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Family Medicine > Case Files 49-54 (C) > Flashcards

Case Files 49-54 (C) Flashcards

1
Q

Which factors increase a woman’s risk of breast cancer?

A

FHx in a first-degree relative (especially if the cancer occurred in a premenopausal woman and was bilateral)

BRCA-1/BRCA-2

Early menarche, late menopause, and nulliparity or first live birth after the age of 30

Obesity and alcohol use (> 3 drinks per day)

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2
Q

Approximately ___% of breast cancers occur in women older than age 50 years

A

70%

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3
Q

Acromegaly

A

A condition that results from the excessive production of growth hormone by a pituitary adenoma

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4
Q

Physical Exam:

Benign vs Malignant

A

Benign: soft, smooth/regular, mobile, tender, < 30

Malignant: firm, irregular, fixed/tethered, painless, > 50

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5
Q

Triple Assessment

A
  1. Clinical breast exam
  2. Imaging
  3. Pathology assessment (core biopsy or surgical excision)
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6
Q

True/False: Breast pain is not a common presentation of breast cancer, particularly when it is bilateral breast pain

A

True

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7
Q

Types of breast pain

A
  • Cyclic mastalgia: diffuse, bilateral, radiating, and related to the woman’s menstrual cycle
  • Noncyclic mastalgia: continuous/intermittent, but not associated with the menstrual cycle
  • Extra-mammary pain: breast pain secondary to another etiology (ie, chest pain)
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8
Q

For women with unrelenting pain in spite of the above modifications, _______, an antigonodotropin, is FDS approved for the treatment of breast pain

A

danazol

side effects: hair loss, acne, weight gain, and irregular menses

other options include: tamoxifen, toremiphene, and bromocriptine

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9
Q

Discharge that is spontaneous, persistent, bloody, from a single duct, associated with a mass, and occurs in women over 40 years of age is more likely to represent a ________

A

pathologic process

most common causes are: intraductal papillomas, duct ectasia, cancers, and infections

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10
Q

The treatment of most unilateral, spontaneous, or bloody nipple discharges is:

A

surgical excision of the terminal duct

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11
Q

Define galactorrhea

A

Discharge of milk or a milk-like secretion from the breast in the absence of parturition or beyond 6 months postpartum in a non-breast-feeding woman

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12
Q

SSRIs

TCAs

Atenolol

Verapamil

Antipsychotics

Cimetidine

Opiates

A

Common medications associated with galactorrhea

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13
Q

Treatment for:

  1. Hyperprolactinemic disorders
  2. Hyperprolactinemic-induced anovulatory infertility
  3. Prolactinomas
A
  1. Dopamine
  2. Bromocriptine
  3. Surgical resection
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14
Q

Diagnosis of PCOS

A

Made by having 2 of the 3 factors:

hyperandrogenism

chronic anovulation

polycystic ovaries on ultrasound

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15
Q

What is the menstrual cycle irregularity associated with PCOS?

A

Anovulation

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16
Q

Treatment of insulin resistance and infertility in patients with PCOS

A

Metformin and thiazolidinediones

Weight loss, clomiphene citrate, aromatase inhibitors, and gonadotropins

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17
Q

Leiomyomata (fibroids)

Endometrial polyps

von Willebrand disease

Warfarin

A

Common causes of abnormal bleeding associated with regular menstrual cycles

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18
Q

Common causes of abnormal bleeding and irregular menstrual cycles

A

aka dysfunctional uterine bleeding (DUB)

generally implies an abnormality within the HPO axis

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19
Q

History of anovulatory menstrual cycles

Obesity

Nulliparity

> 35 years

Tamoxifen use

A

Risk factors for endometrial carcinoma

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20
Q

The evaluation of a woman with DUB is dependent on:

A

age and risk factors

in the period after menarche, watchful waiting is usually indicated

in women < 35 who are not at increased risk of endometrial cancer, treatment may be offered without workup beyond the history and PE

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21
Q

Evaluation of DUB

A

Transvaginal pelvic ultrasound

Endometrial biospy

Hysteroscopy

D&C

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22
Q

Treatment of anovulatory bleeding after a workup has ruled out malignancy

A

*OCPs or progestin alone

Hysterectomy

Ablation

*Reduce the risk of developing endometrial hyperplasia and carcinoma

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23
Q

Which of the following increases risk of endometrial cancer:

smoking, having kids, being obese, or taking OCPs

A

being obese

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24
Q

Initial tests for the evaluation of menstrual irregularities

A

Pregnancy test

TSH

Prolactin level

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25
Q

Commonly isolated organisms found in cases of endometritis

A

Gonorrhea, Chlamydia, Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, and GBS

Diagnosis of endometritis can be confirmed with endometrial biopsy showing inflammatory cells (plasma cells)

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26
Q

The leading cause of blindness in working-age adults in the US

A

Diabetes

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27
Q

Goals for diabetic control

  1. Glycemic
  2. LDL
  3. BP
  4. Life style
A
  1. Hemoglobin A1C of 7% or less
  2. LDL 70-100
  3. BP < 130/80
  4. At least 150 min/wk of moderate-intesnity aerobic physical activity and resistance training 3x per wk
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28
Q

Diabetic ketoacidosis

A

Commonly seen in uncontrolled Type I DM

Type I diabetics are prone to metabolize fats, with the resultant production of ketones

A syndrome characterized by hyperglycemia, high levels of serum acetone, and an anion gap metabolic acidosis

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29
Q

True/False: Type II DM has a stronger familial predisposition than type I

A

True

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30
Q

Nonketotic hyperosmolar syndrome

A

Often seen with uncontrolled Type II DM

Occurs when blood sugar levels become highly elevated, often approaching 1000 mg/dL

Serum osmolarity is elevated (> 320 mOsm/kg) and the patient has a large fluid deficit (up to 9 L)

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31
Q

Maternal complications of gestational DM

A

hyperglycemia

DKA

UTIs

HTN/pre-E

retinopathy

32
Q

Fetal effects of gestational DM

A

Congenital malformations

Macrosomia

RDS

Hypoglycemia

Hyperbilirubinemia

Hypocalcemia

Polycythemia

Hydramnios

33
Q

True/False: Women with gestational diabetes are more prone to develop non-pregnancy-related type 2 diabetes and should be screened with a glucose tolerance test postpartum

A

True

34
Q

ACOG screening guidelines for gestational diabetes

A

50g 1 hr glucose challenge test (GCT) at initial visit for high risk and between 24-28 for all pregnant women

> 130 mg/dL = 100g 3 hr glucose challenge

Diagnosis is made based on greater than two abnormal results (fasting - 95, 1 hr - 180, 2 hr - 155, 3 hr - 140)

35
Q

Diagnostic criteria for diabetes are:

A
  1. Random glucose > 200 with classic symptoms
  2. Fasting glucose > 126
  3. A 2 hr plasma glucose 200 or more after a 75g glucose load
  4. HbA1C > 6.5
36
Q

Instead of A1C, what can you measure in patients with haemoglobinopathies, recent blood loss, or recent changes in diet to screen for diabetes?

A

Fructosamine

Indicates average glucose levels over a 2 to 3 week period

37
Q

Other tests recommended for diabetic screening

A

Fasting lipid profiles

Serum creatinine

Urinalysis

creatinine ratios

eye exam

foot exam

ECG

TSH

38
Q

Lispro or Aspart Insulin

A

Rapid acting

15 min onset of action

3-5 hour duration

39
Q

Regular insulin

A

Short acting

30-60 min onset of action

5-8 hour duration

40
Q

NPH insulin

A

Immediate acting

13 hour onset of action

18-24 hours duration

41
Q

Glargine insulin

insulin detemir

A

Long acting

1 hour onset of action

24 hour duration

42
Q

Biguanides mechanism of action

A

Metformin

Act on the liver to decrease glucose output during gluconeogenesis

Secondary actions include improved insulin sensitivity in the liver and muscle and a hypothesized decrease in intestinal absorption of glucose

43
Q

Most dangerous side effect of metformin

A

Lactic acidosis

Risk is increased by renal insufficiency and metformin in contraindicated in those with a creatinine > 1.5 in men and 1.4 in women, hepatic insufficiency, or congestive heart failure

44
Q

Sulfonylureas mechanism of action

A

First oral agents for type 2 diabetes

Function as insulin secretagogues that stimulate beta cells in the pancrease to secrete insulin

Unlike metformin, sulfonylureas carry a risk of causing hypoglycemia

45
Q

What are considered the best validated second-line add-on therapies if metformin does not control diabetes well enough?

A

Sulfonylureas and insulin

46
Q

The principal action thiazolidinediones (TZDs) is:

glitazone

A

improving insulin sensitivy in muscle and adipose tissue

Secondary actions are decreased hepatic gluconeogenesis and increased peripheral glucose utilization

Because they are metabolized in the liver, they can be used in patients with renal impairment

47
Q

What are meglitinides?

A

Short-acting secretagogues (taken no more than 1 hour before meals)

Increase insulin secretion from the pancreas

Risk of hypoglycemia (especially if meal is skipped after taken medication)

48
Q

How do α-Glucosidase inhibitors work?

A

Delay carbohydrate absorption by inhibiting α-glucosidase in the small intestine, which decreases postprandial hyperglycemia

49
Q

What is pramlintide?

A

An amylinomimetic agent that has physiologic actions equivalent to those of human amylin (glucoregulatory hormone synthesized by pancreatic β cells and released with insulin in response to a meal)

It works to inhibit inappropriately high glucagon secretion secretion during episodes of hyperglycemia

50
Q

GLP-1 Agonist (eg, exenatide)

A

Glucagon-like peptide-1 mimetic

Synthetic peptide that stimulates insulin release

51
Q

DDP-4 inhibitor

A

Examples: sitagliptin, saxagliptin

Inhibit DDP-4 which is an enzyme that inactives incretin hormones GLP-1 and GIP (both stimulate insulin release, and GLP-1 also decreases glucagon secretion from the pancreas leading to reduced hepatic glucose production)

52
Q

Compared to gestational diabetes, patients with type 2 diabetes who become pregnant are at increased risk of what happening to the fetus?

A

Fetal malformations

53
Q

Where else is cytochrome P450 found apart from the liver?

A

Small intestine, lungs, and kidneys

54
Q

What protocol is used to avoid miuse of medications in the elderly?

A

Beers criteria

STOPP (Screening Tool of Older Person’s Prescriptions)

55
Q

Although more than 50 CYP isoenzymes have been identified, __ of these isoenzymes metabolize 90% of drugs

A

6

56
Q

Which medication can be given to increase the therapeutic effect of penicillin?

A

probenecid (decreases renal excretion of pencillin)

57
Q

Why do elderly often have falsely elevated calculated creatinine clearance rates?

A

Because they have decreased muscle mass

Creatinine clearance = (140 - age)x(ideal body wt)x(0.85 for women) / 72x(serum creatinine)

58
Q

A 62-year-old man presents with increasing muscle aches in his thighs/shoulders and complains of dark, tea-colored urine. His only medications are lisinopril, simvastatin, and a baby aspirin. Which food should you ask him about eating and what is most likely going on?

A

Grapefruit (inhibits C P450)

The patient probably has rhabdomyolysis from increased circulating simvastatin

59
Q

A 36-year-old woman presents very distressed after having a positive pregnancy test. She says she has taken her OCPs religiously and the only other medication she takes is an herbal supplement for depression. What supplement is she taking?

A

St. John’s wort

A common herbal antidepressant, can induce CYP3A4 and CYP3A5 causing increased metabolism of estradiol

60
Q

What is the classic sign of a herniated disc?

A

Sciatica

61
Q

What are the most common acquired causes of lumbar spinal stenosis?

A

Degenerative arthritis

Spondylolisthesis

Congenital causes = dwarfism, spina bifida, and myelomeningocele

62
Q

The vast majority of patients visiting a doctor for back pain will be diagnosed with…

A

lumbar strain

63
Q

What imaging should you order for a 45-year-old man presenting with a 2 day history of severe back pain that radiates to his great toe (+ straight leg on exam)?

A

None

There is no evidence that imaging within the first month after a herniated disc has any morbidity benefit (if symptoms persists after 1 month, then MRI is appropriate)

X-rays do not show disks or nerve roots and CT has poorer visualization of soft tissue than a MRI

64
Q

What is the preferred treatment for spinal stenosis (pain relieved by sitting or stooping)?

A

NSAIDS, physical therapy, and epidural steroid injection

65
Q

How to treat cauda equina

A

Decompression

66
Q

Treatment for verterbral fractures

A

kyphoplasty

67
Q

No single words by __ months is a red flag for the presence of autism spectrum disorder (ASD)

A

16 months

68
Q

Which 3 developmental disorders does ASD encompass?

A

Autistic disorder (AD)

Asperger syndrome (AS)

Pervasive developmnetal disorder not otherwise specified (PDD-NOS)

69
Q

Prevalence of ASDs is….

A

1 per 110

70
Q

Common features shared by all ASDs include severe deficits in social skills and limited, repetitive, and stereotyped behavior patterns. Only ___ and ___ are characterized by significant language delays.

A

AD and PDD-NOS

71
Q

What age must a child demonstrate abnormal behavior before in order to be diagnosed with autistic disorder?

A

before age 3

72
Q

The key to successful treatment of ASDs is…

A

early diagnosis leading to early intervention

73
Q

Most common genetic cause of AD and retardation in males

A

Fragile X Syndrome

Characteristics: mental retardation, macrocephaly, large pinnae, large testicles, hypotonia, and hyperextensible joints

74
Q

All children should be screen with the _____ at the 18- and 24-month visits

A

Modified Checklist for Autism in Toddlers (M-CHAT)

Red flags indicating the need for immediate evaluation:

no babbling or pointing by 12 months

no single words by 16 months

no 2-word phrases by 24 months

loss of language or social skills at any age

75
Q

Monotone, restricted speech limited to only one topic

Lack of eye contact

Lack of peer relationships

Repetitive, nonfunctional, atypical behavior of rocking and twirling

A

Asperger syndrome

76
Q

True/False: Parents who have a child with autism have an increased risk for having another child with an ASD

A

True. Recurrence risk of 5-6% when there is an older sibling with an ASD.

Family Medicine (10 decks)

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