Case Files Flashcards
Age for Colon Cancer Screening
Adults older than 50
Age for influenza vaccination
6 months of age & older
Age for Pneumococcal polysaccaride vaccination
65 years or older
Also 65 years or younger who are alcoholics or smokers; have chronic cardiovascular, pulmonary (including asthma), renal or hepatic disease; diabetes, immunodeficient or is asplenic.
One time revaccination after 5 years for those who are immunocompromised and is asplenic.
One time revaccination for those older than 65 if they were vaccinated longer than 5 years previously and were younger than 65 years at the time of initial vaccination.
Age for booster of Tdap
19 and 65 years of age
Recommended for all adults who have not had a Td booster within 10 years and have never had a Tdap vaccine as an adult.
In an adult with chronic lung disease, a one time vaccination with which vaccines is recommended?
Penumonoccal Influenza Tdap booster (if not within 10 years or never received one).
FEV1 ratio & treatment for Mild COPD (Stage 1)
less than 80%
short acting bronchodilators
- Albuterol
- ipratropium
FEV1 ratio & treatment for Moderate COPD (Stage 2)
less than 50-80%
Long acting bronchodilators
- Salmeterol
- Tiotropium
FEV1 ratio & treatment for Severe COPD (Stage 3)
30-50%
Inhaled Steroids
FEV1 ratio & treatment for Very severe COPD (Stage 4)
less than 30%
Long term oxygen therapy & consider surgical interventions.
Patient develops COPD at a young age, does not respond to bronchodilator.
Think alpha1 antitrypsin deficiency
Correlation with pulmonary function and smoking cessation
His current pulmonary function will be unchanged, but the rate of pulmonary function decline will slow.
JVD and lower extremity edema
Cor pulmonale (right sided heart failure due to chronic elevated pressures in the pulmonary circulation.
Radiation exposure greater than what number is associated with fetal harm?
How does X-ray fit into this?
5 rad.
Xrays exposes the fetus to a very small fraction of this amount of radiation (.00017)
Recommended amount of folic acid daily to reduce the risk of NTD
400 to 800 micrograms per day
Recommended amount of folic acid for a women who has had a child with NTD?
4 milligram per day
Recommended amount of folic acid for a omen with diabetes and epilepsy?
1 milligram per day
LMP calculation
First day of LMP, subtract 3 months and add 7 days.
Optimal time for trisomy screen
10-13 weeks for serum hCG and pregnancy associated plasma protein A (PAPP-A).
16-18 weeks triple (AFP, hCG, estriol) or quadruple (triple with inhibin A).
When should all women be offered GBS screening by vaginorectal culture?
35-37 weeks gestation
Proper method of collection of GBS screening by vaginorectal culture?
Swab the lower vagina, perineal area and rectum.
Mother is Rh negative. Next step?
Assess the antibody screen or indirect Coomb’s test. If the antibody screen is neg, there is no isoimmunization and RhoGAM is given at 28 weeks and again at delivery if the baby is confirmed as Rh (anti-D).
Recommended Immunization for a 6 month well child visit.
DTaP (diphtheria, tetanus, acellular pertussis).
Hepatitis B
Haemophilus Influenza Tybe B (HiB)
Rotavirus
inactivated polio vaccine can be given between 6-15 months of age.
Age by which a child should say mama and dada
nonspecifically between 6-9 months.
specific between 8-12 months.
A child should stay in a rear-facing seat until the child weighs at least how many pounds and at least how old?
at least 20 lbs & 1 year old.
All states require testing for congenital disease?
PKU & congenital hypothyroidism
When can a child use a forward facing seat?
between 20-40 lb
When can a booster type seat be used?
greater than 40lbs
True contradiction to providing a vaccination
History of anaphylactic reaction to a specific vaccine component or a severe illness.
Side effects of decongestants
rebound hyperemia and worsening of symptoms
First line therapy for long term management of mild to moderate allergic rhinitis
corticosteroid nasal spray
Indicated for both management of persistent asthma and chronic allergies
Leukotriene inhibitors
First generation antihistamine
diphenhydramine, chlorpheniramine, and hydroxyzine
S.E: sedation
Second generation antihistamine
Loratadine, Desloratadine, Fexofenadine and cetirizine
All have lower incidence of sedation & anticholinergic effects except cetirizine.
At first sign of anaphylaxis, what must be given?
Aqueous epinephrine 1:1000, in a dose of 0.2 to 0.5 ml (0.2 to 0.5 mg) is injected subcutaneously or intramuscularly
Repeated injections every 15-30 mins when necessary.
Treatment for Allergic conjunctivitis
Anti-histamine or anti-inflammatory eye drops
Treatment for bacterial conjunctivitis
Sulfonamide
Treatment for epidemic keratoconjunctivitis (pink eye)
Sulfonamide - prevents secondary bacterial infection
Hot compress to reduce discomfort of lid edema
weak topical steroids to treat corneal infiltrates
Approved non nicotine medications
Bupropion (brand name: Zyban)
Varnicline (brand name: Chantix)
Bupropion is contraindicated in patients with?
eating disorders
seizures
used MAO inhibitor in the last 2 weeks
Mechanism of Bupropion vs. Varenicline?
Bupropion blocks uptake of NE and/or dopamine.
Varenicline is a nicotinic receptor partial agonist
Side effects of Bupropion
insomnia and dry mouth
Side effects of Varenicline
nausea, trouble sleeping, abnormal vivid dreams
What can be used in combination with any of the nicotine supplements?
Bupropion
Nicotine products can also be used in combination with each other.
STD partner notification can occur by which methods?
patient referral or by health department staff.
Traveler’s Diarrhea - Common bacterias
Ecoli (all types) Salmonella Shigella Vibrio non-cholera Capylobacter
Traveler’s Diarrhea - Common viruses
Rotavirus
Norovirus
Traveler’s Diarrhea - Common parasites
Giardia Lamblia
E. Histolytica
Cryptosporidum parvum
Common etiology for traveler’s diarrhea
E. coli
Illness within 6 hours of eating a salad containing mayonnaise
S aureus
Within 8-12 hours of eating
Clostridium perfringens
Within 12-14 hours of eating
E. coli
Most patients with acute diarrhea have self limited processes and do not require much work. What are the exceptions?
Profuse diarrhea, dehydration, fever exceeding 100.4 F (38.0 C), bloody diarrhea, severe abdominal pain, duration of diarrhea for more than 48 hours, and children, elderly patients and immunocompromised patients.
When antibiotics is indicated for travelers’ diarrhea, what are the drugs commonly used?
Ciprofloxcin (500 mg 2x daily) is given for 1 or 3 days. TERATOGENIC.
Azithromycin (single 1000 mg dose in adults or 10 mg/kg daily for 3 days in children). CAN BE USED IN PREGNANT WOMEN.
RIFAXIMIN (200 mg 3x daily for 3 days) - used for noninvasive strains of E.Coli. Not effective against infections associated with fever or blood in stool
What drug can be used to treat C.difficile?
Metronidazole or oral vancomycin
What drug is contraindicated in any patient suspected with C. difficile colitis?
Loperamide - opioid drug, decreases frequency of bowel movements.
It increases the risk of toxin retention and precipitation of toxic megacolon.
National Osteoporosis Foundation recommendation for calcium & vit. D intake for all women over the age of 50.
1200 mg of calcium and 400 to 800 IU of vitamin D per day
Optimal age for Cervical Cancer Screening
21
How often should you get a pap smear?
annual pap smears until age 30, and then spacing out the interval to every 2-3 years
When to stop screening for pap smears?
USPSTF - after 65 both if no new risk factors have been identified (new partner) & if there has been adequate recent screening
American Cancer Society - stop at 70 if a women has 3 consecutive normal pap smears and no abnormal pap smears the last 10 years.
Ottawa Ankle Rules applies to?
Applies to:
(1) non pregnant adults who have normal mental status,
(2) no other significant concurrent injury,
(3) evaluated within 10 days of the injury.
When should X-rays be performed according to Ottawa Ankle Rules?
(1) bony tenderness of the posterior edge or tip of the distal 6 cm of either the medial or lateral malleolus OR
(2) if the patient is unable to bear weight immediately or when examined
What is the most commonly injured ligament?
ATFL, followed by CFL
What should be used in initial evaluation of the painful joint?
Plain film X-rays.
If the patient has normal x-rays and who have a suspected soft tissue (ligament, tendon, cartilage) injury, MRI scanning is usually the net most appropriate imaging study to perform.
Most common cause of a stiff or painful joint following a sprain is?
Inadequate rehabilitation.
When a patient is unable to adequately self-rehabilitate an injury, a physical therapy referral can be beneficial.
Ottawa Knee Rules recommendation for performing an X-ray in a knee injury
Any of the following criteria:
(1) Age 55 years or older
(2) isolated patella tenderness
(3) tenderness of the head of the fibula
(4) inability to flex the knee to 90 degrees
(5) inability to bear weight for four steps immediately and in the examination room (regardless of limping).
Most commonly occurring melanomas in both men and women
Superficial spreading melanomas
Melanoma that is most aggressive and usually invasive at the time of diagnosis?
Nodular Melanomas
Melanoma that is found on the palms of hands, sole of feet and under finger and toenails?
Population most common in?
Acral Lentiginous Melanoma
Asian & African
Melanoma most commonly found in the elderly
Lentigo Maligna
Least common out of the four types
Prognosis of Melanoma
Single most important piece of info for prognosis in melanoma is the thickness.
Melanomas less than 1-mm thick have a low rate of metastasis and a high cure rate with excision.
How does Basal cell carcinoma appear?
Pearly papules, often with central ulceration or with multiple telangiectasis.
Rarely metastasize but can grow large and be locally destructive.
How does Squamous Cell Carcinoma appear?
Irregularly shaped plaques or nodules with raised borders.
Freq. scaly, ulcerated and bleed easily.
Higher rate of metastasis than BCC.
Gross Hematuria
always deserve a full workup.
Urinalysis, urine culture and imaging of upper urinary tract by CT scanning.
Upper tract can be imaged by?
Intravenous pyelogram (IVP) or CT
IVP is xray imaging of the Upper UT after administration of IV contract dye. Widely available and low cost, but can miss small renal masses & does not solid from cystic lesions.
CT detects masses, renal stones, renal or perirenal infections and obstruction.
CT scan should be initially preformed.
Lower tract is commonly evaluated by?
cystoscopy
What is the treatment of choice for Graves disease in adult patients who are not pregnant?
Radioactive iodine
absolutely contraindicated in pregnancy.
What is the treatment of choice for Graves disease in adult patients who are pregnant?
PTU
Test to see if thyroid nodules are malignant
Fine needle aspiration
Thyroid cancer detected during pregnancy
Can be observed until after pregnancy is complete.
If needed, thyroid surgery can be performed safely in 2nd or 3rd trimesters.
Difference between Graves and Thyroiditis in Radionucleotide imaging?
Graves - diffuse hyperactivity with large amounts of uptake
Thyroiditis - patchy uptake with overall reduced activity (tells you it is releasing existing hormone rather than the overproducing new thyroxine).
What is a specific diagnostic test for Graves?
Detection of serum thyroid receptor antibodies.
What test do you do to tell the difference between Familial Hypocalciuric Hypercalcemia or primary hyperparathyroidism?
24 hour urinary calcium excretion.
Hyperparathyroidism - kidneys spill calcium in the urine at normal or elevated level.
FHH- the urinary calcium is low.
Primary Hyperparathyroidism
usually due to excessive production of the parathyroid glands, leading to hypercalcemia.
Secondary Hyperparathyroidism
Parathyroid glands overproduce PTH in response to low calcium levels (can be from dietary calcium or from def. of Vit. D)
Tertiary Hyperparathyroidism
Elevated PTH in patients with renal failure
What are the 3 stages of labor?
Stage 1. Onset of labor until the cervix is completely dilated.
Stage 2. complete cervical dilation (10cm) through the delivery of the fetus.
Stage 3. Begins after delivery and ends with the delivery of the placenta and membranes.
Stage 1 of labor is divided into what 2 phases?
Latent phase of labor - contracts become stronger, longer lasting & more coordinated.
Active phase - usually starts 3-4 cm of cervical dilation is the rate of cervical dilation at its maximum.
What are the three stages of decelerations from the fetal baseline heart rate that occurs?
early, late & variable
early coincides with a contraction in onset of the fetal heart rate decline
late = gradual reduction in fetal heart rate that starts at or after the peak of a contraction and has a gradual return to baseline.
variable = abrupt decrease in fetal heart rate, usually by an abrupt return to baseline that occurs variably in its timing, relative to an contraction
What is early deceleration thought to be caused by?
fetal head compression
What is late deceleration thought to be caused by?
uteroplacental insufficiency
What is variable deceleration caused by?
cord compression
What is the most common cause of blindness worldwide?
Cataract Disease
What is the leading cause of severe vision loss in the elderly?
Age related macular degeneration (AMD)
Presbycusis
high frequency hearing loss along with loss of speech discrimination
Leading cause of blindness in working age adults in the U.S
Diabetic retinopathy
Most common cause of hypertension in children under 6 years of age?
renal parenchymal disease
urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension.
Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated.
thiazolidinediones (TZDs) are associated
fluid retention, and their use can be complicated by the development of heart failure.
Optimal candidates for cardiac resynchronization therapy (CRT)
have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure
The American Heart Association recommends a goal blood pressure of ≤130/80 mm Hg for patients with
hypertension in patients with diabetes mellitus, chronic kidney disease, or coronary artery disease.
According to the U.S. Preventive Services Task Force, which one of the following patients should be screened for an abdominal aortic aneurysm?
in men 65-75 years of age who have ever smoked.
Monotherapy for hypertension in African-American patients
is more likely to consist of diuretics or calcium channel blockers than β-blockers or ACE inhibitors.
Patient with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol?
A. Enoxaparin (Lovenox) B. Metoprolol (Lopressor, Toprol) C. Carvedilol (Coreg) D. Clopidogrel (Plavix) E. Tissue plasminogen activator (tPA)
Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours.
Although some β-blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage adjustment in patients with renal failure.
The most useful diagnostic tool for evaluating patients with heart failure
Two-dimensional echocardiography with Doppler.
Assesses left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function.
Isolated systolic hypertension in the elderly responds best to
diuretics and to a lesser extent, β-blockers.
As the body ages, what happens to each of the following?
A. Maximum heart rate B. Heart rate variability C. Ejection fraction D. Arterial wall elasticity E. Blood pressure
HR trend- DECREASE
HR variability - DECREASE
Ejection Fraction - DECREASE
Arterial wall elasticity - STIFFENS
Blood Pressure - INCREASED
(stiff walls –> peripheral resistance –> increase in BP).
The use of what allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients.
LMWH (Enoxaparin (Lovenox).
The dosage is 1 mg/kg subcutaneously 2x daily.
Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed
Which procedures carries the highest risk for postoperative deep venous thrombosis?
Neurosurgical procedures & orthopedic surgeries.
Orthopedic surgeries - total knee replacement, hip fracture surgery, and total hip replacement.
The most common recommendation for surgical repair is when the aneurysm approaches what size in diameter.?
5.5 cm
What is preferred for treating hypertension in patients who also have diabetes mellitus?
ACE inhibitors
What is indicated for patients with symptomatic aortic stenosis?
Prompt correction of his mechanical obstruction with aortic valve replacement.
Contraindication to the use of beta-blockers for CHF?
Hemodynamic instability, heart block, bradycardia, and severe asthma.
Leading cause of death in women
Cardiovascular disease
A resting 12-lead EKG is recommended for?
Males over 45,
females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.
First line for Acute sinusitis?
Amoxicillin & Trimethoprim-Sulfamethoxazole for 10-14 day.
What should not be used for more than three days to avoid the risk of rebound vasodilation with resulting worsening of symptoms?
Topical decongestants.
Gold standard for diagnosis of GAS infections?
Throat cultures
can take 24-48 hours
What is the drug of choice for GAS pharyngitis?
Pencillin
Oral therapy requires 10 day course of penicillin V.
In penicillin allergic patients, you can use cephalosporins & macrolides.
Findings frequently associated with GAS infections?
Abrupt onset of sore throat and fever, tonsillar and/or palatal patchy, tender cervical adenopathy and absence of cough.
Findings frequently associated with EBV infections?
Exudative pharyngitis, retrocervical or generalized adenopahty and heaptosplenomegaly.
Atypical lymphocytes on peripheral blood smear.
The vast majority of pharyngitis is?
Viral
Treatment for mononucleosis?
Self limiting disease
Most accurate maneuver for detecting an ACL tear
Lachman test
Followed by the anterior drawer test and the pivot shift test.
McMurray’s test is used to detect meniscal tears.
How do you determine if Monoclonal gammopathy of undetermined significance (MGUS) has progressed to multiple myeloma?
Evidence of end organ damage
femoral neuropathy
decreased sensation to pinprick and light touch over the left anterior thigh, and reduced motor strength on hip flexion and knee extension. The straight leg raising test is normal.
straight leg test
If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive and a herniated disc is likely to be the cause of the pain
Diabetic polyneuropathy
symmetric and distal limb sensory and motor deficits.
Meralgia paresthetica
a.k.a lateral femoral cutaneous neuropathy
numbness and paresthesia over the anterolateral thigh with no motor dysfunction.
Iliofemoral atherosclerosis
may produce intermittent claudication involving one or both calf muscles
Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the?
epithelial ovarian cancer
Mainstay therapy for polymyalgia rheumatica.
Corticosteroids
Polymyalgia Rheumatica
What is it?
Who is most commonly affected?
ESR?
Clinical hallmarks?
Systemic symptoms?
inflammatory disorder that occurs in persons over the age of 50.
White women of European ancestry are most commonly affected.
One review found that 4%–13% of patients with clinical polymyalgia rheumatica have a normal erythrocyte sedimentation rate (ESR). As many as 5% of patients initially have a normal ESR that later rises.
Clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder & pelvic girdle.
Variety of systemic symptoms. Fever is common, with temperatures as high as 39°C (102°F) along with night sweats. Additional symptoms include depression, fatigue, malaise, anorexia, and weight loss.
The hallmark biochemical feature of refeeding syndrome is
Hypophosphatemia
Refeeding syndrome = potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally).
When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis can be decreased by?
Rinsing the mouth after each use & using a valved holding chamber to your metered-dose inhaler.
When is Laryngoscopy is recommended?
when hoarseness does not resolve within 3 months or when a serious underlying cause is suspected.
In adults, the most common cause of right heart failure is:
left heart failure
pericarditis
type of pain? Radiation? when the pain is exacerbated? when is the pain lessen? ECG findings?
Sharp Radiates to the trapezius Exacerbated by inspiration Decreased with sitting forward Global ST segment elevation
The goal of LDL cholesterol in anyone with a history of CAD and high risk for future cardiac events
Less than 70 mg/dL
What is contraindicated in myocardial ischemia?
Rapid release, short-acting dihydropyridines (nifedipine).
Increased mortality in multiple trials.
What are the agents of choice for MI?
Beta blockers
increases survival
All patients with MI should receive?
Aspirin and an antithrombotic treatment
ESRD is GFR of less than?
15 mL/min
Normal GFR is between 90-120 mL/min.
What is most important in the prevention of end stage renal disease?
Glycemic Control
Diabetes is a leading cause of end-stage renal disease.
What helps with hypertension and also protects renal function in diabetics and CKD?
ACE inhibitors
Vaginitis Discharges:
Fungal
Bacterial Vaginosis
Trichomonas
Fungal - thick discharge & can cause significant pruritus
Bacterial Vaginosis - thinner and has a fishy odor.
Trichomonas - discharge is frothy & green and patient cervix is frequently very erythematous.
pH of vulvovaginal candidiasis
4.0-5.0
Treatment of uncomplicated candidiasis?
short term intravaginal preparations (cream or vaginal suppositories)
OR
single dose oral fluconazole 150 mg.
Recommended treatment of trichomoniasis
Oral metronidazole, given in a single 2-g oral dose
OR
1-week regiment of 500 mg twice a day to BOTH the patient and her sexual partner.
What are the 4 clinical criteria for Bacterial Vaginosis?
Diagnosis can be based on the presence of 3 of 4 clinical criteria.
- thin homogenous vagina discharge.
- vaginal pH more than 4.5
- a positive KOH “whiff” test
- the presence of clue cells in a wet mount preparation.
Test of choice for determination of the source of lower GI bleeding
Colonoscopy
What helps rule out upper GI bleeding?
Nasogastric tube.
Upper GI - aspirate shows blood
Lower GI - aspirate shows bile
What patients must be evaluated for the presence of colon cancer?
Any patient older than age 50 years who has lower GI bleed
Inflammatory Bowel Diseases - How do you tell the difference between the two?
Ulcerative colitis - continous inflammation of the large bowel, starting from rectum and extending proximally.
Crohn Disease - areas of focal inflammation, but can occur anywhere in the GI tract.
Initial management of asymptotic diverticuli
high fiber diet
Management of severe or recurrent symptomatic cases of diverticuli
surgery
Patients with a heterophil antibody test is positive for infectious mononucleosis should avoid what?
All, or nearly all, patients with mononucleosis have splenomegaly.
Should be advised to avoid contact- or collision-type activities for 3–4 weeks because of the increased risk of rupture.
Initial treatment for a patient with malignancy of hypercalcemia
Fluid replacement with normal saline to correct the volume depletion & to enhance renal calcium excretion.
Restrict use of loop diuretics - danger of fluid overload (and are not very effective alone in promoting renal calcium excretion)
Once the hypercalcemic patient has become EUVOLEMIC by saline repletion then give pamidronate (mainstay treatment).
Uterine fibroid embolization
Procedure done by radiologist.
blocks blood flow to fibroids in the uterus.
Requires a shorter hospitalization and less time off work.
For women who are not planning a pregnancy in the future, UFE is a possible option in place of surgery for fibroids.
Myomectomy
surgical removal of fibroids from the uterus.
Recommended over fibroid embolization for patients who wish to become pregnant in the future.
The Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in patients with which heart condition?
Maneuver decreases venous return to the heart, thereby decreasing cardiac output.
Increases in hypertrophic obstructive cardiomyopathy.
The murmur of mitral valve prolapse becomes longer, and may also become louder.
Melanosis coli
dark pigment is deposited in the lining of the colon.
The brown pigment is lipofuscin in macrophages, not melanin.
from chronic use of herbal laxatives that contain anthraquinones.
Condition can develop after just a few months of laxative use.
Benign
Slipped capital femoral epiphysis
most common hip disorder between ages 8 and 15
More common in boys and overweight or obese children
femoral head is being medially and posteriorly displaced
presents with limping and pain, and limited internal rotation of the hip.
Treatment: Surgery (surgically pinning the femoral head)
Legg–Calvé–Perthes Disease
usual onset of three to ten years of age
Thought to be caused by avascular necrosis of the femoral head, with resultant abnormal growth of the femoral head.
Treatment is conservative, protection of the joint and efforts to maintain range of motion.
Best test for the diagnosis of COPD
Spirometry
has FEV /FVC ratio of 70% or less.
A 30-year-old female asks you whether she should have a colonoscopy, as her father was diagnosed with colon cancer at the age of 58.
You recommend that she have her first screening colonoscopy:
At age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years.
Drug-induced lupus pleuritis
hydralazine, procainamide, and quinidine.
Drug-induced pleural disease
amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin.
Treatment of choice for Wolff-Parkinson-White syndrome
Procainamide although amiodarone may also be used.
Which one of the following is contraindicated in the second and third trimesters of pregnancy? (check one) A. Amoxicillin B. Azithromycin (Zithromax) C. Ceftriaxone (Rocephin) D. Ciprofloxacin (Cipro) E. Doxycycline
Doxycycline is contraindicated in the second and third trimesters of pregnancy due to the risk of permanent discoloration of tooth enamel in the fetus.
Patients with rheumatoid arthritis should be screened for tuberculosis before starting which one of the following medications?
TNF inhibitors have been associated with an increased risk of infections, including tuberculosis.
infliximab, adalimumab, certolizumab pegol, and golimumab.
The most widely used initial assay for detecting hepatitis C virus (HCV) antibody is?
If positive, what should this test be followed by?
If this test is positive, what should it be followed by? What if it’s negative?
enzyme immunoassay.
Followed by a confirmatory test such as the recombinant immunoblot assay.
If positive, the quantitative HCV RNA polymerase chain reaction is used to measure the amount of virus in the blood to distinguish active from resolved HCV infection.
If negative, it indicates a false-positive antibody test.
Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test? A. An upper GI series B. Abdominal ultrasonography C. CT angiography D. MRI of the brain E. Colonoscopy
Since even a temporary reduction in renal function, such as occurs after pyelography or angiography, can cause lactic acidosis in patients taking metformin, the drug should be discontinued 48 hours before such procedures and restarted 48 hours after the procedure if renal function is normal.
The DSM-IV criteria for obsessive-compulsive disorder (OCD) indicate
patient recognizes that the obsessions or compulsions are excessive or unreasonable.
Nursing home–acquired pneumonia drug treatment
Need coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa.
Combination therapy of Ceftazidime, levofloxacin, and vancomycin
Which one of the following has the best evidence that it is safe for use in pregnancy? A. Alprazolam (Xanax) B. Lithium C. Bupropion (Wellbutrin) D. Fluoxetine (Prozac) E. Paroxetine (Paxil)
Fluoxetine (Prozac)
Xanax - cleft lip/ palate
Lithum - terogenic
Wellbutrin - spontaneous abortions
Paroxetine - congential cardiac malformations
Intussusception
paroxysms of colicky abdominal pain.
A mass is palpable in about two-thirds of patients.
usually occurs in children under the age of 2 years
most occur at the ileocecal junction
current jelly stool (mixture of blood and mucus that has sloughed from the affected bowel wall)
Pyloric stenosis
presents with a palpable mass, but usually develops between 4 and 6 weeks of age
Most common cause of GI obstruction in infants.
choledochal cyst
presents with the classic triad of right upper quadrant pain, jaundice, and a palpable mass.
Intestinal malrotation
usually presents within the first 4 weeks of life and is characterized by bilious vomiting.
Meckel’s diverticulum
painless lower gastrointestinal bleeding.
Indicated for the treatment of severe osteoporosis, for patients with multiple osteoporosis risk factors, or for patients with failure of bisphosphonate therapy
Teriparatide
Describe the gait in each of these disorders
A. Visual impairment B. Cerebellar degeneration C. Frontal lobe degeneration D. Parkinson’s disease E. Motor neuropathy
Visual impairment - abducted arms and legs; slow, careful, “walking on ice” movements
Cerebellar degeneration - ataxic gait that is wide-based and staggering.
Frontal lobe degeneration - gait apraxia that is described as “magnetic,” with start and turn hesitation and freezing.
Parkinson’s disease - typical gait that is short-stepped and shuffling
Motor neuropathy - “steppage” gait resulting from foot drop, short strides, a slapping quality, and frequent tripping.
Which interventions is most likely to be successful for a patient with anorexia nervosa?
Family-based treatment
Provides superior results when compared with individual adolescent-focused therapy.
Antidepressants have not been successful.
Which Asthma medications should be used only as additive therapy and not as monotherapy
Long-acting β2-agonists
Because of the risk of asthma exacerbation or asthma-related death, the FDA has added a warning against the use of long-acting β2-agonists as monotherapy.
Erythema toxicum neonatorum
is a common harmless red rash in neonates.
not require any treatment, as it will spontaneously go away in 5–7 days.
macular erythema, papules, vesicles, and pustules, and it resolves without permanent sequelae.
Physicians should counsel all patients with CKD, as well as those at increased risk for CKD, to avoid what as it will increased their risk of deterioration in renal function.
NSAID.
NSAIDs induce renal injury by acutely reducing renal blood flow and, in some patients, by causing interstitial nephritis.
The primary treatment for symptomatic mitral valve prolapse
Beta blockers
Helps relieve symptoms of palpitations or chest pain that might happen with this condition.
Do not improve the functioning of the mitral valve.
prevention of altitude illness in a patient with sulfa allergy - what should be used?
Dexamethasone - it is not contraindicated for those with a sulfa allergy.
Acetazolamide is an effective prophylactic agent, but is contraindicated in patients with a sulfa allergy.
Most common drug-related cause of acute interstitial nephritis.
Antibiotics, especially penicillins, cephalosporins, and sulfonamides.
All patients with suspected pneumonia should have what test done?
a chest xray
Legionella often causes what along with pneumonia?
diarrhea
Bacterias that are classified as atypical pneumonia?
Chlamydia pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae
Drug of choice for pneumonias caused by Legionella or S. Aureus?
Erythromycin
Drug of choice for pneumonias caused by Streptococcus?
Pencillin
Drug of choice for pneumonias caused by Hemophilus influenza?
Cefuroxime
Common infection seen after influenza infection
Staph. Aureus
The use of antidepressants in bipolar disorder may precipitate?
acute manic behaviors
First line treatment for depression
SSRI
What is the most common cause of erythema multiforme, accounting for more than 50% of cases?
Herpes simplex virus (HSV)
accounting for more than 50% of cases.
Bereavement - when is the diagnosis of major depression made?
If the symptoms last longer than 2 months and involves suicide ideations, morbid preoccupations or psychosis.
Bipolar disorder
episodes must last longer than 1 week and should be abrupt, not continuous.
continuous suggest personality disorder or schizophrenia.
A single episode of mania is sufficient for diagnosis of bipolar disorder
All patients diagnosed with depression should be questioned about?
Mania as treatments are different.
Treated with mood stabilizers such as valproate, carbamazepine and lithium.
Trazodone
Atypical antidepressant
risk of priaprism (rare)
highly sedating and frequently used as a sleep aid
All antidepressants carry and FDA “black box’ warning that they increase the risk of?
suicidal thoughts and behaviors in children, adolescents and young adults, especially in the first few months of treatment.
Persons with depression have a greater chance of developing or dying from?
cardiovascular disease
What is given during or immediately after the third stage of labor to aid in producing increased uterine tone?
oxytocin (Pitocin)
In women who are not breast feeding, menstruation using restarts by?
third postpartum month
Most common cause of postpartum hemorrhage?
Uterine atony
Failure of uterus to contract adequately results in continued bleeding from uterine vasculature.
Treatment of uterine atony?
IV administration of oxytocin and initiation of bimanual uterine usage.
When these fail, give methylergonovine intramuscularly. This drug is contraindicated in patients with hypertension (may cause abrupt increase in blood pressure).
4 Ts of postpartum hemorrhage
Tone, Trauma, Tissue, Thrombin
Postpartum fever, especially associated with uterine tenderness and foul smelling loch
endometritis
Contradictions to breast feeding?
HIV infection
Acute active Hep. B infection
Recommended waiting time to start oral contraceptives in breast feeding women vs. non breast feeding women
breast feeding: 6 weeks postpartum
Non-breast feeding: 3 weeks
OCP in breast feeding vs. non breast feeding - what should be used?
Breast feeding: protesting-only pill (combination OCP may reduce lactation).
Non-breast feeding: combination OCP
Drug used to treat mastitis
Cephalexin or penicillin based antibiotic
IUD may be placed at which week of postpartum visit?
6 weeks postpartum as earlier placement is associated with increased rate of expulsion of the device.
Omeprazole therapy is associated with
Increased risk of community-acquired pneumonia & Clostridium difficile colitis.
Acutely decrease the absorption of vitamin B 12,
Decreases calcium absorption, leading to an increased risk of hip fracture.
Next step in management of patient over the age of 35 who experiences abnormal vaginal bleeding.
endometrial biopsy.
must have an endometrial assessment to exclude endometrial hyperplasia or cancer.
For patients with a history of previous stroke, JNC-7 recommends using
combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke.
Most effective treatment for chronic plaque psoriasis and has fewer adverse effects?
topical corticosteroids.
The American Psychiatric Association and the Institute for Clinical Systems Improvement both recommend which drugs for patients who have an incomplete response to antidepressant therapy.
a trial of lithium or low-dose triiodothyronine (T3 )
Ehrlichiosis causes
thrombocytopenia
Malaria causes
Hemolytic Anemia
Apraxia
interference with skilled movement
Aphasia
language disorder
Astereognosis
unable to recognize objects by palpation in one hand but not the other
Pertussis in adults
prodromal phase that lasts 1–2 weeks (indistinguishable from a viral URI).
More severe cough after the second week - may be severe enough to cause vomiting or fracture ribs.
May have increased lacrimation and conjunctival injection.
The incubation period is long compared to a viral infection, usually 7–10 days.
Vacuum-assisted delivery
Increased fetal risk.
Has less maternal soft-tissue trauma.
Increased likelihood of a severe perineal laceration.
An increased incidence of shoulder dystocia
The best initial imaging study for acute pelvic pain in women is
transvaginal ultrasonography
provides the greatest level of detail regarding the uterus and adnexae, superior to transcutaneous ultrasonography.
Upper extremity & Lower extremity DVT treatment
heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.
BNP level greater than what is consistent with the diagnosis of CHF?
500 pg/mL
When acute pulmonary edema caused by CHF is diagnosed, the next step in management is?
Administration of loop diuretic.
DOC: Furosemide (potent diuretic effect and its rapid bronchial vasculature vasodilation).
Patient has CHF and whose blood pressure is elevated, what is the drug of choice?
Nitroglycerin.
can rapidly reduce BP
reduces preload and afterload.
Patients with CHF and reduced left ventricular function, what is first line therapy?
ACE inhibitors.
reduce preload, after load, improve cardiac output and inhibit RAAS.
Diuretics are used to reduce fluid overload in both acute and chronic settings - when is loop used versus thiazides?
Loop (furosemide, bumetanide, toresemide, ethacrynic acid) can be used in all stages of CHF and are used in pulmonary edema & refactory heart failure.
Thiazide diuretics are used in mild heart failure and can be used in combination with other diuretics in severe CHF.
Combination oral contraceptives offer significant protection against
ovarian cancer, endometrial cancer, iron-sdefiency anemia, PID and fibrocystic breast disease
Progestin-only oral is best suited for patients who are
breast feeding
OCPs may prolong the effects of?
theophylline, benzodiazepine & caffeine
Medroxyprogesterone provides contraceptive protection for how many weeks?
injectable form of a progestin.
14 weeks
Absolute versus relative contraindications for IUD
Absolute: current, recent (within 3 months) or recurrent endometritis, PID, or STD, pregnancy, anatomically distorted uterine cavity and known/suspected HIV.
Relative: gonorrhea/chlamydia, multiple sex partners, undiagnosed abnormal vaginal bleeding, known or suspected uterine or cervical malignancy and previous problems with IUD.
Painless versus painful for the following:
Diverticular bleeding,
Angiodysplasia,
Ischemic colitis
ischemic colitis - abdominal pain, bloody diarrhea, and cardiovascular risks.
Diverticular bleeding and angiodysplasia are painless.
An elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which vitamin?
Vitamin B 12
Red flags suggesting the need for immediate evaluation of speech delay?
include no babbling in a 12-month-old,
not saying “mama” or “dada” at 18 months,
a vocabulary of less than 25 words at age 2,
and using less than 200 words at age 3.
Children should be able to follow two-step commands by 2 years of age.
A hospitalized patient is being treated with vancomycin for an infection due to methicillin-resistant Staphylococcus aureus (MRSA). Which one of the following is most important to monitor?
A. Hepatic function
B. Trough serum levels
C. Peak serum levels
D. Audiograms
When a person takes a dose of vancomycin, the amount in the blood rises for a period of time, peaks, and then begins to fall, usually reaching its lowest level, or trough, just before the next dose.
The best predictor of vancomycin efficacy is the trough serum concentration, which should be over 10 mg/L to prevent development of bacterial resistance.
Femoroacetabular impingement - what is it and what is the most sensitive physical finding?
Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position.
Reproduction of the pain on range-of-motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding.
Pain associated with avascular necrosis of the hip?
Similar to Femoroacetabular impingement where it is insidious and heightened when bearing weight.
But tenderness is usually evident with hip motion in ANY direction.
Bursitis of the hip?
manifests as soreness after exercise and tenderness over the affected bursa.
What percentage of women having unprotected intercourse will be pregnant in 1 year?
80%
All adolescents should be screened annually for?
hypertension, eating disorders and obesity.
What’s the physiologic difference between males and females that can affect pharmokinetics of medications with narrow TI?
lower GFR in women, higher fat stores in women, lower BMI in women, less gastric acid secretion in women, GI transit times are slower in women
How can reduce ACL tears?
neuromuscular training, plyometrics, and strength training
What’s the target glucose range for critically ill patients?
140-180 mg/dl
Which one of the following is the recommended duration of dual anti platelet therapy (aspirin 162-325mg and clopidogrel 75mg) after placement of a drug-eluting coronary artery stent, metal stents, and sirolimus eluting stents?
Drug eluting stents–> 6 months, Metal stents–> 1 month, Sirolimus eluting stents–> 3 months
Most effective treatment in Intrahepatic cholestasis of pregnancy?
Urosidol - controls pruritis and decreases LFTs
What’s the rationale for treating Pertussis with antibiotics?
Reduces the risk of transmission to others
What’s a tarsal coalition?
fusion of 2+ tarsal bones. it occurs in mid to late adolescence and bilateral in those affected. Pain occurs around the ankle, and there is decreased range of motion of the hindfoot and pain on foot inversion on examination.
Breast cancer screening has resulted in an increase in?
Diagnosis of localized disease
Which antidepressant is least likely to cause weight gain?
Buproprion
What does Medicare pay for?
Medicare Part A (hospital insurance) covers inpatient care in hospitals and skilled nursing facilities, hospice, and home health services, but not custodial or long-term care.
Medicare Part B (medical insurance) covers outpatient physician services, including office visits and home health services.
Medicare Part C (Medicare Advantage Plans) is offered by private companies, and combines Part A and Part B coverage. These plans always cover emergency and urgent care, and may offer extra coverage such as vision, hearing, dental, and/or health and wellness programs. Most plans also include
Medicare Part D, which provides prescription drug coverage. Medicare Part D plans vary with regard to cost and drugs covered.
Lumbar spinal stenosis has an increased in pain during what position?
Spinal extension
Spinal flexion relieves pain, as does sitting
Which NSAIDS are safe in lactating women?
Ibufprofen, Naproxen, Indomethacin
How do NSAIDS and aspirin differ in their cardioprotective effects?
NSAIDS have the potential to increase cardiovascular morbidity, worsen heart failure, increase blood pressure, and increase events such as ischemia and acute myocardial infarction
NSAIDS should be avoided in?
persons with hepatic cirrhosis.
While hepatotoxicity with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet function.
In addition, NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in patients with cirrhosis.
GH deficiency vs. Constitutional Growth delay?
GH deficiency: delayed bone age with reduced growth velocity, suggesting an underlying cause. Growth curve falls below 3rd percentile.
Constitutional Growth delay: bone age may be delayed, but by 24 months, growth curve will be parallel to the 3rd percentile.
Preferred method for diagnosing psychogenic non epileptic seizures?
video-electroencephalography (vEEG) monitoring
Presentation of Herpangina?
fever, vesicles and subsequent ulcers develop in the posterior pharyngeal area
Presentation of Roseacea, and treatment?
Most often in women 30-60
Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules
Flushing can be triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis
Topical Metronidazole and benzoyl peroxide
What finding is diagnostic for a child that is sexually abused?
Any STDW infection in a postnatal prepubertal child –> Gonorrhea, Syphilis, HIV, and postnatal acquired Chlamydia
Most common pathogens causing foot infections in diabetics?
Staph and Strep
What is associated with the least likelihood of neurologic recovery in a comatose patient due to cardiac arrest?
Myoclonus Epilepticus at 24 hours would be least likely for recovery.
Duration of CPR is not a factor, and the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours.
Primary Hyperparathyroid vs. FHH?
Primary: PTH levels are high, hypercalcemia, and increased urinary excretion of calcium
FHH: PTH levels normal or high, hypercalcemia, and low urinary excretion of calcium
Differentiated by a 24-hour urine collection for calcium
How to test for latent TB infection?
In vitro interferon-gamma release assays (IGRAs)
It targets specific antigens to mycobacterium TB, which are absent in BCG vaccine strains and from commonly encountered non mycobacterium
What is “functional abdominal pain” and how is it managed?
The diagnosis of functional abdominal pain is made when no structural, infectious, inflammatory, or biochemical cause for the pain can be found.
most common cause of recurrent abdominal pain in children 4–16 years of age.
Management: focusing on participation in normal age-appropriate activities, reducing stress and addressing emotional distress, and teaching the family to cope with the symptoms in a way that prevents secondary gain on the part of the child.
Treatment for acute management of sustained ventricular tachyarrhythmias regardless of hemodynamic stability?
Amiodarone
First-line treatment for atrial fibrillation only in symptomatic patients with left ventricular dysfunction and heart failure?
Amiodarone
Management of thoracic vertebral compression fracture?
- Decrease activity until pain is tolerable, then possible bracing, followup in 1 week.
- Vertebroplasty if the pain doesn’t improve in 2 weeks
On his first screening colonoscopy, a 67-year-old male is found to have a 0.5-cm adenomatous polyp with low-grade dysplasia.
According to current guidelines, when should this patient have his next colonoscopy?
in 5 years.
Patients with one or two small (
Most appropriate treatment for infertility?
Metformin
What’s Conversion aphonia?
often caused by a traumatic event.
patient loses his or her spoken voice, but the whispered voice is maintained.
The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing
First-line treatment for symptomatic osteoarthritis of the knee in a patient with renal dysfunction?
Acetaminophen
Initial diagnostic workup for chronic pelvic pain?
Transvaginal U/S
What’s the Modified Centor scoring system for management of sore throat?
The patients are judged on four criteria, with one point added for each positive criterion:
History of fever
Tonsillar exudates
Tender anterior cervical adenopathy
Absence of cough
The Modified Centor Criteria add the patient’s age to the criteria:
Age 44 subtract 1 point
Guidelines for management state:
-1, 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%)
2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2)
4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%)
What will a PFT show in a patient with vocal cord dysfunction?
Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase
What is posterior tibial tendon tendinopathy and how is it managed?
Women in their 40’s
Trauma is not usually recalled, but possible twisting of the foot
Single leg toe raise is positive
Pain on resistance of plantar flexion
Pain on inversion and weight bearing on foot
MGT: Immobilization in cast for 3 weeks
Why is ACE inhibitors C/I in bilateral renal artery stenosis?
worsens renal function, resulting in a significant increase in creatinine
What imaging would you do to either rule out or confirm a PE in a patient with DVT?
CT angiography
Placenta abruption?
3rd trimester painful vaginal bleeding, fetal distress, uterine tenderness, uterine pain between contractions
Treatment of Restless Leg Syndrome?
Iron supplements in patients with ferritin levels <50 (nl: 10-200)
Avoid antihistamines, caffeine, SSRI, TCA
Initial diagnostic procedure in Acute diverticulitis?
CT of abdomen and pelvis.
CT provides information on the extent and stage of the disease, and may suggest other diagnoses
What does “Patient centered medical team” describe?
A physician-led team of care providers taking responsibility for the quality and safety of an individual’s health
What are the 3 cutoffs for positive Mantoux Tuberculin Test?
> /= 5: immunocomprised, high risk of exposure
/=10: increased probability of exposure or risk such as hospital workers, children, immigrants, employees/residents of nursing homes, chronic shelters
/=15: low risk of exposure
For individuals who are subject to repeated testing, such as health-care workers, an increase in induration of 10 mm or more within a 2-year period would be considered positive and an indication of a recent infection with Mycobacterium tuberculosis.
Management of Heparin Induced Thrombocytopenia?
D/C Heparin and start non-heparin anticoagulant such as argatroban or desirudin
Management of Chronic Primary Insomnia?
CBT
Treatment of Lichen Planus?
Topical Corticosteroids (Clobetasol) Topical Calcineurin inhibitors (Tacrolimus) if topical corticosteroids are ineffective
Need for immediate evaluation of speech therapy include?
No babbling at 12 months, not saying mama or dada at 18m, vocab less than 25 words at 2 y.o, vocab less than 200 words at 3 y.o, unable to follow 2 step command at 2 y.o.
What’s the best predictor of vancomycin efficacy?
Trough serum concentration, which should be over 10 mg/L to prevent development of bacterial resistance
Treatment of pyelonephritis in a pregnant woman?
Ampicillin with gentamicin or cephalosporin
Most appropriate initial test to r/o adrenal insufficiency?
Morning cortisol test.
A single morning serum cortisol level >13µg/dL reliably excludes adrenal insufficiency.
If the morning cortisol level is lower than this, further evaluation with a 1µg ACTH stimulation test is necessary
What MUST be present to Dx Polymyalgia Rheumatica?
bilateral shoulder or hip stiffness and aching for at least one month
All patients ages 13-64 should be screened for…?
HIV
What is the recommendation for a patient with no hx of CAD but with frequent PVC and cardiac RF?
Evaluate for underlying coronary artery disease such as stress test, echo, and ambulatory rhythm monitoring
frequent PVC is defined as >30 per hour. frequent PVC is linked to acute MI and sudden death.
What is a perinephric abscess and how would you diagnose it?
collection of pus around the kidney.
most of perinephric infections are caused as an extension of an ascending UTI, commonly associated with renal calculi or urinary tract obstruction.
CT of the abdomen
Dx of mild persistent asthma?
Sx more than 2 times a week, but not daily, and use of albuterol inhaler more than 2x a week, but not daily.
treatment: low dose inhaled steriod
What’s the most consistent finding in IBS?
Abdominal Pain
Screening for DM?
BMI >25 with no sx, who have 1 or more RF for DM
screening for all adults with no risk factors starting at age 45, every 3 years.
Diagnostic imaging for possible septic arthritis?
Ultrasound
Female Athlete Triad?
Amenorrhea, Stress fractures/osteoporosis, disordered eating
Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test.
Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of –1 to –2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score <–2
MCC of persistent/recurrent acute otitis media in children?
- Strep Pneumo
- H. Influenza
- Moraxella
Initial treatment for ventricular fibrillation when an initial defibrillation attempt fails?
For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should be given a vasopressor, which can be either epinephrine or vasopressin. Vasopressin may be substituted for the first or second dose of epinephrine.
Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor.
Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available.
Gold standard for the Dx of Renal Colic?
CT
Radiographic features of a benign pulmonary nodule? malignant pulmonary nodule?
Benign: diameter 10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year
Management for patients with asymptomatic aortic stenosis, even with severe disease?
Watchful waiting.
Patients with chronic cough, and no other Sx.
A trial of an inhaled bronchodilator and antihistamine therapy does not improve the patient’s symptoms.
Next step?
Trial of PPI
One of the most common causes of chronic cough is GERD.
When is surgery beneficial in rotator cuff injuries?
In cases of acute, traumatic, complete rotator cuff tears in young patients, repair is recommended in less than 6 weeks, as muscle atrophy is associated with reduced surgical benefit
Advanced age and limited strength are also associated with reduced surgical benefit.
What is a likelihood ratio?
Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease.
Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it.
How do you treat mild persistent asthma?
start with a daily low-dose inhaled corticosteroid or leukotriene receptor antagonist
then progressing to a medium-dose inhaled corticosteroid or low-dose inhaled corticosteroid plus a long-acting inhaled β-agonist.
What drug is contraindicated in DM?
Metformin– renal damage.
It should be stopped in females with
a creatinine level ≥1.4 mg/dL and in males with a creatinine level ≥1.5 mg/dL.
Treatment for Lichen Sclerosis?
Lichen Sclerosis is chronic, progressive, inflammatory skin condition found in the anogenital region. It is characterized by intense vulvar itching.
Treatment: Topical Corticosteroids
Benefit of physical activity in the elderly?
reduce the risk of falls
The USPSTF currently recommends daily aspirin use for which one population?
males 45–79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage
females 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage
Treatment for Fibromyalgia?
Amitryptiline
CXR of head-on collision shows a widened mediastinum is suggestive of what?
Deceleration-type blows to the chest can produce partial or complete transection of the aorta
Initial Sx of Hodgkin’s Lymphoma?
Painless Lymphadenopathy
Patient <30 complains of Irregular heavy menstrual bleeding. P/E, pelvic exam, and pap are all normal. Pre test negative. CBC is normal. Next step?
cyclic admin of progesterone for 3 months.
progesterone will produce a definitive flow and control the bleeding.
What is Pseudoaddiction?
Patient behaviors that may occur when pain is undertreated.
Patients with unrelieved pain may become focused on obtaining specific medications, seem to watch the clock, or engage in other behaviors that appear to be due to inappropriate drug seeking.
Pseudoaddiction can be distinguished from true addiction because the behaviors will resolve when the pain is effectively treated.
Guidelines of Dx and management of Bronchiolitis?
While the guideline does not support routine use of bronchodilators in the management of bronchiolitis, it does allow for a trial of bronchodilators as an option in selected cases, and continuation of the treatment if the patient shows objective improvement in respiratory status.
FDA recommends that over-the-counter cough and cold products not be used in children below what age?
2 years old.
What can decrease gout attacks?
Dairy products.
How to diagnosis melanoma?
simple excision with clear margins
First line treatment for Acute otitis media?
Amoxicillin
What’s the USPSTF recommendation for screening for abdominal aneurysm?
one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65–75 who have ever smoked
screening these patients for AAA and surgical repair of large AAAs (≥5.5 cm) leads to decreased AAA-specific mortality
hemoglobin A1c of 7.0% would correspond to which one of the following mean (average) plasma glucose levels
154 mg/dl
HbA1c of 6%= 120 mg/dl
HbA1c of 8%= 180 mg/dl
Presentation of Acute angle closure glaucoma?
acute onset of severe pain, blurred vision, halos around lights, increased intraocular pressure, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea
Central retinal artery findings?
amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and “boxcarring” of the retinal vessels
Retinal detachment findings?
normal vision or peripheral or central vision loss; absence of pain; increasing floaters; and a normal conjunctiva, cornea, and pupil
Initial treatment for SVT?
Adenosine is indicated for supra ventricular tachycardia with a narrow QRS complex (not for ventricular tachycardia).
Most common cause of urinary incontinence in elderly men and women?
Detrusor instability
Incontinence May become worse after surgical repair of BPH
Cluster headache?
predominantly a male disorder. The mean age of onset is 27–30 years. Attacks often occur in cycles and are unilateral. Short lasting.
Migraine headaches are more common in women, start at an earlier age (second or third decade), and last longer (4–24 hours)
Zanamavir is contraindicated in?
COPD, asthma, or respiratory distress
What antiviral treatment should be given for all persons with clinical deterioration requiring hospitalization, even if the illness started more than 48 hours before admission?
Osteltamivir
How to manage childhood bullying?
Explore whether his school counselor has a process to address this problem
What imaging study can determine the cause of Heart failure?
An echocardiogram is the study of choice, as it will assess left ventricular function– determines diastolic vs. systolic dysfunction.
What is Nephrogenic systemic fibrosis? How to detect it?
disease of fibrosis of the skin and internal organs reminiscent but distinct from scleroderma or scleromyxedema. It is caused by gadolinium exposure used in imaging in patients who have renal insufficiency
Skin biopsy is diagnostic
Initial management of a child with ibuprofen intoxication?
Oral activated charcoal within an hour of ingestion
Pharmacologic therapy should be initiated in pregnant women with gestational diabetes mellitus whose fasting plasma glucose levels remain above 100 mg/dL despite diet and exercise?
A combination of intermediate-acting insulin (e.g., NPH) and a short-acting insulin (e.g., lispro) twice daily
Treatment of endocarditis?
A patient who does not have a prosthetic valve should be started on vancomycin and gentamicin until the organism is known
Findings of Polycythemia Vera?
should be suspected in African-Americans or white females whose hemoglobin level is >16 g/dL or whose hematocrit is >47%. For white males, the thresholds are 18 g/dL and 52%
Major criteria include an increased red cell mass, a normal O2 saturation,and the presence of splenomegaly.
Minor criteria includeelevated vitamin B 12 levels, elevated leukocyte alkaline phosphatase, a platelet count >400,000/mm3 and a WBC count >12,000/mm3 .
First-line therapy for nausea and vomiting of pregnancy?
Vitamin B6 with or without Doxylamine
What is the management of an isolated, enlarged cervical lymph node?
Immediate biopsy is warranted if the patient does not have inflammatory symptoms and the lymph node is >3 cm, if the node is in the supraclavicular area, or if the patient has coexistent constitutional symptoms such as night sweats or weight loss. Immediate evaluation is also indicated if the patient has risk factors for malignancy.
In a patient with no risk factors for malignancy and no concerning symptoms, monitoring the node for 4–6 weeks is recommended.
Treatment in resistant or refractory hypertension (defined as a blood pressure ≥140/90 mm Hg, or ≥130/80 mm Hg), in patients with diabetes mellitus or renal disease (i.e., with a creatinine level >1.5 mg/dL or urinary protein excretion >300 mg over 24 hours), despite adherence to treatment with full doses of at least three antihypertensive medications, including a diuretic?
adding a loop diuretic if serum creatinine is >1.5 mg/dL in patients with resistant hypertension.
First line treatment in head lice?
permethrin
Which foods frequently causes of cross reactive food allergy symptoms in latex allergic individuals?
Avocados, bananas, and kiwis
Management of thyroid nodules?
All patients who are found to have a thyroid nodule on a physical examination should have their TSH measured.
Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed.
For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant
Most beneficial for Borderline Personality Disorder?
Psychotherapy
Cholinesterase inhibitors (donepezil) are associated with increased risk…?
bradycardia requring a pacemaker
Anticoagulant prophylaxis (Enoxaparin) recommendation?
patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy.
Initial treatment of status epileptics?
Lorazepam.
This is followed by phenytoin, given via a dedicated peripheral intravenous line.
Fosphenytoin, midazolam, or phenobarbital can be used if there is no response to lorazepam
According to JNC 7, the risk of cardiovascular disease begins to increase when the systolic blood pressure exceeds a threshold of ?
Systolic BP >115 and Diastolic >75
In a patient with a severe anaphylactic reaction to peanuts, the most appropriate route for epinephrine is?
IM
Management of Placenta Previa?
in the absence of bleeding, the most appropriate management is to repeat the ultrasonography in the third trimester
Because many placenta previas resolve close to term, a decision regarding mode of delivery should not be made until after ultrasonography is performed at 36 weeks gestation
Findings of premature ovarian failure
irregular or occasional period for years
<40 years old
infertility
LH and FSH high
Antibiotics in nursing home acquired pneumonia, in need of intensive care?
Empiric coverage for methicillin-resistant Staphylococcus aureus and double coverage for pseudomonal pneumonia–Ceftazidime (Fortaz), imipenem/cilastatin (Primaxin), and vancomycin (Vancocin)
Which medication falsely decreases PSA levels?
Finasteride
Most useful findings for identifying dehydration in children?
prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern, low serum bicarb level (<17)
Unlike in adults, calculation of the BUN/creatinine ratio is not useful in children. Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age in children.
What does A technetium-99m blood pool scan find?
Determines the source of bleeding in GI.
A lower GI series is usually nondiagnostic during heavy, active bleeding.
A small-bowel radiograph may be helpful after the active bleeding has stopped, but not during the acute phase of the bleeding
Those taking red yeast rice for the management of hyperlipidemia should be monitored for?
Liver enzymes.
useful for patients unable to tolerate statins due to myalgias, but requires periodic monitoring of liver enzymes because its metabolic effects and potential for consequences are similar to those of statins
Treatment of asymptomatic multiple myeloma?
None.
The standard treatment for symptomatic patients under age 65 is autologous stem cell transplantation
Side effects of inhaled corticosteroid usage for COPD?
candidal infection of the oropharynx, hoarseness, and an increased risk of developing pneumonia
For a healthy 1-month-old, daily vitamin D intake should be?
It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D, beginning soon after birth.
The “Get Up and Go Test” evaluates what?
Risk of falling
involves asking the patient to rise from a chair, walk 10 feet, turn, return to the chair, and sit down. Any unsafe or ineffective movement with this test suggests balance or gait impairment and an increased risk of falling. If the test is abnormal, referral to physical therapy for complete evaluation and assessment should be considered
An elevation of serum alkaline phosphatase combined with an elevation of 5’-nucleotidase is most suggestive of conditions affecting?
Liver.
Placenta, liver, bone, and intestines may have an elevated ALP
Management of stroke with a patient with hypertension?
Maintaining adequate tissue oxygenation is an important component of the emergency management of stroke. Hypoxia leads to anaerobic metabolism and depletion of energy stores, increasing brain injury.
Contraindication of antihypertensives which may decrease cerebral perfusion. Only treat if Systolic BP >220 and Mean BP >130
Most specific finding for peritonsillar abscess?
Trismus– difficulty opening mouth
Initial treatment for scaphoid fracture?
Thumb spica splint
Most common side effect of Chantix?
Nausea
What should be assessed in women with postpartum depression?
Thyroid function since hyper/hypothyroidism are more common post partum
Postpartum blues resolves in 10 days
Post partum depression treated with Setraline in breastfeeding women
Treatment of Bullous Impetigo?
Staph Aureus is MCC.
Trimethoprim/sulfamethoxazole and clindamycin are options for outpatient therapy.
Intravenous vancomycin can be used to treat hospitalized patients with more severe infections.
What is Proctalgia fugax?
episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination
What is Telogen effluvium?
a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.
RF for osteoporosis? Best diagnostic test?
Asian ethnicity, low body weight, positive family history, postmenopausal status with no history of hormone replacement, and low calcium intake.
The best diagnostic test for osteoporosis is a central DXA scan of the hip, femoral neck, and lumbar spine
Triquetral fracture?
Triquetral fractures typically occur with hyperextension of the wrist. Dorsal avulsion fractures are more common than fractures of the body of the bone. Tenderness is characteristically noted on the dorsal wrist on the ulnar side distal to the ulnar styloid.
The typical radiologic finding is a small bony avulsion visible on a lateral view of the wrist.
Which drug inhibits platelet function for the life of the platelet?
Aspirin- irreversible COX inhibitor
Most efficacious medications for the treatment of allergic rhinitis?
Intranasal glucocorticosteroids
Treatment acute laryngotracheitis (croup)?
A single dose of dexamethasone, either orally or intramuscularly
Evaluation fo stroke risk used to quantify risk of stroke for patients who have atrial fibrillation and to aid in the selection of antithrombotic therapy?
CHADS.
C=CHF H=hypertension A=age 75 D=DM S=Secondary prevention for prior ischemic stroke or TIA
Each of these clinical parameters is assigned one point, except for secondary prevention, which is assigned 2 points.
Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk with a score 3.
Experts typically prefer treatment with aspirin rather than warfarin when the risk of stroke is low.
What should be evaluated by a cardiologist prior to clearance to participate in athletics?
Any patient with:
a diastolic murmur,
grade 3/6 or louder systolic murmur,
murmur that suggestive of HCM, or
signs of marfan syndrome
Recommended test screening for presumptive gonorrhea or chlamydia in sexually active males.
urine for nucleic acid amplification.
A urethral swab is only appropriate for diagnostic testing in a male who has a urethral discharge.
Systolic and diastolic values for:
Normal blood pressure
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
Normal blood pressure < 120 or <80
Prehypertension: 120 - 139 or 80-89
Stage 1 hypertension: 140-159 or 90-99
Stage 2 hypertension: greater or equal to 160 or greater or equal to 100
In primary treatment of hypertension, what is the recommended first line therapy?
Thiazide diuretics
Patients with stage 2 hypertension or anyone who’s blood pressure is above the recommended goal by less than or equal to 20/10 mm Hg should be started on:
combination therapy with two medications given either as separate prescriptions or a fixed dose combination of medications.
The foreign body in the esophagus needs to be removed by when and which methods?
in less than 24 hours by upper endoscopy.
If sharp or elongated object (>6 cm) has already passed through the stomach & duodenum, daily x-rays will be done to follow the progress of the object.
those that do not advance within 3 days will require surgical intervention.
Most foreign body ingestion by children will pass spontaneously, but which objects require immediate intervention in the esophagus?
button batteries, sharp objects and multiple magnets in the esophagus should be removed endoscopically.
Normal pressure hydrocephalus
dementia, incontinence and gait disturbance
Distinguish between the following:
Dementia with Lewy bodies Alzheimer disease Frontemportal dementia Vascular dementia Dementia of Parkinson Disease
Dementia with Lewy bodies - vivid hallucinations, fluctuation in cognition and often parkinson extrapyramidal signs and postural instability; daytime drowsiness and sleeping, staring into space for prolong period of time and episodes of disorganized speech.
Alzheimer disease - memory impairment
Frontemportal dementia - behavioral changes, including disinhibition or language problems such as aphasia.
Vascular dementia - sudden onset and progresses into a stepwise fashion. Patients function at a certain level and then show an acute deterioration when the initial or subsequent infract occur.
Dementia of Parkinson - tremor, bradykineseia and rigidity precede the onset of memory impairment by more than 1 year.
What is recommended by American Academy of Neurology for the routine evaluation of dementia?
A non contrast head CT or MRI
What should be used to confirm the presence of dementia?
A validated test, such as the MMSE (mini mental status examination).
Alzheimer medications
may delay the progression of the disease, but may not reverse any decline that has already happened.
BMI values for:
Underweight Normal Overweight Obese Extreme Obesity
Underweight less than 18.5 Normal 18.5 to 24.9 Overweight is 25 to 29.9 Obesity: 30 - 29.9 Extreme: 40+
Treatment plan (dietary restriction, increased physical activity & behavior therapy) for obesity should begin in patients with?
BMI greater than 25 who have visceral obesity, documented by increase waist circumference greater than 40 in men and greater than 35 in women OR
waist to hip ratio greater than 0.9 in men and greater than 0.85 in women.
A calorie deficit of 500 to 1000 cal/d produces a weight loss of how many lbs and kg per week?
1-2 lb/week (.45 to .91 kg/week)
When is pharmacologic therapy offered for patients with obesity?
pharmacologic therapy offered BMI greater than 30 or BMI 27-30 with comorbid conditions.
Potential candidates for surgical treatment of obesity?
BMI greater than 40 who have failed diet and exercise (with our without drug therapy) OR greater than 35 with comorbid conditions.
Guidelines from 2001 National Cholesterol Education program suggest that clinical identification of metabolic syndrome should be based upon any 3 of the following traits:
- abdominal obesity (waist circumference in men greater than 102 cm (40 in) and in women greater than 88 cm (35 in).
- Serum Triglycerides greater than or equal to 150 mg/dL.
- Serum HDL cholesterol less than 40 mg/dl in men and less than 50 mg/dl in women.
- Blood pressure greater than or equal to 130/85 mm Hg.
- Fasting plasma glucose greater than or equal to 100 mg/dL.
What can be used for long term therapy of obesity?
Orlistat
According to the international headache society, symptoms diagnostic of migraine headache includes?
moderate to severe headache with pulsating quality;
unilateral location
nausea and/or vomiting
photophobia
Phonophobia
Worsening with activity
Multiple attacks lasting for 4 hours to 3 days
absent of history that headache is the result of another cause.
Tension headache
pericranial muscle tenderness and
bilateral bandlike distribution of the pain
last from 30 mins to 7 days
Initial treatment for episodic tension headache versus frequent headache sufferers?
Episodic includes aspirin, acetaminophen and NSAIDs.
Frequent headaches: combination of antidepressant medication and stress management therapy.
Cluster headache
Unilateral
can be located in orbital, super orbital or temporal region.
Deep excruciating pain lasting from 15 mins to 3 hours.
More common in Men
Acute treatment of cluster headache
100% oxygen at 6 L/min, dihydroergotamine and triptans.
Nausea or vomiting associate with migraine, what type of drug will you use?
triptan delivered by injection or nasal spray
Five factors that are considered to determine the LDL goal of a given individual?
- Cigarette smoking
- Hypertension (BP greater or equal to 140/90 mm Hg or on antihypertensive medication)
- Low HDL
- Age (Greater or equal to 45 for males;
greater or equal to 55 for females). - Family history of premature CHD (male first degree relative greater or equal to 55; female first degree relative greater or equal to 65).
***A high HDL is considered a negative risk, which removes one other risk factor from the total.
What is a major risk for developing CHD?
LDL cholesterol
Recommended measuring lipid levels in all adults older than age 20 years every 5 years.
Optimal lipid levels for someone with CHD or a CHD risk equivalent:
LDL Cholesterol
HDL Cholesterol
Total Cholesterol
LDL Cholesterol < 40 is low
Total Cholesterol <200 is desirable
According to ATP III guidelines, What is the therapeutic LDL total for patients with VERY HIGH risk of CHD?
LDL goal of less than 70 mg/dL for patients with high risk of CHD.
High risk category includes people with CHD and either multiple risk factors (especially diabetes), poor controlled risk factors (especially smoking), multiple risk factors of metabolic syndrome, or an acute coronary syndrome.
According to the American Heart Association, optimal fasting levels for triglycerides are?
< 100 mg/dl
Lifestyle change and fish oil supplements are the mainstay therapy for cardiovascular disease.
First line pharmacotherapy for LDL cholesterol reduction is?
When starting the drug, what must be checked & monitored?
Statin
When started, fasting lipids should be rechecked in 6 weeks. If LDL goal is not met, the dose can be increased or a second agent added.
Liver enzymes must be monitored (6-12 weeks after initiation or dosage change, then every 6-12 months).
Specific dietary recommendations for hyperlipidemia should included?
A reduction of saturated fats to less than 7% of total calories and an intake of less than 200 mg/d of cholesterol.
In someone with high blood cholesterol levels, what tests will you run to investigate?
fasting blood glucose,
TSH
Liver enzymes
Creatinine level
Diabetes, hypothyroidism, obstructive liver disease, and chronic renal failure are common secondary causes of dyslipidemia.
What type of fracture is a common injury that is often confused with abuse, but not often caused by abuse?
Spiral fracture of the tibia is known as “toddler’s fracture”
Children with septic hip joint will often lay with their hip?
flexed, abducted and externally rotated.
This helps reduce the pain and they will have significant pain with any internal rotation or extension of the joint.
Definitive diagnosis with a children with septic joint is?
joint aspiration.
Transient synovitis
self limited inflammatory response that is a common cause of hip pain in children.
Typically occur in children ages 3 to 10.
Often follows viral infection.
Low grade or no fever, normal WBC count, Normal ESR.
Examination pain with internal rotation of the hip and overall range of motion is limited
Transient synovitis versus septic arthritis in children?
Transient synovitis - low grade or no fever, normal WBC count (less than 10,000), Normal ESR.
Septic arthritis - elevated WBC (> than 50,000), elevated ESR
Kocher criteria to utilize risk for septic arthritis in children
- Nonweight bearing
- ESR > 40
- WBC > 12,000
- Temp: Fever > 101.3 (38.5),
**NEWT mnemonic
0 = less than 0.2 risk 1 = 3% risk 2 = 93% risk 4 = almost 100% risk
Patient is afebrile, has pain free rotation of hip greater than 30 degrees, has normal WBC count and normal ESR, what can be done?
short term follow up can be assured, the patient can be followed clinically and should improve in a few days.
Can give NSAID.
If it worsens, then an aspiration should be done (might be septic joint).
How do you lower the risk for surgical site infections (SSI)?
Prophylactic antibiotics should be given within 1 hour before surgery and discontinued within 24 hours after surgery
Pain in the calf of foot on dorsiflexion
Homan Sign. Is demonstrated in some cases of DVT.
Diagnosis of DVT
duplex ultrasound, but most accurately confirmed with venography.
If fever occurs within 36 hours postlapratomy, what are the two important infectious etiologies to keep in mind?
bowel injury with leakage of gastrointestinal contents into the peritoneum and invasive soft-tissue would infection caused by B-hemolytic streptococci or clostridium species.
In the first 48 to 72 postoperative hours, what causes 90% of pulmonary complications of surgery?
atelectasis
surgical site infections (SSI) - most important therapy
Incision and drainage. Antibiotics are used solely in cases of significant systemic involvement.
Most common acute cause of wheezing in children younger than 2 years of age, especially in infants who are 1 to 3 months of age?
Bronchiolitis
Infants younger than 6 months are most severely affected, owing to smaller, more easily obstructed airways and decreased ability to clear secretions.
RSV accounts for 70% of these cases.
The diagnosis of bronchiolitis
Based on clinical presentation, the patient age, seasonal occurrence and findings from the physical examination .
Management of RSV bronchiolitis
self limited disease and can safely manage in an outpatient setting.
Patients who are in respiratory distress, younger than 3 months old or premature, those with comorbid conditions, lethargy, hypoxemia or hypercarbia and those with atelectasis or consolidation in chest radiograph need to be hospitalized.
When is supplemental oxygen and supportive care needed in RSV bronchiolitis?
SpO2 <90%
Most important therapy for supportive care is humidified oxygen.
What accounts for as many as 80% of croup cases?
Parainfluenza viruses
What is the most common cause of airway obstruction in children aged 6 months to 6 years and is the leading cause of hospitalization for children younger than 4 years?
Coup.
viral infection that causes inflammation of the subglottic region of the larynx that produces barking cough, hoarseness, stridor and degrees of respiratory distress that is more severe at night.
What confirms the diagnosis of croup?
imaging studies
Frontal neck X-ray shows a steeple sign, which is indicative of subglottic narrowing of the tracheal lumen
Mild vs. moderate vs. severe coup treatment
Mild - Does not require any specific therapy, but has a single dose of corticosteroid that may reduce the need for hospitalization.
Moderate - requires additional measures such as epinephrine to prevent hospitalization
Severe - hospitalization
Epiglottis
bacterial infection of the supraglottic tissue and surrounding areas
commonly affects children younger than 5. Has decreased due to introduction of Hib vaccine.
MEDICAL EMERGENCY
Thumb print sign on X-ray (protrusion of the enlarged epiglottis from the anterior all of the hypopharynx seen on a lateral neck X-ray)
child is usually noticeably anxious and assumes the sitting position, leaning forward on outstretched arms with chin thrust forward and neck hyperextended (tripod position) so as to increase airway diameter.
Diagnosis & treatment of Retropharyngeal abscess
affects children 2-4
Diagnosis is made by lateral neck films which show bulging in posterior pharynx
Treatment: antibiotics such as cephalosporin and antistaphylococcal penicillins. Incision and drainage is also an option.
Peritonsillar abscess - common in? clinical presentation? treatment?
more common in young teenagers
infection of the superior pole of the tonsils
fever, severe sore throat, muffled voice, drooling, truisms and neck pain are typical symptoms.
See deviation of the uvela from the midline.
Usually caused by Strep progenies, S. Aureus and anaerobes.
Drainage of the abscess is first line treatment
Treatment of mild to moderate abdominal pain associated with IBS?
What do you use for more severe and persistent pain?
Dicyclomine (antispasmodic anticholinergic medication)
For more severe, use TCAs, like amitriptyline.
First line therapy in constipation predominant IBS
Psyllium (fiber supplementation)
Diarrhea predominant IBS treatment
Loperamide may reduce the frequency of loose stools as well as decrease bowel urgency.
Alosetron is FDA approved for severe diarrhea symptoms lasting over 6 months.
What are FDA approved options for treatment of alcohol dependence in conjunction with behavior therapy?
Naltrexone and acamprosate
Acamprosate acts on the GABA and glutamate pathway.
Most common valular heart defect in the US occurring in 3-6% of the population?
MVP
Any patient with a QT interval greater than how many sec is at increased risk for dangerous dysrhythmias?
500 msec
Drugs that can cause prolong QT intervals
Quinidine, Procainamide, Sotalol, Amiodarone and TCA
Brugada syndrome
What is it?
Inheritance pattern?
What is found on ECG?
ion channel disorder, Autosomal dominant
most common in asian males
dangerous arrhythmia that can result in sudden death
Right bundle branch block pattern and elevation at the J point that is greater than 2 mm, with slowly descending segment in conjunction with flat or negative T waves in the right precordial leads, V1, V2, V3.
Long QT interval
AD
more common in women
presents with palpitations and/or syncope and have family history of syncope or sudden death.
Defined as QT 470 msec in men or greater than 480 in women.
When does PVC require workup and when does it require no investigation?
PVCs in the presence of known cardiac metabolic disease or presence of worrying symptoms (such as near syncope, seizures) require aggressive workup because of the risk of ventricular tachycardia or fibrillation.
PVC occurring at rest and disappearing with exercise are usually benign, commonly seen in athletes and require no investigation.
Most common cause of sudden cardiac death in adolescents?
HCM
Gold standard for diagnosis of HCM?
echocardiography
demonstrates thickened intraventricular septum.
What is appropriate test in all patients with palpitations even if they are symptom free during physical encounter?
12 lead ECG.
When should stress testing be avoided?
CHM or severe aortic stenosis
Patients may develop heart rhythm disturbances which may be nonrecoverable
Primary supraventricular rhythm disturbances
B-blockers or calcium channel blockers
Symptomatic paroxysmal supraventricular tachycardia
Vagal stimulation (carotid sinus massage, valsalva maneuver and cold applications to face) may break an episode of SVT.
If unsuccessful, IV adenosine.
Chronic atrial fib should be treated with medication that ventricular rate below?
What are the agents?
100 beats/min
Rate control agents - beta blockers or calcium channel blockers
A return to normal sinus rhythm may be attempted with electrical cardioversion or anti arrhythmic drugs such as amiodarone, sotalol or with class 1 C drugs such as flecainide and propafenone.
***Class 1C drugs should not be used in the presence of structural cardiac disease or cardiac hypertrophy
Most patients with atrial fib will also require?
anticoagulation with warfarin (increased risk of embolic stroke from blood clots that form in the cardiac atrium).
Patients who has ventricular tachycardia and are UNSTABLE need?
to be electrically cardioverted.
Then give Amiodarone once stable.
Patients who has ventricular tachycardia and are STABLE need?
Amiodarone
Most common cause of palpitations?
Primary rhythm disturbances, making up 40% of the cases (caffeine, etc).
When is it appropriate to use a 24-72 hour Holter monitor versus 30-day even monitor for a patient?
24-72 hour Holter monitor - patient who has frequent (daily) palpitations
30 day event monitor - better test in someone with infrequent episodes
treatment for local reactions from insect stings that occur almost IMMEDIATELY
Local tissue response is a consequence of a histamine-like reaction caused by venom that is released by the sting.
Give ice and antihistamines for itching
Treatment for large local reactions from insect stings that are DELAYED (24 to 48 hours)
It is an IgE mediated reaction.
May respond to a course of oral steroids
Current recommendations for antibiotic prophylaxis for patients with moderate to severe wounds from dog, cat or human bites
Amoxicillin-clavulanate given orally for 5-7 days.
When cellulitis is involved, give a longer course - 7 to 14 days (1-2 weeks).
What is common to the management of both bee stings and bite wounds?
Tetanus vaccination
The most important step in preventing the infectious complications of bite wounds is?
Proper would care with local cleaning of the wound with soap and water, irrigation with saline and debridement of devitalized tissue should take place as soon as possible
Patients with TIA are at a increased risk of a
subsequent stroke
Assessment used to identify patients at high risk of ischemic stroke in the 7 seven days after a TIA.
Mnemonic: ABCD2
Age (greater or equal to 60) = 1 point.
BP elevation when first assessed after TIA (systolic > or equal to 140 mmHg or diastolic greater or equal to 90) = 1 point
Clinical features (unilateral weakness = 2 points; isolated speech disturbance = 1 point’ other = 0)
Duration of neurologic symptoms (greater or equal to 60 = 2 points; 10 to 59 minutes = 1 point; less than 10 = 0 points).
Diabetes (present = 1 point).
Score 0-3: Low risk (1 percent)
Score 4-5: Moderate risk (4 percent)
Score 6-7: High risk (8 percent)
What is the single most important risk factor for stroke?
Hypertension
Stroke affecting the MCA - what will the patient experience?
aphasia (when dominant hemisphere is involved), contralateral hemiparesis, sensory loss spatial ungulate an contralateral impaired conjugate gaze.
Stroke affecting the ACA - what will the patient experience?
foot and leg deficits are more frequent than arm deficits.
Have cognitive and personality changes.
Stroke affecting the Vertebrobasilar artery -what will the patient experience?
motor and sensory loss in all four limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria and dysphagia.
There can be ipsilateral limb ataxia and gait ataxia if the cerebellum is affected.
What risk factors for stroke can’t be changed?
Age
Heredity (family history) and race
Sex (gender)
Prior stroke, TIA or heart attack.
Initial test of choice for stroke?
CT scan of the brain without contrast
CT of the brain may not show an ischemic stroke for up to 72 hours, but can exclude most cases of intracranial hemorrhage, tumors or abscesses quickly.
Most patients with a nonhemorrhagic stroke should be given what within the first 48 hours?
aspirin
When is antihypertensive medication recommend in a stroke?
Unless a hypertensive encephalopathy, aortic dissection, acute renal failure or pulmonary edema is present, the treatment of arterial hypertension should be cautious.
Recommended when systolic BP is greater than 220 mm Hg or the diastolic BP is greater than 120 mm Hg.
If the patient is suitable for thrombolytic treatment, mediation is needed to decrease systolic BP to 185 mm Hg and the diastolic BP to less than 110.
The commonly used agents: IV labetolol, nicardipine and sodium nitroprusside.
Carotid endarterectomy (CEA) is indicated for?
symptomatic patients with carotid stenosis greater than 70%
What is TIA, how long does it last?
transient episode of neurologic dysfunction caused by ischemia without acute infarction.
Typically lasts less than 1 hour in duration.
Which type of stroke patients benefit from IV administration of recombinant tissue-type plasminogen activator (rtPA)?
What are the contraindications?
those treated within 3 hours of the onset of ischemic stroke.
Can not be used recent surgery, trauma, GI bleeding, MI or use of certain anticoagulants medications and uncontrolled hypertension.
Early post treatment care of a stroke includes?
mobilization once the patient is stable and evaluate of the patients ability to swallow.
Treatment for Patients with stroke but no detected sources of embolism?
antiplatelet agents (not anticoagulants)
Aspirin, clopidogrel or a combination of aspirin and dipyridamole are acceptable agents
Treatment for Patients with a recent TIA or ischemic stroke or ipsilateral severe (greater than 70%) carotid artery stenosis?
carotid endarterectomy (CEA)
when it is less than 50%, there is no indication for CEA
Patients with a history of symptomatic cerebrovascular disease should be treated to an LDL goal of?
Less than 100 mg/dL
When do you anticoagulant with warfarin?
Patients with:
persistent or paroxysmal atrial fibrillation (reduces embolic stroke)
very advanced heart failure.
ischemic strokes caused by MI
Existence of left ventricular thrombus
Rheumatic heart disease or mechanical heart valve.
When do you use prophylactic use of TMP-SMX in aids patients?
when their CD4 count is less than 200 cells or if there is a history of oropharyngeal candidiasis.
Post exposure risk of developing HIV infection can be reduced by?
immediate and careful cleaning of the exposure/puncture site along with with post exposure prophylactic (PEP) treatment with antiretroviral therapy.
PEP should ideally be started within 2 hours after exposure and should only be used when exposure to HIV contaminated blood is likely.
But there is no definite time limit.
Recommended length of PEP is 4 weeks.
Standard screening test for HIV is? What is used to confirm?
detection of HIV antibodies using enzyme linked immosorbent assay (ELISA).
Western blot is used to confirm (detects antibodies to HIV antigens of specific molecular weights).
Reporting of HIV
reportable to local health authorities, but partner notification laws vary by state.
When do you use prophylactic use of Mycobacterium avium in aids patients?
Use azithromycin or clarithromycin if CD4 count falls to less than 50
What vaccine is contraindicated in HIV?
varicella vaccine. it is a live attenuated virus.
This vaccine is also contraindicted in pregnant people
Jaundice typically remains undetected on examination until the drum bilirubin level is greater than?
twice the upper limit or 2 mg/dl
Hepatitis A immunoglobulin is preferred in patients?
whom vaccine is contraindicated,
adults greater than 40 years of age,
immunocompromised individuals,
those who have had chronic liver diagnosed.
Hepatitis B causes up to how many percentage of Hepatocellular carcinoma worldwide?
80%
There is no vaccine available for which hepatitis?
C
Which hepatitis is the leading cause of liver transplant in the United States?
C
What antibodies are present in chronic Hepatitis C?
HCV RNA and Anti-HCV antibodies
For patients with new onset dyspepsia who are older than 55 years or have symptoms that may be associated with upper GI malignancy should be considered for?
Endoscopy
Serologic testing for anti-H pylori antibodies cannot do what?
distinguish an active infection from a treated one.
Active infection can be confirmed by urea death testing.
Gold standard for diagnosis for H.pylori?
Endoscopy with biopsy testing for H.pylori.
A patient who is older than 50 years and who has blood in the stool should also undergo what regardless of the upper endoscopic findings?
colonoscopy.
to ensure there is not a colon cancer also contributing to the GI blood loss.
Dyspepsia in patients younger than age 55 with no alarm symptoms can be managed by?
H pylori “test and treat” protocol followed by acid suppression preferably using PPI especially if symptoms remain.
A test for active H ypylori infection should be preformed. (stool antigen or serum IgA ELISA antibodies)
What is now the preferred non invasive office test for Pylori?
stool antigen testing
due to its superior pp. and ability to use post treatment to test for eradication.
HHV6
Roseola
Virus affects before age 3
High fever followed by rash
Rsh starts on trunk and spreads rapidly to extremities, with sparing of face. Rash tends to disappear in 1 or 2 days.
No treatment require. Diagnosis is clinical.
Contagious period of chicken pox
4 to 5 days after the appearance of the rash or until all lesions have crusted over.
How long after contact with an infected person for someone to develop chicken pox?
10-21 days.
Varicella vaccination is recommended?
12 to 18 months with a booster dose at age 4 to 6 years.
Herpes Zoster vaccine is recommended for people over what age?
60
Parvo B19 causes what to the following:
children
adults
sickle cell
pregnancy
children - slapped cheek, lacy pruritic rash on trunk and extremities
adults - arthritis
sickle cell - aplastic crisis with anemia and
leukopenia
pregnancy - fetal hydrops and pregnancy loss
Group A beta-hemolytic strep
rash of scarlet fever starts about 2 days after the onset of sore throat and fever.
Rash feels like sandpaper.
Starts on the upper trunk and spreads to the rest of the trunk and extremities.
First line treatment: penicillin, with macrocodes or cephalosporins as alternatives in those allergic.
Presumed meningitis treatment in infants in less than 30 days old?
ampicillin plus gentamicin, while vancomycin plus ceftriaxone may be used.
First choice for proven meningococcal meningitis treatment?
Penicillin G
Close contacts of someone with meningococcal infection prophylaxis?
ciprofloxacin or rifampin
For women older than 35 years, the identification of a new solid breast mass should prompt?
triple assessment, which includes a clinical breast examination, imaging (mammography) and pathology assessment either by core biopsy or surgical excision.
For women younger than 35, the identification of a new solid breast mass should prompt?
ultrasonography
FDA approved for the treatment of breast pain
Danazol (antigonadotropin) but is relatively expensive and has numerous side effects (hair loss, acne, weight gain and irregular menses)
Treatment of most unilateral, spontaneous or blood nipple discharges
surgical excision of the terminal duct involved
Risk factors for endometrial cancer?
history of anovulatory menstrual cycles obesity nulliparity age older than 35 years use of tamoxifen or unopposed exogenous estrogen
Initial tests for menstrual irregularities?
pregnancy test, TSH and prolactin levels
Diabetic patients should be controlled
- HA1C of 7% or less
- LDL 70-100
- BP less than 130/80
- Life style modifications including diet consisting of low carb and low saturated fat and physical activity (at least 150 min/wk of moderate intensity physical activity and resistance training 3 times/week)
Gestational diabetes is treated with
careful diet management via patient education and nutritional counseling and when necessary, insulin
Diagnostic criteria for diabetes
- Random glucose of 200 mg/dl with classic symptoms.
- A fasting glucose greater or equal to 126 mg/dl.
- 2 hour plasma glucose 200 mg/dL or more after a 75-g glucose load
- HbA1c of 6.5 % or greater
Metformin can lower HbA1c by?
1.5 to 2%
drug of choice to begin with unless contraindications are present; do not cause hypoglycemia when used in mono therapy.
Metformin is contraindicated in those with ?
creatinine more than 1.5 mg/dL in men and more than 1.4 mg/dL in women,
hepatic insufficiency
CHF
Gestational diabetes versus pregestational diabetes in terms of fetus malformations
Gestational diabetes - fetal macrosomia and polyhydramnios (organs have already been formed in this stage)
Pregestational diabetes (5-10 weeks) - greater fetal malformations (b/c this is the stage where organs are forming)
Treatment of acute mechanical back pain (less than 4 weeks)
NSAIDS, acetaminophne, muscle relaxants, heat and early mobility
Treatment for moderate to severe back pain
combination of muscle relaxant and an NSAID
MRI is not recommended for patients with sciatica unless
symptoms last for greater than 1 month or if the patient is not a candidate for surgery or epidural injection.
Sciatic is a classic sign of herniated disc. Sharp pain or burning back pain that radiates down the back and side of the leg, distal to the knee.
Treatment of spinal stenosis?
NSAIDS and analgesics, physical therapy and epidural corticosteroids.
Treatment of caudal equine syndrome
surgical decompression of the entrapped caudal equina to prevent further neurological deterioration.
Physical findings of caudal equina syndrome?
Pain elicited by straight leg raise, reduction in anal sphincter tone and decreased ankle reflexes.
Most important treatment for Tourette
education counseling of patient and family
Pharmacotherapy should be considered if there is continued functional impairment despite education and behavioral therapy.
First line: Clonidine (safe and ability to help with comorbid ADHD and OCD).
Primozide and haloperidol is more effective for tics than clonidine but have more risk of long term side effects.
What drug helps with chorea in Huntington?
Benazine, a dopamine depleting agent
Dx of moderate persistent asthma?
daily symptoms and use of albuterol inhaler daily.
Tx: low dose inhaled steroid and long acting b-agonist or medium dose inhaled steroid
Dx of severe persistent asthma?
symptoms throughout the day and use of albuterol inhaler several times per day.
Tx: high dose inhaled and long acting b-agonist
Dx of intermittent asthma?
symptoms less than 2 days a week and use of albuterol less than 2 times a week.
No medication needed; short acting b-agonist need for symptoms
Treatment for asthma always begin with
education and counseling, environmental controls and management of coexisting conditions.
For moderate to severe exacerbations of asthma, what do you use?
Oral steroid treatment is recommended: 1 to 2 mg/kg per day for 3 to 10 days in children, or 40 to 60 mg per day in one or two divided doses for 5 to 10 days in adults.
Inhaled steroids are not insufficient because of their delayed onset of action.
A Mallampati score of what suggests increased risk for Obstructive sleep Apnea?
score of 3 or more
- entire tonsil visible
- upper half of tonsil fossa visible
- soft palate and hard palate visible
- only hard palate visible
What is considered to be a high risk for obstructive sleep apnea?
Obesity
Severe OSA is defined as having more than how many RDI per hour?
What is moderate versus mild?
RDI = respiratory disturbance index
Severe = more than 30 RDI per hour Moderate = 15 - 30 RDI Mild = 5 to 15 RDI per hour
Indicated to improve patient comfort while using PAP
heated humidification
The USPSTF recommend routine osteoporosis screening for women what age?
65 years or older without previous known fractures or secondary causes of osteoporosis.
Routine screening for women <65 years old whose 10 year fracture risk is greater than or equal to that of a 65 year old white women with no additional risks.
First line treatment to reduce risk fracture risk in a patient with osteoporosis?
Bisphosphonates such as alendronate.
Diabetic peripheral neuropathy treatment
anticonvulsant (gapapentin)
Opioid narcotics side effects include
sedation and constipation.
When necessary, stool softeners or stimulant laxatives should be provided.
Initial management of chronic pain
nonpharmacologic therapy
exercise, PT, rehab programs, behavioral, acupuncture, mediation.
In older people, what is the most common cause of bilateral lower extremity swelling?
chronic venous insufficiency
In lymphedema what sign is seen?
Kaposi-Stemmer sign
inability to pinch fold of skin on dorm of foot at base of 2nd toe
If DVT is suspected, what should be ordered?
D-dimer
If normal: rules out DVT
If positive, a venous doppler of the lower extremities should be ordered
Venous insufficiency non pharmacological mainstays
compression leg stockings and leg elevation
What has been shown to decrease symptoms associated with venous insufficiency
horse chestnut seed extract
inhibits elastin and hyaluroniase
