Aquifer Flashcards

1
Q

Ottawa ankle rules

A

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
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2
Q

Cervical cancer screening guidelines by age group

A

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)

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3
Q

Risk groups that need more freq cervical cancer screening

A
  • 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

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4
Q

criteria for stopping cervical cancer screening in women >65

A

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

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5
Q

Screening mammography criteria

A

Every 2 years for women age 50-74

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6
Q

Screening mammography criteria

A

Biennially for women age 50-74

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7
Q

What tool can you use to individualize recommendations for mammogram?

A

Gail criteria

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8
Q

When should Tdap be given in adults?

A

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

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9
Q

Perimenopausal symptoms due to estrogen deficiency

A

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

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10
Q

Osteoporosis screening guidelines

A

DEXA for >65

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

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11
Q

Osteoporosis risk factors

A

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

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12
Q

Adult physical activity guidelines

A

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

incorporate strengthening exercises at least twice a week

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13
Q

smoking cessation strategies

A

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

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14
Q

Pap smear adequacy

A

> 5000 squamous cells

sufficient endocervical cells

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15
Q

Pap smear results

A

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
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16
Q

Indications for exercise stress testing

A

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

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17
Q

frequency of fasting lipid screen

A

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

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18
Q

Side effects of SSRIs/SNRIs

A
headache
GI- nausea, diarrhea
sleep disturbances- drowsiness, insomnia (infrequently)
SIADH
sexual dysfunction 
serotonin syndrome
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19
Q

common causes of insomnia in the elderly

A

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

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20
Q

diagnostic criteria for major depressive disorder

A

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

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21
Q

most common means of suicide in the elderly

A

drug overdose

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22
Q

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

A

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

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23
Q

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

A
  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.
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24
Q

adult depression screening

A

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)

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25
Dementia screening tool
Mini-Cog (faster, more sens and specific than MMSE)
26
risk factors for elder abuse:
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.
27
firstline therapy for insomnia in adults
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
28
pharmocotherapy for insomnia
*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
29
Medical conditions associated with depression (causes it or comorbid at higher rates)
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)
30
6 signs of limb-threatening injury
6 P's ``` pain pallor pulselessness paresthesia perishing cold (unable to regulate body temp) paralysis ```
31
Earliest sign of compartment syndrome
pain, esp disproportionate
32
Most reliable sign of compartment syndrome
paresthesias (skin sensation such as burning, prickling, itching, tingling)
33
Most common mechanism of ankle injury
combination of planter flexion and inversion
34
Most often damaged ankle ligaments
the lateral stabilizing ligaments - anterior talofibular - calcaneofibular - posterior talofibular (strongest, rarely injury in inversion)
35
Most easily injured ankle ligament
anterior talofibular
36
ankle anterior drawer test assesses __.
anterior talofibular ligament
37
ankle inversion stress test assesses __
calcaneofibular ligament
38
Mechanism of medial ankle sprain
excessive eversion and dorsiflexion
39
medial ankle sprains are uncommon because of __
bony articulation between medial malleoulus and talus
40
Grade I ankle sprain
stretching or small ligament tear slight to no functional loss no mechanical instability no excessive stretching or opening of the joint with stress
41
Grade II ankle sprain
``` 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 ```
42
Grade III sprain
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
43
Cross legged test detects ___ and is performed by __.
high ankle sprains (syndesmotic injury between tibia and fibula) having patient cross their legs with injured leg resting at midcalf on the knee
44
Pain control for ankle sprains
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.
45
Ankle strengthening exercises
eversion and inversion against fixed object for 10 sec planterflexion and dorsiflexion against fixed object for 10 sec can progress to resistance band
46
TMP-SMP can be prescribed for uncomplicated UTI but consider other options if greater than __ percent resistance
20%
47
Ottawa rules for foot radiography
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
48
list examples of conditions that can cause palpitations in the follow categories: ``` Cardiovascular Psychiatric Medications Substances Endocrinologic Hematologic Infectious ```
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
49
Many typical symptoms of hyperthyroidism are absent in patients age __. Instead they may present with __
>70 years sinus tachy and/or fatigue afib or weight loss with no other symptoms
50
mildly elevated TSH / normal T4
subclinical hypothyroidism
51
inappropr normal TSH / high T4
pituitary adenoma | or thyroid hormone resistance
52
decr TSH / normal T4, high T3
T3 toxicosis
53
decr TSH / decr T4
central/pituitary hypothyroidism (TSH and/or TRH deficiency)
54
Graves disease cause _% of hyperthyroidism
60-80%
55
How to elicit lid lag
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!
56
Graves disease antibodies
anti thyrotropin receptor (TRAb) - TSH receptor
57
methimazole vs RAI treatment
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.
58
causes of hyperthyroidism with low RAIU
``` subacute thyroiditis silent thyroiditis iodine induced exogenous L-thyroxine struma ovarii amiodarone ```
59
microvascular complications DM
retinopathy nephropathy neuropathy- sensory, motor (ankle jerk reflex), autonomic (sex, gastroparesis)
60
macrovascular complications DM
CAD CVA PAD
61
goal BP in diabetics with HTN
<130/80
62
start statin for DM with LDL __
>70
63
In pts with ASCVD or CKD, what are the best second line DM agents in addition to metformin and why?
GLP-1 receptor agonist | or SGLT2 inhibitor bc of demonstrated cardiovascular risk reduction
64
Diagnostic criteria for DM
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
65
Three fundoscopic findings in severe diabetic retinopathy Hallmark of proliferative retinopathy
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
66
DM optimal blood glucose
fasting: 80-120 | postprandial 1-2h after meal: <180
67
__ is the single greatest contributor to death in the US
smoking
68
__ is the largest risk factor for cardiovascular mortality in the US
HTN
69
Majority of deaths from DM are from __ and __
increase in cardiovascular disease; chronic renal failure
70
Half life of warfarin and implications
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
71
Course of action when goal INR is substantially overshot
Hold warfarin and give oral dose of Vitamin K
72
Grade 1 ulcer
diabetic ulcer, superficial
73
Grade 2 ulcer
ulcer extension - involving ligament, tendon, joint capsule, or fascia
74
Grade 3 ulcer
deep ulcer with abscess or osteomyelitis
75
Grade 4 ulcer
gangrene forefoot (partial)
76
Grade 5 ulcer
extensive gangrene of foot
77
management Grade 1-2 ulcer
outpatient- extensive debridement, local wound care, relief of pressure. tx for infection if there is significant erythema and/or purulent exudate
78
Grade 3 ulcer management
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
79
Grade 5 ulcer management
emergent hospitalization and surgical consultation, often resulting in amputation
80
Requirements for treating DVT outpatient
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)
81
advantages of LMWH over unfractionated heparin for DVT therapy
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
82
one advantage of unfractionated heparin over LMWH
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)
83
when would you choose unfractionated heparin over LMWH for DVT therapy?
patient with a significant bleeding risk (eg recent admit for GI bleeding)
84
What three agents can be used to treat DVT after stabilization?
1. warfarin 2. Factor Xa inhibitors (fondaparinux, rivaroxaban, apixaban) 3. Direct thrombin inhibitor (dabigatran)
85
pros/cons of warfarin
pros: cheap, providers familiar with it cons: highly variable dosing range, need for freq lab monitoring, lots of interactions with other meds
86
pros/cons of Factor Xa inhibitors
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
87
pros/cons of direct thrombin inhibitor ie Dabigatran
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
88
3 overarching goals of DVT therapy
1. immediately stop growth of thromboemboli (heparin) 2. promote thromboembolic resolution 3. prevent recurrence
89
When is extended anticoagulation indicated after a DVT or PE?
active cancer (no scheduled stop date)
90
When are patients anticoagulated indefinitely after DVT or PE?
pts with inherited coagulation disorders
91
Which pts are likely to benefit from screening for inherited thrombophilia?
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
92
main use of D-dimer
exclude thromboembolic disease where the probability is LOW
93
test with best sensitivity and specificity for DVT
venous doppler lower extremity
94
Wells criteria for DVT
- 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)
95
Wells criteria cutoffs for DVT probability
0: low prob 1-2: moderate 3 or more: high
96
Differential for unilateral LE edema
``` lymphedema cellulitis DVT venous insufficiency PAD ```
97
5 systems that can get end organ disease from HTN
``` Heart- LVH, angina or MI, HF Brain- CVA, TIA Kidneys- chronic renal failure Blood vessels- peripheral vascular disease Eyes- retinopathy ```
98
what qualifies as family history of premature CVD
men <55 | women <65
99
secondary causes of HTN
- OSA - primary aldosteronism - renovascular disease - renal parenchymal disease - drug/ETOH induced (NSAIDS, sympathomimetics, cocaine) - pheochromocytoma - aortic coarctation - thyroid - primary hyperparathyroidism - cushing's
100
Most adults can start at __mg thiazide for BP. Elderly adults should be started at __ or __mg due to risk of ___.
25mg 6.25; 12.5; hypotensive episodes or electrolyte abnormalities
101
weight loss reduces BP by __
1 mmHg per kilogram of loss
102
What is DASH eating plan?DASH eating plan reduces BP by _
diet rich in fruit, veg, low fat dairy, with reduced saturated and total fat 11 mmHg
103
Dietary sodium reduction by __% (about __mg per day) reduces BP by __
25%; 1000mg per day 4-6 mmHg (no added sodium)
104
specific measures to reduce dietary sodium
- eat fresh foods - check labels and ensure "no added sodium" - minimize adding salt to food at table - rinse beans
105
-moderation of ETOH consumption can reduce BP by _ max daily consumption for men and women?
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)
106
increasing dietary potassium can improve BP by __ good sources of K?
4-5mmHg fresh fruits and veg, low fat dairy, some fish and meats, nuts, soy products
107
aspirin should be initiated in pts with HTN age ___ who have ___% ASCVD risk and what 3 other factors?
50-59 greater than 10% ASCVD - no increased risk bleeding - life expectancy at least 10 years - willing to take asa at least 10 years
108
which antihypertensives should be avoided in pregnant women or reprod-age not on contraception?
ARBs
109
4 chest pain characteristics that decr likelihood of ACS
4 P's 1. pleuritic - worsened by respiration 2. pulsating 3. positional 4. reproduced by palpation stabbing pain
110
5 possible causes pleuritic CP
PE, PTX, viral or idiopathic pleurisy, PNA, pleuropericarditis
111
list 6 independent risk factors for coronary heart disease
1. HDL <40 2. DM 3. Smoking 4. history premature CHD in a first degree relative 5. sedentary lifestyle 6. obesity
112
PQRST mnemonic for CC like chest pain
``` Provocation/Palliation Quality Region/Radiation Severity Timing Symptoms associated ```
113
Differential for palpitations
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
114
4 items that can suggest cardiac cause of palpitations
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
115
history of palpitations during __ or __ increase likelihood that arrythmia is cause
sleep; work
116
Non-MSK causes of back pain
- 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)
117
Red flags serious illness or neuro impairment with back pain
- fever - unexplained weight loss - pain at night - bowel or bladder incontinence - neurologic sxs - saddle anesthesia
118
Disc herniation is classically exacerbated by __ and relieved by __
exac sitting or bending; relieved by lying or standing
119
increased pain with coughing and sneezing suggests __
disc herniation
120
Inidications of imaging for back pain
- progressive neuro deficits - not responding to conservative treatment - red flags
121
Back pain CANCER red flags
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
122
back pain INFECTION red flags
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)
123
red flags CAUDA EQUINA SYNDROME
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
124
red flags SIGNIFICANT herniated nucleus pulposus
1. major muscle weakness (3/5 strength or less) | 2. foot drop
125
red flags VERTEBRAL FX
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
126
Acute sciatica is __ lasting up to __ weeks. It can be caused by a variety of conditions such as _
lower back pain with radiculopathy below the knee; 6 weeks disk herniation, lumbar spinal stenosis, facet joint osteoarthritis, spinal cord infection or tumr, spondylolisthesis
127
Risk factors for LBP
- 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
128
Most low back pain resolves within ___
one month
129
Back exam should be performed sequentially in what positions
1. standing 2. sitting 3. supine
130
Difficulty with heel walk associated with __ disc herniation
L5 *note: expect normal gait even with disc herniation
131
Difficulty with toe walk associated with __ disc herniation
S1
132
Stoop test - what is it and what does it test?
Have patient go from standing to squatting Pts with central spinal stenosis- squatting will reduce the pain
133
Restricted and painful lumbar flexion suggestive of __ (3)
herniation OA, or muscle spasm
134
pain with lumbar extension suggestive of _
spinal stenosis or degenerative disease
135
AHCPR guidelines for back XR
- 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
136
Why are Lumbar spine films not so great
lack specificity. Pts with symptoms and pathology may have normal looking XR / asymptomatic pts may have abnormal XRs
137
MRI indicated for back pain if
- 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
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 ?
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.
139
Most neuropathic back pain is due to impingement of __ , __, __ nerve roots. Hence focus on reflexes, muscle strength, sensation of _
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)
140
SLR pain earlier than __ degrees suggestive of malingering.
30
141
how can you distinguish between tight hamstrings and a sciatic nerve problem?
raise leg to point of pain, lower slightly dorsiflex foot if no pain with dorsiflection, pt has tight hamstrings
142
normal leg can be raise __ degrees
80
143
what is positive passive SLR
pain radiating down posterior/lateral thigh past knee
144
How is FABER test performed | What is a positive test
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
145
3 components of conservative therapy for LBP
- pharmacologic- NSAID and/or muscle relaxant - local heat/cold therapy - activity- stay active / PT
146
Treatment after adequatee trial of conservative therapy for 5 weeks
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
147
when and what labs should you order for LBP?
labs generally not needed CBC and ESR if suspect tumor or infection
148
Noble's test- how is it performed and what does it diagnose?
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
149
OA often affects __, ___, and ___
knees, hips, back
150
RA typically affects __ or more joints, often including __ and __
3 | hands, feet
151
Patellar apprehension test- how to perform and what does it diagnose
detects patellar subluxation (incopmlete or partial kneecap dislocation) positive if pain or giving away sensation when attempting to translate patella laterally
152
IF concerned about septic arthritis or acute inflammatory arthropathy of knee, what labs should you check
CBC with diff ESR/CRP arthrocentesis fluid for cell count with diff, glucose, protein, bacterial culture and sens, polarized light microscopy
153
Simple knee joint effusion produces __ colored fluid. Can occur in what conditions
clear, straw-colored | OA, degenerative meniscal injuries
154
Bloody knee aspirate can be associated with __ or ___
``` knee sprain (ie ACL, PCL) acute meniscal tear ```
155
Knee aspirate with blood and fat globules caused by __
osteochondral fracture
156
If considering RA as cause of knee pain, what labs/tests should you get
RF in blood (not sensitive but has high PPV) | Hand XR can identify erosions and soft tissue swelling
157
Initial management of OA
Exercise / PT! guidelines strongly recommend Weight loss if obese
158
One time ultrasound screen for AAA recommended in what group
MEN age 65-75 with history of smoking
159
Lachman test assesses __
stability of ACL
160
Tinel's test
tap over median nerve to reproduce sxs
161
Phalen's test
flex wrist by having pt put dorsal surfaces of hands together for 30-60 seconds to reprod sxs
162
Durkan's sign
compress carpal tunnel for 30 seconds to reproduce sxs *most sensitive and specific out of three physical exam tests
163
3 Grade A ways to manage OA pain
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
164
Intra-articular knee corticosteroid injection should be considered if _ guidelines for how often you can use injection?
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
165
when could you get a knee XR to assess osteoarthritis?
- diagnosis uncertain - to evaluate severity/location of OA - no improvement with conservative treatment
166
what knee XR views should you get to assess OA
AP lateral standing Merchant's view (top view with knee at 45 degrees to show alignment of patella in groove of femur)
167
4 major radiographic features of OA
- 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
168
on knee XR: ____ correlate best with pain ____ best predicts disease progression
patellofemoral and tibiofemoral joint osteophytes- pain joint space narrowing- progression
169
Diagnostic test of choice for carpal tunnel syndrome
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
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 __
ability to perform activities of daily living set attainable functional goals
171
List 4 chronic pain meds
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
172
Pts with chronic pain should be screened and treated for __
comorbid depression there are high rates of depression among pts with chronic pain.
173
colon cancer screening recommended for pts age __
50-75
174
mammogram screening recommended __ (frequency) for pts age ___
once every two years 50-74
175
Community residents aged ___ should be encouraged to ___
exercise to prevent falls
176
options for pts who fail conservative therapy including acetaminophen for knee pain
NSAID but consider GI tox, renal and BP effects esp in older pts screen for depression Tramadol if all else fails
177
what condition should you ask about before prescribing tramadol
seizures can lower seizure threshold
178
differential diagnosis for knee pain
- 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
179
USPSTF recommendations for chlamydia screening
All sexually active women 24 and younger Sexually active women 25 and older who are at increased risk
180
Risk factors for chlamydial infection
- h/o chlamydia - new or multiple sex partners - inconsistent condom use - exchanging sex for money or drugs
181
All women (normal risk) planning or capable of pregnancy should take supplement with ___ (amount) folic acid
400-800 mcg
182
Women with __ should take 1mg folic acid
DM or epilepsy
183
Women who've had a child with previous neural tube defect should take ___mg folic acid
4
184
Preconception counseling should include screening for what diseases
- sickle cell - thalassemia - tay sachs - CF (fam hx) - nonsyndromic hearing loss (connexin-26) (fam hx)
185
Preconception infectious disease screening/immunizations/counseling
- 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
186
Preconception lifestyle counseling
- 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
187
Pelvic exam signs of pregnancy
- softening of cervix - softening of uterus - blue-purple cervix and vaginal walls (hyperemia)
188
Naegele's rule to calculate estimate due date
first day of LMP | add 1 year, subtract 3 months, add 1 week
189
First sign of significant bleed
increased pulse bleeding can continue for a while before blood pressure drops
190
Ectropion is when ___ and is common in __
central part of cervix looks red from protrusion of endocervical epithelium protruding thru cervical os women taking OCPs
191
When should EGA/EDD based on LNMP be changed to reflect ultrasound calculations?
First and second trimester | if ultrasound shows EGA/EDD >7 days calculated from LNMP
192
adolescent interview mnemonic
``` Home Education/employment Eating Activities Drugs Sexuality Suicide/depression Safety/violence ```
193
Three ways to deal with inevitable abortion
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.
194
What should you not forget to do in an abortion?
confirm Rh negative patients have gotten RhoGam
195
Initial pregnancy labs (6)
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
196
Labs to investigate first trimester vaginal bleeding
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
197
progesterone level __ highly assoc with sustainable IUP
>25
198
progresterone level __ highly associated with evolving miscarriage or ectopic pregnancy
<5
199
may be not be able to detect IUP until b-hCG reaches __
1500-1800 (transvaginal)
200
detection of IUP by transabdominal U/S needs b-hCG level __
>5000
201
in normal pregnancy, b-hCG doubles every __ in the first __ weeks of gestation
48 hours; 6-7 weeks
202
molar pregnancies may have b-hCG around ___
10,000
203
what is threatened abortion?
bleeding before 20 weeks
204
inevitable abortion
dilated cervical os. everything still in uterus
205
incomplete abortion
some but not all intrauterine contents expelled
206
missed abortion
fetal demise without cervical dilation or uterine activity often found incidentally on U/S without presentation of bleeding
207
septic abortion
with intrauterine infection- usu have abdominal tenderness and fever
208
complete abortion
products of conception completely expelled from uterus
209
three most common causes of bleeding in early pregnancy
- spontaneous abortion - ectopic - idiopathic bleeding in a viable pregnancy
210
management of stable patient who complains of vaginal bleeding in pregnancy
serial quant b-hCG and ultrasounds
211
uterine fundus rises 1cm for every week of pregnancy after __ weeks
20
212
when should RhoGam be given for Rh neg pts?
- 24 weeks - 72h after gestation - with any episodes of vaginal or intrauterine bleeding
213
quad serum screening measures __ and is performed at ___ weeks
AFP, hCG, unconjugated estriol, inhibin A (abnml levels may indic incr risk NTD, trisomy 21, 18) 15-21 weeks
214
dietary advice for n/v in pregnancy
- 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
215
Screening for gestational diabetes should be performed at ___ weeks with ___
24-28 weeks | 1 hour glucose tolerance test
216
symptoms of severe preeclampsia
- visual disturbance - severe HA - RUQ or epigastric pain - N/V - decr UOP
217
if 1 hour GTT elevated, get 3h. components of 3 hour GTT and what diagnoses gestational diabetes
fasting, 1, 2, 3 hours postprandial | above cutoff for at least two measurements
218
postpartum blues typically last __
2 weeks
219
screening for gestational DM is positive if
fasting glucose >126 | OR 1 hour glucose >130 or 140
220
pregnant women should be tested for GBS at __ weeks with ___. IF positive, treat with __ (__alternative)
36 weeks; vaginal and rectal swab; penicillin; ampicillin alternative
221
studies to evaluate RUQ pain (5) and rationale
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
222
next step for biliary colic
surgical consult for elective cholecystectomy waiting is not appropr, can lead to complications down the line
223
moderate drinking definition
up to 1 drink per day (women) | or 2 drinks per day (men)
224
binge drinking
five or more drinks on one occasion for one or more days in a 30-day period
225
heavy drinking
five or more drinks on one occasion for five or more days in a 30-day period
226
alcohol use disorder
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)
227
AUDIT-C screening
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?
228
moderate evidence to support medications __ and __ for treating alcohol use disorder
naltrexone, acamprosate
229
treatment options for alcohol use disorder
- 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
230
differential for RUQ abdominal piain
- duodenal ulcer - hepatitis - biliary colic - cholecystitis - pancreatitis
231
macule
flat change in skin color <1cm
232
patch
macule greater than 1cm
233
what skin fungal infections require systemic antifungals?
tinea capitis (topical therapies can't penetrate infected hair shaft) tinea unguium (onychomycosis)
234
plaque
elevated flat lesion >1cn
235
papule
small raised palpable lesions <1cm
236
symptoms of prostatitis
pain (lower abdomen, testicles, penis, wih ejaculation) bladder irritaiton bladder outlet obstruction sometimes blood in semen
237
atopic eczema involves __ surfaces
flexor
238
what are annular lesions what conditions might you see them
circular with normal skin in the center drug eruptions, secondary syphilis, SLE
239
linear arrangement of lesions can indicate __
contact reaction
240
what are zostiform lesions
arranged along cutaneous distribution of a spinal nerve
241
eczema treatment
steroid cream
242
three vehicles for topical steroids and what they're good for
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.
243
side effects topical steroids
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
244
most widely used treatment of SCC
surgical excision
245
behavior modifications to decrease LUTS of BPH
- 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
246
___ decrease BPH urinary symptoms
alpha-adrenergic antagonists ("-zosin") - causes muscles of urethra to relax
247
___ decrease prostate size
5a-reductase inhibitors (finasteride, dutasteride)
248
when might you use combination treatment with alpha-antagonist and 5a-reductase inhibitor for BPH?
- severe symptoms - large prostate >40g - inadequate response to max dose monotherapy with alpha-antagonist
249
when is surgical intervention needed for BPH?
- 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
250
what tests/labs should be done to evaluate suspected BPH?
digital rectal exam- prostate characteristics for malignancy, rectal sphincter tone UA- detect UTI, blood (stones, bladder cancer) serum PSA
251
risks and benefits of HRT
- 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
252
bleeding with hormone replacement can be normal in the first ___ (timeframe)
12 months bleeding after 12 months always needs investigation
253
Differential for abnormal uterine bleeding
- 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
254
physical exam for AUB
- pelvix exam - neck - thyroid - skin - bruises (evidence bleeding disorder), jaundice - abdomen - hepatomegaly (coagulopathy from liver disease)
255
endometrium thickness __ is reassuring that a pt does not have endometrial cancer
<4mm
256
workup for postmenopausal abnormal bleeding
- CBC- anemia, thrombocytopenia - TSH - transvaginal ultrasound - endometrial bx FSH and LH elevation can be used to confirm menopause but NOT helpful to assess bleeding.
257
postmenopausal women should get ___ calcium and ___ vitamin D in their diet
1200mg calcium | 800-1000 IU vitamin D
258
BMD t-score classification
0 to -1 normal -1 to -2.5 osteopenia below -2.5 osteoporosis
259
4 possible osteoporosis tx
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
260
alternatives for HRT for hot flashes
SSRI/SNRI | gabapentin, clonidine
261
using combined estrogen/progesterone beyond __ (timeframe) increases risk of breast cancer
3 years
262
definition of menopause is no period after __ (timeframe)
12 months
263
what tests can confirm menopause? how?
FSH and LH levels during menopause, granulosa cells make less inhibin, so less negative feedback on FSH and LH
264
what is considered late menopause what is considered early menarche
after age 52 before age 12
265
tx local vaginal pruritis, dryness
topical estrogen- cream or ring
266
risk factors to consider before starting hormone therapy
- age - family or personal h/o heart disease, sroke, breas cancer, blood clots, osteoporosis - meds
267
diagnostic criteria for medication overuse headache (aka analgesic rebound HA)
- > 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
268
characteristics of migraine
pulsating/throbbing unilateral photophobia, phonophobia last few hours to few days, typically not more than a week
269
two migraine specific medications
triptans | ergot alkaloids
270
what older medication is NOT recommended for migraines? why?
fioricet (acetaminophen/butalbital/caffeine) Fiorinal (aspirin/buttalbital/caffeine) --> increased risk of overuse
271
when should migraine prophylaxis be initiated? when should migraine ppx be considered?
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
272
best two options for migraine ppx
propranolol amytriptylline (TCA) *divalproex and topiramate have signific possible side effects and are expensive
273
symptoms opioid use disorder
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
274
characteristics of tension headaches
hatband distribution = includes occipital area of head; BL tight/squeezing pain
275
tx rebound headaches
discontinue analgesics | **Counsel that headaches may worsen before resolving over time
276
physical or environmental triggers of tension and migraine HA
- intense exercise - bright or flickering lights - sleep disturbance - emotional stress - menses, ovulation, pregnancy (tho HA often improve in pregnancy) - acute illness - fasting
277
meds/substances that can trigger tension and migrain HA
- estrogen (birth control. HRT) - tobacco, too much caffeine, ETOH - aspartame and phenylalanine (from diet sodea)
278
how to test CN 2-12
- 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
279
4 things you can tell patients to do for migraine and tension HA
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)
280
CI triptans
- 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
281
CI ergotamines
- concurrent use of triptans - heart disease or angina, HTN, PVD - renal insufficiency - pregnancy, breastfeeding
282
systems-based differential for abdominal pain
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
283
what agents have been proven to casue/contribute to PUD what things do NOT cause PUD?
- NSAIDS (asa, ibuprofen) - physiologic stress (esp ICU) - smoking - h. pylori things that DONT cause PUD: - psychosocial stress - caffeine
284
abdominal alarm sxs warranting referral for endoscopy
- 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
285
how is H. pylori thought to be spread?
fecal-oral transmission during childhood in underdeveloped countries prevalence is decreasing worldwide
286
2 acceptable treatment options for h. pylori
triple therapy- ppi, amox, clarithro 10-14d OR quadruple therapy- ppi, metronidazole, tetracycline, bismuth subsalicylate 10-14d
287
2 ways to confirm h. pylori eradication
stool antigen test urea breath test- more expensive, pt must've stopped PPI, bismuth, abx for at least 2 weeks before
288
best initial test for h. pylori in high prevalence populations
IgG test. confirms evidence of past infection however if low prevalnce, this test can have high false positives
289
2 options salvage therapy for h. pylori
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)
290
management of PUD resistant to salvage therapy
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
291
indications to test for proof of h. pylori eradication
- 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
292
after h pylori ruled out, what therapies are there for functional dyspepsia?
TCAs various herbal remedies but not enough evidence to make a recommendation
293
what can cause false positive guaiac tests
-diet high in red meat, iron, vitamin C
294
gold standard test to confirm GERD
24 hour pH probe | this test not usually required to diagnose GERD
295
criteria for diagnosing IBS
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
296
initial steps in management of IBS
behavioral therapies and exercise | discuss diet
297
what can you do if you suspect IPV and boyfriend refuses to leave the room
take the pt for an out of room exam, or to get a UA
298
non judgmental ways to ask/screen for IPV
- 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
299
definition orthostasis
-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
300
purpose and method for Timed Up and Go Test
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
301
TUG __ seconds indicates impaired mobility
> 30 seconds
302
FAST test for stroke
Facial droop Arm weakness Speech difficulty Time to call emergency services
303
what is one of the most sensitive tests for UE weakness
pronator drift
304
what features in a history make seizure unlikely
- pt recalls event - no post ictal period of confusion - no focal findings - no oral injury or urinary/fecal soiling
305
stroke sxs must have occurred less than ___ hours to consider giving tPA
4.5
306
sxs R parietal infarct in R hand dominant pt
- 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
307
symptoms L MCA stroke
- expressive and receptive aphasia | - R facial weakness
308
mechanisms of TIA or possible stroke
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
309
Rhythm control for AF carries greatest risk of stroke under what conditions?
- pt has AF for >48 hours | - or pt has not been given 3 weeks of prior anticoagulant therapy
310
options to prevent first stroke in pt with AF
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
311
options to prevent stroke in pts with previous h/o stroke or TIA
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
312
goal BP after a stroke
130/80
313
tx hyperlipidemia in tia/stroke pt
high intensity statin ie atorva 40 or 80, or rosuva 20
314
test for initial emergency evaluation of suspected ischemic stroke
- 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
315
differential for dizziness/lightheadedness with focal neuro findings
- 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
316
physical exam of neuro sxs
- CN 7 - auscultate carotids for bruits - romberg - cardiopulm - gross visual fields - proprioception - mental status exam - strength - ECG
317
severe or life threatening causes of abdominal pain
- appendicitis - hepatitis - pancreatitis - ovarian pathology (torsion, ruptured cyst) - ectopic preg - normal preg - PID - trauma
318
Modified centor criteria
1 point: - tonsillar exudate or erythema - anterior cervical adenopathy - fever - no cough PLUS 1 point if age <15 MINUS 1 point if age > 45
319
when should rapid strep test be collected
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)
320
most common complications of flu
OM | PNA
321
signals of influenza complications
- sxs last 5-7d without any relief - diff breathing - worsening cough - difficulty maintaining hydration
322
what BMI is considered overweight for children? obese?
overweight 85-95th percentile | obese > 95 percentile
323
what words are most motivating for change for weight counseling
unhealthy weight | weight problem
324
DM screening for children
- 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
325
HLD screening for children
-every child with NMI >85th percentile. Goal total cholest 170, LDL 130
326
treatment HLD in children
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
327
what is metabolic syndrome in adults
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
328
complications of obesity in children
- 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)
329
first stage of pediatric weight management for overweight/obese
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
330
pulmonary findings indicating consolidation
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)
331
how to distinguish acute URI from acute bronchitis
in acute bronchitis, coughing lasts for more than 5 days
332
non MSK causes of shoulder pain
- MI - lung cancer - cholecystitis - ruptured ectopic referred pain
333
urgent causes of shoulder pain
- 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
334
shoulder pain red flags septic arthritis or bursitis, and subsequent evaluation predisposing factors for these conditions?
-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
335
what conditions cause both restricted passive and active ROM
- adhesive capsulitis | - glenohumeral arthritis (much less common site of OA than the primary weightbearing joints of lower extremity)
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 ___
both- joint disease | only loss active rom- muscle tissue
337
anatomic stabilizers of shoulder joint
- labrum (increases articulating surface area and depth of glenoid fossa) - rotator muscle group - glenohumeral ligaments
338
difference between tendinitis and tendinopathy
- tendinitis is acute - tendinopathy is chronic condition that may imply degenerative path. characterized by fibroblastic response, lack of acute phase reactants
339
management of rotator cuff tendinopathy/impingement
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
340
what questions should you ask before using NSAIDS
- 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
341
muscles that make up rotator cuff
Supraspinatus, infraspinatus, teres minor, subscapularis
342
how to assess cremaster reflex
lightly stroke or pinch superior inner thigh --> brisk ipsilateral testicular retraction
343
what is blue dot sign
small bluish discoloration seen through skin of upper testis; pathognomonic for appendiceal torsion when tenderness is also present
344
prehn sign
pain relieved by lifting of testicle, indicates epididymitis (testicular torsion is not relieved by lifting testicle)
345
differential for groin pain in an adolescent
- trauma - testicular torsion - torsion of testicular appendages - epididymitis - referred pain (from retrocecal appendicitis) - varicocele, hydrocele - inguinal hernia - testicular tumor - HSP
346
causes of testicular torsion
- 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
347
what two tests can diagnose testicular torsion
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)
348
viability of a torsed testis depends on
duration of torsion and pain
349
treatment of testicular torsion
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.
350
types of testicular tumor
1. Germ cell - seminomatous - nonseminomatous 2. non germ cell 3. extragonadal (lymphoma, leukemia, melanoma are the most common cancers that met to testicle)
351
_____ are most common kind of testicular tumor
germ cell
352
testicular cancer is most common malignancy in males age __
15-35
353
dull aching scrotal pain worse when standing is most likely ___
varicocele
354
surgery should be performed on a diagnosed testicular torsion within __ hours
6
355
functon supraspinatus
assists in abduction
356
function infraspinatus
assists external rotation
357
function teres minor
assists infraspinatous in external rotation
358
function subscapularis
assists internal rotation of shoulder
359
visual appearance of posterior shoulder dislocation
arm adducted and internally rotated
360
visual appearance of anterior shoulder dislocation
fullness of anterior shoulder w/ large dimple in posterior shoulder
361
Two tests for biceps tendinopathy
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
362
clunk test
for labral injury. place one hand at back of glenohumeral joint. rotate arm externally from extension through to forward flexion checking for clunk sound
363
difference between fatigue and sleepiness
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
364
differential of fatigue
- depression - OSA - anemia - occult malignancy - CAD - DM - sleep restriction/inadequate sleep due to life - hypothyroid - chronic fatigue syndrome
365
diagnostic criteria for chronic fatigue syndreom
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
366
response to a pt refusing screening
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?
367
breast self exam USPSTF
NOT recommended- increases rates of biopsy without improving cancer detection or treatment
368
lung cancer screening recommendation
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
369
prostate cancer screening recommendation
grade C | engage in shared decision making for men aged 55-69 years
370
when should routine screening be discontinued
age 75 | sonner if pt has life-limiting health problems such as severe COPD, CHF, or dementia
371
barriers to screening
- 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
372
what can anoscopy detect
fissures and internal hemorrhoids which can be missed with colonoscope
373
risk factors for CRC
- 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,
374
what should a referral letter include
- pt ID info - reason for referral - w/u completed to date - meds, alelrgies, problem list - copies of significant lab/studies
375
colon cancer screening types and timing
- 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
376
mnemonic for delivering bad news
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
377
clinical tools to help stage CRC
- endorectal U/S to assess depth of invasion - CT abd/pelvis (mets) - CXR (mets)
378
most common sites of CRC mets
pelvic lymph nodes liver lung
379
what marker can be used to assess CRC prognosis? what levels are assoc with worse prognosis
CEA > 5
380
what is paroxysmal nocturnal dyspnea
sudden severe SOB at night that awakens a person from sleep, often with coughing and wheezing.
381
paroxysmal nocturnal dyspnea is most closely associated with __
CHF
382
difference between paroxysmal nocturnal dyspnea and orthopnea
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.
383
difference between acute and chronic bronchitis
acute: productive cough lasting 1-3 weeks | chronic bronchitis: productive cough for at least 3 months for the past two years
384
differential for SOB in middle aged man who smokes
COPD asthma acute bronchitis lung cancer
385
classic exam findings of COPD
1. increased AP diameter of chest 2. decr diaphragmatic excursion 3. wheezing (often end-expiratory) 4. prolonged expiratory phase
386
gold standard to diagnose COPD? what is the result?
PFTs | FEV1/FVC ratio less than 70% or 5th percentile AFTER bronchodilator
387
classifying COPD severity
``` FEV1 cutoffs 80-50-30 >80% (mild, GOLD 1) 50-79% (moderate, GOLD 2) 30-49% (severe, GOLD 3) <30% (very severe, GOLD 4) ```
388
differences between COPD and asthma based on history
- asthma sxs vary day to day, sxs more common at night or early morning - COPD symptoms slowly progress
389
symptom management of COPD
- 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
390
side effects of beta agonist overuse
- hypokalemia - tachycardia - tremor
391
clue for COPD caused by alpha-1 antitrypsin deficiency
age younger than 45 | not old enough to have developed the long term effects from smoking
392
things to tell patient about benefits of smoking on COPD
- 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
393
expected change in spirometry after bronchodilation if asthma
increase FEV1 >= 12% after bronchodilation
394
definition of COPD exarcebation
acute change in COPD pt's baseline dyspnea, cough, and/or sputum
395
treatment of COPD exarcebations
inhaled bronchodilators (esp inhaled beta 2 agonists w/ or w/o anticholinergics) + oral glucocorticoids
396
when to give abx for COPD exacerbation
- 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
397
when is O2 indicated for COPD
spo2 < 88%
398
relationship between COPD and heart failure?
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.
399
what immunizations should COPD pt be sure to get
influenza yearly | pneumococcal (PPSV23 age 19-64) (PCV13 then PPSV23 a year later for all adults 65 and up)
400
most common causes of dementia in order
1. alzheimer's 2. vascular dementia (usu have cardiovasc risk factors like HTN, smoking) 3. dementia with lewy bodies
401
main tool to diagnose delirium
Confusion Assessment Method (CAM)
402
What are Instrumental Activities of Daily Living? list some examples
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)
403
possible causes of delirium
infection- urinary, respiratory urinary retention pain depression electrolyte disturbance medication withdrawal (eg etoh, benzos most freq) adverse drug effects acute cerebrovascular events
404
normal vs abnormal postvoid residual volume
< 50 mL <100 mL is acceptable in patients > 65 but abnormal in younger pts > 200 is abnormal
405
medications for alzheimer's
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
406
nonpharmacologic treatment of Alzheimer's
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
407
interventions to slow progression of CAD
- BP control - aspirin when appropriate - statin - beta blockers even if normal BP - immunizations flu and pneumococcal
408
what is acute coronary syndrome
umbrella term to cover any clinical symptoms compatible with acute MI. also includes unstable angina, STEMI, NSTEMI
409
CHF findings on CXR
- 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
410
ACCF/AHA staging of CHF
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
411
firstline treatment for diastolic HF
beta blockers
412
what specific thing on EKG is strongly suggestive of LVH
big S wave in V3
413
can someon have pure systolic or diastolic HF?
can't have pure systolic HF. all pts with systolic dysfunction also have concomitant diastolic dysfunction
414
differential for new onset CHF
- 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
415
types of non-ischemic cardiomyopathy
dilated hypertrophic arrhytmogenic RV dysplasia restrictive cardiomyopathy
416
possible causes of NICM
idiopathic viral toxic (eg ETOH) infiltrative (eg sarcoidosis)
417
what is primary vs secondary dysmenorrhea?
primary dysmenorrhea: painful menses w/o pelvic pathology secondary: painful menses 2/2 some pelvic pathology
418
primary dysmenorrhea associated with increasing amounts of ___
prostaglandins
419
risk factors for primary dysmenorrhea
mood disorders smoking worse state of health stressors
420
dysmenorrhea is more likely to occur with ___ onst of menses
earlier
421
differential for secondary dysmenorrhea
- 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)
422
what is a clinical factor that can differentiate endometriosis from leiomyoma
dyspareunia common in endometriosis, rare with leiomyoma
423
premenstrual syndrome treatment
- 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)
424
SSRI regimen options for PMS
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
425
what is metrorrhagia
irregular bleeding
426
signs of cervical polyp
bleeding after intercourse
427
normal baseline fetal HR
110-160 npm
428
normal baseline fetal HR normal fetal HR variability
110-160 bpm moderate variability between 6-25 bpm changes that are not accels or decels
429
evidence of active labor
- strong regular contractions every three to five minutes | - cervical dilation >6cm in the setting of contractions
430
abs contraindications for digital cervical exam
- 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)
431
steps to decrease maternal blood loss
- 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
432
criteria for preeclampsia
-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
433
evaluation of preeclampsia
r/o HELLP or preexlampsia w/ severe features - renal fnx - liver fnx - CBC for hemoconcentration or thrombocytopenia
434
criteria for preeclampsia with severe features
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
435
what could late decel indicate
uteroplacental insufficiency - baby not getting enough O2, early hypoxemia during contractions
436
management of late decels
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
437
intrapartum fetal HR pattern classification
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
438
caues of postpartum hemorrhage
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
439
apgar scoring
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)
440
what fetal HR tracing might indicate cord compression
variable decels (decr in fetal HR that varies in timing, duration, intensity)
441
when should uncomplicated OM be treated with abx?
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
442
Strep pharyngitis should be treated with __
penicillin
443
When should abx be prescribed for sinusitis
if symptoms have lasted > 7 days | or there is double worsening (symptoms get better, then get suddenly worse)
444
Symptomatic treatment of URI
- decogestant (eg pseudoephedrine) or saline nasal spray for congestion - tylenol for fever and pain - nasal ipratropium spray can slightly reduce rhinorrhea, but not congestion
445
three categories of "dizziness"
1. presyncope- feeling lightheaded or faint 2. disequilibrium- feeling of being off balance 3. vertigo- sensation of room spinning
446
lightheadedness/like i'm going to faint is generally classified as __ and usually caused by __
presyncope' inadequate cerebral perfusion
447
possible etiologies of presyncome
- 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
448
sxs Meniere's disease
classic triad episodes of unilateral hearing loss, tinnitus, vergio
449
where is the problem in central vs peripheral vertigo how can you differentiate between peripheral and central nystagmus
central: CNS peripheral: inner ear or vestibular system peripheral nystagmus improves with gaze fixation
450
common causes of vertigo in primary practice
1. BPPV (most common) | 2. vestibular neuritis, acute labyrinthitis (often preceded by URI)
451
what is vestibular neuritis
when viral (less commonly bacterial) infection of inner ear causes inflammation of vestibular branch of CN 8
452
what is acute labyrinthitis
when an infection affects BOTH branches of CN 8 resulting in tinnitus and/or hearing loss and vertigo
453
what is dix-hallpike and what does it test for
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
454
what is head thrust test and what does it test for
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
455
when is neuroimaging indicated for vertigo
if there is evidence of a central lesion if they have symptoms suggestive of stroke or acute TIA
456
4 ways to manage peripheral vertigo
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
457
what is epley's maneuver for and how do you do it
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.
458
difference between vestibular neuritis and acute labyrinthitis
(both common assoc with recent URI) *acute labyrinthitis has hearing changes
459
vertigo with positive dix-hallpike on the right, negative head thrust test (no saccades elicited) - what's next?
epley maneuver despite negative head thrust, which would suggest central lesion, the dix-hallpike maneuver is diagnostic for BPPV.
460
list three medical condiions that can predispose to obesity
1. cushing's syndrome 2. hypothyroidism 3. hypogonadism
461
list 4 medical conditions associated with obesiy
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)
462
Hb A1c for prediabees
5.7-6.4%
463
causes secondary dyslipidemia
- T2DM - cholestatic or obstructive liver disease (like pbc) - nephrotic syndrome - hypothytoid - acute hepatitis - ETOH - thiazides, beta blockers, oral estrogens, protease inhibitors
464
most effective HDL raising agent
niacin
465
first line therapy for reducing triglycerides
fibric acid derivatives
466
___ should be measured in all pts before starting statin therapy
ALT
467
symptoms of mono? when would you suspect mono?
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
468
what medicaiton should you DEFINITELY AVOID in mononucleosis?
treatment with amoxicillin or ampicillin bc misdiagnosed as strep pharyngitis...90% will develop a classic prolonged, pruritic maculopapular rash!
469
sxs of epiglottitis
- rapid onset in pts 1-6yo - inspiratory stridor, hot potato muffled voice, dysphagia, drooling - clasically tripoding
470
when should you consider diagnosis of pertussis
initial sxs are nonspecific, like common cold consider pertussis when cough has worsened and has been present for at least 2 weeks
471
how long dose i take for positive monospot test
at least 7 days into illness
472
what tshould you do if a rapid strep comes back negative
- in children, negative test should be backed by throat culture - consider backup throat culture in adolescents - adults don't need backup culture
473
options for treating group A strep phayrngitis
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
474
when should vaccines be postponed/withheld?
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
475
what are contraindicatiosn for certain vaccines?
immunodeficiency (either in pt or household member) chemotherapy pregnancy
476
anticipatory guidance for 5 yo well child exam
- 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
477
ADHD diagnosis is not usually made til age __
6 | age-appropriate activiy commonly ymistaken for ADHD in younger children
478
criteria for ADHD
symptoms more freq or severe compared to children of samge age behavior present in at least 2 ssettings, for at least 6 months
479
how to determine if child needs lead screening at 5yo well check
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
480
which children need selective screening for anemia at periodic visits?
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)
481
which children should get annual tuberculin skin test?
- HIV infected | - incarcerated adolescents
482
what is included in questionnaire for determining risk of latent TB in US children
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)
483
what vaccines are due for 5 yo
DTaP booster IPV (polio) MMR Varicella
484
first does of meningococcal vaccine given at age __
11-12
485
first HPV vaccine given age ___
at least 9 years old
486
rotavirus vaccine age
must be started before 15 weeks and completed by 8 months of age
487
vaccine requiremens before starting elementary schools
``` 2 MMR 2 varicella 3 Hep B (hep has three letters) 4 polio (you have four extremities, polio can affect extremities 5 DTaP ```
488
definition of Small for Gestational Age
weight below 10th percentiel for gestational age
489
what is term pregnancy
born at > 37 weeks
490
SGA babies are at risk for?
hypothermia hypoglycemia polycythemia
491
Which medications are routinely given to newborns and why?
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
492
difference in timing of gonococcal vs chlamydial eye infection in new borns?
chlamydia occurs later, 1-2 weeks after birth
493
causes of absent red reflex in newborn
congenital cataracts | retinoblastoma
494
causes of chorioretinitis in newborn
congenital toxo, CMV
495
possible effects of maternal anticonvulsant use on newborn
``` cardiac defects dysmorphic craniofacial features hypoplastic nails and distal phalanges IUGR microcephaly ```
496
newborn with irritability, hyperactivity, hypertonicity can be due to __
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)
497
presentation of symptomatic congenital CMV infection
``` microcephaly jaundice petechiae hepatosplenomegaly low birth weight ```
498
presentation of congenital rubella
sensorineural deafness eye abnormalities patent ductus arteriosus
499
normal infants will lose up to 10% of their birth weight in ___. they should return to normal birth weight by __.
first several days after delivery; 2 weeks
500
differential of fussy infant
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
501
definition colic
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
502
hallmark of GERD in infants
dribbling milk afer feeds | no sign of distress
503
signs of intussuscepion | when does it tpresent
afer 3 monhs of life sudden on se, severe, paroxysmal colicky pain recurring at freq inerrvervals
504
it can ake up o __ (ime) afer deliver for signific milk producttion
72
505
it can take up to __ (time) after deliver for signific milk producttion
72
506
exclusivel or partially breastfed babies should received __ supplement
400 units vitamin D daily starting soon after birth
507
caloric requirement for preterm 1-2 month old
115-130
508
caloric req very preterm 1-2 month old
up to 150 kcal
509
babies are read to begin spoon feeding solids at age __
4-6 montths
510
children should sit in rear facing carseats until age __
2
511
6 mo developmental milestones
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)
512
12 month developmental milesotnes
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
513
most freq diagnosed neoplasm in infanst
neuroblastoma
514
5 month old- born w/ macrocephaly, macroglossia, hypospadias. abdominal mass palpaed, does not cross midline. diagnosis?
wilm's tumor - commonly a/w Beckwith-Wiedemann syndrome! (a genetic overgrowth syndrome)
515
favorable prognostic factors of neuroblastoma
- younger age (eg <18 months good prog even witth disseminated disease) - non amplification of myc gene
516
histology in neuroblastomas
small blue cells forming pseudorosettes
517
3 yo developmental milestones
-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
518
4 yo developmental milestones
- 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
519
5 yo developmental milestones
- 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
520
children should be screened for anemia a age __ using ___
12 months | fingerstick Hgb/Hct
521
possible eiologies dry cough vs wet cough
dry: environmental irritant, asthma wet: lower respiratory infection
522
causes of barking cough
croup subglotic disease FB
523
casues of brass or honking cough
habitial cough | tracheitis
524
causes paorxysmal cough
pertussis chlamydia mycoplasma FB
525
causes cough worse at night
asthma sinusitis postnasal drip
526
intermitent vs mild vs moderate persistent asthma
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
527
what is considered chronic cough
> 3 weeks
528
next step for all children with chronic cough
CXR
529
treatment of mild persistent asthma
SABA plus low dose ICS
530
when is LABA used in asthma
reserved for severe persisent asthma - sxs throughout the day, awakenings every night
531
defects assoc with taking anticonvulsants during pregnancy
cardiac defects dysmorphic craniofacial features hypoplastic nails and distal phalanges IUGR, microcephaly
532
signs of newborn opiate withdrawal
CNS- irritability, hyperactivity, hypertonicity incessant high-pitched cry, tremors, seizures GI- vomiting, diarrhea, poor feeding, incessant hnunger, salivation nasal stuffiness, sneezing, awning
533
list three adverse effects of ADHD meds
- suppress appetite - decrease growth velocity - insomnia (typically worse in the firs days of med)
534
when should children be screening for DM
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
535
causes of secondary HTN in children
- 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)
536
how o differentiate between weight gain vs underlying endocrine disorder
endocrine disease that cause weight gain usually limit growth and lead to short stature
537
what ECG changes suggest coronary artery disease
- horizontal ST depression or downsloping ST - convex ST elevation - Q waves
538
diet additions to lower heart disease risk
fish twice a week | oils in tofu, soyfbeans, flaxseeds, walnuts
539
technique for taking BP
- 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
540
when should 2 BP meds be initiated for newly diagnosed HTN
>20/10 above goal
541
initial testing for new diagnosis of HTN
- 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)
542
Questions to help assess a patient's understanding of their illness
- 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?
543
how does MODERATE alcohol consumption affect BP?
decreases BP 2-3mmHg (but don't encourage ps to start drinking alcohol for this lol)
544
what is cardiac sndrome X
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
545
course of action for pt presenting with unstable angina
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