Aquifer Flashcards
Ottawa ankle rules
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
Cervical cancer screening guidelines by age group
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)
Risk groups that need more freq cervical cancer screening
- 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
criteria for stopping cervical cancer screening in women >65
adequate screening within the last 10 years, ie 3 consecutive normal pap with cytology OR 2 consecutive normal pap with HPV testing
Screening mammography criteria
Every 2 years for women age 50-74
Screening mammography criteria
Biennially for women age 50-74
What tool can you use to individualize recommendations for mammogram?
Gail criteria
When should Tdap be given in adults?
Tdap should replace a single dose of Td for adults age 19-64 who have not previously received Tdap
Perimenopausal symptoms due to estrogen deficiency
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
Osteoporosis screening guidelines
DEXA for >65
for <65 use WHO fx assessment tool to risk stratify. screen if risk of fx >9.3 percent over 10 years.
Osteoporosis risk factors
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
Adult physical activity guidelines
each week:
150 minutes moderate-intensity exercise OR
75 minutes vigrous exercise OR
combination of both
incorporate strengthening exercises at least twice a week
smoking cessation strategies
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
Pap smear adequacy
> 5000 squamous cells
sufficient endocervical cells
Pap smear results
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
Indications for exercise stress testing
asymptomatic males >45 with one or more risk factors )hypercholest, HTN, smoking, FHx premature CAD) may get useful prognostic info from exercise testing
frequency of fasting lipid screen
adults >21 every 4-6 years lipid screening and reassess ASCVD risk
fasting- at least 8 hours after last food intake
Side effects of SSRIs/SNRIs
headache GI- nausea, diarrhea sleep disturbances- drowsiness, insomnia (infrequently) SIADH sexual dysfunction serotonin syndrome
common causes of insomnia in the elderly
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
diagnostic criteria for major depressive disorder
depressed mood or anhedonia PLUS at least five of SIGECAPS, present for at least 2 weeks
most common means of suicide in the elderly
drug overdose
labs or studies that can be done to rule out medical causes of insomnia, fatigue, and depression
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
SAFE-T (Suicide Assessment Five Step Evaluation and Triage) components
- Risk factors
- Protective Factors
- Suicide inquiry- thoughts, plans, behaviors, intent
- Risk level/intervention
- Document- risk level and rational, trreatment plan to address/reduce current risk, firearms instructions if relevant, followup.
adult depression screening
PHQ-2:
over the past 2 weeks, have you often been bothered by
- Little interest or pleasure in doing things, or
- 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)
Dementia screening tool
Mini-Cog (faster, more sens and specific than MMSE)
risk factors for elder abuse:
- Dementia.
- Shared living situation of elder and abuser (except in financial abuse).
- Caregiver substance abuse or mental illness.
- 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. - Social isolation of the elder from people other than the abuser.
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
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
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)
6 signs of limb-threatening injury
6 P’s
pain pallor pulselessness paresthesia perishing cold (unable to regulate body temp) paralysis
Earliest sign of compartment syndrome
pain, esp disproportionate
Most reliable sign of compartment syndrome
paresthesias (skin sensation such as burning, prickling, itching, tingling)
Most common mechanism of ankle injury
combination of planter flexion and inversion
Most often damaged ankle ligaments
the lateral stabilizing ligaments
- anterior talofibular
- calcaneofibular
- posterior talofibular (strongest, rarely injury in inversion)
Most easily injured ankle ligament
anterior talofibular
ankle anterior drawer test assesses __.
anterior talofibular ligament
ankle inversion stress test assesses __
calcaneofibular ligament
Mechanism of medial ankle sprain
excessive eversion and dorsiflexion
medial ankle sprains are uncommon because of __
bony articulation between medial malleoulus and talus
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
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
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
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
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.
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
TMP-SMP can be prescribed for uncomplicated UTI but consider other options if greater than __ percent resistance
20%
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
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
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
mildly elevated TSH / normal T4
subclinical hypothyroidism
inappropr normal TSH / high T4
pituitary adenoma
or thyroid hormone resistance
decr TSH / normal T4, high T3
T3 toxicosis
decr TSH / decr T4
central/pituitary hypothyroidism (TSH and/or TRH deficiency)
Graves disease cause _% of hyperthyroidism
60-80%
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!
Graves disease antibodies
anti thyrotropin receptor (TRAb) - TSH receptor
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.
causes of hyperthyroidism with low RAIU
subacute thyroiditis silent thyroiditis iodine induced exogenous L-thyroxine struma ovarii amiodarone
microvascular complications DM
retinopathy
nephropathy
neuropathy- sensory, motor (ankle jerk reflex), autonomic (sex, gastroparesis)
macrovascular complications DM
CAD
CVA
PAD
goal BP in diabetics with HTN
<130/80
start statin for DM with LDL __
> 70
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
Diagnostic criteria for DM
- random BG >=200 plus symptoms of hyperglycemia (eg polyuria, unexplained weight loss) or hyperglycemic crisis
- fasting plasma glucose > 126
- Hgb A1c >= 6.5%
- 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
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
DM optimal blood glucose
fasting: 80-120
postprandial 1-2h after meal: <180
__ is the single greatest contributor to death in the US
smoking
__ is the largest risk factor for cardiovascular mortality in the US
HTN
Majority of deaths from DM are from __ and __
increase in cardiovascular disease; chronic renal failure
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
Course of action when goal INR is substantially overshot
Hold warfarin and give oral dose of Vitamin K
Grade 1 ulcer
diabetic ulcer, superficial
Grade 2 ulcer
ulcer extension - involving ligament, tendon, joint capsule, or fascia
Grade 3 ulcer
deep ulcer with abscess or osteomyelitis
Grade 4 ulcer
gangrene forefoot (partial)
Grade 5 ulcer
extensive gangrene of foot
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
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
Grade 5 ulcer management
emergent hospitalization and surgical consultation, often resulting in amputation
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)
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
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)
when would you choose unfractionated heparin over LMWH for DVT therapy?
patient with a significant bleeding risk (eg recent admit for GI bleeding)
What three agents can be used to treat DVT after stabilization?
- warfarin
- Factor Xa inhibitors (fondaparinux, rivaroxaban, apixaban)
- Direct thrombin inhibitor (dabigatran)
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
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
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
3 overarching goals of DVT therapy
- immediately stop growth of thromboemboli (heparin)
- promote thromboembolic resolution
- prevent recurrence
When is extended anticoagulation indicated after a DVT or PE?
active cancer (no scheduled stop date)
When are patients anticoagulated indefinitely after DVT or PE?
pts with inherited coagulation disorders
Which pts are likely to benefit from screening for inherited thrombophilia?
- initial thrombosis prior to age 50 without obvious risk factor
- FHx VTE
- recurrent venous thrmbosis
- thrombosis in unusual vascular beds eg portal, hepatic, mesenteric, cerebral veins
main use of D-dimer
exclude thromboembolic disease where the probability is LOW
test with best sensitivity and specificity for DVT
venous doppler lower extremity
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)
Wells criteria cutoffs for DVT probability
0: low prob
1-2: moderate
3 or more: high
Differential for unilateral LE edema
lymphedema cellulitis DVT venous insufficiency PAD
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
what qualifies as family history of premature CVD
men <55
women <65
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
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
weight loss reduces BP by __
1 mmHg per kilogram of loss
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
Dietary sodium reduction by __% (about __mg per day) reduces BP by __
25%; 1000mg per day
4-6 mmHg
(no added sodium)
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
-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)
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
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
which antihypertensives should be avoided in pregnant women or reprod-age not on contraception?
ARBs
4 chest pain characteristics that decr likelihood of ACS
4 P’s
- pleuritic - worsened by respiration
- pulsating
- positional
- reproduced by palpation
stabbing pain
5 possible causes pleuritic CP
PE, PTX, viral or idiopathic pleurisy, PNA, pleuropericarditis
list 6 independent risk factors for coronary heart disease
- HDL <40
- DM
- Smoking
- history premature CHD in a first degree relative
- sedentary lifestyle
- obesity
PQRST mnemonic for CC like chest pain
Provocation/Palliation Quality Region/Radiation Severity Timing Symptoms associated
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
4 items that can suggest cardiac cause of palpitations
- duration greater than 5 min
- description of irregular beat (ex pt can tap it out with fingers)
- previous history of heart disease
- male sex
history of palpitations during __ or __ increase likelihood that arrythmia is cause
sleep; work
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)
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
Disc herniation is classically exacerbated by __ and relieved by __
exac sitting or bending; relieved by lying or standing
increased pain with coughing and sneezing suggests __
disc herniation
Inidications of imaging for back pain
- progressive neuro deficits
- not responding to conservative treatment
- red flags
Back pain CANCER red flags
- h/o cancer
- > 10kg unexplained weight loss within 6 months
- age >50 or <17
- pain persists for more than 4-6wks
- night pain or Pain at rest
back pain INFECTION red flags
- persistent fever >100.4
- h/o IVDA
- recent bacterial infection, particularly bacteremia (UTI, cellulitis, PNA)
- immunocompromised (chornic steroid use, DM, HIV)
red flags CAUDA EQUINA SYNDROME
- urinary incont or retention
- Anal sphincter tone decr or fecal intont
- saddle anesthesia
- BL LE weakness or numbness
- progressive neuro deficits
red flags SIGNIFICANT herniated nucleus pulposus
- major muscle weakness (3/5 strength or less)
2. foot drop
red flags VERTEBRAL FX
- prolonged corticosteroid use
- mild traumage age >50
- age >70
- h/o osteoporosis
- recent significant trauma any age (MVC, fall from substantial height)
- previous vertebral fx
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
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
Most low back pain resolves within ___
one month
Back exam should be performed sequentially in what positions
- standing
- sitting
- supine
Difficulty with heel walk associated with __ disc herniation
L5
*note: expect normal gait even with disc herniation
Difficulty with toe walk associated with __ disc herniation
S1
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
Restricted and painful lumbar flexion suggestive of __ (3)
herniation
OA, or
muscle spasm
pain with lumbar extension suggestive of _
spinal stenosis or degenerative disease
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
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
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
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 ?
- 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.
- Imaging has risks
- 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.
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)
SLR pain earlier than __ degrees suggestive of malingering.
30
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
normal leg can be raise __ degrees
80
what is positive passive SLR
pain radiating down posterior/lateral thigh past knee
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
3 components of conservative therapy for LBP
- pharmacologic- NSAID and/or muscle relaxant
- local heat/cold therapy
- activity- stay active / PT
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
when and what labs should you order for LBP?
labs generally not needed
CBC and ESR if suspect tumor or infection
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
OA often affects __, ___, and ___
knees, hips, back
RA typically affects __ or more joints, often including __ and __
3
hands, feet
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
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
Simple knee joint effusion produces __ colored fluid. Can occur in what conditions
clear, straw-colored
OA, degenerative meniscal injuries
Bloody knee aspirate can be associated with __ or ___
knee sprain (ie ACL, PCL) acute meniscal tear
Knee aspirate with blood and fat globules caused by __
osteochondral fracture
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
Initial management of OA
Exercise / PT! guidelines strongly recommend
Weight loss if obese
One time ultrasound screen for AAA recommended in what group
MEN age 65-75 with history of smoking
Lachman test assesses __
stability of ACL
Tinel’s test
tap over median nerve to reproduce sxs
Phalen’s test
flex wrist by having pt put dorsal surfaces of hands together for 30-60 seconds to reprod sxs
Durkan’s sign
compress carpal tunnel for 30 seconds to reproduce sxs
*most sensitive and specific out of three physical exam tests
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
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
when could you get a knee XR to assess osteoarthritis?
- diagnosis uncertain
- to evaluate severity/location of OA
- no improvement with conservative treatment
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)
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
on knee XR:
____ correlate best with pain
____ best predicts disease progression
patellofemoral and tibiofemoral joint osteophytes- pain
joint space narrowing- progression
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
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
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
Pts with chronic pain should be screened and treated for __
comorbid depression
there are high rates of depression among pts with chronic pain.
colon cancer screening recommended for pts age __
50-75
mammogram screening recommended __ (frequency) for pts age ___
once every two years
50-74
Community residents aged ___ should be encouraged to ___
exercise to prevent falls
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
what condition should you ask about before prescribing tramadol
seizures
can lower seizure threshold
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
USPSTF recommendations for chlamydia screening
All sexually active women 24 and younger
Sexually active women 25 and older who are at increased risk
Risk factors for chlamydial infection
- h/o chlamydia
- new or multiple sex partners
- inconsistent condom use
- exchanging sex for money or drugs
All women (normal risk) planning or capable of pregnancy should take supplement with ___ (amount) folic acid
400-800 mcg
Women with __ should take 1mg folic acid
DM or epilepsy
Women who’ve had a child with previous neural tube defect should take ___mg folic acid
4
Preconception counseling should include screening for what diseases
- sickle cell
- thalassemia
- tay sachs
- CF (fam hx)
- nonsyndromic hearing loss (connexin-26) (fam hx)
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
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
Pelvic exam signs of pregnancy
- softening of cervix
- softening of uterus
- blue-purple cervix and vaginal walls (hyperemia)
Naegele’s rule to calculate estimate due date
first day of LMP
add 1 year, subtract 3 months, add 1 week
First sign of significant bleed
increased pulse
bleeding can continue for a while before blood pressure drops
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
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
adolescent interview mnemonic
Home Education/employment Eating Activities Drugs Sexuality Suicide/depression Safety/violence
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.
What should you not forget to do in an abortion?
confirm Rh negative patients have gotten RhoGam
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
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
progesterone level __ highly assoc with sustainable IUP
> 25
progresterone level __ highly associated with evolving miscarriage or ectopic pregnancy
<5
may be not be able to detect IUP until b-hCG reaches __
1500-1800 (transvaginal)
detection of IUP by transabdominal U/S needs b-hCG level __
> 5000
in normal pregnancy, b-hCG doubles every __ in the first __ weeks of gestation
48 hours; 6-7 weeks
molar pregnancies may have b-hCG around ___
10,000
what is threatened abortion?
bleeding before 20 weeks
inevitable abortion
dilated cervical os. everything still in uterus
incomplete abortion
some but not all intrauterine contents expelled
missed abortion
fetal demise without cervical dilation or uterine activity
often found incidentally on U/S without presentation of bleeding
septic abortion
with intrauterine infection- usu have abdominal tenderness and fever
complete abortion
products of conception completely expelled from uterus
three most common causes of bleeding in early pregnancy
- spontaneous abortion
- ectopic
- idiopathic bleeding in a viable pregnancy
management of stable patient who complains of vaginal bleeding in pregnancy
serial quant b-hCG and ultrasounds
uterine fundus rises 1cm for every week of pregnancy after __ weeks
20
when should RhoGam be given for Rh neg pts?
- 24 weeks
- 72h after gestation
- with any episodes of vaginal or intrauterine bleeding
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
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
Screening for gestational diabetes should be performed at ___ weeks with ___
24-28 weeks
1 hour glucose tolerance test
symptoms of severe preeclampsia
- visual disturbance
- severe HA
- RUQ or epigastric pain
- N/V
- decr UOP
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
postpartum blues typically last __
2 weeks
screening for gestational DM is positive if
fasting glucose >126
OR 1 hour glucose >130 or 140
pregnant women should be tested for GBS at __ weeks with ___. IF positive, treat with __ (__alternative)
36 weeks; vaginal and rectal swab; penicillin; ampicillin alternative
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
next step for biliary colic
surgical consult for elective cholecystectomy
waiting is not appropr, can lead to complications down the line
moderate drinking definition
up to 1 drink per day (women)
or 2 drinks per day (men)
binge drinking
five or more drinks on one occasion for one or more days in a 30-day period
heavy drinking
five or more drinks on one occasion for five or more days in a 30-day period
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)
AUDIT-C screening
- How often did you have a drink containing alcohol in the past year
- How many drinks did you have on a typical day?
- How often did you have 6 or more drinks at one time in the past year?
moderate evidence to support medications __ and __ for treating alcohol use disorder
naltrexone, acamprosate
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
differential for RUQ abdominal piain
- duodenal ulcer
- hepatitis
- biliary colic
- cholecystitis
- pancreatitis
macule
flat change in skin color <1cm
patch
macule greater than 1cm
what skin fungal infections require systemic antifungals?
tinea capitis (topical therapies can’t penetrate infected hair shaft)
tinea unguium (onychomycosis)
plaque
elevated flat lesion >1cn
papule
small raised palpable lesions <1cm
symptoms of prostatitis
pain (lower abdomen, testicles, penis, wih ejaculation)
bladder irritaiton
bladder outlet obstruction
sometimes blood in semen
atopic eczema involves __ surfaces
flexor
what are annular lesions
what conditions might you see them
circular with normal skin in the center
drug eruptions, secondary syphilis, SLE
linear arrangement of lesions can indicate __
contact reaction
what are zostiform lesions
arranged along cutaneous distribution of a spinal nerve
eczema treatment
steroid cream
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.
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
most widely used treatment of SCC
surgical excision
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
___ decrease BPH urinary symptoms
alpha-adrenergic antagonists (“-zosin”) - causes muscles of urethra to relax
___ decrease prostate size
5a-reductase inhibitors (finasteride, dutasteride)
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
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
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
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
bleeding with hormone replacement can be normal in the first ___ (timeframe)
12 months
bleeding after 12 months always needs investigation
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
physical exam for AUB
- pelvix exam
- neck - thyroid
- skin - bruises (evidence bleeding disorder), jaundice
- abdomen - hepatomegaly (coagulopathy from liver disease)
endometrium thickness __ is reassuring that a pt does not have endometrial cancer
<4mm
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.
postmenopausal women should get ___ calcium and ___ vitamin D in their diet
1200mg calcium
800-1000 IU vitamin D
BMD t-score classification
0 to -1 normal
-1 to -2.5 osteopenia
below -2.5 osteoporosis
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
alternatives for HRT for hot flashes
SSRI/SNRI
gabapentin, clonidine
using combined estrogen/progesterone beyond __ (timeframe) increases risk of breast cancer
3 years
definition of menopause is no period after __ (timeframe)
12 months
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
what is considered late menopause
what is considered early menarche
after age 52
before age 12
tx local vaginal pruritis, dryness
topical estrogen- cream or ring
risk factors to consider before starting hormone therapy
- age
- family or personal h/o heart disease, sroke, breas cancer, blood clots, osteoporosis
- meds
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
characteristics of migraine
pulsating/throbbing
unilateral
photophobia, phonophobia
last few hours to few days, typically not more than a week
two migraine specific medications
triptans
ergot alkaloids
what older medication is NOT recommended for migraines? why?
fioricet (acetaminophen/butalbital/caffeine)
Fiorinal (aspirin/buttalbital/caffeine)
–> increased risk of overuse
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
best two options for migraine ppx
propranolol
amytriptylline (TCA)
*divalproex and topiramate have signific possible side effects and are expensive
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
characteristics of tension headaches
hatband distribution = includes occipital area of head; BL
tight/squeezing pain
tx rebound headaches
discontinue analgesics
**Counsel that headaches may worsen before resolving over time
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
meds/substances that can trigger tension and migrain HA
- estrogen (birth control. HRT)
- tobacco, too much caffeine, ETOH
- aspartame and phenylalanine (from diet sodea)
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
4 things you can tell patients to do for migraine and tension HA
- headache diary - track severity, effective treatments, triggers
- caffeine can help but excess can worsen esp when coming off of it
- sleep- regular routine, try sleep same time q night
- relieve stress (meditation, set limits on other people’s expectations, moderate reg exercise, sleep)
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
CI ergotamines
- concurrent use of triptans
- heart disease or angina, HTN, PVD
- renal insufficiency
- pregnancy, breastfeeding
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
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
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
how is H. pylori thought to be spread?
fecal-oral transmission during childhood in underdeveloped countries
prevalence is decreasing worldwide
2 acceptable treatment options for h. pylori
triple therapy- ppi, amox, clarithro 10-14d
OR quadruple therapy- ppi, metronidazole, tetracycline, bismuth subsalicylate 10-14d
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
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
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)
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
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
after h pylori ruled out, what therapies are there for functional dyspepsia?
TCAs
various herbal remedies but not enough evidence to make a recommendation
what can cause false positive guaiac tests
-diet high in red meat, iron, vitamin C
gold standard test to confirm GERD
24 hour pH probe
this test not usually required to diagnose GERD
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 :
- related to defecation
- a/w change in stool frequency
- a/w change in stool form
*diagnosis based on history, exam, and absence of alarm symptoms
initial steps in management of IBS
behavioral therapies and exercise
discuss diet
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
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
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
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
- sit in chair with back against chair and arms resting in lap
- without using your arms, stand up from chair and walk 10 ft
- turn around, walk back to chair, and sit down
TUG __ seconds indicates impaired mobility
> 30 seconds
FAST test for stroke
Facial droop
Arm weakness
Speech difficulty
Time to call emergency services
what is one of the most sensitive tests for UE weakness
pronator drift
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
stroke sxs must have occurred less than ___ hours to consider giving tPA
4.5
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
symptoms L MCA stroke
- expressive and receptive aphasia
- R facial weakness
mechanisms of TIA or possible stroke
- embolic = from heart and carotid
- thrombotic (vascular occlusion)
- cardiogenic - decr in cerebral perfusion dt decr cardiac output, severe hypotension, or hypoxemia
- hemorrhagic- pathologic cerebrovascular changes in brain attributable to aging, smoking, htn, hld
- heme- hyperviscosity or myeloproliferative syndromes, vascular obstruction (sickle cell), hypercoagulable states
- Vascular- htn leading to thrombosis or bleeding, compression of cranial vessels, vasospasm, vasculitis
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
options to prevent first stroke in pt with AF
- warfarin (target INR 2-3) - rec for all pts w/ nonvalvular AF who can get it safely
- antiplt therapy with aspirin
- 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
- direct oral anticoagulants like dabigatran and rivaroxaban - very expensive, need careful adherence to prevent lapses in anticoag protection
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
goal BP after a stroke
130/80
tx hyperlipidemia in tia/stroke pt
high intensity statin ie atorva 40 or 80, or rosuva 20
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
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
physical exam of neuro sxs
- CN 7
- auscultate carotids for bruits
- romberg
- cardiopulm
- gross visual fields
- proprioception
- mental status exam
- strength
- ECG
severe or life threatening causes of abdominal pain
- appendicitis
- hepatitis
- pancreatitis
- ovarian pathology (torsion, ruptured cyst)
- ectopic preg
- normal preg
- PID
- trauma
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
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)
most common complications of flu
OM
PNA
signals of influenza complications
- sxs last 5-7d without any relief
- diff breathing
- worsening cough
- difficulty maintaining hydration
what BMI is considered overweight for children? obese?
overweight 85-95th percentile
obese > 95 percentile
what words are most motivating for change for weight counseling
unhealthy weight
weight problem
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
HLD screening for children
-every child with NMI >85th percentile. Goal total cholest 170, LDL 130
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
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
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)
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
pulmonary findings indicating consolidation
- egophony (when pt says E, examiner hears A)
- tactile fremitus (increased areas of vibration indic consolidation, decr vibration indic effusion)
- dullness to percussion
- crackles
- whispered pectoriloquy (whispered words heard louder over areas of consolidation)
how to distinguish acute URI from acute bronchitis
in acute bronchitis, coughing lasts for more than 5 days
non MSK causes of shoulder pain
- MI
- lung cancer
- cholecystitis
- ruptured ectopic
referred pain
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
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
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)
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
anatomic stabilizers of shoulder joint
- labrum (increases articulating surface area and depth of glenoid fossa)
- rotator muscle group
- glenohumeral ligaments
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
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
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
muscles that make up rotator cuff
Supraspinatus, infraspinatus, teres minor, subscapularis
how to assess cremaster reflex
lightly stroke or pinch superior inner thigh –> brisk ipsilateral testicular retraction
what is blue dot sign
small bluish discoloration seen through skin of upper testis; pathognomonic for appendiceal torsion when tenderness is also present
prehn sign
pain relieved by lifting of testicle, indicates epididymitis (testicular torsion is not relieved by lifting testicle)
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
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
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)
viability of a torsed testis depends on
duration of torsion and pain
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.
types of testicular tumor
- Germ cell
- seminomatous
- nonseminomatous - non germ cell
- extragonadal (lymphoma, leukemia, melanoma are the most common cancers that met to testicle)
_____ are most common kind of testicular tumor
germ cell
testicular cancer is most common malignancy in males age __
15-35
dull aching scrotal pain worse when standing is most likely ___
varicocele
surgery should be performed on a diagnosed testicular torsion within __ hours
6
functon supraspinatus
assists in abduction
function infraspinatus
assists external rotation
function teres minor
assists infraspinatous in external rotation
function subscapularis
assists internal rotation of shoulder
visual appearance of posterior shoulder dislocation
arm adducted and internally rotated
visual appearance of anterior shoulder dislocation
fullness of anterior shoulder w/ large dimple in posterior shoulder
Two tests for biceps tendinopathy
- speed’s test - arm in front in 60 degrees of flexion, supinated. resist forward flexion of arm while palpating biceps tendon
- yergason’s test - grap pt wrist and resist pt attempt to active supinate the arm and flex the elbow
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
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
differential of fatigue
- depression
- OSA
- anemia
- occult malignancy
- CAD
- DM
- sleep restriction/inadequate sleep due to life
- hypothyroid
- chronic fatigue syndrome
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
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?
breast self exam USPSTF
NOT recommended- increases rates of biopsy without improving cancer detection or treatment
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
prostate cancer screening recommendation
grade C
engage in shared decision making for men aged 55-69 years
when should routine screening be discontinued
age 75
sonner if pt has life-limiting health problems such as severe COPD, CHF, or dementia
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
what can anoscopy detect
fissures and internal hemorrhoids which can be missed with colonoscope
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,
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
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
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
clinical tools to help stage CRC
- endorectal U/S to assess depth of invasion
- CT abd/pelvis (mets)
- CXR (mets)
most common sites of CRC mets
pelvic lymph nodes
liver
lung
what marker can be used to assess CRC prognosis? what levels are assoc with worse prognosis
CEA > 5
what is paroxysmal nocturnal dyspnea
sudden severe SOB at night that awakens a person from sleep, often with coughing and wheezing.
paroxysmal nocturnal dyspnea is most closely associated with __
CHF
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.
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
differential for SOB in middle aged man who smokes
COPD
asthma
acute bronchitis
lung cancer
classic exam findings of COPD
- increased AP diameter of chest
- decr diaphragmatic excursion
- wheezing (often end-expiratory)
- prolonged expiratory phase
gold standard to diagnose COPD? what is the result?
PFTs
FEV1/FVC ratio less than 70% or 5th percentile AFTER bronchodilator
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)
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
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
side effects of beta agonist overuse
- hypokalemia
- tachycardia
- tremor
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
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
expected change in spirometry after bronchodilation if asthma
increase FEV1 >= 12% after bronchodilation
definition of COPD exarcebation
acute change in COPD pt’s baseline dyspnea, cough, and/or sputum
treatment of COPD exarcebations
inhaled bronchodilators (esp inhaled beta 2 agonists w/ or w/o anticholinergics) + oral glucocorticoids
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
when is O2 indicated for COPD
spo2 < 88%
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.
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)
most common causes of dementia in order
- alzheimer’s
- vascular dementia (usu have cardiovasc risk factors like HTN, smoking)
- dementia with lewy bodies
main tool to diagnose delirium
Confusion Assessment Method (CAM)
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)
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
normal vs abnormal postvoid residual volume
< 50 mL
<100 mL is acceptable in patients > 65 but abnormal in younger pts
> 200 is abnormal
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
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
interventions to slow progression of CAD
- BP control
- aspirin when appropriate
- statin
- beta blockers even if normal BP
- immunizations flu and pneumococcal
what is acute coronary syndrome
umbrella term to cover any clinical symptoms compatible with acute MI. also includes unstable angina, STEMI, NSTEMI
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
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
firstline treatment for diastolic HF
beta blockers
what specific thing on EKG is strongly suggestive of LVH
big S wave in V3
can someon have pure systolic or diastolic HF?
can’t have pure systolic HF. all pts with systolic dysfunction also have concomitant diastolic dysfunction
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
types of non-ischemic cardiomyopathy
dilated
hypertrophic
arrhytmogenic RV dysplasia
restrictive cardiomyopathy
possible causes of NICM
idiopathic
viral
toxic (eg ETOH)
infiltrative (eg sarcoidosis)
what is primary vs secondary dysmenorrhea?
primary dysmenorrhea: painful menses w/o pelvic pathology
secondary: painful menses 2/2 some pelvic pathology
primary dysmenorrhea associated with increasing amounts of ___
prostaglandins
risk factors for primary dysmenorrhea
mood disorders
smoking
worse state of health
stressors
dysmenorrhea is more likely to occur with ___ onst of menses
earlier
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)
what is a clinical factor that can differentiate endometriosis from leiomyoma
dyspareunia common in endometriosis, rare with leiomyoma
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)
SSRI regimen options for PMS
- 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
what is metrorrhagia
irregular bleeding
signs of cervical polyp
bleeding after intercourse
normal baseline fetal HR
110-160 npm
normal baseline fetal HR
normal fetal HR variability
110-160 bpm
moderate variability between 6-25 bpm changes that are not accels or decels
evidence of active labor
- strong regular contractions every three to five minutes
- cervical dilation >6cm in the setting of contractions
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)
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
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
evaluation of preeclampsia
r/o HELLP or preexlampsia w/ severe features
- renal fnx
- liver fnx
- CBC for hemoconcentration or thrombocytopenia
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
what could late decel indicate
uteroplacental insufficiency - baby not getting enough O2, early hypoxemia during contractions
management of late decels
- continous fetal monitoring
- position mom on side to decr pressure on vena cava and incr blood flow to heart, max CO and blood flow to uterus
- monitor BP. if low, may benefit from fluid bolus
- O2 face mask. no clear supporting evidence, but doesn’t cause harm
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
caues of postpartum hemorrhage
the $ T’s (most common first)
- Tone- uterine atony leading to continued bleeding
- Trauma- perineal or cervical lacs, uterine inversion
- Tissue- retained or invasive placental tissue in uterus
- Thrombin- a bleeding disorder- much less common than other three causes
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)
what fetal HR tracing might indicate cord compression
variable decels (decr in fetal HR that varies in timing, duration, intensity)
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
Strep pharyngitis should be treated with __
penicillin
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)
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
three categories of “dizziness”
- presyncope- feeling lightheaded or faint
- disequilibrium- feeling of being off balance
- vertigo- sensation of room spinning
lightheadedness/like i’m going to faint is generally classified as __ and usually caused by __
presyncope’ inadequate cerebral perfusion
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
sxs Meniere’s disease
classic triad
episodes of unilateral hearing loss, tinnitus, vergio
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
common causes of vertigo in primary practice
- BPPV (most common)
2. vestibular neuritis, acute labyrinthitis (often preceded by URI)
what is vestibular neuritis
when viral (less commonly bacterial) infection of inner ear causes inflammation of vestibular branch of CN 8
what is acute labyrinthitis
when an infection affects BOTH branches of CN 8 resulting in tinnitus and/or hearing loss and vertigo
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
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
when is neuroimaging indicated for vertigo
if there is evidence of a central lesion
if they have symptoms suggestive of stroke or acute TIA
4 ways to manage peripheral vertigo
- diuretics and low salt diet to decr endolymph- commonly used to tx meniere’s.
- Epley maneuver (canalith repositioning) - for BPPV.
- vestibular rehab
- vestibular suppressant medications - meclizine, dimenhydrinate (anticholinergic vestibular suppresants)
anti-emetics can be used as adjuncts
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.
difference between vestibular neuritis and acute labyrinthitis
(both common assoc with recent URI)
*acute labyrinthitis has hearing changes
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.
list three medical condiions that can predispose to obesity
- cushing’s syndrome
- hypothyroidism
- hypogonadism
list 4 medical conditions associated with obesiy
ask about symptoms of these
- sleep apnea (snoring, datime somnolence, morning HA)
- cardiovascular disease (chest pain or pressure, dyspnea)
- cerebrovascular disease (changes in vision, focal neuro sxs)
- peripheral vascular disease (claudication)
Hb A1c for prediabees
5.7-6.4%
causes secondary dyslipidemia
- T2DM
- cholestatic or obstructive liver disease (like pbc)
- nephrotic syndrome
- hypothytoid
- acute hepatitis
- ETOH
- thiazides, beta blockers, oral estrogens, protease inhibitors
most effective HDL raising agent
niacin
first line therapy for reducing triglycerides
fibric acid derivatives
___ should be measured in all pts before starting statin therapy
ALT
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
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!
sxs of epiglottitis
- rapid onset in pts 1-6yo
- inspiratory stridor, hot potato muffled voice, dysphagia, drooling
- clasically tripoding
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
how long dose i take for positive monospot test
at least 7 days into illness
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
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
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
what are contraindicatiosn for certain vaccines?
immunodeficiency (either in pt or household member)
chemotherapy
pregnancy
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
ADHD diagnosis is not usually made til age __
6
age-appropriate activiy commonly ymistaken for ADHD in younger children
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
how to determine if child needs lead screening at 5yo well check
selective screening if yes to any of the following
- does oyur child live in/regularly visit a house or childcare facility built before 1950
- 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?
- does your child have sibling or playmate who has or had lead poisoning
which children need selective screening for anemia at periodic visits?
- at risk for Fe deficiency b c of special health needs
- low iron diet (ie nonmeat)
- environmental factors (eg poverty, limited food access)
which children should get annual tuberculin skin test?
- HIV infected
- incarcerated adolescents
what is included in questionnaire for determining risk of latent TB in US children
- has family member or contact had TB
- has family member had positive ppd
- was child born in a high risk country? (anywhere other than US, canada, aus, NZ, western europe)
- has child traveled to a high risk country for more than 1 week? (had contact with resident populations)
what vaccines are due for 5 yo
DTaP booster
IPV (polio)
MMR
Varicella
first does of meningococcal vaccine given at age __
11-12
first HPV vaccine given age ___
at least 9 years old
rotavirus vaccine age
must be started before 15 weeks and completed by 8 months of age
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
definition of Small for Gestational Age
weight below 10th percentiel for gestational age
what is term pregnancy
born at > 37 weeks
SGA babies are at risk for?
hypothermia
hypoglycemia
polycythemia
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
difference in timing of gonococcal vs chlamydial eye infection in new borns?
chlamydia occurs later, 1-2 weeks after birth
causes of absent red reflex in newborn
congenital cataracts
retinoblastoma
causes of chorioretinitis in newborn
congenital toxo, CMV
possible effects of maternal anticonvulsant use on newborn
cardiac defects dysmorphic craniofacial features hypoplastic nails and distal phalanges IUGR microcephaly
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)
presentation of symptomatic congenital CMV infection
microcephaly jaundice petechiae hepatosplenomegaly low birth weight
presentation of congenital rubella
sensorineural deafness
eye abnormalities
patent ductus arteriosus
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
differential of fussy infant
- colic
- pyloric stenosis
- intussusception
- 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
- GERD
- infection
- FTT
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
hallmark of GERD in infants
dribbling milk afer feeds
no sign of distress
signs of intussuscepion
when does it tpresent
afer 3 monhs of life
sudden on se, severe, paroxysmal colicky pain recurring at freq inerrvervals
it can ake up o __ (ime) afer deliver for signific milk producttion
72
it can take up to __ (time) after deliver for signific milk producttion
72
exclusivel or partially breastfed babies should received __ supplement
400 units vitamin D daily starting soon after birth
caloric requirement for preterm 1-2 month old
115-130
caloric req very preterm 1-2 month old
up to 150 kcal
babies are read to begin spoon feeding solids at age __
4-6 montths
children should sit in rear facing carseats until age __
2
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)
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
most freq diagnosed neoplasm in infanst
neuroblastoma
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)
favorable prognostic factors of neuroblastoma
- younger age (eg <18 months good prog even witth disseminated disease)
- non amplification of myc gene
histology in neuroblastomas
small blue cells forming pseudorosettes
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
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
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
children should be screened for anemia a age __ using ___
12 months
fingerstick Hgb/Hct
possible eiologies dry cough vs wet cough
dry: environmental irritant, asthma
wet: lower respiratory infection
causes of barking cough
croup
subglotic disease
FB
casues of brass or honking cough
habitial cough
tracheitis
causes paorxysmal cough
pertussis
chlamydia
mycoplasma
FB
causes cough worse at night
asthma
sinusitis
postnasal drip
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
what is considered chronic cough
> 3 weeks
next step for all children with chronic cough
CXR
treatment of mild persistent asthma
SABA plus low dose ICS
when is LABA used in asthma
reserved for severe persisent asthma - sxs throughout the day, awakenings every night
defects assoc with taking anticonvulsants during pregnancy
cardiac defects
dysmorphic craniofacial features
hypoplastic nails and distal phalanges
IUGR, microcephaly
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
list three adverse effects of ADHD meds
- suppress appetite
- decrease growth velocity
- insomnia (typically worse in the firs days of med)
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
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)
how o differentiate between weight gain vs underlying endocrine disorder
endocrine disease that cause weight gain usually limit growth and lead to short stature
what ECG changes suggest coronary artery disease
- horizontal ST depression or downsloping ST
- convex ST elevation
- Q waves
diet additions to lower heart disease risk
fish twice a week
oils in tofu, soyfbeans, flaxseeds, walnuts
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
when should 2 BP meds be initiated for newly diagnosed HTN
> 20/10 above goal
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)
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?
how does MODERATE alcohol consumption affect BP?
decreases BP 2-3mmHg (but don’t encourage ps to start drinking alcohol for this lol)
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
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
