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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
When is thyroid U/S used?
Evaluate nodules and enlargement, not hyperthyroidism
26
Peak incidence of Graves disease?
40-60 y/o
27
Unique signs of Graves disease
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)
28
True or false - treatment of hyperthryoidism also treats eye manifestations.
False - it does not affect the eye manifestations; radioactive iodine treatment may make it worse
29
Rx - hyperthyroidism
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
30
Rare AE of methimazole?
Agranulocytosis
31
Symptoms of hypothyroidism?
Weight gain, cold intolerance, pedal edema, heavy periods, fatigue
32
Rx - hypotyroidism
Thyroxine (starting dose 1.5-1.8 mcg/kg); repeat TSH in 6 weeks; when stable check 1-2x/year
33
2 signs to evaluate appendicitis
Psoas and obturator
34
AUDIT-C questions
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?
35
Positive AUDIT-C?
4+ for men, 3+ for women
36
DDx - RUQ pain
Biliary colic, cholecystitis, duodenal ulcer, hepatitis, acute pancreatitis, pneumonia/pleurisy, MI, renal pain/colic, pyelonephritis, herpes zoster, appendictis
37
Presentation of biliary colic?
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
38
Classically radiates under the R shoulder blade?
Biliary colic
39
Hallmark of biliary colic?
Resumption of normal gallbladder function and resolution of symptoms within 4-6 hours (when stone moves away from the outlet)
40
Presentation of cholecystitis?
Severe persistent RUQ pain;
41
Compare the severity of pain in biliary colic and cholecystitis
Cholecystitis is more severe than biliary colic; associated with N/V, fever; occurs after a large fatty meal Positive Murphy's sign
42
Classically occurs after a large fatty meal
Cholecystitis (but biliary colic does too)
43
Specificity and sensitivity of Murphy's sign for cholecystitis?
High specificity | Low sensitivity
44
Compare the cause of biliary colic and cholecystitis
Cholecystitis - stone does not dislodge from the duct
45
Presentation of duodenal ulcer?
Typically epigastric pain, RUQ and LUQ possible; alleviated by food (NOT aggravated) and antacids; indigestion and nausea are common; vomiting and radiation are uncommon
46
Presentation of hepatitis?
RUQ pain, most of the time does not have acute onset; associated with N/V, malaise, anorexia, itching, icterus/jaundice; physical exam - hepatomegaly
47
Presentation of acute pancreatitis?
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
What are the two rare physical exam signs of acute pancreatitis?
Grey Turner sign - ecchymotic discoloration in the flank | Cullen sign - ecchymotic discoloration in the periumbilical region
49
Typical approach with a transient episode of biliary colic?
Surgical consult for cholecystectomy; watchful waiting is not appropriate
50
Binge vs. heavy drinking
5+ alcohol drinks on 1 occasion on 1+ days in a 30-day period vs. 5+ days in a 30-day period
51
Dx substance use disorder + severity grading
Dx with 2+ symptoms Mild: 2-3 Moderate: 4-5 Severe: 6+
52
Define macule vs. papule
Change in the color of the skin; flat, <1 vs. >1cm in diameter
53
Papule vs. nodule vs. plaque
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
Compare the distribution of psoriasis and actopic eczema.
Psoriasis - extensor surfaces | Atopic eczema - flexor surfaces
55
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.
2; 6
56
List risk factors for both melanoma and non-melanoma skin cancer.
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
Discuss sun exposure as a risk factor for non-melanoma and melanoma skin cancer.
Non: Cumulative | Melanoma - Intermittent intense
58
Compare risk factors related to indoor and outdoor work for melanoma and non-melanoma skin cancers.
Non - outdoor work | Melanoma - indoor work
59
Compare risk factors related to family history for melanoma and non-melanoma skin cancers.
Non - no significant family history | Melanoma - melanoma in a 1st or 2nd degree relative
60
Single greatest risk factor for non-melanoma skin cancer
80% of lifetime sun exposure obtained before 18 years of age
61
What type of sun exposure increases risk for melanoma?
Intense, intermittent exposure and blistering sunburn in childhood and adolescence
62
Compare exposures contributing to risk for melanoma and non-melanoma skin cancers.
Non - coal-tar, tobacco, psoralen | M - radiation
63
Compare skin lesions as risk factors for melanoma and non-melanoma skin cancers.
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
Conditions predisposing to risk of melanoma and non-melanoma skin cancers.
Non - chronic osteomyelitis of the sinus tracts, HPV infection M - FAMMS, immunosuppression
65
Describe appearance of SqCC of the skin.
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
Appearance of actinic keratoses
Scaly, keratotic patches; often more easily felt than seen (vs. SqCC, which has a raised base)
67
Appearance of basasl cell carcinoma
Plaque-like or nodular, waxy, transluscent appearance, often with ulceration and/or telangiectasia; usually no change in skin color
68
Prevalence of different types of primary skin cancers
Basal cell - 60% Squamous cell - 20% Melanoma - 1%
69
Median age of diagnosis of melanoma
53
70
Presentation - lichen planus
2-10 mm flat-topped papules with an irregular angulated border (polygonal papules); flexor surface of wrists, legs above ankles
71
Rx - eczema?
Steroid cream
72
Type of topical base best for acute exudative inflammation
Cream
73
Topical base with increased potency
Ointment
74
Type of topical base with a drying effect; what is better for dry skin?
Cream; ointment
75
What should be treated with a level I-II topical steroid?
Psoriasis, lichen planus, severe hand eczema, alopecia areata
76
What should be treated with a level III-V topical steroid?
Atopic dermatitis, nummular eczema, stasis dermatitis, seborrheic dermatitis
77
What should be treated with a level VI-VII topical steroid?
Dermatitis (eyelids, diaper area, mild facial), mild intertrigo
78
Most common effects of topical steroids?
Skin atrophy
79
Treat tinea capitis?
ORAL griseofluvin (topical cannot penetrate the infected hair shaft)
80
If a lesion is
3
81
Diameter > ___mm is concerning for melanoma
6
82
Acute vs. chronic bronchitis
Productive cough lasting 1-3 week vs. productive cough for at least 3 months for the past 2 years
83
___ can cause cough in the absence of fever.
Acute bronchitis
84
Cardinal symptom of COPD?
Dyspnea with exertion
85
Dyspnea is a non-specific finding (17% specificity). ___ is more closely associated with CHF.
Paroxysmal nocturnal dyspnea (PND)
86
Classic findings on physical for COPD?
``` 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
What 4 items predict the presence of COPD?
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
Dx - COPD?
PFT - either a FEV1/FVC ratio <5th percentile or <70%
89
True or false - the current literature doesn't support he use of CXR to rule in or out COPD.
True
90
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.
Dyspnea
91
Severity of COPD?
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
A clinical diagnosis of COPD should be considered in any any middle-aged or older adult with what history?
Dyspnea, chronic cough or sputum production, or a history of tobacco use
93
Major clinical distinction between COPD and asthma?
COPD is not reversible via bronchodilator therapy; asthma is.
94
Compare the onset of COPD vs. asthma
COPD - mid-life onset | Asthma - early life onset
95
Compare the progression of symptoms of COPD vs. asthma
COPD - progress slowly | Asthma - vary day to day
96
Compare the occurrence of symptoms of COPD vs. asthma
COPD - symptoms during exertion | Asthma - symptoms more common at night or early morning
97
Compare the relationship to smoking of COPD vs. asthma
COPD - long history of smoking | Asthma - not dependent on smoking
98
Compare the relationship of COPD and asthma to rhinitis/allergy/eczema
COPD - not related | Asthma - often related
99
Compare the pathophysiology of asthma vs. COPD.
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
Define significant reversibility with bronchodilator
Increase in FEV1 of 12+%
101
FVC is normal to decreased in ___, but always decreased in ___.
COPD; asthma
102
Rx - mild symptomatic COPD
1. Albuterol (or other SABA) metered-dose inhaler prn 2. Add daily dose of LABA if symptoms are inadequately controled 3. Smoking cessation
103
Risks of overuse of beta-agonists?
Tachycardia, exaggerated somatic tremor, hypokalemia (especially with thiazides)
104
When does the major benefit of smoking cessation occur?
In the first year
105
Define GOLD Symptom Groups A-D Based on Symptoms SCores and # of Exacerbations
A: CAT<10, 0-1 exacerbations B: CAT>10, 0-1 exacerbations C: CAT<10, 2+ exacerbations D: CAT>10, 2+ exacerbations
106
Rx GOLD group B
SABA, LABA or LAMA (or both if symptoms worsen)
107
Rx GOLD group C
SABA, LABA, LAMA, inhaled corticosteroid
108
Rx GOLD group D
ICS added to LABA and/or LAMA; can sub or ad Roflumilast (PDE4 inhibitor); SABA prn O2 therapy if Osat <88%
109
What immunizations are recommndd in adults with COPD?
Influenza and pneumococcal (PPSV23); TdaP if due for Td booster
110
What is a COPD exacerbation?
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
Rx - COPD exacerbation
Inhaled bronchodilators (esp beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids
112
When should antibiotics be given to patients with COPD exacerbation?
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
Mechanism of COPD leading to heart failure
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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