Aquifer

Question 1

Ottawa ankle rules

Answer 1

only get ankle XR if pain in malleolar zone and

• bony tenderness along distal posterior edge of either malleolus OR
• unable to bear weight (4 steps unassisted) right after injury and while in ED

Question 2

Cervical cancer screening guidelines by age group

Answer 2

21-29: screening every 3 years

30-65: can screen every 5 years if co-tested for HPV (preferred) OR every 3 years with cytology alone (acceptable)

Question 3

Risk groups that need more freq cervical cancer screening

Answer 3

• immunocompromised
• HIV+
• history of CIN 2, 3, or cancer
• exposure to DES in utero

*note cigarette smoking is strongly correlated with cervical dysplasia and cancer

Question 4

criteria for stopping cervical cancer screening in women >65

Answer 4

adequate screening within the last 10 years, ie 3 consecutive normal pap with cytology OR 2 consecutive normal pap with HPV testing

Question 5

Screening mammography criteria

Answer 5

Every 2 years for women age 50-74

Question 6

Screening mammography criteria

Answer 6

Biennially for women age 50-74

Question 7

What tool can you use to individualize recommendations for mammogram?

Answer 7

Gail criteria

Question 8

When should Tdap be given in adults?

Answer 8

Tdap should replace a single dose of Td for adults age 19-64 who have not previously received Tdap

Question 9

Perimenopausal symptoms due to estrogen deficiency

Answer 9

Vaginal dryness; decreased libido
Hot flashes - dress in light layers, use fan, regular exercise, avoid spicy foods and heat, manage stress
Mood swings - esp depression

Question 10

Osteoporosis screening guidelines

Answer 10

DEXA for >65

for <65 use WHO fx assessment tool to risk stratify. screen if risk of fx >9.3 percent over 10 years.

Question 11

Osteoporosis risk factors

Answer 11

low estrogen states (early menopause, prolonged premenopausal amenorrhea, low weight)

low physical activity

inadeq calcium intake (eg poor nutrition, alcoholism)

family history osteoporotic fx
personal h/o previous fx as an adult
smoking
white

Question 12

Adult physical activity guidelines

Answer 12

each week:
150 minutes moderate-intensity exercise OR
75 minutes vigrous exercise OR
combination of both

incorporate strengthening exercises at least twice a week

Question 13

smoking cessation strategies

Answer 13

set quit date
use nicotine replacement
taking meds
choose a substitute activity (eg walk, chew gum when urge to smoke occurs)
make a list of reasons why imp to quit and keep it handy
keep track of where, when, and why you smoke to help identify triggers to avoid
throw away all smoking things- ashtrays, lighters, etc
join support group

Question 14

Pap smear adequacy

Answer 14

> 5000 squamous cells

sufficient endocervical cells

Question 15

Pap smear results

Answer 15

Negative for intraepithelial lesion or malignancy

Evidence of epithelial abnormalities:

• ASC- atypical squamous cells. some abnormal cells, may be infection, irritation, or precancerous
• LSIL- low grade squamous intraepith lesion. may prgress to high grade, but most regress
• HSIL- considered a significant precancerous lesion
• squamous cell carcinoma

Question 16

Indications for exercise stress testing

Answer 16

asymptomatic males >45 with one or more risk factors )hypercholest, HTN, smoking, FHx premature CAD) may get useful prognostic info from exercise testing

Question 17

frequency of fasting lipid screen

Answer 17

adults >21 every 4-6 years lipid screening and reassess ASCVD risk
fasting- at least 8 hours after last food intake

Question 18

Side effects of SSRIs/SNRIs

Answer 18

headache
GI- nausea, diarrhea
sleep disturbances- drowsiness, insomnia (infrequently)
SIADH
sexual dysfunction 
serotonin syndrome

Question 19

common causes of insomnia in the elderly

Answer 19

envirmonment
drugs/etoh/caffeine
parasomnias-like restless leg
disturbances in sleep wake cycle- jet lag, shift work
psych- depression, anxiety
cardiorespiratory disease (asthma, copd, HF)
pain or pruritis
GERD
hyperthyroidism- elderly often don’t present with the typical sxs

Question 20

diagnostic criteria for major depressive disorder

Answer 20

depressed mood or anhedonia PLUS at least five of SIGECAPS, present for at least 2 weeks

Question 21

most common means of suicide in the elderly

Answer 21

drug overdose

Question 22

labs or studies that can be done to rule out medical causes of insomnia, fatigue, and depression

Answer 22

CBC- anemia and vitamin deficiencies
CMP- electrolyte, renal, hepatic problems
TSH- hypo or hyperthyroidism
ESR- rheumatologic disease
ECG if pt using drugs that might alter cardiac conductivity such as TCAs

Question 23

SAFE-T (Suicide Assessment Five Step Evaluation and Triage) components

Answer 23

1. Risk factors
2. Protective Factors
3. Suicide inquiry- thoughts, plans, behaviors, intent
4. Risk level/intervention
5. Document- risk level and rational, trreatment plan to address/reduce current risk, firearms instructions if relevant, followup.

Question 24

adult depression screening

Answer 24

PHQ-2:

over the past 2 weeks, have you often been bothered by

1. Little interest or pleasure in doing things, or
2. Feeling down, depressed, hopeless

For each question the patient can answer:

Not at all (0 points)
Several days (1 point)
More than half the days (2 points),
Nearly every day (3 points).

(if positive, follow with PHQ-9)

Question 25

Dementia screening tool

Answer 25

Mini-Cog (faster, more sens and specific than MMSE)

Question 26

risk factors for elder abuse:

Answer 26

1. Dementia.
2. Shared living situation of elder and abuser (except in financial abuse).
3. Caregiver substance abuse or mental illness.
4. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder’s dependency and the resulting stress has not been found to
   predict abuse.
5. Social isolation of the elder from people other than the abuser.

Question 27

firstline therapy for insomnia in adults

Answer 27

CBT
-sleep restriction therapy- reduce in bed time to average number of hours patient has actually been able to sleep over the last two wks (rather than time in bed awake). as sleep efficiency improves, increase time allowed in bed 15-20 min every five days until achieve optimal sleep time

-sleep compression therapy- decr amt of time spent in bed to gradually match total sleep time rather than making and immediate substantial change

Question 28

pharmocotherapy for insomnia

Answer 28

*all drugs a/w side effects esp prolonged sedation and dizziness, that can result in risk of injuries and confusion

Benzo Receptor Agonists (zolpidem, eszopiclone) - improve sleep onset latency, total sleep time, and wake after sleep onset

TCAs - doxepin 3-6mg is the only suggested agent in this class

Orexin receptor antagonist (suvorexant)- improved sleep onset and/or sleep maintenance

Question 29

Medical conditions associated with depression (causes it or comorbid at higher rates)

Answer 29

Hypothyroidism (check TSH)
Parkinson’s (is an early feature; pts with depression who start developing movement prob should promptly be evaluated to r/o)
Dementia (MMSE)

Question 30

6 signs of limb-threatening injury

Answer 30

6 P’s

pain
pallor 
pulselessness
paresthesia
perishing cold (unable to regulate body temp)
paralysis

Question 31

Earliest sign of compartment syndrome

Answer 31

pain, esp disproportionate

Question 32

Most reliable sign of compartment syndrome

Answer 32

paresthesias (skin sensation such as burning, prickling, itching, tingling)

Question 33

Most common mechanism of ankle injury

Answer 33

combination of planter flexion and inversion

Question 34

Most often damaged ankle ligaments

Answer 34

the lateral stabilizing ligaments

• anterior talofibular
• calcaneofibular
• posterior talofibular (strongest, rarely injury in inversion)

Question 35

Most easily injured ankle ligament

Answer 35

anterior talofibular

Question 36

ankle anterior drawer test assesses __.

Answer 36

anterior talofibular ligament

Question 37

ankle inversion stress test assesses __

Answer 37

calcaneofibular ligament

Question 38

Mechanism of medial ankle sprain

Answer 38

excessive eversion and dorsiflexion

Question 39

medial ankle sprains are uncommon because of __

Answer 39

bony articulation between medial malleoulus and talus

Question 40

Grade I ankle sprain

Answer 40

stretching or small ligament tear
slight to no functional loss
no mechanical instability
no excessive stretching or opening of the joint with stress

Question 41

Grade II ankle sprain

Answer 41

incomplete ligament tear
moderate functional impairment
some loss of motor function
mild to moderate instability
stretching of joint with stress but with a definite stopping point

Question 42

Grade III sprain

Answer 42

complete tear and loss of ligament integrity
severe swelling and ecchymosis
unable to bear weight
mechanical instability
significant stretching of joing with stress, NO definite stopping endpoint

Question 43

Cross legged test detects ___ and is performed by __.

Answer 43

high ankle sprains (syndesmotic injury between tibia and fibula)

having patient cross their legs with injured leg resting at midcalf on the knee

Question 44

Pain control for ankle sprains

Answer 44

FIRST check for history of problems with ulcers or anti-inflammatory drugs

Patients can take 2 or even 3 ibuprofen at a time but be sure to eat snack or meal beforehand. Take up to three times a day if needed.

Question 45

Ankle strengthening exercises

Answer 45

eversion and inversion against fixed object for 10 sec
planterflexion and dorsiflexion against fixed object for 10 sec

can progress to resistance band

Question 46

TMP-SMP can be prescribed for uncomplicated UTI but consider other options if greater than __ percent resistance

Answer 46

20%

Question 47

Ottawa rules for foot radiography

Answer 47

pain in the midfoot region AND

1) bony tenderness at navicular bone or base of 5th metatarsal
OR
b) unable to bear weight four steps right after injury and in the ED

Question 48

list examples of conditions that can cause palpitations in the follow categories:

Cardiovascular
Psychiatric
Medications
Substances
Endocrinologic
Hematologic
Infectious

Answer 48

cardio- arrythmia, cardiomyopathy, hypovolemia
psych- anxiety, panic attacks
meds- caffeine, stimulants, theophylline, albuterol
substances- tobacco, caffeine, alcohol intox or withdrawal, cocaine
endocrine- hyperthyroidism, pheo, hypoglycemia
heme- anemia
infectious- febrile illness

Question 49

Many typical symptoms of hyperthyroidism are absent in patients age __. Instead they may present with __

Answer 49

> 70 years

sinus tachy and/or fatigue
afib or weight loss with no other symptoms

Question 50

mildly elevated TSH / normal T4

Answer 50

subclinical hypothyroidism

Question 51

inappropr normal TSH / high T4

Answer 51

pituitary adenoma

or thyroid hormone resistance

Question 52

decr TSH / normal T4, high T3

Answer 52

T3 toxicosis

Question 53

decr TSH / decr T4

Answer 53

central/pituitary hypothyroidism (TSH and/or TRH deficiency)

Question 54

Graves disease cause _% of hyperthyroidism

Answer 54

60-80%

Question 55

How to elicit lid lag

Answer 55

move finger SLOWLY from upper to lower field of vision. upper eyelid lags behind the upper edge of iris as eye moves down.

if move finger too fast, may miss it!

Question 56

Graves disease antibodies

Answer 56

anti thyrotropin receptor (TRAb) - TSH receptor

Question 57

methimazole vs RAI treatment

Answer 57

methimazole takes months to take effect, pts have to be on it for many years. appropriate dose fluctuates so must have freq bloodwork to adjust. more likely to have sxs as fluctuations are hard to predict.

RAI concentrated in thyroid has very few side effects. most get low thyroid but easy to manage once find apprp dose, only need blood leveles once or twice a year.

Question 58

causes of hyperthyroidism with low RAIU

Answer 58

subacute thyroiditis
silent thyroiditis
iodine induced
exogenous L-thyroxine
struma ovarii
amiodarone

Question 59

microvascular complications DM

Answer 59

retinopathy
nephropathy
neuropathy- sensory, motor (ankle jerk reflex), autonomic (sex, gastroparesis)

Question 60

macrovascular complications DM

Answer 60

CAD
CVA
PAD

Question 61

goal BP in diabetics with HTN

Answer 61

<130/80

Question 62

start statin for DM with LDL __

Answer 62

> 70

Question 63

In pts with ASCVD or CKD, what are the best second line DM agents in addition to metformin and why?

Answer 63

GLP-1 receptor agonist

or SGLT2 inhibitor bc of demonstrated cardiovascular risk reduction

Question 64

Diagnostic criteria for DM

Answer 64

1. random BG >=200 plus symptoms of hyperglycemia (eg polyuria, unexplained weight loss) or hyperglycemic crisis
2. fasting plasma glucose > 126
3. Hgb A1c >= 6.5%
4. two hour plasma glucose >=200 during OGTT
   * fasting glucose, OGTT, and A1c need to be confirmed on a different day unless pt has unequivocal sxs of hyperglycemia

Question 65

Three fundoscopic findings in severe diabetic retinopathy

Hallmark of proliferative retinopathy

Answer 65

retinal hemorrhage- dark blots w indistinct borders indicating partial obstruction and infarction

cotton wool spots- white spots with fuzzy borders indicating areas of previous infarction

microanuerysms- punctate dark lesions indicating vascular dilatation

neovascularization- hallmark of proliferative retinopathy. growth of new vessels prompted by retinal vessel occlusion and hypoxia

Question 66

DM optimal blood glucose

Answer 66

fasting: 80-120

postprandial 1-2h after meal: <180

Question 67

__ is the single greatest contributor to death in the US

Answer 67

smoking

Question 68

__ is the largest risk factor for cardiovascular mortality in the US

Answer 68

HTN

Question 69

Majority of deaths from DM are from __ and __

Answer 69

increase in cardiovascular disease; chronic renal failure

Question 70

Half life of warfarin and implications

Answer 70

40 hours
takes 5-7 days to reach steady state
when adjusting warfarin dosage, should wait at least this long before rechecking INR, as checking sooner can lead to overreactions and great swings in INR

Question 71

Course of action when goal INR is substantially overshot

Answer 71

Hold warfarin and give oral dose of Vitamin K

Question 72

Grade 1 ulcer

Answer 72

diabetic ulcer, superficial

Question 73

Grade 2 ulcer

Answer 73

ulcer extension - involving ligament, tendon, joint capsule, or fascia

Question 74

Grade 3 ulcer

Answer 74

deep ulcer with abscess or osteomyelitis

Question 75

Grade 4 ulcer

Answer 75

gangrene forefoot (partial)

Question 76

Grade 5 ulcer

Answer 76

extensive gangrene of foot

Question 77

management Grade 1-2 ulcer

Answer 77

outpatient- extensive debridement, local wound care, relief of pressure. tx for infection if there is significant erythema and/or purulent exudate

Question 78

Grade 3 ulcer management

Answer 78

eval for possible osteomyelitis and PAD. both of these conditions may need to be addressed before ulcer resolves. typically need at least brief hospitalization to address

Question 79

Grade 5 ulcer management

Answer 79

emergent hospitalization and surgical consultation, often resulting in amputation

Question 80

Requirements for treating DVT outpatient

Answer 80

Patient:
HD stable
Good renal function
Low risk for bleeding

Home environment stable and supportive, with access to INR monitoring (if using warfarin as anticoagulant)

Question 81

advantages of LMWH over unfractionated heparin for DVT therapy

Answer 81

Longer half-life, can give subQ once or twice a day
Don’t need lab monitoring
Thrombocytopenia less likely (though may still need periodic platelet monitoring)
Bleeding complications less common
Fixed dosing
Can use outpatient

Question 82

one advantage of unfractionated heparin over LMWH

Answer 82

it can be immediately shut off and reversed in case of bleeding due to its very short half life. HENCE, choose this in patient with a significant bleeding risk (eg recent admit for GI bleeding)

Question 83

when would you choose unfractionated heparin over LMWH for DVT therapy?

Answer 83

patient with a significant bleeding risk (eg recent admit for GI bleeding)

Question 84

What three agents can be used to treat DVT after stabilization?

Answer 84

1. warfarin
2. Factor Xa inhibitors (fondaparinux, rivaroxaban, apixaban)
3. Direct thrombin inhibitor (dabigatran)

Question 85

pros/cons of warfarin

Answer 85

pros: cheap, providers familiar with it
cons: highly variable dosing range, need for freq lab monitoring, lots of interactions with other meds

Question 86

pros/cons of Factor Xa inhibitors

Answer 86

pros: doesn’t need weekly lab monitoring, fewer bleeding complications than warfarin and LMWH
cons: expensive, hard to reverse anticoagulation if there’s a bleed

*can’t use in pregnant pts or renal disease

Question 87

pros/cons of direct thrombin inhibitor ie Dabigatran

Answer 87

pros: doesn’t need lab monitoring. advantage of Xa inhibitors b/c has a reversal agent (idarucizumab) that can be used in cases of serious bleeding
* can’t use in pregnant pts or renal disease

Question 88

3 overarching goals of DVT therapy

Answer 88

1. immediately stop growth of thromboemboli (heparin)
2. promote thromboembolic resolution
3. prevent recurrence

Question 89

When is extended anticoagulation indicated after a DVT or PE?

Answer 89

active cancer (no scheduled stop date)

Question 90

When are patients anticoagulated indefinitely after DVT or PE?

Answer 90

pts with inherited coagulation disorders

Question 91

Which pts are likely to benefit from screening for inherited thrombophilia?

Answer 91

1. initial thrombosis prior to age 50 without obvious risk factor
2. FHx VTE
3. recurrent venous thrmbosis
4. thrombosis in unusual vascular beds eg portal, hepatic, mesenteric, cerebral veins

Question 92

main use of D-dimer

Answer 92

exclude thromboembolic disease where the probability is LOW

Question 93

test with best sensitivity and specificity for DVT

Answer 93

venous doppler lower extremity

Question 94

Wells criteria for DVT

Answer 94

• active cancer (ongoing tx, within 6 months, or palliative)
• paralysis, paresis, or recent plaster immobilization of the legs
• recently bedridden for >3 days or major surgery within 4 weeks
• localized tenderness along distribution of deep venous system
• entire leg swollen
• calf swelling >3cm compared to asymptomatic leg (measured 10cm below tibial tuberosity)
• pitting edema greater in symptomatic leg
• collateral superficial veins (non vericose)

Question 95

Wells criteria cutoffs for DVT probability

Answer 95

0: low prob
1-2: moderate
3 or more: high

Question 96

Differential for unilateral LE edema

Answer 96

lymphedema
cellulitis
DVT
venous insufficiency
PAD

Question 97

5 systems that can get end organ disease from HTN

Answer 97

Heart- LVH, angina or MI, HF
Brain- CVA, TIA
Kidneys- chronic renal failure
Blood vessels- peripheral vascular disease
Eyes- retinopathy

Question 98

what qualifies as family history of premature CVD

Answer 98

men <55

women <65

Question 99

secondary causes of HTN

Answer 99

• OSA
• primary aldosteronism
• renovascular disease
• renal parenchymal disease
• drug/ETOH induced (NSAIDS, sympathomimetics, cocaine)
• pheochromocytoma
• aortic coarctation
• thyroid
• primary hyperparathyroidism
• cushing’s

Question 100

Most adults can start at __mg thiazide for BP.

Elderly adults should be started at __ or __mg due to risk of ___.

Answer 100

25mg

6.25; 12.5; hypotensive episodes or electrolyte abnormalities

Question 101

weight loss reduces BP by __

Answer 101

1 mmHg per kilogram of loss

Question 102

What is DASH eating plan?DASH eating plan reduces BP by _

Answer 102

diet rich in fruit, veg, low fat dairy, with reduced saturated and total fat

11 mmHg

Question 103

Dietary sodium reduction by __% (about __mg per day) reduces BP by __

Answer 103

25%; 1000mg per day
4-6 mmHg

(no added sodium)

Question 104

specific measures to reduce dietary sodium

Answer 104

• eat fresh foods
• check labels and ensure “no added sodium”
• minimize adding salt to food at table
• rinse beans

Question 105

-moderation of ETOH consumption can reduce BP by _

max daily consumption for men and women?

Answer 105

6 mmHg

no more than 2 drinks per daily for men / 1 drink per day in women and lighter weight

(2 drinks = 24oz beer, 10oz wine, 3 oz 80-proof whiskey)

Question 106

increasing dietary potassium can improve BP by __

good sources of K?

Answer 106

4-5mmHg

fresh fruits and veg, low fat dairy, some fish and meats, nuts, soy products

Question 107

aspirin should be initiated in pts with HTN age ___ who have ___% ASCVD risk and what 3 other factors?

Answer 107

50-59
greater than 10% ASCVD

• no increased risk bleeding
• life expectancy at least 10 years
• willing to take asa at least 10 years

Question 108

which antihypertensives should be avoided in pregnant women or reprod-age not on contraception?

Answer 108

ARBs

Question 109

4 chest pain characteristics that decr likelihood of ACS

Answer 109

4 P’s

1. pleuritic - worsened by respiration
2. pulsating
3. positional
4. reproduced by palpation

stabbing pain

Question 110

5 possible causes pleuritic CP

Answer 110

PE, PTX, viral or idiopathic pleurisy, PNA, pleuropericarditis

Question 111

list 6 independent risk factors for coronary heart disease

Answer 111

1. HDL <40
2. DM
3. Smoking
4. history premature CHD in a first degree relative
5. sedentary lifestyle
6. obesity

Question 112

PQRST mnemonic for CC like chest pain

Answer 112

Provocation/Palliation
Quality
Region/Radiation
Severity
Timing 
Symptoms associated

Question 113

Differential for palpitations

Answer 113

Dysrhythmia
valvular heart disease
coronary heart disease

hyperthyroidism

anxiety/panic disorder

vasomotor symptoms of menopause

anemia

drugs - caffeine, etoh, tobacco, street drugs…low threshold for urine drug screen

Rx drugs- sympathomimetics, vasodilators, anticholinergics, beta blocker withdrawal

Question 114

4 items that can suggest cardiac cause of palpitations

Answer 114

1. duration greater than 5 min
2. description of irregular beat (ex pt can tap it out with fingers)
3. previous history of heart disease
4. male sex

Question 115

history of palpitations during __ or __ increase likelihood that arrythmia is cause

Answer 115

sleep; work

Question 116

Non-MSK causes of back pain

Answer 116

• Neoplastic
• Inflammatory (RA)
• Visceral (endometriosis, prostatitis, kidney stone)
• Infection (discitis, Herpes Zoster, osteomyelitis, pyelo, spinal or epidural abscess)
• vascular (aortic aneurysm)
• Endocrine (hyperparthyroid, osteomalacia, osteoporosis, Paget dz)

Question 117

Red flags serious illness or neuro impairment with back pain

Answer 117

• fever
• unexplained weight loss
• pain at night
• bowel or bladder incontinence
• neurologic sxs
• saddle anesthesia

Question 118

Disc herniation is classically exacerbated by __ and relieved by __

Answer 118

exac sitting or bending; relieved by lying or standing

Question 119

increased pain with coughing and sneezing suggests __

Answer 119

disc herniation

Question 120

Inidications of imaging for back pain

Answer 120

• progressive neuro deficits
• not responding to conservative treatment
• red flags

Question 121

Back pain CANCER red flags

Answer 121

1. h/o cancer
2. > 10kg unexplained weight loss within 6 months
3. age >50 or <17
4. pain persists for more than 4-6wks
5. night pain or Pain at rest

Question 122

back pain INFECTION red flags

Answer 122

1. persistent fever >100.4
2. h/o IVDA
3. recent bacterial infection, particularly bacteremia (UTI, cellulitis, PNA)
4. immunocompromised (chornic steroid use, DM, HIV)

Question 123

red flags CAUDA EQUINA SYNDROME

Answer 123

1. urinary incont or retention
2. Anal sphincter tone decr or fecal intont
3. saddle anesthesia
4. BL LE weakness or numbness
5. progressive neuro deficits

Question 124

red flags SIGNIFICANT herniated nucleus pulposus

Answer 124

1. major muscle weakness (3/5 strength or less)

2. foot drop

Question 125

red flags VERTEBRAL FX

Answer 125

1. prolonged corticosteroid use
2. mild traumage age >50
3. age >70
4. h/o osteoporosis
5. recent significant trauma any age (MVC, fall from substantial height)
6. previous vertebral fx

Question 126

Acute sciatica is __ lasting up to __ weeks. It can be caused by a variety of conditions such as _

Answer 126

lower back pain with radiculopathy below the knee; 6 weeks

disk herniation, lumbar spinal stenosis, facet joint osteoarthritis, spinal cord infection or tumr, spondylolisthesis

Question 127

Risk factors for LBP

Answer 127

• prolonged sitting (truck driving, desk jobs)
• deconditioning
• suboptimal lifting habits
• repetitive bending and lifting
• spondylosis, disc-space narrowing, spinal instability, spina bifida occulta
• obesity
• low education a/w prolonged illness
• psychosocial- anxiety, depression, life stressors
• occupation-job dissatisfaction, incr manual demands, compensation claims

Question 128

Most low back pain resolves within ___

Answer 128

one month

Question 129

Back exam should be performed sequentially in what positions

Answer 129

1. standing
2. sitting
3. supine

Question 130

Difficulty with heel walk associated with __ disc herniation

Answer 130

L5

*note: expect normal gait even with disc herniation

Question 131

Difficulty with toe walk associated with __ disc herniation

Answer 131

S1

Question 132

Stoop test - what is it and what does it test?

Answer 132

Have patient go from standing to squatting

Pts with central spinal stenosis- squatting will reduce the pain

Question 133

Restricted and painful lumbar flexion suggestive of __ (3)

Answer 133

herniation
OA, or
muscle spasm

Question 134

pain with lumbar extension suggestive of _

Answer 134

spinal stenosis or degenerative disease

Question 135

AHCPR guidelines for back XR

Answer 135

• h/o trauma
• h/o cancer
• F/C/weight loss
• strenuous lifting in pt with osteoporosis
• osteoporosis
• prolonged steroid use
• age <20 or >70
• pain worse when supine or severe at night
• spinal fracture, tumor, or infection

Question 136

Why are Lumbar spine films not so great

Answer 136

lack specificity.

Pts with symptoms and pathology may have normal looking XR / asymptomatic pts may have abnormal XRs

Question 137

MRI indicated for back pain if

Answer 137

• worsening or unremitting neuro deficit or radiculopathy
• progressive major motor weakness
• cauda equina compression
• suspected systemic disorder (mets or infectious)
• failed 6 weeks conservative care

Question 138

Explain to pt why, in the absence of red flags or findings suggestive of systemic disease, imaging is not indicated until 4-6 weeks of conservative treatment ?

Answer 138

1. Tests will not help you feel better faster
   Most people with lower-back pain feel better in about a month, whether or not they have an imaging test.

People who get an imaging test for their back pain do not get better faster. And sometimes they feel worse than people who took over-the-counter pain medicine and followed simple steps, like walking, to help their pain.

Imaging tests can also lead to surgery and other treatments that you do not need. In one study, people who had an MRI were much more likely to have surgery than people who did not have an MRI. But the surgery did not help them get better any faster.

2. Imaging has risks
3. Imaging can be expensive

Spine XRs expose patient to radiation. Esp concerning in young women because radiation exposure to ovaries in a single L spine radiograph equals getting daily CXR for more than a year

CT expose pts to contrast that have renal tox and even higher doses of radiation. Routine imaging not associated with better outcomes. May find abnormalities unrelated to back pain, can cause anxiety and could lead to more testing and possibly unnecessary intervention.

Question 139

Most neuropathic back pain is due to impingement of __ , __, __ nerve roots. Hence focus on reflexes, muscle strength, sensation of _

Answer 139

L4, L5, S1

patellar reflex (L2-4)
achilles reflex (S1))

strength

• hip flexion and adduction (L2, 3, 4), abduction (L4, 5, S1)
• knee flexion (L5, S1, S2) and extension (L2, 3, 4)
• ankle dorsiflexion (L4, 5) and plantar flexion (S1, S2)

sharp and light touch along great toe (L5), lateral malleoulus and posterolateral foot (sS1)

Question 140

SLR pain earlier than __ degrees suggestive of malingering.

Answer 140

30

Question 141

how can you distinguish between tight hamstrings and a sciatic nerve problem?

Answer 141

raise leg to point of pain, lower slightly
dorsiflex foot

if no pain with dorsiflection, pt has tight hamstrings

Question 142

normal leg can be raise __ degrees

Answer 142

80

Question 143

what is positive passive SLR

Answer 143

pain radiating down posterior/lateral thigh past knee

Question 144

How is FABER test performed

What is a positive test

Answer 144

flex hip and place foot on opposite knee
apply pressure on tested knee while stabilizing opposite hip

positive if pain at hip or sacral joing, or leg can’t lower to the point of being parellel to opposite leg

Question 145

3 components of conservative therapy for LBP

Answer 145

• pharmacologic- NSAID and/or muscle relaxant
• local heat/cold therapy
• activity- stay active / PT

Question 146

Treatment after adequatee trial of conservative therapy for 5 weeks

Answer 146

if pain for 5 weeks with progression of neuro deficit and poor pain control ,refer to spine surgeon for consult

if no red flags, could continue conservative therapy. however if patient already getting PT, more PT unlikely to help

some evidence that acupuncture can help in LBP

Question 147

when and what labs should you order for LBP?

Answer 147

labs generally not needed

CBC and ESR if suspect tumor or infection

Question 148

Noble’s test- how is it performed and what does it diagnose?

Answer 148

iliotibial band tendonitis

Pt lays supine and repeatedly flexes and extends knee while physician monitors lateral femoral epicondyle with their thumb. pain usu worse when knee flexed at 30 degrees

Question 149

OA often affects __, ___, and ___

Answer 149

knees, hips, back

Question 150

RA typically affects __ or more joints, often including __ and __

Answer 150

3

hands, feet

Question 151

Patellar apprehension test- how to perform and what does it diagnose

Answer 151

detects patellar subluxation (incopmlete or partial kneecap dislocation)

positive if pain or giving away sensation when attempting to translate patella laterally

Question 152

IF concerned about septic arthritis or acute inflammatory arthropathy of knee, what labs should you check

Answer 152

CBC with diff
ESR/CRP

arthrocentesis fluid for cell count with diff, glucose, protein, bacterial culture and sens, polarized light microscopy

Question 153

Simple knee joint effusion produces __ colored fluid. Can occur in what conditions

Answer 153

clear, straw-colored

OA, degenerative meniscal injuries

Question 154

Bloody knee aspirate can be associated with __ or ___

Answer 154

knee sprain (ie ACL, PCL)
acute meniscal tear

Question 155

Knee aspirate with blood and fat globules caused by __

Answer 155

osteochondral fracture

Question 156

If considering RA as cause of knee pain, what labs/tests should you get

Answer 156

RF in blood (not sensitive but has high PPV)

Hand XR can identify erosions and soft tissue swelling

Question 157

Initial management of OA

Answer 157

Exercise / PT! guidelines strongly recommend

Weight loss if obese

Question 158

One time ultrasound screen for AAA recommended in what group

Answer 158

MEN age 65-75 with history of smoking

Question 159

Lachman test assesses __

Answer 159

stability of ACL

Question 160

Tinel’s test

Answer 160

tap over median nerve to reproduce sxs

Question 161

Phalen’s test

Answer 161

flex wrist by having pt put dorsal surfaces of hands together for 30-60 seconds to reprod sxs

Question 162

Durkan’s sign

Answer 162

compress carpal tunnel for 30 seconds to reproduce sxs

*most sensitive and specific out of three physical exam tests

Question 163

3 Grade A ways to manage OA pain

Answer 163

EXERCISE- eg walking, cycling, tai chi

Acetaminophen (preferred over NSAIDs due to better safety and side effect profile)

NSAIDs (diclofenac may be the most effective NSAID) (weaker evidence for topical diclofenac) (NSAIDs also increase risk of MI)

Tramadol- modest benefit but use is limited by side effects. can lower seizure threshold in pts with epilepsy

Question 164

Intra-articular knee corticosteroid injection should be considered if _

guidelines for how often you can use injection?

Answer 164

knee joint is inflamed (swelling and pain)

no more than 3 a year
no more than one a month

Grade B; short term benefit with few adverse effects

Question 165

when could you get a knee XR to assess osteoarthritis?

Answer 165

• diagnosis uncertain
• to evaluate severity/location of OA
• no improvement with conservative treatment

Question 166

what knee XR views should you get to assess OA

Answer 166

AP
lateral
standing
Merchant’s view (top view with knee at 45 degrees to show alignment of patella in groove of femur)

Question 167

4 major radiographic features of OA

Answer 167

• joint space narrowing
• subchondral sclerosis
• osteophytes (bone spurs)
• subchondral cysts (fluid filled sacs in bone marrow)

**knee XRs are insensitive for detecting early OA and dont correlate well with degree of symptoms

Question 168

on knee XR:
____ correlate best with pain
____ best predicts disease progression

Answer 168

patellofemoral and tibiofemoral joint osteophytes- pain

joint space narrowing- progression

Question 169

Diagnostic test of choice for carpal tunnel syndrome

Answer 169

nerve conduction study - not typically needed to diagnose if HP suggests carpal tunnel

should only be done if sxs fail to improve with conservative tx, motor dysfunction, or thenar atrophy on exam

Question 170

Must educate pt on expectations for pain control and attainable goals. Should not expect to be entirely pain free. Should judge pain control based on __

Answer 170

ability to perform activities of daily living

set attainable functional goals

Question 171

List 4 chronic pain meds

Answer 171

opioids- controversial, uncertain benefits for long term control, serious adverse effects

TCAs- helpful esp for neuropathic pain, and aids sleep interrupted by pain. limited by anticholinergic side effects. CI in severe cardiovasc disease/conduction prob

SSRIs/SNRIs- effective in certain types of pain like fibromyalgia and diab neuropathy.

Anticonvulsants- gabapentin and pregabalin for neuropathic pain

Question 172

Pts with chronic pain should be screened and treated for __

Answer 172

comorbid depression

there are high rates of depression among pts with chronic pain.

Question 173

colon cancer screening recommended for pts age __

Answer 173

50-75

Question 174

mammogram screening recommended __ (frequency) for pts age ___

Answer 174

once every two years

50-74

Question 175

Community residents aged ___ should be encouraged to ___

Answer 175

exercise to prevent falls

Question 176

options for pts who fail conservative therapy including acetaminophen for knee pain

Answer 176

NSAID but consider GI tox, renal and BP effects esp in older pts

screen for depression

Tramadol if all else fails

Question 177

what condition should you ask about before prescribing tramadol

Answer 177

seizures

can lower seizure threshold

Question 178

differential diagnosis for knee pain

Answer 178

• patellofemoral pain syndrome
• iliotibial band tendonitis
• sprain ACL, PCL, MCL, LCL
• meniscal tear
• septic arthritis
• Lyme
• OA
• RA, psoriatic. SLE
• gout/pseudogout
• Baker’s cyst

Question 179

USPSTF recommendations for chlamydia screening

Answer 179

All sexually active women 24 and younger

Sexually active women 25 and older who are at increased risk

Question 180

Risk factors for chlamydial infection

Answer 180

• h/o chlamydia
• new or multiple sex partners
• inconsistent condom use
• exchanging sex for money or drugs

Question 181

All women (normal risk) planning or capable of pregnancy should take supplement with ___ (amount) folic acid

Answer 181

400-800 mcg

Question 182

Women with __ should take 1mg folic acid

Answer 182

DM or epilepsy

Question 183

Women who’ve had a child with previous neural tube defect should take ___mg folic acid

Answer 183

4

Question 184

Preconception counseling should include screening for what diseases

Answer 184

• sickle cell
• thalassemia
• tay sachs
• CF (fam hx)
• nonsyndromic hearing loss (connexin-26) (fam hx)

Question 185

Preconception infectious disease screening/immunizations/counseling

Answer 185

• HIV, syphilis
• Hep B vaccination
• preconception vaccines (rubella, varicella- they’re live)
• Toxoplasma counseling (avoid cat litter, garden soil, raw meat)
• CMV, paro B19- frequent handwashing, universal precautions

Question 186

Preconception lifestyle counseling

Answer 186

• exercise
• avoid hyperthermia (hot tubs, overheating)
• caution against obesity or underweight
• screen domestic violence
• assess risk nutritional deficiencies (vegan, pica, milk intol, Ca or Fe def)
• avoid overuse vitamine A and D
• limit caffeine to 2 cups coffee a day

Question 187

Pelvic exam signs of pregnancy

Answer 187

• softening of cervix
• softening of uterus
• blue-purple cervix and vaginal walls (hyperemia)

Question 188

Naegele’s rule to calculate estimate due date

Answer 188

first day of LMP

add 1 year, subtract 3 months, add 1 week

Question 189

First sign of significant bleed

Answer 189

increased pulse

bleeding can continue for a while before blood pressure drops

Question 190

Ectropion is when ___ and is common in __

Answer 190

central part of cervix looks red from protrusion of endocervical epithelium protruding thru cervical os

women taking OCPs

Question 191

When should EGA/EDD based on LNMP be changed to reflect ultrasound calculations?

Answer 191

First and second trimester

if ultrasound shows EGA/EDD >7 days calculated from LNMP

Question 192

adolescent interview mnemonic

Answer 192

Home
Education/employment
Eating
Activities
Drugs
Sexuality
Suicide/depression
Safety/violence

Question 193

Three ways to deal with inevitable abortion

Answer 193

Expectant - watch and wait. takes up to a month, delays emotional closure

Surgical - indicated for unusually heavy bleeding or patient preference. CONTRAindicated in pelvic infection

Medical- vaginal misoprostol (cytotec) and generally takes 3-4 days.

Question 194

What should you not forget to do in an abortion?

Answer 194

confirm Rh negative patients have gotten RhoGam

Question 195

Initial pregnancy labs (6)

Answer 195

CBC- anemias (nutritional, congenital) and platelet disorders

Blood type to detect Rh antibody presence

Rubella antibody test
Hep B surface antigen test
RPR for syphilis
HIV status

Question 196

Labs to investigate first trimester vaginal bleeding

Answer 196

CBC - for hgb/hct

wet mount for trichomonas, PCR for GC chlamydia (all STIs can cause vaginal bleeding)

progesterone - good PPV and NPV at extremes of reference range. in between 5-25 doesn’t help distinguish IUP from ectopic

quantitative beta-hCG

Question 197

progesterone level __ highly assoc with sustainable IUP

Answer 197

> 25

Question 198

progresterone level __ highly associated with evolving miscarriage or ectopic pregnancy

Answer 198

<5

Question 199

may be not be able to detect IUP until b-hCG reaches __

Answer 199

1500-1800 (transvaginal)

Question 200

detection of IUP by transabdominal U/S needs b-hCG level __

Answer 200

> 5000

Question 201

in normal pregnancy, b-hCG doubles every __ in the first __ weeks of gestation

Answer 201

48 hours; 6-7 weeks

Question 202

molar pregnancies may have b-hCG around ___

Answer 202

10,000

Question 203

what is threatened abortion?

Answer 203

bleeding before 20 weeks

Question 204

inevitable abortion

Answer 204

dilated cervical os. everything still in uterus

Question 205

incomplete abortion

Answer 205

some but not all intrauterine contents expelled

Question 206

missed abortion

Answer 206

fetal demise without cervical dilation or uterine activity

often found incidentally on U/S without presentation of bleeding

Question 207

septic abortion

Answer 207

with intrauterine infection- usu have abdominal tenderness and fever

Question 208

complete abortion

Answer 208

products of conception completely expelled from uterus

Question 209

three most common causes of bleeding in early pregnancy

Answer 209

• spontaneous abortion
• ectopic
• idiopathic bleeding in a viable pregnancy

Question 210

management of stable patient who complains of vaginal bleeding in pregnancy

Answer 210

serial quant b-hCG and ultrasounds

Question 211

uterine fundus rises 1cm for every week of pregnancy after __ weeks

Answer 211

20

Question 212

when should RhoGam be given for Rh neg pts?

Answer 212

• 24 weeks
• 72h after gestation
• with any episodes of vaginal or intrauterine bleeding

Question 213

quad serum screening measures __ and is performed at ___ weeks

Answer 213

AFP, hCG, unconjugated estriol, inhibin A
(abnml levels may indic incr risk NTD, trisomy 21, 18)

15-21 weeks

Question 214

dietary advice for n/v in pregnancy

Answer 214

• frequent small melas
• avoid foods and textures that cause nausea
• solid foods should be bland, high in carbs, low fat
• salty foods can usu be tolerated in morning
• sour/tart liquids often tolerated better than water

Question 215

Screening for gestational diabetes should be performed at ___ weeks with ___

Answer 215

24-28 weeks

1 hour glucose tolerance test

Question 216

symptoms of severe preeclampsia

Answer 216

• visual disturbance
• severe HA
• RUQ or epigastric pain
• N/V
• decr UOP

Question 217

if 1 hour GTT elevated, get 3h.

components of 3 hour GTT and what diagnoses gestational diabetes

Answer 217

fasting, 1, 2, 3 hours postprandial

above cutoff for at least two measurements

Question 218

postpartum blues typically last __

Answer 218

2 weeks

Question 219

screening for gestational DM is positive if

Answer 219

fasting glucose >126

OR 1 hour glucose >130 or 140

Question 220

pregnant women should be tested for GBS at __ weeks with ___. IF positive, treat with __ (__alternative)

Answer 220

36 weeks; vaginal and rectal swab; penicillin; ampicillin alternative

Question 221

studies to evaluate RUQ pain (5) and rationale

Answer 221

CBC- leukocytosis to suggestion infection, anemia to suggest internal bleeding

Electrolytes- imbalance from vomiting

liver chemistries- assess for acute or chronic hepatic cell injury

UA- assess for blood that might suggest renal colic

amylase/lipase to assess for pancreatitis

Question 222

next step for biliary colic

Answer 222

surgical consult for elective cholecystectomy

waiting is not appropr, can lead to complications down the line

Question 223

moderate drinking definition

Answer 223

up to 1 drink per day (women)

or 2 drinks per day (men)

Question 224

binge drinking

Answer 224

five or more drinks on one occasion for one or more days in a 30-day period

Question 225

heavy drinking

Answer 225

five or more drinks on one occasion for five or more days in a 30-day period

Question 226

alcohol use disorder

Answer 226

2 or more of following:

• want to cut or stop drinking more than once, but couldn’t
• spent lots of time drinking, being sick from drinking, or getting over after effects
• craving
• drinking or being sick from drinking often interferes with taking care of home/fam, has caused job or school troubles
• continue drinking even though causing trouble with family or friends
• given up/cut back on activities that they enjoy in order to drink
• more than once gotten into situations while or after drinking that increased patient’s chances of getting hurt (driving, swimming, walking in dangerous area, using machinery, unsafe sex)
• continued drinking even though making pt feel depressed
• had to drink more than they once did to get same effect
• withdrawal symptoms (trouble sleeping, shaky, irritable, anxiety, depression, restless, nausea, sweating, hallucinations)

Question 227

AUDIT-C screening

Answer 227

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?
3. How often did you have 6 or more drinks at one time in the past year?

Question 228

moderate evidence to support medications __ and __ for treating alcohol use disorder

Answer 228

naltrexone, acamprosate

Question 229

treatment options for alcohol use disorder

Answer 229

• breif session with family physician with advice and goal setting
• refer for CBT/CBI to work on awareness of behavior and develop new more adaptive behaviors
• refer for Motivational Enhancement Therapy
• medications
• support group

Question 230

differential for RUQ abdominal piain

Answer 230

• duodenal ulcer
• hepatitis
• biliary colic
• cholecystitis
• pancreatitis

Question 231

macule

Answer 231

flat change in skin color <1cm

Question 232

patch

Answer 232

macule greater than 1cm

Question 233

what skin fungal infections require systemic antifungals?

Answer 233

tinea capitis (topical therapies can’t penetrate infected hair shaft)

tinea unguium (onychomycosis)

Question 234

plaque

Answer 234

elevated flat lesion >1cn

Question 235

papule

Answer 235

small raised palpable lesions <1cm

Question 236

symptoms of prostatitis

Answer 236

pain (lower abdomen, testicles, penis, wih ejaculation)

bladder irritaiton

bladder outlet obstruction

sometimes blood in semen

Question 237

atopic eczema involves __ surfaces

Answer 237

flexor

Question 238

what are annular lesions

what conditions might you see them

Answer 238

circular with normal skin in the center

drug eruptions, secondary syphilis, SLE

Question 239

linear arrangement of lesions can indicate __

Answer 239

contact reaction

Question 240

what are zostiform lesions

Answer 240

arranged along cutaneous distribution of a spinal nerve

Question 241

eczema treatment

Answer 241

steroid cream

Question 242

three vehicles for topical steroids and what they’re good for

Answer 242

ointment- good for dry skin. greater penetration so higher potency

lotion/gel- drying effect so good for acute exudative inflammation. most useful for scalp bc penetrates easily and leaves little residue

cream- drying effect so good for acute exudative inflammation. most cosmetically appealing.

Question 243

side effects topical steroids

Answer 243

skin atrophy- most common

hypopigmentation (most noticeable in darker skin)

high and ultra high potency steroids can cause systemic effects - HPA axis suppression, glaucoma, septic necrosis femoral head, hyperglycemia, HTN

Question 244

most widely used treatment of SCC

Answer 244

surgical excision

Question 245

behavior modifications to decrease LUTS of BPH

Answer 245

• avoid fluids before bedtime or going out
• reduce consumption of mild diuretics like caffeine, alcohol esp in evening
• limiting use of salt and spices
• maintaining voiding schedules
• don’t take decongestants like sudafed
• don’t take antihistamines like benadryl

Question 246

___ decrease BPH urinary symptoms

Answer 246

alpha-adrenergic antagonists (“-zosin”) - causes muscles of urethra to relax

Question 247

___ decrease prostate size

Answer 247

5a-reductase inhibitors (finasteride, dutasteride)

Question 248

when might you use combination treatment with alpha-antagonist and 5a-reductase inhibitor for BPH?

Answer 248

• severe symptoms
• large prostate >40g
• inadequate response to max dose monotherapy with alpha-antagonist

Question 249

when is surgical intervention needed for BPH?

Answer 249

• BOO creating risk for upper urinary tract injury (such as hydronephrosis, renal insuff) or lower urinary tract injury (retention)
• recurrent UTI
• bladder decompensation
• failure of combination treatment

Question 250

what tests/labs should be done to evaluate suspected BPH?

Answer 250

digital rectal exam- prostate characteristics for malignancy, rectal sphincter tone

UA- detect UTI, blood (stones, bladder cancer)

serum PSA

Question 251

risks and benefits of HRT

Answer 251

• improves low estrogen symptoms (hot flashes, mood, vaginal dryness and dyspareunia, sleep problems)
• decr risk osteoporosis (grade D, shouldn’t be used just for this purpose)

-incr risk stroke- must assess personal and family h/o cardiovascular disease

Question 252

bleeding with hormone replacement can be normal in the first ___ (timeframe)

Answer 252

12 months

bleeding after 12 months always needs investigation

Question 253

Differential for abnormal uterine bleeding

Answer 253

• cervical polyps (more common in postpartum and perimenopausal)
• endometrial hypyerplasia
• hormone-producing ovarian tumor
• endometrial cancer
• proliferative endometrium

medications (anticoag, SSRI, antipsychotic, corticosteroid, hormonal meds)

disorders of thyroid, heme, hepatic, adrenal, pit, hypothalamic systems

Question 254

physical exam for AUB

Answer 254

• pelvix exam
• neck - thyroid
• skin - bruises (evidence bleeding disorder), jaundice
• abdomen - hepatomegaly (coagulopathy from liver disease)

Question 255

endometrium thickness __ is reassuring that a pt does not have endometrial cancer

Answer 255

<4mm

Question 256

workup for postmenopausal abnormal bleeding

Answer 256

• CBC- anemia, thrombocytopenia
• TSH
• transvaginal ultrasound
• endometrial bx

FSH and LH elevation can be used to confirm menopause but NOT helpful to assess bleeding.

Question 257

postmenopausal women should get ___ calcium and ___ vitamin D in their diet

Answer 257

1200mg calcium

800-1000 IU vitamin D

Question 258

BMD t-score classification

Answer 258

0 to -1 normal
-1 to -2.5 osteopenia
below -2.5 osteoporosis

Question 259

4 possible osteoporosis tx

Answer 259

bisphosphonates - inhibit bone resorption. zoledronic acid is intravenous version given annually for pts who don’t tolerate oral

PTH (Forteo)- approved for osteoporosis at high risk of fracture. given subQ. expensive, has not been demonstrated effective/safe past 2 years

selective estrogen receptor modulator (raloxifene)- used if bisphosphonates not tolerated. only prevent vertebral fx

calcitonin - shown to reduce vertebral fx only. for most women, there are other more effective tx

Question 260

alternatives for HRT for hot flashes

Answer 260

SSRI/SNRI

gabapentin, clonidine

Question 261

using combined estrogen/progesterone beyond __ (timeframe) increases risk of breast cancer

Answer 261

3 years

Question 262

definition of menopause is no period after __ (timeframe)

Answer 262

12 months

Question 263

what tests can confirm menopause? how?

Answer 263

FSH and LH levels

during menopause, granulosa cells make less inhibin, so less negative feedback on FSH and LH

Question 264

what is considered late menopause

what is considered early menarche

Answer 264

after age 52

before age 12

Question 265

tx local vaginal pruritis, dryness

Answer 265

topical estrogen- cream or ring

Question 266

risk factors to consider before starting hormone therapy

Answer 266

• age
• family or personal h/o heart disease, sroke, breas cancer, blood clots, osteoporosis
• meds

Question 267

diagnostic criteria for medication overuse headache (aka analgesic rebound HA)

Answer 267

• > 15 headaches per month (almost daily, often present first waking up, often aggravated by mild physical or mental exertion)
• regular overuse of any analgesic for > 3 months
• development or worsening of headache during medication overuse
• headache resolves or reverts to its previous pattern within 2 months after stopping overused medication

Question 268

characteristics of migraine

Answer 268

pulsating/throbbing
unilateral
photophobia, phonophobia
last few hours to few days, typically not more than a week

Question 269

two migraine specific medications

Answer 269

triptans

ergot alkaloids

Question 270

what older medication is NOT recommended for migraines? why?

Answer 270

fioricet (acetaminophen/butalbital/caffeine)

Fiorinal (aspirin/buttalbital/caffeine)

–> increased risk of overuse

Question 271

when should migraine prophylaxis be initiated?

when should migraine ppx be considered?

Answer 271

lifestyle changes not effective and

• at least 6 headaches per month
• at least 4 headache days with at least some impairment
• at least 3 headache days with severe impairment or requiring bedrest

-consider ppx if above minus ~1 day

Question 272

best two options for migraine ppx

Answer 272

propranolol
amytriptylline (TCA)

*divalproex and topiramate have signific possible side effects and are expensive

Question 273

symptoms opioid use disorder

Answer 273

opioids taken in larger amounts than intended
unsuccessful efforts to control use
significant time spent in opioid-related activities
craving
use results in unmet obligations at work, school, or home
continued use despite significant interpersonal problems related to use
other activities neglected due to use
use in physically hazardous situations
continued use despite physical or psychological problems related to use
tolerance
withdrawal

Question 274

characteristics of tension headaches

Answer 274

hatband distribution = includes occipital area of head; BL

tight/squeezing pain

Question 275

tx rebound headaches

Answer 275

discontinue analgesics

**Counsel that headaches may worsen before resolving over time

Question 276

physical or environmental triggers of tension and migraine HA

Answer 276

• intense exercise
• bright or flickering lights
• sleep disturbance
• emotional stress
• menses, ovulation, pregnancy (tho HA often improve in pregnancy)
• acute illness
• fasting

Question 277

meds/substances that can trigger tension and migrain HA

Answer 277

• estrogen (birth control. HRT)
• tobacco, too much caffeine, ETOH
• aspartame and phenylalanine (from diet sodea)

Question 278

how to test CN 2-12

Answer 278

• pupils, visual confrontation, EOMI
• convergence
• touch face
• brows, frown, eyes shut, show teeth, smile, puff cheeks
• finger rub
• shoulders against resistance
• tongue and palate midline

Question 279

4 things you can tell patients to do for migraine and tension HA

Answer 279

1. headache diary - track severity, effective treatments, triggers
2. caffeine can help but excess can worsen esp when coming off of it
3. sleep- regular routine, try sleep same time q night
4. relieve stress (meditation, set limits on other people’s expectations, moderate reg exercise, sleep)

Question 280

CI triptans

Answer 280

• concurrent use ergotamine or MAOI
• h/o hemiplegic or basilar migraine
• signific cardio/cerebrovasc/peripheral vasc disease
• severe HTN
• pregnancy
• *may cause serotonin syndrome in combination with SSRI

Question 281

CI ergotamines

Answer 281

• concurrent use of triptans
• heart disease or angina, HTN, PVD
• renal insufficiency
• pregnancy, breastfeeding

Question 282

systems-based differential for abdominal pain

Answer 282

GI- lost of things
cardiac- MI, angina, AAA or rupture
psych- anxiety, somatoform disorder, ptsd
pulm- pleurisy, PNA, PE, tumor
renal- stone, pyelo, cystitis, tumor
MSK- abd wall strain, hernia, abscess, trauma
metabolic- drug OD, ketoacidosis, iron or lead poisoning, uremia

also: dietary intolerances
meds/supplements

Question 283

what agents have been proven to casue/contribute to PUD

what things do NOT cause PUD?

Answer 283

• NSAIDS (asa, ibuprofen)
• physiologic stress (esp ICU)
• smoking
• h. pylori

things that DONT cause PUD:

• psychosocial stress
• caffeine

Question 284

abdominal alarm sxs warranting referral for endoscopy

Answer 284

• dysphagia (stricture, adenoca, motility disorder)
• odynophagia (infections eg candidiasis, erosions, cancer)
• initial onset of GI sxs after age 50 (incr chance cancer)
• early satiety (gastroparesis, gastric outlet obstruction-stricture or cancer)
• hematochezia (red blood with stool- rapidly bleeding ulcer or mucosal erosions)
• iron defic anemia
• recurrent vomiting (severe gastr outlet obstr)
• weight loss

Question 285

how is H. pylori thought to be spread?

Answer 285

fecal-oral transmission during childhood in underdeveloped countries

prevalence is decreasing worldwide

Question 286

2 acceptable treatment options for h. pylori

Answer 286

triple therapy- ppi, amox, clarithro 10-14d

OR quadruple therapy- ppi, metronidazole, tetracycline, bismuth subsalicylate 10-14d

Question 287

2 ways to confirm h. pylori eradication

Answer 287

stool antigen test

urea breath test- more expensive, pt must’ve stopped PPI, bismuth, abx for at least 2 weeks before

Question 288

best initial test for h. pylori in high prevalence populations

Answer 288

IgG test. confirms evidence of past infection

however if low prevalnce, this test can have high false positives

Question 289

2 options salvage therapy for h. pylori

Answer 289

try not to use abx that patient has previoulsy taken to treat h pylori

levofloxacin triple therapy (ppi, amoxicillin, levofloxacin)

OR quadruple therapy (PPI, tetracycline, metronidazole, bismuth subsalicylate)

Question 290

management of PUD resistant to salvage therapy

Answer 290

refer for upper endoscopy to r/o PUD or malignancy and undergo mucosal biopsy to evaluate for persistent h pylori infection

consider abd u/s to eval for biliary disease as a cause of persistent epigastric pain

Question 291

indications to test for proof of h. pylori eradication

Answer 291

• pt with h pylori associated ulcer
• symptoms persist despite approp tx for h pylori
• pts with h pylori-associated MALT lymphoma
• h/o resection for early gastric cancer
• plans to resume chronic NSAID therapy

Question 292

after h pylori ruled out, what therapies are there for functional dyspepsia?

Answer 292

TCAs

various herbal remedies but not enough evidence to make a recommendation

Question 293

what can cause false positive guaiac tests

Answer 293

-diet high in red meat, iron, vitamin C

Question 294

gold standard test to confirm GERD

Answer 294

24 hour pH probe

this test not usually required to diagnose GERD

Question 295

criteria for diagnosing IBS

Answer 295

Rome Criteria

Recurrent abdominal pain at least once a week in the past three months with at least 2 of the following features :

1. related to defecation
2. a/w change in stool frequency
3. a/w change in stool form

*diagnosis based on history, exam, and absence of alarm symptoms

Question 296

initial steps in management of IBS

Answer 296

behavioral therapies and exercise

discuss diet

Question 297

what can you do if you suspect IPV and boyfriend refuses to leave the room

Answer 297

take the pt for an out of room exam, or to get a UA

Question 298

non judgmental ways to ask/screen for IPV

Answer 298

• all couples disagree at some point in time. what happens when you and your partner argue or disagree?
• because violence is so common, and there are so many forms of violence, I am asking all my patients about it. Is anyone now or has anyone in the past hurt you physically or sexually? is anyone threatening you?
• do you feel safe at home

Question 299

definition orthostasis

Answer 299

-drop in systolic 20 or diastolic 10, or pulse increased by 20 –> measured three minutes after a patient goes from supine to sitting or standing

Question 300

purpose and method for Timed Up and Go Test

Answer 300

to measure mobility and fall risk in people who can walk on their own. they can use their usual footwear and usual assistive devices they have

1. sit in chair with back against chair and arms resting in lap
2. without using your arms, stand up from chair and walk 10 ft
3. turn around, walk back to chair, and sit down

Question 301

TUG __ seconds indicates impaired mobility

Answer 301

> 30 seconds

Question 302

FAST test for stroke

Answer 302

Facial droop
Arm weakness
Speech difficulty
Time to call emergency services

Question 303

what is one of the most sensitive tests for UE weakness

Answer 303

pronator drift

Question 304

what features in a history make seizure unlikely

Answer 304

• pt recalls event
• no post ictal period of confusion
• no focal findings
• no oral injury or urinary/fecal soiling

Question 305

stroke sxs must have occurred less than ___ hours to consider giving tPA

Answer 305

4.5

Question 306

sxs R parietal infarct in R hand dominant pt

Answer 306

• L hemiplegia (paralysis)
• spatial and perceptual problems (misjudge distances, attempt to read holding books upside down)
• ignore ppl/objects in left visual field
• not pay attn to left side of room
• may deny ttheir stroke disability

Question 307

symptoms L MCA stroke

Answer 307

• expressive and receptive aphasia

- R facial weakness

Question 308

mechanisms of TIA or possible stroke

Answer 308

1. embolic = from heart and carotid
2. thrombotic (vascular occlusion)
3. cardiogenic - decr in cerebral perfusion dt decr cardiac output, severe hypotension, or hypoxemia
4. hemorrhagic- pathologic cerebrovascular changes in brain attributable to aging, smoking, htn, hld
5. heme- hyperviscosity or myeloproliferative syndromes, vascular obstruction (sickle cell), hypercoagulable states
6. Vascular- htn leading to thrombosis or bleeding, compression of cranial vessels, vasospasm, vasculitis

Question 309

Rhythm control for AF carries greatest risk of stroke under what conditions?

Answer 309

• pt has AF for >48 hours

- or pt has not been given 3 weeks of prior anticoagulant therapy

Question 310

options to prevent first stroke in pt with AF

Answer 310

1. warfarin (target INR 2-3) - rec for all pts w/ nonvalvular AF who can get it safely
2. antiplt therapy with aspirin
3. dual antiplt therapy with clopidogrel and aspirin- more protective than asa alone but incr risk major bleeding. may be reasonable for high risk pts with AF deemed unsuitable for anticoagulation
4. direct oral anticoagulants like dabigatran and rivaroxaban - very expensive, need careful adherence to prevent lapses in anticoag protection

Question 311

options to prevent stroke in pts with previous h/o stroke or TIA

Answer 311

strokeTIA with paroxysmal AF –> warfarin or DOAC

if unable to take oral anticoagulant –> ASA alone. combo of clopidogrel and ASA carries bleeding risk similar to warfarin, thus not reco for pts with hemorrhagic contraindic to warfarin

Question 312

goal BP after a stroke

Answer 312

130/80

Question 313

tx hyperlipidemia in tia/stroke pt

Answer 313

high intensity statin ie atorva 40 or 80, or rosuva 20

Question 314

test for initial emergency evaluation of suspected ischemic stroke

Answer 314

• CT and MRI
• CMP - abnormal renal function or electrolyte disturbances are prevalent in pts with risk factors for stroke
• ECG - high incidence of heart idsease in stroke pts. cardiac monitoring in first 24h after stroke to screen for af and other arrythmias
• markers for cardiac ischemia - potential complic of acute cerebrovasc dz
• CBC, PT/PTTT - abnormalities can prompt consideration of infectious, hypoxic, thrombotic, and hemorrhagic etiologies
• O2 sat - may lessen extent of brain injury by maintaining o2 satt

Question 315

differential for dizziness/lightheadedness with focal neuro findings

Answer 315

• seizure
• stroke, TIA
• CAD (coronary blockage, decr CAD, dysrhythmia which can be sign of undiagnosed CAD)
• medication side effect (thiazides and electrolyte disturbances
• AF
• structural herat disease
• hypertensive emergency

Question 316

physical exam of neuro sxs

Answer 316

• CN 7
• auscultate carotids for bruits
• romberg
• cardiopulm
• gross visual fields
• proprioception
• mental status exam
• strength
• ECG

Question 317

severe or life threatening causes of abdominal pain

Answer 317

• appendicitis
• hepatitis
• pancreatitis
• ovarian pathology (torsion, ruptured cyst)
• ectopic preg
• normal preg
• PID
• trauma

Question 318

Modified centor criteria

Answer 318

1 point:

• tonsillar exudate or erythema
• anterior cervical adenopathy
• fever
• no cough

PLUS 1 point if age <15
MINUS 1 point if age > 45

Question 319

when should rapid strep test be collected

Answer 319

all children w/ modified centor 2 or more

adults w/ modified centor of 3 more more

(reflecting lower prevalence of strep among adults with sore throat)

Question 320

most common complications of flu

Answer 320

OM

PNA

Question 321

signals of influenza complications

Answer 321

• sxs last 5-7d without any relief
• diff breathing
• worsening cough
• difficulty maintaining hydration

Question 322

what BMI is considered overweight for children? obese?

Answer 322

overweight 85-95th percentile

obese > 95 percentile

Question 323

what words are most motivating for change for weight counseling

Answer 323

unhealthy weight

weight problem

Question 324

DM screening for children

Answer 324

• BMI above 85 percentile with risk facotrs (fating gluco 100, elevated fasting insulin level)
• BMI above 95th percentile without risk factors

recheck every 2 years

Question 325

HLD screening for children

Answer 325

-every child with NMI >85th percentile. Goal total cholest 170, LDL 130

Question 326

treatment HLD in children

Answer 326

diet and exercise

drug treatment rec if LDL>190 or LDL >160 with risk factors
drug tx only rec for children > 10 years and either tannger stage 2 (male) or have achieved menarche

Question 327

what is metabolic syndrome in adults

Answer 327

at least 3 of 5:

• TG >= 150 (or on meds)
• low HDL (<40 men, <50 women) or on meds for low HDL
• fasting BG >= 100 (or on meds for hyperglycemia)
• abd obesi (waist circumference >40” men, >50” women)
• HTN

Question 328

complications of obesity in children

Answer 328

• MSK: blount’s dz (progressive bowing of legs), slipped femoral epiphysis
• GI: statosis, gallbladder
• GYN: early menarche, PCOS
• skin: acanthosis nigricans, intertrigo (initially presents as red plaque on ea side of skin fold)

Question 329

first stage of pediatric weight management for overweight/obese

Answer 329

5-2-1-0 counseling

5 servings fruits and veggies
2 hours screen time
1 hr physical activity
0 sugar sweetened beverages

family meals
healthy breakfast
allow child to self-regulate meals

Question 330

pulmonary findings indicating consolidation

Answer 330

1. egophony (when pt says E, examiner hears A)
2. tactile fremitus (increased areas of vibration indic consolidation, decr vibration indic effusion)
3. dullness to percussion
4. crackles
5. whispered pectoriloquy (whispered words heard louder over areas of consolidation)

Question 331

how to distinguish acute URI from acute bronchitis

Answer 331

in acute bronchitis, coughing lasts for more than 5 days

Question 332

non MSK causes of shoulder pain

Answer 332

• MI
• lung cancer
• cholecystitis
• ruptured ectopic

referred pain

Question 333

urgent causes of shoulder pain

Answer 333

• septic gelnohumeral arthritis
• septic subacromial bursitis

can lead to local tissue destruction and loss of function, extension of infection to deeper spaces such as bone, or to distance sites by bactermia which may progress to sepsis

Question 334

shoulder pain red flags septic arthritis or bursitis, and subsequent evaluation

predisposing factors for these conditions?

Answer 334

-redness or swelling and/or systemic complaints like F/C, myalgias

eval: ultrasound or MRI and same day consult with orthopedic surgeon
definitive eval includes aspiration and culture of fluid. definitive tx of confirmed septic arthritis or bursitis = surgical drainage and tailored abx therapy and hospital admission

RF: DM, alcoholism, or other immune compromising conditions

Question 335

what conditions cause both restricted passive and active ROM

Answer 335

• adhesive capsulitis

- glenohumeral arthritis (much less common site of OA than the primary weightbearing joints of lower extremity)

Question 336

in general terms, pt with loss of active AND passive ROM is more likely to have issue with ___ while pt with loss of only active ROM more likely to have issues with ___

Answer 336

both- joint disease

only loss active rom- muscle tissue

Question 337

anatomic stabilizers of shoulder joint

Answer 337

• labrum (increases articulating surface area and depth of glenoid fossa)
• rotator muscle group
• glenohumeral ligaments

Question 338

difference between tendinitis and tendinopathy

Answer 338

• tendinitis is acute
• tendinopathy is chronic condition that may imply degenerative path. characterized by fibroblastic response, lack of acute phase reactants

Question 339

management of rotator cuff tendinopathy/impingement

Answer 339

PT for 6 weeks to re-establish more normal ROM followed by progressive strengthening of rotator cuff and scapular stabilizers

• relative rest (limit further damage while focus on PT)
• topical and/r oral pain meds as needed

Question 340

what questions should you ask before using NSAIDS

Answer 340

• allergies or intolerance to NSAIDs
• other meds pt is taking to ensure you avoid durg interactions
  3. potential for pregnancy for femal pts of childbearing age

Question 341

muscles that make up rotator cuff

Answer 341

Supraspinatus, infraspinatus, teres minor, subscapularis

Question 342

how to assess cremaster reflex

Answer 342

lightly stroke or pinch superior inner thigh –> brisk ipsilateral testicular retraction

Question 343

what is blue dot sign

Answer 343

small bluish discoloration seen through skin of upper testis; pathognomonic for appendiceal torsion when tenderness is also present

Question 344

prehn sign

Answer 344

pain relieved by lifting of testicle, indicates epididymitis (testicular torsion is not relieved by lifting testicle)

Question 345

differential for groin pain in an adolescent

Answer 345

• trauma
• testicular torsion
• torsion of testicular appendages
• epididymitis
• referred pain (from retrocecal appendicitis)
• varicocele, hydrocele
• inguinal hernia
• testicular tumor
• HSP

Question 346

causes of testicular torsion

Answer 346

• congenital anomaly
• undescended testes (often occurs with development of a testicular tumor presumbly caused by incr weight)
• recent trauma or vigorous exercise

*testicular torsion can also occur without any apparent reason

Question 347

what two tests can diagnose testicular torsion

Answer 347

color doppler ultrasonography (faster and more readily available) (decr or absent intratesticular blood flow, often torsed testicle looks enlarged)

radionuclide scintigraphy (tt have decr radiotracer in ischemic testis)

Question 348

viability of a torsed testis depends on

Answer 348

duration of torsion and pain

Question 349

treatment of testicular torsion

Answer 349

nonsurgical- attempt manual detorsion. if successful, still must perform orchiopexy. if fails, must explore surg

surgical- unwind testis. if not viable, remove it. if viable, the perform orchiopexy to prevent recurrence. contralateral should also undergo orchiopexy.

Question 350

types of testicular tumor

Answer 350

1. Germ cell
   - seminomatous
   - nonseminomatous
2. non germ cell
3. extragonadal (lymphoma, leukemia, melanoma are the most common cancers that met to testicle)

Question 351

_____ are most common kind of testicular tumor

Answer 351

germ cell

Question 352

testicular cancer is most common malignancy in males age __

Answer 352

15-35

Question 353

dull aching scrotal pain worse when standing is most likely ___

Answer 353

varicocele

Question 354

surgery should be performed on a diagnosed testicular torsion within __ hours

Answer 354

6

Question 355

functon supraspinatus

Answer 355

assists in abduction

Question 356

function infraspinatus

Answer 356

assists external rotation

Question 357

function teres minor

Answer 357

assists infraspinatous in external rotation

Question 358

function subscapularis

Answer 358

assists internal rotation of shoulder

Question 359

visual appearance of posterior shoulder dislocation

Answer 359

arm adducted and internally rotated

Question 360

visual appearance of anterior shoulder dislocation

Answer 360

fullness of anterior shoulder w/ large dimple in posterior shoulder

Question 361

Two tests for biceps tendinopathy

Answer 361

1. speed’s test - arm in front in 60 degrees of flexion, supinated. resist forward flexion of arm while palpating biceps tendon
2. yergason’s test - grap pt wrist and resist pt attempt to active supinate the arm and flex the elbow

Question 362

clunk test

Answer 362

for labral injury. place one hand at back of glenohumeral joint. rotate arm externally from extension through to forward flexion checking for clunk sound

Question 363

difference between fatigue and sleepiness

Answer 363

fatigue- feeling of exhaustion/tiredness that is not relieved by rest, often worsened by exertion

sleepiness- feeling of tiredness that gives pt tendency to fall asleep, is often relieved by either rest or exertion

Question 364

differential of fatigue

Answer 364

• depression
• OSA
• anemia
• occult malignancy
• CAD
• DM
• sleep restriction/inadequate sleep due to life
• hypothyroid
• chronic fatigue syndrome

Question 365

diagnostic criteria for chronic fatigue syndreom

Answer 365

at least 6 months of disabling fatigue not explained by any other medical cause

plus 4 of following:

• impaired memory or concentration
• post-exertional malaise
• tender LAD
• sore throat
• HA
• myalgias
• arthralgias

Question 366

response to a pt refusing screening

Answer 366

I hear your concern. I still recommend these test for you at some point, and we can talk about them more whenever you’d like. May I ask you about them again sometime?

Question 367

breast self exam USPSTF

Answer 367

NOT recommended- increases rates of biopsy without improving cancer detection or treatment

Question 368

lung cancer screening recommendation

Answer 368

annual low-dose CT scan for lung cancer in adults age 55-80 with 30 pack year history and currently smoke or quit within 15 years

should stop screening 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 curative lung surgery

Question 369

prostate cancer screening recommendation

Answer 369

grade C

engage in shared decision making for men aged 55-69 years

Question 370

when should routine screening be discontinued

Answer 370

age 75

sonner if pt has life-limiting health problems such as severe COPD, CHF, or dementia

Question 371

barriers to screening

Answer 371

• lack of awareness
• denial of vulnerability
• lack of insurance
• have not received a screening recommendation
• fear of pain with a procedure
• fear of finding bad results

Question 372

what can anoscopy detect

Answer 372

fissures and internal hemorrhoids which can be missed with colonoscope

Question 373

risk factors for CRC

Answer 373

• age >50
• history of CRC or adenomas
• history of ovarian, endometrial, or breast cancer
• history of longstanding chronic UC or crohn’s
• history of DM
• first degree relative with : CRC, adenomas diag before age 60,

Question 374

what should a referral letter include

Answer 374

• pt ID info
• reason for referral
• w/u completed to date
• meds, alelrgies, problem list
• copies of significant lab/studies

Question 375

colon cancer screening types and timing

Answer 375

• colonoscopy q10 years
• flex sig q5 years (less available in US)
• FOBT every year
• Fecal immunochemical testing (FOT) every year
• FIT-DNA every 1-3 years
• CT colonography (lower procedural risk vs colonoscopy but signific radiation exposure and risk of incidental findings leading to unnecessary colonoscopies)
• flex sig + FIT every 10 years

Question 376

mnemonic for delivering bad news

Answer 376

SPIKES

Setting up: private room, encourage pt to bring family members for support

Perception: find out pt’s understanding of situation before launching into explanation - allows you to dispel misinformation and identify denial

Invitation: ask how pt would like you to explain the information about the diagnosis

Knowledge and information: expressing your own emotions about the bad news can lessen shock of the news (eg it makes me very sad to have to tell you that…). Use non technical words and avoid being oerly blunt

Emotions- address emotions with empathic response. First, identify the emotion the patient is expressing. Then let the patient know that you understand their emotion (I can tell you weren’t expecting to hear this / I imagine this isn’t what you wanted to hear)

Strategy and Summary: lay out plan for what will happen next, how pt can contact you, when you will see them again - can relieve anxiety and uncertainty. Summarize info and check for understanding to prevent misunderstandings and aovid overly optimistic or pessimistic response

Question 377

clinical tools to help stage CRC

Answer 377

• endorectal U/S to assess depth of invasion
• CT abd/pelvis (mets)
• CXR (mets)

Question 378

most common sites of CRC mets

Answer 378

pelvic lymph nodes
liver
lung

Question 379

what marker can be used to assess CRC prognosis? what levels are assoc with worse prognosis

Answer 379

CEA > 5

Question 380

what is paroxysmal nocturnal dyspnea

Answer 380

sudden severe SOB at night that awakens a person from sleep, often with coughing and wheezing.

Question 381

paroxysmal nocturnal dyspnea is most closely associated with __

Answer 381

CHF

Question 382

difference between paroxysmal nocturnal dyspnea and orthopnea

Answer 382

PND develops several hours after person with HF has fallen asleep. Orthopnea occurs immediately. PND is relieved by sitting upright but not as quickly as simple orthopnea.

Question 383

difference between acute and chronic bronchitis

Answer 383

acute: productive cough lasting 1-3 weeks

chronic bronchitis: productive cough for at least 3 months for the past two years

Question 384

differential for SOB in middle aged man who smokes

Answer 384

COPD
asthma
acute bronchitis
lung cancer

Question 385

classic exam findings of COPD

Answer 385

1. increased AP diameter of chest
2. decr diaphragmatic excursion
3. wheezing (often end-expiratory)
4. prolonged expiratory phase

Question 386

gold standard to diagnose COPD? what is the result?

Answer 386

PFTs

FEV1/FVC ratio less than 70% or 5th percentile AFTER bronchodilator

Question 387

classifying COPD severity

Answer 387

FEV1 cutoffs 80-50-30
>80% (mild, GOLD 1)
50-79% (moderate, GOLD 2)
30-49% (severe, GOLD 3)
<30% (very severe, GOLD 4)

Question 388

differences between COPD and asthma based on history

Answer 388

• asthma sxs vary day to day, sxs more common at night or early morning
• COPD symptoms slowly progress

Question 389

symptom management of COPD

Answer 389

• start with SABA prn (eg albuterol)
• if sxs still inadeq controlled, add daily long-acting bronchodilator

choice between beta 2 agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects

combining bronchodilators of diff classes may improve efficacy and decr risk of side effects compared to increasing dose of a single bronchodilator

Question 390

side effects of beta agonist overuse

Answer 390

• hypokalemia
• tachycardia
• tremor

Question 391

clue for COPD caused by alpha-1 antitrypsin deficiency

Answer 391

age younger than 45

not old enough to have developed the long term effects from smoking

Question 392

things to tell patient about benefits of smoking on COPD

Answer 392

• your lungs will work better within the 1st year of quitting smoking
• when you quit smoking, your lungs will not age as quickly as if you continued smoking
• even if you quit and start smoking again, there may be benefit to you

Question 393

expected change in spirometry after bronchodilation if asthma

Answer 393

increase FEV1 >= 12% after bronchodilation

Question 394

definition of COPD exarcebation

Answer 394

acute change in COPD pt’s baseline dyspnea, cough, and/or sputum

Question 395

treatment of COPD exarcebations

Answer 395

inhaled bronchodilators (esp inhaled beta 2 agonists w/ or w/o anticholinergics) + oral glucocorticoids

Question 396

when to give abx for COPD exacerbation

Answer 396

• has three cardinal sxs (increased dyspnea, sputum volume, and sputum purulence)
• has two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms
• severe COPD exacerbation that requires mechanical ventilation

Question 397

when is O2 indicated for COPD

Answer 397

spo2 < 88%

Question 398

relationship between COPD and heart failure?

Answer 398

HF is one of the major complications of COPD…cor pulmonale

chronic hypoxia -> pulmonary vasoconstriction -> incr pulmonary pressure -> pulmonary HTN and R heart failure -> peripheral edema, incr JVD.

Question 399

what immunizations should COPD pt be sure to get

Answer 399

influenza yearly

pneumococcal (PPSV23 age 19-64) (PCV13 then PPSV23 a year later for all adults 65 and up)

Question 400

most common causes of dementia in order

Answer 400

1. alzheimer’s
2. vascular dementia (usu have cardiovasc risk factors like HTN, smoking)
3. dementia with lewy bodies

Question 401

main tool to diagnose delirium

Answer 401

Confusion Assessment Method (CAM)

Question 402

What are Instrumental Activities of Daily Living? list some examples

Answer 402

IADLs are skills required for living independently - shopping, cooking, using the phone, managing money, medications, transportation

vs ADLs are skills required for basic living (bathing, dressing, trnasferring, continence, toileting, feeiding- usu acquired by first time one leaves home about 5-6yo kindergarten age)

Question 403

possible causes of delirium

Answer 403

infection- urinary, respiratory

urinary retention

pain

depression

electrolyte disturbance

medication withdrawal (eg etoh, benzos most freq)

adverse drug effects

acute cerebrovascular events

Question 404

normal vs abnormal postvoid residual volume

Answer 404

< 50 mL

<100 mL is acceptable in patients > 65 but abnormal in younger pts

> 200 is abnormal

Question 405

medications for alzheimer’s

Answer 405

cholinesterase inhibitors (donepezil, rivastigmine, tacrine, galantamine)

Memantine (NMDA antagonist)

atypical antipsychotis for behavioral disturbance (olanzapine, resperidone). but best to address any underlying exacerbating actors. long term use of antipsychotis have increased mortality

Question 406

nonpharmacologic treatment of Alzheimer’s

Answer 406

respite care for primary caregiver (eg have family members take turns replacing primary caregiver; pay for home health aid come at various intervals) - may allow delay of long term institutionalization

Question 407

interventions to slow progression of CAD

Answer 407

• BP control
• aspirin when appropriate
• statin
• beta blockers even if normal BP
• immunizations flu and pneumococcal

Question 408

what is acute coronary syndrome

Answer 408

umbrella term to cover any clinical symptoms compatible with acute MI. also includes unstable angina, STEMI, NSTEMI

Question 409

CHF findings on CXR

Answer 409

• cardiomegaly - width of heart more than half the width of the thorax
• central vascular congestion and hilar fullness
• cephalization of pulmonary vasculature (typically pulm vessels not well seen in upper lung fields, but in CHF they become engorged and look like white circles)
• Kerley B lines- small lines in periphery of lung fields on PA view. represent interstitial fluid in lug tissue
• blunting of costophrenic angle - indic pleural effusions

Question 410

ACCF/AHA staging of CHF

Answer 410

stage A: at risk of CHF but no known findings or sxs

Stage B: evidence of decreased cardiac function (eg decr EF) but never symptoms

Stage C: ever had symptoms or phsyical findings of CHF

D: symptoms unable to be controlled

Question 411

firstline treatment for diastolic HF

Answer 411

beta blockers

Question 412

what specific thing on EKG is strongly suggestive of LVH

Answer 412

big S wave in V3

Question 413

can someon have pure systolic or diastolic HF?

Answer 413

can’t have pure systolic HF. all pts with systolic dysfunction also have concomitant diastolic dysfunction

Question 414

differential for new onset CHF

Answer 414

• MI
• arrythmias
• ischemic cardiomyopathy (usu due to longterm risk factors like HTN, HLD, DM resulting in signific CAD; over time damage and scarring to myocardium lead to reduced sysyolic function)
• uncontrolled HTN (leading to uncontrolled HTN)

Less common:

• anemia
• NICM
• PE, can cause R HF
• hypothyroidism
• valvular disease

Question 415

types of non-ischemic cardiomyopathy

Answer 415

dilated
hypertrophic
arrhytmogenic RV dysplasia
restrictive cardiomyopathy

Question 416

possible causes of NICM

Answer 416

idiopathic
viral
toxic (eg ETOH)
infiltrative (eg sarcoidosis)

Question 417

what is primary vs secondary dysmenorrhea?

Answer 417

primary dysmenorrhea: painful menses w/o pelvic pathology

secondary: painful menses 2/2 some pelvic pathology

Question 418

primary dysmenorrhea associated with increasing amounts of ___

Answer 418

prostaglandins

Question 419

risk factors for primary dysmenorrhea

Answer 419

mood disorders
smoking
worse state of health
stressors

Question 420

dysmenorrhea is more likely to occur with ___ onst of menses

Answer 420

earlier

Question 421

differential for secondary dysmenorrhea

Answer 421

• adenomyosis
• uterine polyps
• uterine leiomyomas (fibroids)
• chronic PID
• endometriosis
• cervical stenosis
• ovarian cyst (usu midcycle)
• IBS, IBD (but will have sxs also at other times during the month)

Question 422

what is a clinical factor that can differentiate endometriosis from leiomyoma

Answer 422

dyspareunia common in endometriosis, rare with leiomyoma

Question 423

premenstrual syndrome treatment

Answer 423

• danazol (androgenic, lowers estrogen and inhibits ovulation. androgenic effects makes it not popular)
• GnRH agonsits like leuprolide inhibit ovulation. but anti-estrogen effects like vaginal dryness make it unpopular
• SSRIs
• OCPs not always effective for PMS, but good place to start (most favorable pill is formulation with drospirenone/ethinyl estradiol)

Question 424

SSRI regimen options for PMS

Answer 424

1. daily treatment
   2a. intermittent- start 2 weeks before menses (luteal phase) until menses start
   2b. intermittent- start on the first day pt has symptoms and continue until menses start or three days later

Question 425

what is metrorrhagia

Answer 425

irregular bleeding

Question 426

signs of cervical polyp

Answer 426

bleeding after intercourse

Question 427

normal baseline fetal HR

Answer 427

110-160 npm

Question 428

normal baseline fetal HR

normal fetal HR variability

Answer 428

110-160 bpm

moderate variability between 6-25 bpm changes that are not accels or decels

Question 429

evidence of active labor

Answer 429

• strong regular contractions every three to five minutes

- cervical dilation >6cm in the setting of contractions

Question 430

abs contraindications for digital cervical exam

Answer 430

• pt report of vaginal bleeding with undocumented placental location, or known low lying placenta or placenta previa (can worsen bleeding)
• pt with known premature of PROM report of leaking vaginal fluid (can introduce bacteria into uterus potentially causing infection)

Question 431

steps to decrease maternal blood loss

Answer 431

• give mom pitocin after baby is born to help placenta detach quicker
• timing of clamping umbilical cord. delay clamping can reduce risk of anemia in newborns/infants. ~30-60s delay

Question 432

criteria for preeclampsia

Answer 432

-high bp >140/90 on at least 2 readings greater than 6h apart in woman who previously had normal bp and is over 20 week gestation
AND proteinuria on two occasions ideally 6h apart (at least 300mg on 24h collection, urine protein/cr >=0.3, at least 1+ or 30mg/dl on dipstick)

OR elevated bp plus any criteria for preeclampsia with severe features

Question 433

evaluation of preeclampsia

Answer 433

r/o HELLP or preexlampsia w/ severe features

• renal fnx
• liver fnx
• CBC for hemoconcentration or thrombocytopenia

Question 434

criteria for preeclampsia with severe features

Answer 434

any ONE:

• severe htn at least 160 sys or 110 diastolic (2 readings at least 4h apart)
• RUQ pain or doubling transaminases
• plt <100k
• Cr >1.1 or doubled
• pulm edema
• new and persistent cerebral or visual disturbances

Question 435

what could late decel indicate

Answer 435

uteroplacental insufficiency - baby not getting enough O2, early hypoxemia during contractions

Question 436

management of late decels

Answer 436

1. continous fetal monitoring
2. position mom on side to decr pressure on vena cava and incr blood flow to heart, max CO and blood flow to uterus
3. monitor BP. if low, may benefit from fluid bolus
4. O2 face mask. no clear supporting evidence, but doesn’t cause harm

Question 437

intrapartum fetal HR pattern classification

Answer 437

Category 1

• normal FHR (110-160_
• moderate HR variability
• +/- accels
• +/- early decels (usu indic fetal head compression when fetus low in pelvis, often occurs during pushing)

Category II- anything that doesn’t fit I or III

Category III

• no fetal HR variability PLUS one:
  
  • recurrent late decels (more than 50% of contractions in 20 min)
  • recurrent variable decls

OR

sinusoidal FHR pattern

Question 438

caues of postpartum hemorrhage

Answer 438

the $ T’s (most common first)

1. Tone- uterine atony leading to continued bleeding
2. Trauma- perineal or cervical lacs, uterine inversion
3. Tissue- retained or invasive placental tissue in uterus
4. Thrombin- a bleeding disorder- much less common than other three causes

Question 439

apgar scoring

Answer 439

Activity (muscle tone, absent, flexed, active)
Pulse (absent, <100, >100)
Grimace- reflex irritability (floppy, minimal response to stim, prompt response)
Appearance-skin color (blue or pale, pink body blue extremities, pink)
Respiration (absent, slow and irregular, vigorous)

Question 440

what fetal HR tracing might indicate cord compression

Answer 440

variable decels (decr in fetal HR that varies in timing, duration, intensity)

Question 441

when should uncomplicated OM be treated with abx?

Answer 441

children less than 6 months old

6 mo-2 years observe cautiously

do not prescribe abx for children age 2-12 with non severe OM when observing 48-72 hours is reasonable

Question 442

Strep pharyngitis should be treated with __

Answer 442

penicillin

Question 443

When should abx be prescribed for sinusitis

Answer 443

if symptoms have lasted > 7 days

or there is double worsening (symptoms get better, then get suddenly worse)

Question 444

Symptomatic treatment of URI

Answer 444

• decogestant (eg pseudoephedrine) or saline nasal spray for congestion
• tylenol for fever and pain
• nasal ipratropium spray can slightly reduce rhinorrhea, but not congestion

Question 445

three categories of “dizziness”

Answer 445

1. presyncope- feeling lightheaded or faint
2. disequilibrium- feeling of being off balance
3. vertigo- sensation of room spinning

Question 446

lightheadedness/like i’m going to faint is generally classified as __ and usually caused by __

Answer 446

presyncope’ inadequate cerebral perfusion

Question 447

possible etiologies of presyncome

Answer 447

• MI (inadeq CO due to pump failure)
• Afib, thyroid storm (inadeq CO due to decr filling time)
• bradyarrhytmias
• valvular heart disease (inadeq CO due to decr HR)
• dehydration (inadeq CO due to decr preload or vol depletion)
• acute blood loss

Question 448

sxs Meniere’s disease

Answer 448

classic triad

episodes of unilateral hearing loss, tinnitus, vergio

Question 449

where is the problem in central vs peripheral vertigo

how can you differentiate between peripheral and central nystagmus

Answer 449

central: CNS
peripheral: inner ear or vestibular system

peripheral nystagmus improves with gaze fixation

Question 450

common causes of vertigo in primary practice

Answer 450

1. BPPV (most common)

2. vestibular neuritis, acute labyrinthitis (often preceded by URI)

Question 451

what is vestibular neuritis

Answer 451

when viral (less commonly bacterial) infection of inner ear causes inflammation of vestibular branch of CN 8

Question 452

what is acute labyrinthitis

Answer 452

when an infection affects BOTH branches of CN 8 resulting in tinnitus and/or hearing loss and vertigo

Question 453

what is dix-hallpike and what does it test for

Answer 453

sit on table so that when they lay down their head will extend just beyond head of table

turn head turned 45 degrees. lay down
observe nystagmus until it resolves or if no nystagmus, wait 20-30 sec

sit the patient back up
repeat test with pt looking the other way

Question 454

what is head thrust test and what does it test for

Answer 454

firmly hold pt’s head and apply brief, fast head turn to either side. observe eye movements

catch-up saccades when head is turned to affected side, but not unaffected side, is positive for a peripheral vestibular lesion

normal head thrust with vertigo means lesion is central

Question 455

when is neuroimaging indicated for vertigo

Answer 455

if there is evidence of a central lesion

if they have symptoms suggestive of stroke or acute TIA

Question 456

4 ways to manage peripheral vertigo

Answer 456

1. diuretics and low salt diet to decr endolymph- commonly used to tx meniere’s.
2. Epley maneuver (canalith repositioning) - for BPPV.
3. vestibular rehab
4. vestibular suppressant medications - meclizine, dimenhydrinate (anticholinergic vestibular suppresants)
   anti-emetics can be used as adjuncts

Question 457

what is epley’s maneuver for and how do you do it

Answer 457

treat BPPV

ed for right sided sxs

sitting on exam table, turn 45 degrees toward right. quickly lie back with head hanging over exam table.
once nystagmus has stopped, turn head 90 degrees to the left and hold 30 seconds.
roll onton left side, with face at a 45 degree angle to floor. Hold 30 more seconds.
Return to sitting. After 40 seconds pt can resume normal head position.

Question 458

difference between vestibular neuritis and acute labyrinthitis

Answer 458

(both common assoc with recent URI)

*acute labyrinthitis has hearing changes

Question 459

vertigo with positive dix-hallpike on the right, negative head thrust test (no saccades elicited) - what’s next?

Answer 459

epley maneuver

despite negative head thrust, which would suggest central lesion, the dix-hallpike maneuver is diagnostic for BPPV.

Question 460

list three medical condiions that can predispose to obesity

Answer 460

1. cushing’s syndrome
2. hypothyroidism
3. hypogonadism

Question 461

list 4 medical conditions associated with obesiy

Answer 461

ask about symptoms of these

1. sleep apnea (snoring, datime somnolence, morning HA)
2. cardiovascular disease (chest pain or pressure, dyspnea)
3. cerebrovascular disease (changes in vision, focal neuro sxs)
4. peripheral vascular disease (claudication)

Question 462

Hb A1c for prediabees

Answer 462

5.7-6.4%

Question 463

causes secondary dyslipidemia

Answer 463

• T2DM
• cholestatic or obstructive liver disease (like pbc)
• nephrotic syndrome
• hypothytoid
• acute hepatitis
• ETOH
• thiazides, beta blockers, oral estrogens, protease inhibitors

Question 464

most effective HDL raising agent

Answer 464

niacin

Question 465

first line therapy for reducing triglycerides

Answer 465

fibric acid derivatives

Question 466

___ should be measured in all pts before starting statin therapy

Answer 466

ALT

Question 467

symptoms of mono? when would you suspect mono?

Answer 467

Triad of fever, pharyngitis, LAD
also:
-posterior cervical LAD common and specific

suspect in someone after negative rapid strep or throat culture in pt who is ill for > 7-10 days

Question 468

what medicaiton should you DEFINITELY AVOID in mononucleosis?

Answer 468

treatment with amoxicillin or ampicillin bc misdiagnosed as strep pharyngitis…90% will develop a classic prolonged, pruritic maculopapular rash!

Question 469

sxs of epiglottitis

Answer 469

• rapid onset in pts 1-6yo
• inspiratory stridor, hot potato muffled voice, dysphagia, drooling
• clasically tripoding

Question 470

when should you consider diagnosis of pertussis

Answer 470

initial sxs are nonspecific, like common cold

consider pertussis when cough has worsened and has been present for at least 2 weeks

Question 471

how long dose i take for positive monospot test

Answer 471

at least 7 days into illness

Question 472

what tshould you do if a rapid strep comes back negative

Answer 472

• in children, negative test should be backed by throat culture
• consider backup throat culture in adolescents
• adults don’t need backup culture

Question 473

options for treating group A strep phayrngitis

Answer 473

Penicillin V (first line) tid for 10 days

Penicllin G IM if pt tunlikely to finish entire course of oral abx

Amoxicillin liquoid ofen given to children bc it tastes better. but broader, more likely to contrib to resistance

1st gen cephalosporins. if allergic to penicillin, bu tno an immediate type of hypersensitivity

macrolides for pts with penicillin allergy

Question 474

when should vaccines be postponed/withheld?

Answer 474

moderatte to severe illness (eg high fever, oitis, diarrhea, vomiting)

recent exposures to infectious diseases, or mild illness with or without fever should receive their vaccines

Question 475

what are contraindicatiosn for certain vaccines?

Answer 475

immunodeficiency (either in pt or household member)
chemotherapy
pregnancy

Question 476

anticipatory guidance for 5 yo well child exam

Answer 476

• nutrition (whole grains, limit sugary drinks- no more than 4-6oz juice)
• physical activity- 60 min every day. limit screen time 2h a day to help keep active

oral health- schedule dentist. teach brush teeth,. discuss flossing, fluoride, sealants

sexuality-expect normal curiosity of genitalia and sex. explain good touch/bad touch and that certain body parts are private

Question 477

ADHD diagnosis is not usually made til age __

Answer 477

6

age-appropriate activiy commonly ymistaken for ADHD in younger children

Question 478

criteria for ADHD

Answer 478

symptoms more freq or severe compared to children of samge age

behavior present in at least 2 ssettings, for at least 6 months

Question 479

how to determine if child needs lead screening at 5yo well check

Answer 479

selective screening if yes to any of the following

1. does oyur child live in/regularly visit a house or childcare facility built before 1950
2. does your child live in/regularly visit a house or childcare facility built before 1978 that is being or has recently been renovated or remodeled within he last 6 months?
3. does your child have sibling or playmate who has or had lead poisoning

Question 480

which children need selective screening for anemia at periodic visits?

Answer 480

1. at risk for Fe deficiency b c of special health needs
2. low iron diet (ie nonmeat)
3. environmental factors (eg poverty, limited food access)

Question 481

which children should get annual tuberculin skin test?

Answer 481

• HIV infected

- incarcerated adolescents

Question 482

what is included in questionnaire for determining risk of latent TB in US children

Answer 482

1. has family member or contact had TB
2. has family member had positive ppd
3. was child born in a high risk country? (anywhere other than US, canada, aus, NZ, western europe)
4. has child traveled to a high risk country for more than 1 week? (had contact with resident populations)

Question 483

what vaccines are due for 5 yo

Answer 483

DTaP booster
IPV (polio)
MMR
Varicella

Question 484

first does of meningococcal vaccine given at age __

Answer 484

11-12

Question 485

first HPV vaccine given age ___

Answer 485

at least 9 years old

Question 486

rotavirus vaccine age

Answer 486

must be started before 15 weeks and completed by 8 months of age

Question 487

vaccine requiremens before starting elementary schools

Answer 487

2 MMR
2 varicella
3 Hep B (hep has three letters)
4 polio (you have four extremities, polio can affect extremities
5 DTaP

Question 488

definition of Small for Gestational Age

Answer 488

weight below 10th percentiel for gestational age

Question 489

what is term pregnancy

Answer 489

born at > 37 weeks

Question 490

SGA babies are at risk for?

Answer 490

hypothermia
hypoglycemia
polycythemia

Question 491

Which medications are routinely given to newborns and why?

Answer 491

IM Vit K (preven hemorrhagic disease of he newborn aka vit K deficiency bleeding)

Hep B vaccine- decr risk vertical transmission

Erthromyycin eye drops- prevent gonococcal conjuncitvitis

Question 492

difference in timing of gonococcal vs chlamydial eye infection in new borns?

Answer 492

chlamydia occurs later, 1-2 weeks after birth

Question 493

causes of absent red reflex in newborn

Answer 493

congenital cataracts

retinoblastoma

Question 494

causes of chorioretinitis in newborn

Answer 494

congenital toxo, CMV

Question 495

possible effects of maternal anticonvulsant use on newborn

Answer 495

cardiac defects
dysmorphic craniofacial features
hypoplastic nails and distal phalanges
IUGR
microcephaly

Question 496

newborn with irritability, hyperactivity, hypertonicity can be due to __

Answer 496

maternal use of opiates during pregnancy

newborn can also have GI (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excess salivation)
and respiratory sxs (nasal stuffiness, sneezing, yawning)

Question 497

presentation of symptomatic congenital CMV infection

Answer 497

microcephaly
jaundice
petechiae
hepatosplenomegaly
low birth weight

Question 498

presentation of congenital rubella

Answer 498

sensorineural deafness
eye abnormalities
patent ductus arteriosus

Question 499

normal infants will lose up to 10% of their birth weight in ___. they should return to normal birth weight by __.

Answer 499

first several days after delivery; 2 weeks

Question 500

differential of fussy infant

Answer 500

1. colic
2. pyloric stenosis
3. intussusception
4. allergy to breast milk…PCP should counsel continuation of breastfeeding and reassre that babies often have early feeing difficulties but it’s well established that breasttfeeding causes the fewest digesttive difficulties
5. GERD
6. infection
7. FTT

Question 501

definition colic

Answer 501

WEssel rule of three

unexplained paroxysmal bouts of fussing and crying that lasts at least:

• 3h a day
• 3 times a week
• for longer than 3 weeks

Question 502

hallmark of GERD in infants

Answer 502

dribbling milk afer feeds

no sign of distress

Question 503

signs of intussuscepion

when does it tpresent

Answer 503

afer 3 monhs of life

sudden on se, severe, paroxysmal colicky pain recurring at freq inerrvervals

Question 504

it can ake up o __ (ime) afer deliver for signific milk producttion

Answer 504

72

Question 505

it can take up to __ (time) after deliver for signific milk producttion

Answer 505

72

Question 506

exclusivel or partially breastfed babies should received __ supplement

Answer 506

400 units vitamin D daily starting soon after birth

Question 507

caloric requirement for preterm 1-2 month old

Answer 507

115-130

Question 508

caloric req very preterm 1-2 month old

Answer 508

up to 150 kcal

Question 509

babies are read to begin spoon feeding solids at age __

Answer 509

4-6 montths

Question 510

children should sit in rear facing carseats until age __

Answer 510

2

Question 511

6 mo developmental milestones

Answer 511

motor: rolls over, sits unsupported. no head lag when pulled from supine to siting

Fine motor: reaches for objects. looks for dropped items

Language: turns twd voice. babbles

social: feeds self. demonstrates stranger recognition (prelude to stranger anxiety)

Question 512

12 month developmental milesotnes

Answer 512

Gross moor: stands allone

Fine motor: pincer grasp

Language: mama and dada, and 1-2 other words

Social: hands parent a book to read, points when wants something, imitates activities. plays ball with examiner

Question 513

most freq diagnosed neoplasm in infanst

Answer 513

neuroblastoma

Question 514

5 month old- born w/ macrocephaly, macroglossia, hypospadias. abdominal mass palpaed, does not cross midline. diagnosis?

Answer 514

wilm’s tumor - commonly a/w Beckwith-Wiedemann syndrome! (a genetic overgrowth syndrome)

Question 515

favorable prognostic factors of neuroblastoma

Answer 515

• younger age (eg <18 months good prog even witth disseminated disease)
• non amplification of myc gene

Question 516

histology in neuroblastomas

Answer 516

small blue cells forming pseudorosettes

Question 517

3 yo developmental milestones

Answer 517

-brushes teeth w/ assist, feeds self

• builds 6-8 cube tower
• throws ball overhand
• tricycle
• copies circle
• speaks 2-3 word sentences
• knows name and use of cup, ball, spoon, crayon

Question 518

4 yo developmental milestones

Answer 518

• knows gender and age
• plays with toys, engages in fantasy play
• states first and last name, sings song, most speech clearl understandable
• draws person with 3 parts, copies a cross. pours, cus and mashes own food
• hops on 1 foot, balances for 2 seconds

Question 519

5 yo developmental milestones

Answer 519

• lisens and atetnds. can tell diff between real and make believe. shows sympathy/concern for others
• articulates well, tells simple story with full sentences. usues approp tenses and pronouns. countts to 10. follows simple directions
• draws person with >6 body parts
• prints some letters and numbers
• copies squares and riangles

-balances on one foot. hops and skips
ties a note
mature pencil grasp

undresses/dresses with minimal assist

Question 520

children should be screened for anemia a age __ using ___

Answer 520

12 months

fingerstick Hgb/Hct

Question 521

possible eiologies dry cough vs wet cough

Answer 521

dry: environmental irritant, asthma
wet: lower respiratory infection

Question 522

causes of barking cough

Answer 522

croup
subglotic disease
FB

Question 523

casues of brass or honking cough

Answer 523

habitial cough

tracheitis

Question 524

causes paorxysmal cough

Answer 524

pertussis
chlamydia
mycoplasma
FB

Question 525

causes cough worse at night

Answer 525

asthma
sinusitis
postnasal drip

Question 526

intermitent vs mild vs moderate persistent asthma

Answer 526

intermittent:
less than twice a week or two nights a month

Mild:
more than twice a week but not daily
nighttime awakenings 3-4 times a month

Moderate:
daily symptoms
nighttime awakening more than once a week but not nightly

Question 527

what is considered chronic cough

Answer 527

> 3 weeks

Question 528

next step for all children with chronic cough

Answer 528

CXR

Question 529

treatment of mild persistent asthma

Answer 529

SABA plus low dose ICS

Question 530

when is LABA used in asthma

Answer 530

reserved for severe persisent asthma - sxs throughout the day, awakenings every night

Question 531

defects assoc with taking anticonvulsants during pregnancy

Answer 531

cardiac defects
dysmorphic craniofacial features
hypoplastic nails and distal phalanges
IUGR, microcephaly

Question 532

signs of newborn opiate withdrawal

Answer 532

CNS- irritability, hyperactivity, hypertonicity

incessant high-pitched cry, tremors, seizures

GI- vomiting, diarrhea, poor feeding, incessant hnunger, salivation

nasal stuffiness, sneezing, awning

Question 533

list three adverse effects of ADHD meds

Answer 533

• suppress appetite
• decrease growth velocity
• insomnia (typically worse in the firs days of med)

Question 534

when should children be screening for DM

Answer 534

starting age 10 or onset of puberty and BMI >85th percentile plus 2 risk factors

• firs tor second degree FHX DM2
• race/ethnicity
• signs of insulin resistance or conditions a/w insulin resistance
• maternal history of DM, or gestational DM during this child’s getation

screen every 3 years

Question 535

causes of secondary HTN in children

Answer 535

• umbilical vessel acces (predispose to renal vascular disease)
• UTI (renal scarring)
• catecholamine excess
• FHx renal disease (ask if fam has needed dialysis)
• aortic coarctation (pay attn to femoral pulse, document a BP in LE)

Question 536

how o differentiate between weight gain vs underlying endocrine disorder

Answer 536

endocrine disease that cause weight gain usually limit growth and lead to short stature

Question 537

what ECG changes suggest coronary artery disease

Answer 537

• horizontal ST depression or downsloping ST
• convex ST elevation
• Q waves

Question 538

diet additions to lower heart disease risk

Answer 538

fish twice a week

oils in tofu, soyfbeans, flaxseeds, walnuts

Question 539

technique for taking BP

Answer 539

• should be seated quietly for 5 min
• in a chair with BACK supported (not on exam table)
• arm a heart level
• appropriate cuff size!! bladder of cuff must be at least 80% of arm circumference

Question 540

when should 2 BP meds be initiated for newly diagnosed HTN

Answer 540

> 20/10 above goal

Question 541

initial testing for new diagnosis of HTN

Answer 541

• lipid profile (risk factor mod)
• BMP (if need change HTN med, ca assess hyperparathyroid, assess renal fnx)
• TSH (secondary cause)
• UA (for proteinuria, evidence of hypertensive nephropathy)
• ECG (only if <18yo or findings suggesting heart issues)
• optional urine albumin/Cr ratio (monitor progression of renal disease)

Question 542

Questions to help assess a patient’s understanding of their illness

Answer 542

• what do you think caused your problem? what do you call it?
• why do you think it started when it did?
• how does it affect your life?
• how severe is it? what worries you the most?
• what kind of treatment do you think would work?
• how can the doctor be most helpful to you?

what is most important for you?

• have you seen anyone else about this problem? any other physcians?
• have you used nonmedical remedies or treatments for your problems?
• who advises you about your health?

Question 543

how does MODERATE alcohol consumption affect BP?

Answer 543

decreases BP 2-3mmHg (but don’t encourage ps to start drinking alcohol for this lol)

Question 544

what is cardiac sndrome X

Answer 544

typical angina like pain and abnormal stress test c/w CAD, but normal cardiac cath angiogram.

may be due to cardiac microvascular dysfunction and/or abnormal cardiac pain perception

Question 545

course of action for pt presenting with unstable angina

Answer 545

cardiac cath

high pretest prob of cardiac disease
if sxs had been going on for 6 weeks, would be intermed prob and could do exercise stress test