQ and LUQ possible; alleviated by food (NOT aggravated) and antacids; indigestion and nausea are common; vomiting and radiation are uncommon

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46
Q

Presentation of hepatitis?

A

RUQ pain, most of the time does not have acute onset; associated with N/V, malaise, anorexia, itching, icterus/jaundice; physical exam - hepatomegaly

47
Q

Presentation of acute pancreatitis?

A

Epigastric pain, radiates to the back, worsens rapidly, N/V, jaundice if common bile duct is obstruction, may progress to shock and coma; abdominal tenderness

48
Q

What are the two rare physical exam signs of acute pancreatitis?

A

Grey Turner sign - ecchymotic discoloration in the flank

Cullen sign - ecchymotic discoloration in the periumbilical region

49
Q

Typical approach with a transient episode of biliary colic?

A

Surgical consult for cholecystectomy; watchful waiting is not appropriate

50
Q

Binge vs. heavy drinking

A

5+ alcohol drinks on 1 occasion on 1+ days in a 30-day period vs. 5+ days in a 30-day period

51
Q

Dx substance use disorder + severity grading

A

Dx with 2+ symptoms
Mild: 2-3
Moderate: 4-5
Severe: 6+

52
Q

Define macule vs. papule

A

Change in the color of the skin; flat, <1 vs. >1cm in diameter

53
Q

Papule vs. nodule vs. plaque

A

Papule - solid, raised, distinct borders <1cm
Nodule - solid, raised, >1cm; may be in the epidermis, dermis, or subQ
Plaque - solid, raised, flat-topped lesion >1cm

54
Q

Compare the distribution of psoriasis and actopic eczema.

A

Psoriasis - extensor surfaces

Atopic eczema - flexor surfaces

55
Q

If squamous cell carcinoma is >___cm in diameter, there is a high risk for recurrence and mets. If nevi are >__mm in diameter, they tend to be malignant.

A

2; 6

56
Q

List risk factors for both melanoma and non-melanoma skin cancer.

A
  1. White race, celtic ancestry
  2. Fair complexion, people who burn easily/tan poorly and freckle, red/blonde/light brown hair
  3. Whites living near the equator
  4. Xeroderma pigemntosum
  5. Increasing age
  6. M>F, but M»>F for non
57
Q

Discuss sun exposure as a risk factor for non-melanoma and melanoma skin cancer.

A

Non: Cumulative

Melanoma - Intermittent intense

58
Q

Compare risk factors related to indoor and outdoor work for melanoma and non-melanoma skin cancers.

A

Non - outdoor work

Melanoma - indoor work

59
Q

Compare risk factors related to family history for melanoma and non-melanoma skin cancers.

A

Non - no significant family history

Melanoma - melanoma in a 1st or 2nd degree relative

60
Q

Single greatest risk factor for non-melanoma skin cancer

A

80% of lifetime sun exposure obtained before 18 years of age

61
Q

What type of sun exposure increases risk for melanoma?

A

Intense, intermittent exposure and blistering sunburn in childhood and adolescence

62
Q

Compare exposures contributing to risk for melanoma and non-melanoma skin cancers.

A

Non - coal-tar, tobacco, psoralen

M - radiation

63
Q

Compare skin lesions as risk factors for melanoma and non-melanoma skin cancers.

A

Non- burn scars and chronic skin ulcers

M - non-familial dysplastic nevi, non-dysplastic nevi (indicates risk NOT PRECURSOR), large number of benign pigmented nevi, giant pigmented congenital nevi

64
Q

Conditions predisposing to risk of melanoma and non-melanoma skin cancers.

A

Non - chronic osteomyelitis of the sinus tracts, HPV infection
M - FAMMS, immunosuppression

65
Q

Describe appearance of SqCC of the skin.

A

Scaly, erythematous, raised base; patch, plaque, or nodule; may have scaling/ulcerated center; borders are often irregular and bleed easily; heaped-up edges are fleshy rather than clear; located on extremities and face

66
Q

Appearance of actinic keratoses

A

Scaly, keratotic patches; often more easily felt than seen (vs. SqCC, which has a raised base)

67
Q

Appearance of basasl cell carcinoma

A

Plaque-like or nodular, waxy, transluscent appearance, often with ulceration and/or telangiectasia; usually no change in skin color

68
Q

Prevalence of different types of primary skin cancers

A

Basal cell - 60%
Squamous cell - 20%
Melanoma - 1%

69
Q

Median age of diagnosis of melanoma

A

53

70
Q

Presentation - lichen planus

A

2-10 mm flat-topped papules with an irregular angulated border (polygonal papules); flexor surface of wrists, legs above ankles

71
Q

Rx - eczema?

A

Steroid cream

72
Q

Type of topical base best for acute exudative inflammation

A

Cream

73
Q

Topical base with increased potency

A

Ointment

74
Q

Type of topical base with a drying effect; what is better for dry skin?

A

Cream; ointment

75
Q

What should be treated with a level I-II topical steroid?

A

Psoriasis, lichen planus, severe hand eczema, alopecia areata

76
Q

What should be treated with a level III-V topical steroid?

A

Atopic dermatitis, nummular eczema, stasis dermatitis, seborrheic dermatitis

77
Q

What should be treated with a level VI-VII topical steroid?

A

Dermatitis (eyelids, diaper area, mild facial), mild intertrigo

78
Q

Most common effects of topical steroids?

A

Skin atrophy

79
Q

Treat tinea capitis?

A

ORAL griseofluvin (topical cannot penetrate the infected hair shaft)

80
Q

If a lesion is

A

3

81
Q

Diameter > ___mm is concerning for melanoma

A

6

82
Q

Acute vs. chronic bronchitis

A

Productive cough lasting 1-3 week vs. productive cough for at least 3 months for the past 2 years

83
Q

___ can cause cough in the absence of fever.

A

Acute bronchitis

84
Q

Cardinal symptom of COPD?

A

Dyspnea with exertion

85
Q

Dyspnea is a non-specific finding (17% specificity). ___ is more closely associated with CHF.

A

Paroxysmal nocturnal dyspnea (PND)

86
Q

Classic findings on physical for COPD?

A 
Increased AP diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase
Decreased height of the larynx at full expiration
87
Q

What 4 items predict the presence of COPD?

A

Smoking more than 40 pack-years
Self-reported history of chronic obstructive airway disease
Maximum laryngeal height of 4cm or less
Age at least 45 years

88
Q

Dx - COPD?

A

PFT - either a FEV1/FVC ratio <5th percentile or <70%

89
Q

True or false - the current literature doesn’t support he use of CXR to rule in or out COPD.

A

True

90
Q

It makes sense to get a CXR when a patient presents with ___, not to rule in or out COPD but to rule out other diagnoses.

A

Dyspnea

91
Q

Severity of COPD?

A

Post-bronchodilator FEV1 impairment:

> 80% - GOLD 1 (mild)
50-79% - GOLD 2 (moderate)
30-49% GOLD 3 (severe)
<30% GOLD 4 (very severe)

Also, FEV1/FVC <0.7

92
Q

A clinical diagnosis of COPD should be considered in any any middle-aged or older adult with what history?

A

Dyspnea, chronic cough or sputum production, or a history of tobacco use

93
Q

Major clinical distinction between COPD and asthma?

A

COPD is not reversible via bronchodilator therapy; asthma is.

94
Q

Compare the onset of COPD vs. asthma

A

COPD - mid-life onset

Asthma - early life onset

95
Q

Compare the progression of symptoms of COPD vs. asthma

A

COPD - progress slowly

Asthma - vary day to day

96
Q

Compare the occurrence of symptoms of COPD vs. asthma

A

COPD - symptoms during exertion

Asthma - symptoms more common at night or early morning

97
Q

Compare the relationship to smoking of COPD vs. asthma

A

COPD - long history of smoking

Asthma - not dependent on smoking

98
Q

Compare the relationship of COPD and asthma to rhinitis/allergy/eczema

A

COPD - not related

Asthma - often related

99
Q

Compare the pathophysiology of asthma vs. COPD.

A

Asthma - allergic bronchoconstrictive response due to mast cells, T helper cells, and eosinophils

COPD - inflammatory and destructive process due to macrophages, T killer cells ,and neutrophils

100
Q

Define significant reversibility with bronchodilator

A

Increase in FEV1 of 12+%

101
Q

FVC is normal to decreased in ___, but always decreased in ___.

A

COPD; asthma

102
Q

Rx - mild symptomatic COPD

A
  1. Albuterol (or other SABA) metered-dose inhaler prn
  2. Add daily dose of LABA if symptoms are inadequately controled
  3. Smoking cessation
103
Q

Risks of overuse of beta-agonists?

A

Tachycardia, exaggerated somatic tremor, hypokalemia (especially with thiazides)

104
Q

When does the major benefit of smoking cessation occur?

A

In the first year

105
Q

Define GOLD Symptom Groups A-D Based on Symptoms SCores and # of Exacerbations

A

A: CAT<10, 0-1 exacerbations
B: CAT>10, 0-1 exacerbations
C: CAT<10, 2+ exacerbations
D: CAT>10, 2+ exacerbations

106
Q

Rx GOLD group B

A

SABA, LABA or LAMA (or both if symptoms worsen)

107
Q

Rx GOLD group C

A

SABA, LABA, LAMA, inhaled corticosteroid

108
Q

Rx GOLD group D

A

ICS added to LABA and/or LAMA; can sub or ad Roflumilast (PDE4 inhibitor); SABA prn

O2 therapy if Osat <88%

109
Q

What immunizations are recommndd in adults with COPD?

A

Influenza and pneumococcal (PPSV23); TdaP if due for Td booster

110
Q

What is a COPD exacerbation?

A

Event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum beyond normal day-to-day variations and is acute in onset;

Difficulty catching breath, chest tightness, fever, increased coughing, change in cough

111
Q

Rx - COPD exacerbation

A

Inhaled bronchodilators (esp beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids

112
Q

When should antibiotics be given to patients with COPD exacerbation?

A

Increased dyspnea + increased sputum volume + increased sputum purulence (or 2 of these symptoms if increased sputum purulence is included)

Sveere exacerbation that requires ventilation

113
Q

Mechanism of COPD leading to heart failure

A

hronic hypoxia causes pulmonary vasoconstriction, which increases BP in the pulmonary vessels, causing permanent damage and irreversible HTN

Family Medicine Clerkship (7 decks)

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