Case files Flashcards
what is the gold standard test for diagnosing subarachnoid hemorrhage? What is it’s main limitation?
- an LP showing Xanthochromia (RBCs)
- may be negative early in the disease course
Recommended screening test for cardiovascular conditions in a 52-y/o male with no medical problems in for physical?
- Blood pressure
- Lipids
Recommended screening test for cancer in a 52-y/o male with no medical problems in for physical?
- Fecal occult blood testing, Flex sig, colonoscopy or double contrast barium enema to screen for colorectal cancer
- There is insufficient evidence to recommend for or against universal prostate cancer screening by PSA testing
Recommended immunizations in a 52-y/o male with no medical problems in for physical?
-Tetanus toxoid, reduce diphtheria toxoid, and acellular pertussis vaccine (Tdap) if he has not had one before and if it has been 10 years or more since he has had a tetanus-diphtheria (Td) vaccine, or if he required booster protection against pertussis, influenza vaccine annually, in the fall or winter months
how often should tetanus vaccine be given
every 10 years
at what age should you screen me and women for lipid disorders?
- men 35 or older
- women 45 or older
- screen adults overs 20 who are at increased risk for cardiovascular disease
at what age are men recommended to take aspirin daily to reduce the risk of MI as long as the benefit outweighs their risk of GI hemorrhage
45-79
describe the screening for AAA?
-US to assess for AAA is recommended in men aged 65 to 75 who have ever smoked
Recommendation for AAA screening for men who have NEVER smoked?
No recommendation
Recommendation for AAA screening for women who have NEVER smoked?
recommended against
Describe the recommendation for screening for AAA in women aged 65-75 who have smoked?
insufficient evidence
Age to start screening both men and women for colorectal cancer
50
recommendation for routine screening for prostate cancer using digital exam or PSA?
recommended against
Who should undergo annual low-dose CT of chest to screen for lung cancer?
- men and women aged 50 to 80 with a 30 or more pack-year history who continue to smoke or who quit less than 15 years ago
- screening for lung cancer with routine chest x-ray is not recommended
recommendation for DM2 screening
- insufficient evidence to recommend screening asymptomatic adults
- screening recommended for adults with HTN (135/89 or more sustained or untreated) or hyperlipidemia
routine screening of thyroid disease in asymptomatic individuals?
-insufficient evidence
age for Pneumococcal polysaccharide and pneumococcal conjugate vaccines?
-all adults 65 and older
in whom is Hep B vaccination recommended
- those at high risk of exposure
- health care
- those exposed to blood or blood products
- dialysis Pts
- IV drug users
- Persons with multiple sex partners or recent STD
- Men who have sex with men
- All patients with diabetes who have not previously been immunized
In whom Is hep A vaccine recommended
- chronic liver disease
- those who use clotting factors
- occupational exposure to hep A
- IV drug users
- Men who have sex with men
- those who travel where hep A is endemic
Who need meningococcal vaccine
- high risk groups
- college dorm residents
- military recruits
- complement deficiencies
- functional or anatomic asplenia
- those who travel where its endemic
what is the appropriate treatment of an acute exacerbation of COPD
- antibiotic
- bronchodilators
- systemic corticosteroids
what vaccine should all smokers and those with chronic pulmonary disease receive
- pneumococcal vaccine
- influenza
When is oxygen therapy needed for COPD
- Stage IV
- FEV1/FVC
What is the only intervention that has been shown to decrease mortality of COPD?
Oxygen therapy and must be worn for at least 15 h/d
What are the most common bacteria implicated in COPD exacerbations
- Pneumococcus
- Haemophilus influenza
- Moraxella catarrhalis
If a man presents with the sudden onset of monoarticular joint pain what is the first diagnosis that needs to be excluded
an infected joint
what are the ages of men and women that most gout attacks occur? Why is there a difference?
- Men 30-50
- Women 50-70 (postmenopausal)
- Pre menopausal women are less likely due to increased level of female sex hormones, which aid in urinary excretion of uric acid
Why may thiazide diuretics induce hyperuricemia
increasing urinary urate reabsorption
Describe the joint aspirate in crystal induced arthritis
-WBC count 2000 to 60,000 with <90% neutrophils
Describe the joint aspirate in a septic joint
-WBC average 100,000 with more than 90% neutrophils
Describe the serum uric acid levels in an acute attack of gout
- may be normal or even low
- likely as a result of the existing deposition of urate crystals
describe X-rays of OA at first
usually normal
what level do you want the uric acid to be in someone with recurrent gout attacks?
below 5
What are the 2 options for maintenance therapy of gout and what is the MOA of each
- Probenecid, increases urinary excretion
- allopurinol, reduces production of uric acid
what are first line agents in treatment of RA
-Disease-modifying antirheumatic drugs (DMARDs) . . sulfasalazine and methotrexate
what are the indications for an ultrasound in pregnancy?
- not mandatory in routine, low-risk prenatal care
- evaluation of uncertain gestational age
- size/date discrepancies, vaginal bleeding
- multiple gestations
- other high risk situations
What Laboratory studies are recommended at the initial prenatal visit
- CBC
- HBsAg
- HIV
- Syphilis RPR
- urinalysis and urine culture
- rubella antibody
- Blood type and Rh status with antibody screen
- Pap smear
- cervical swab for gonorrhea and chlamydia
What is the risk to the pregnancy based on the radiation exposure from dental x-rays
- Risk for the baby is increased once radiation exposure is greater than 5 rad
- The radiation exposure from routine dental x-rays is .00017 rad
The optimal time for the trisomy screen
- first trimester for Nuchal translucency (NT) via US
- combo of NT with serum markers hCG and PAPP-A b/t 10 and 13 weeks
- Second trimester triple (AFP, hCG, estriol) or quadruple (triple + inhibin-A) between 16 and 18 weeks
- Conceerning results from the above tests may warrant more invasive testing to confirm chromosome abnormalities (Chorionic villous sampling at 10 to 13 weeks or amniocentesis at 16 to 18 weeks)
What is Advanced Maternal age
pregnant woman who will be 35 years or beyond at the estimated date of delivery (EDD)
Describe Asymptomatic Bacteriuria
-100,000 cfu/mL or more of a pure pathogen of a mid-stream voided specimen without clinical symptoms. In pregnant women this increases risk for acute pyelonephritis, preterm delivery, and low birth weight; therefore, early detection is paramount and treatment is mandated
For low risk women, how much folic acid daily is recommended to reduce the risk of neural tube defects
400-800 ug
How much folic acid a day is recommended in women with diabetes mellitis or epilepsy
1 mg
How much folic acid should a woman who has had a child with a neural tube defect take?
4 mg daily
Women who will be what age or older at the anticipated time of delivery should be educated about age related risk
35
what is one of the most crucial pieces of information in an initial prenatal visit
-accuracy of dating . . by using LMP
Describe Naegele’s rule in dating a fetus
subtract 3 months and add 7 days to the first day of the LMP
When should fetal heart tones be obtainable
by 10 weeks gestation
Describe how often prenatal visits are typically
- every 4 weeks until 28 week gestation
- every 2 weeks from 28-36 weeks
- every week from 36 wk to delivery
If Prenatal Hb is < 10.5 what are possible ramifications?
- Preterm delivery
- Low fetal iron stores
- Identify thalassemia
If Prenatal Hb is < 10.5 what is the next step?
- Mild: therapeutic trial of iron
- Moderate: ferritin and Hb electrophoresis
If prenatal Rubella test is negative what are ramifications?
Nonimmune to rubella
If prenatal Rubella test is negative what is the next step?
- Stay away from sick individuals
- vaccinate with live attenuated vaccine postpartum
if prenatal HIV ELISA is positive, what antiretroviral is used and when is it started?
- Zidovudine
- 2nd trimester
What weeks of gestation are the triple and quadruple screen best to screen for trisomies?
-weeks 15 to 20 (2nd trimester)
What is the most common cause for a false positive serum screen for trisomies
incorrect gestational dating
What testing can be performed at 10-14 weeks (1st trimester) for trisomies
-Nuchal translucency combined with maternal serum analyte levels (free hCG and PAPP-A)
what are the recommended immunizations for a 6 month well-child visit (in a child who is up to date on routine immunizations)?
- Diphtheria
- Tetanus
- Acellular pertussis (DTap) no. 3
- Hep B no. 3
- Haemophilus influenza type b (Hib) no. 3
- Pneumococcal conjugate vaccine (PCV 13) no. 3
- rotavirus no. 3
- inactivated polio vaccine (IPV) no. 3 can be given between 6 and 18 months
- if encounter is during “flu season”, annual influenza vaccination is recommended beginning at 6 months
At what age should a child be able to say “mama” and “dada”
nonspecifically b/t 6 and 9 months
-becomes specific between 8 and 15 months
When is it recommended that a child can be put in a forward facing car seat
-A child should stay in a rear-facing car seat until the age of 2 or until the child reaches the maximum height and weight limit for the car seat
What is amblyopia?
What is the most common cause?
- monocular childhood vision reduction caused by abnormal vision development
- Strabismus
What is strabismus?
-ocular misalignment
All states require screening testing for what childhood disorders?
- PKU
- congenital hypothyroidism
- as early treatment can prevent the development of profound mental retardation
What is the Mantoux test
-an intradermal injection of PPD tuberculin and is the screening test of choice for newborns
Describe the recommendation for screening of high cholesterol in children
- All children at least one time b/t the ages of 9 and 11 and again b/t 17 and 21
- screening for hyperlipidemia should begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors
When is it recommended that all children see a dentist
by 12 months
Screen time for children (like TV and games) should be limited to how much daily
1 to 2 hours or less
What is the leading cause of death in children older than 1 year?
-Accidents and injuries
What are the top 3 causes of death in infants younger than 1 year
- congenital abnormalities
- short gestation
- sudden infant death syndrome (SIDS)
At what weight can a child start using a forward facing booster seat in the rear rather than a car seat
40 lbs
A 35 year old asthmatic woman complains of chronic nasal congestion that is worse in the spring and the fall.
Most likely Dx?
-allergic rhinitis
A 35 year old asthmatic woman complains of chronic nasal congestion that is worse in the spring and the fall.
next step in management?
-antihistamines, decongestants, or intranasal steroids
A 35 year old asthmatic woman complains of chronic nasal congestion that is worse in the spring and the fall.
Considerations and possible complications of therapy?
- Recognition and reduction of potential allergen exposure will yield more success in management than pharmacotherapy alone
- Excessive use of topical decongestants can cause rebound congestion
appearance of the mucosa of nasal turbinates in allergic rhinitis
- swollen (boggy)
- has a pale, bluish-gray color
- thin, watery secretions are seen
what medication offers the most consistent symptomatic relief in allergic rhinitis
nasal corticosteroids
At the first suspicion of anaphylaxis, what should be given?
- Aqueous epinephrine 1:1000, in a dose of .2 to .5 mg, injected SQ or IM
- repeated infections can be given every 5 to 15 minutes when necessary
Most likely diagnosis in a 65 y/o women with worsening dyspnea on exertion, fatigue, dizziness, and palpitations. She is found to have conjunctival pallor and guaiac-positive stool.
- Anemia secondary to GI bleeding
- other considerations should include new-onset angina, CHF, and Afib
in a 65 y/o women with worsening dyspnea on exertion, fatigue, dizziness, and palpitations, after the initial workup for cardiac and pulmonary causes is negative and the Hb and Hct are low, what would you evaluate for the cause of the anemia?
- CBC with peripheral smear
- reticulocyte count
- iron studies
- vitamin B12 levels
- Folic acid levels
- A gastroenterology consult for possible EGD and colonoscopy to further investigate the source of GI bleed should be considered
Conjunctival pallor is recommended as a reliable sign of anemia in the elderly and commonly noted in patients with hemoglobin levels of what?
less than 9 g/dL
What are signs suggestive of Vitamin B12 deficiency anemia?
- Glossitis
- decreased vibratory and positional senses
- ataxia
- paresthesia
- confusion
- dementia
- pearly gray hair at an early age
What cause of anemia may produce Koilonychias (spoon nails), glossitis, or dysphagia
profound iron deficiency anemia
Jaundice in anemia can be a clue that what is a contributing factor?
-hemolysis
Splenomegaly in anemia can indicate that what may be present?
-thalassemia or neoplasm
What should the initial workup of anemia include?
- CBC with measurement of RBC indices
- peripheral blood smear
- reticulocyte count
- further laboratory studies would be indicated base on the results of the initial tests and the presence of symptoms or signs suggestive of other diseases
What do iron studies show in iron deficiency anemia?
- Low serum iron
- Low ferritin
- High TIBC
Elevated levels of what can be used to confirm vitamin B12 deficiency
-Methylmalonic acid (MMA)
Elevated levels of what can be used to confirm folate deficiency?
homocysteine
Folate deficiency anemia is usually seen in who
alcoholics
B12 deficiency anemia is usually seen in who
- ppl with pernicious anemia (lack of intrinsic factor)
- Hx of gastrectomy
- diseases of malabsorption (bacterial infx, Crohn, celiac)
What level of Hb is commonly used as a threshold for transfusion?
7 g/dL
What is considered first line therapy in uncomplicated iron deficiency anemia
-ferrous sulfate
A 40 yr old man who recently returned from Mexico with profuse, acute, nonbloody diarrhea, and dry mucous membranes on examination, which are consistent with developing dehydration. An ill family member with identical symptoms suggests an infectious cause of this acute illness. Most likely dx?
Acute gastroenteritis
A 40 yr old man who recently returned from Mexico with profuse, acute, nonbloody diarrhea, and dry mucous membranes on examination, which are consistent with developing dehydration. An ill family member with identical symptoms suggests an infectious cause of this acute illness. Next steps?
- Fecal leukocyte or fecal lactoferrin testing
- Rehydration with oral or IV fluids
A 40 yr old man who recently returned from Mexico with profuse, acute, nonbloody diarrhea, and dry mucous membranes on examination, which are consistent with developing dehydration. An ill family member with identical symptoms suggests an infectious cause of this acute illness. Potential complication?
- Dehydration
- Electrolyte abnormalities
What are the most probable etiologies of diarrhea?
- virus
- E. coli
- Shigella
- Salmonella
- Giardia
- Amabiasis
The presence of blood in the stool of an acute diarrhea patient would suggest what type of infection?
- Invasive bacterial
- such as, EHEC nad EIEC, Yersinia, Shigella, and Entamaeba histolytica
Examining stool for leukocytes is an inexpensive test that helps differentiate b/t types of infectious diarrhea. if present, suspicion is higher for what
- Salmonella
- Shigella
- Yersinia
- EHEC and EIEC
- C. diff
- Campylobacter
- E. histolytica
Describe the role of lactoferrin in a diarrhea workup?
- it is an iron binding protein found in PMNs and bodily secretions such as breast milk
- GI inflammation causes immune activated PMNs to release lactoferrin
- Lactoferrin elevations in stool can be seen with IBS, intestinal bacterial infections, parasitic infections, and others.
- Lactoferrin will be LOW IN VIRAL INFECTIONS, making it a useful test for distinguishing viral from bacterial diarrhea
Describe the role of stool cultures in the evaluation of diarrhea?
- they have limited benefit due to high cost and inefficient results
- should be limited to individuals with blood diarrhea, diarrhea lasting for more than 3 to 7 days, immunocompromised patients, and evidence of systemic disease or severe dehydration
Describe Traveler’s Diarrhea prophylaxis
- best method is to avoid contaminated food and water
- Antibx is not indicated unless pt is at increased risk (IBD, renal disease, or immunocompromised) . . Fluoroquinolones usually used
- antibacterial and antisecretory effects of bismuth subsalicylate decrease the incidence of TD (avoid if allergic to aspirin, pregnant, taking methotrexate, probenecid, or doxy for malaria prophylaxis)
Describe the use of antibiotics in Treatment of TD when indicated?
- Ciprofloxacin (500 mg BID) for 3 days . . cannot be used in children or pregnant women
- Azithromycin, given as a 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 TID for 3 days can be used in TD caused by noninvasive strains of E coli. not effective against infections associated with fever or blood in the stool
USPSTF recommendation for interval for screening mammography in a 55 yr old woman
-Biennial (every 2 years), b/t ages of 50 and 74
Describe the USPSTF recommendation on lipid screening in women?
- Women more than age 45 with risk factors for heart disease, including diabetes, previous Hx of heart disease, family history of CVD, tobacco use, HTN, and obesity should be screened with a lipid panel
- Also, women b/t ages of 20 and 44 who have risk factors should have a one-time screening
Describe the link b/t hormone replacement therapy and risk of cardiovascular disease in post menopausal women
- Increased rates of adverse cardiovascular outcomes in women taking either estrogen alone or combined estrogen and progesterone
- For this reason, the use of hormone replacement therapy for the prevention of chronic conditions (osteoporosis) is not advised
Describe USPSTF recommendation for PAP smear for any women with a cervix
- begin at age 21 and 3 year intervals
- For women more that 30 desiring longer intervals, contesting for HPV can be used in conjunction with cytology once every 5 years
HPV vaccine against high risk subtypes is available as a three series. It is indicated for who?
- females aged 11 through 26
- To date, there is no recommendation to alter the pap smear screening intervals for women who have been vaccinated
USPSTF recommends stopping Pap smears at what age and with what stipulation
-age 65 in women who have had three consecutive negative pap results and 2 consecutive negative HPV results within the last 10 years
What are the risk factors for osteoporosis
- advancing age
- tobacco use
- low body weight
- poor nutrition
- Caucasian or Asian ancestry
- family history
- low calcium intake
- sedentary lifestyle
What are the additions risk factors for osteoporosis in men
- prolonged use of corticosteroids
- presence of diseases that alter hormone levels (such as chronic kidney or lung disease)
- undiagnosed low testosterone levels
Osteoporosis is present if the patient’s T-score from DXA scane is what
at or below -2.5
Osteopenia is present if the T score is what
between -1.0 and -2.5
the USPSTF recommends screening for osteoporosis via DXA in women at what age
over 65 and considering screening in women younger than 64 with higher risk
-there is no current recommendation on repeating screening if the initial test is normal
Describe the recommendation for calcium and vitamin D intake in women to prevent osteoporosis
- women over age of 51 consume 1200 mg of calcium daily
- women over age of 50 consume 800 to 1000 IU of Vitamin D daily
- per NOF **** not USPSTF
at what ages does USPSTF recommend that physicians screen women for domestic violence
b/t 14 and 46
What are the different pneumonics of screening tools for domestic violence
- HITS
- STaT
- HARK
What factors are associated with intimate partner violence
- young age
- low income status
- Pregnancy
- mental illness
- alcohol or substance use by victims or partners
- separated or divorced status
- Hx of childhood sexual/physical abuse
What is the most commonly injured ankle ligament?
ATF followed by CFL (calcaneofibular ligament)
Describe a grade 1 ankle sprain
- stretch of a single ligament, most commonly ATF
- minor swelling
- no mechanical instability
- w/o significant loss of function
- pt can usually bear weight with, at most, mild pain
Describe a grade 2 ankle sprain
- partial ligamentous tear
- more severe pain, swelling, and bruising
- mild to moderate joint instability
- significant pain with weight bearing
- loss of range of motion **
Describe a grade 3 ankle sprain
- complete ligamentous tear
- significant joint instability, swelling, loss of function
- inability to bear weight
The Ottawa ankle rules are a decision model designed to aid a physician in determining which patients with ankle injuries need an x-ray. When properly applied, these have a sensitivity approaching 100% in ruling out significant malleolar and midfoot fractures. the rules state that x-rays of the ankle should be performed when?
- if there is bony tenderness of the posterior edge or tip of the distal 6 cm of either medial or lateral malleolus
- Tenderness in the midfoot coupled with point tenderness over the bony aspects of base of fifth metatarsal or the navicular
- if patient is unable to bear weight immediately or when examined
Describe the role of cryotherapy in the role of managing an ankle injury
-recommended in the first 3 to 7 days after an ankle sprain for short term pain relief and improved functionality
What are the Ottawa Knee rules for when to get a knee xray
- age 55 or older
- isolated patella tenderness
- tenderness of the head of the fibula
- inability to flex the knee to 90 degress
- inability to bear weight for 4 steps immediately and in the exam reoom (regardless of limping)
When should range of motion exercises be started after injury in patients with sprains and strains
-48 to 72 hours after injury
What is the most common cause of persistently stiff, painful, or unstable joints following sprains?
inadequate rehabilitation
A closed packet containing pus
Abscess
A blister greater than .5 cm in diameter
bulla
A closed, saclike, membranous capsule containing a liquid or semisolid material
Cyst
A discoloration of the skin that is neither raised nor depressed
macule
A small mass of rounded or irregular shape that is greater than 1.0 cm in diameter
nodule
A small, circumscribed ELEVATED lesion of the skin that is less than 1.0 cm in diameter
papule
A plateaulike, raised, solid area on the skin that covers a large surface area in relation to its height above the skin
Plaque
A lesion through the skin or mucous membrane resulting from loss of tissue
ulcer
A small blister less than .5 cm in diameter
vesicle
What is the most common type of melanoma in both sexes
superficial spreading melanoma
what is the most common melanoma found in African americans and asians
Acral lentiginous melanoma
The single most important piece of information for prognosis in melanoma is the thickness of the tumor, known as the Breslow measurement. Melanomas less than how thick have a low rate of metastasis?
< 1 mm
A 40 year-old male smoker is found incidentally to have red blood cells in his urine sample on urinalysis. Current diagnosis?
Asymptomatic microscopic hematuria
A 40 year-old male smoker is found incidentally to have red blood cells in his urine sample on urinalysis. Initial approach?
- Repeat urinalysis
- Asses for risk factors and possible reversible causes such as UTI, vigorous exercise, or recent urologic procedure
- perform renal function testing
- Depending on low or high risk of malignancy, perform additional imaging of lower and/or upper urinary tract
A 40 year-old male smoker is found incidentally to have red blood cells in his urine sample on urinalysis. Workup and plan?
- R/O infection by performing urine culture
- obtain further hx including exercise routine or recent urologic procedures
- Perform renal function testing to rule out renal disease
- If all is negative, evaluate for malignancy by imaging of the upper urinary tract via CT urography and lower urinary tract via cystoscopy
A 40 year-old male smoker is found incidentally to have red blood cells in his urine sample on urinalysis. Concerns and counseling
- primary concern is to rule out malignancy including RCC and transitional cell carcinoma
- Counsel on importance of workup but reassure about low prevalence of condition
The American urological Association (AUA) defines significant microscopic hematuria as what?
more than 3 RBCs per HPF on urinalysis with microscopy
Describe the workup for an asymptomatic pt with a UA result of fewer than 3 RBCs per HPF
- repeat UA three times at 6 week intervals
- If negative (consistently < 3 RBCs per HPF), the workup is complete and pt should be reassured
Hematuria is divided into glomerular, renal (nonglomerular), and urologic etiologies. What is glomerular hematuria associated with?
- significant proteinuria
- erythrocyte casts
- dysmorphic RBCs
Hematuria is divided into glomerular, renal (nonglomerular), and urologic etiologies. What is Renal hematuria associated with?
- secondary to tubulointerstitial, renovascular, and metabolic disorders
- also associated with significant proteinuria; however, there are no associated dysmorphic RBCs or erythrocyte casts
Hematuria is divided into glomerular, renal (nonglomerular), and urologic etiologies. What is urologic hematuria associated with?
- tumors
- calculi
- infections
- trauma
- BPH
- ABSENCE of proteinuria, dysmorphic RBCs, and erythrocyte casts
Recommendation for routine screening for bladder Cx in asymtptomatic patients with microscopic hematuria?
-Although malignancy is found in 5% of all pts with incidental asymptomatic microscopic hematuria, the USPSTF currently does NOT recommend routine screening for bladder cancer in asymptomatic pts
Given the limited specificity of the dipstick method, the initial finding of hematuria by the dipstick method should be confirmed how?
by microscopic evaluation of urinary sediment
Interstitial nephritis, often caused by analgesics or other drugs, is suggested by the presence of what in the urine
eosinophils
Most likely dx of hyperthyroidism secondary to Graves disease. What is the most appropriate imaging study?
nuclear medicine thyroid scan with uptake
Most likely dx of hyperthyroidism secondary to Graves disease. Definitive nonsurgical treatment?
Thyroid ablation with radioactive iodine
what is the ost common cause of noniatrogenic hyperthyroidism
Graves disease
Medical treatment of Graves disease?
- antithyroid drugs (PTU and methimazole)
- and/or beta-blockers to block peripheral effects
- only temporary measures used to give patients symptomatic relief. The definitive treatment is radioactive iodine, which destroys the thyroid galnds
At least 40% of patients who receive radioactive iodine eventually develop what?
-hypothyroid
in older patients, hypothyroidism can be confused with what?
Alzheimer dx
Are functional adenomas that present with hyperthyroidism usually malignant or benign?
rarely malignant
thyroid nodules measuring greater than 1 cm by US in a person with normal or elevated TSH requires what
biopsy with fine-needle aspiration
Describe the treatment of hyperthyroidism in pregnancy
-due to adverse effects of methimazole on fetal development, PTU should be used in 1st trimester of pregnancy, and methimazole in second and third trimesters
what should be the next step if thyroid cancer is detected in pregnancy
- can usually be observed until after pregnancy is complete
- if need, thyroid surgery can be performed safely in 2nd and 3rd trimesters
A 25-year-old pregnancy woman at term presents with spontaneous rupture of membranes and subsequent uterine contractions, signaling the onset of labor. What signs confirm the rupture of membranes?
- Visualization of amniotic fluid leaking from the cervix
- presence of pooling of amniotic fluid in the posterior vaginal fornix
- demonstration of a pH above 6.5 in fluid collected from the vagina using Nitrazine paper
- visualization of “ferning” on a sample of fluid on an air-dried microscope slide
Labor is typically divided into three stages. The first stage is what
from the onset of labor until the cervix is completely dilated
What is the second stage of labor?
from complete cervical dilation (10 cm) through the delivery of the fetus
What is the third stage of labor
-begins after the delivery of the baby and ends with the delivery of the placenta and membranes
What is considered normal baseline heart rate of a fetus during labor
110-160
What is a category I Fetal Heart tracing (FHT)
- considered normal
- includes each of the five characteristics:
- baseline HR 110-160
- moderate baseline FHR variability
- no late or variable decels
- both accelerations and early decelerations may be absent or present
What is a category III FHT
- considered abnormal
- includes EITHER absent baseline FHR variability plus any of the following three: repeated late cedels, variable decels or bradycardia
- OR a sinusoidal pattern
During labor, the fetal head descends through the birth canal and undergoes four cardinal movements. What are they
- During initial descent, head undergoes flexion
- the internal rotation, causing fetal occiput to move anteriorly toward maternal symphysis pubis
- as head approaches vulva, undergoes extension,
- external rotation to face either maternal right or left
Cervical dilation beyond 4 cm means what phase
active phase
What on FHT are thought to be due to compression of fetal head
Early decelerations
The presence of acceleration on a fetal heart tracing is very reassuring and consistent with a fetal pH of what
greater than 7.2
A 58 year old woman with a Hx of recurrent nephrolithiasis, presenting for follow-up and found to have calcium oxalate stones. She had an initial serum calcium levels that was elevated, as was the repeat serum calcium 1 weeks later. At the time of her follow-up, she was completely asymptomatic. She takes no meds and has family Hx only for HTN. most likely cause and next step?
- Hyperparathyroidism
- serum PTH levels
Calcium levels on CMP can be misinterpreted when a patient has hypoalbuminemia. What is the corrected calcium equation
[.8 x (normal albumin - patients albumin)] + serum calcium
. . . . Normal Albumin is presumed to be 4
What is the second leading cause of hypercalcemia
Cancer
It is useful to categorize the etiologies of hypercalcemia into what five main areas
- PTH related
- Malignancy
- renal failure
- high bone turnover
- vitamin D related
What pneumonic is useful to categorize the constellation of physical symptoms associated with hypercalcemia
- “Stones, bones, psychic groans, and abdominal moans”
- Stones: renal calculi
- Bones: bone pain including arthritis and osteoporosis
- Psychic groans: poor concentration, weakness, fatigue, stupor, coma
- Abdominal groans: abdominal pain, constipation, N/B, pancreatitis, anorexia
What are the most serious manifestations of hypercalcemia and how are they treated?
- Dysrhythmias and coma
- rehydration with NS 4 to 6 L in 24 hours
- then IV bisphosphonates
In a patient with hyperkalemia with cardiac changes what should the first intervention be
give IV calcium to stabilize the cardiac membranes and reduce the risk of arrhythmia
A 75 y/o man who presents with loss of speech discrimination and complains of difficulty understanding speech and conversation in noisy areas. Most likely Dx?
Presbycusis: gradual hearing loss of elderly
A 75 y/o man who presents with loss of speech discrimination and complains of difficulty understanding speech and conversation in noisy areas. Next step?
- Presbycusis is Dx of exclusion
- Hearing aids are underused in presbycusis, but are potentially beneficial for most type of hearing loss, including sensorineural hearing loss.
- referral to an audiologist for testing and consideration of amplification with a hearing aid may be important next step
What is the leading cause of severe vision loss in the elderly
-AMD (age-related macular degeneration)
What is the most common cause of blindness worldwide
Cataracts
What is the leading cause of blindness in working-age adults in the US
diabetic retinopathy
What are the common causes of geriatric hearing impairments
- presbycusis
- noise-induced hearing loss
- cerumen impaction
- otosclerosis
- central auditory processing disorder
What is the leading cause of nonfatal injuries in the elderly
falls
What is a rapid and fairly reliable office-based screening for dementia
- clock draw
- three-item recall
A 45 y/o man, who has no hx of lung disease and does not smoke, with 3 weeks of productive cough following an upper respiratory infection. Most likely Dx?
Acute bronchitis
A 45 y/o man, who has no hx of lung disease and does not smoke, with 3 weeks of productive cough following an upper respiratory infection. Next step?
- Bronchodilators
- analgesics
- antitussives
- Antibx have NOT been consistently shown to be beneficial
- illness is usually self limited
Common noninfectious causes of cough
- Asthma
- COPD
- malignancy
- postnasal drip
- GERD
- medication side effect (ACEI)
- CHF
What organisms are most commonly responsible for acute bacterial sinusitis
- Strep pneumo, H. influenza
- These 2 plus Moraxella catarrhalis in children
Treatment of acute sinusitis should be directed at the likely causative agents. What are widely used first line agents
- Amoxicillin
- Trimethoprim-sulfamethoxazole
Describe the clinical finding frequently associated with Group A beta-hemolytic streptococcus (strep throat)
- abrupt onset of sore throat and fever
- tonsillar and/or palatal petechiae
- tender cervical adenopathy
- ABSENCE of cough
What ECG finding can make the determination of an acute MI extremely difficult
- LBBB
- in these patients it is particularly important to obtain serum markers of myocardial damage
What is a normal GFR
90 to 120 ml/min
What are the recommended treatments for Chlamydia cervicitis
- Azithromycine
- or Doxycycline
Because of the clinical similarity b/t PID and ectopic pregnancy, what should be performed on all patients suspected of having PID
serum pregnancy test
What are the MATERNAL benefits to breast-feeding?
- a more rapid return of uterine tone with reduced bleeding and quicker return to nonpregnant size
- a more rapid return to prepregnancy body weight
- a reduced incidence of ovarian and breast cancer
- contraceptive effects
- lower cost
counseling regarding the use of diaphragm contraceptive after an uncomplicated pregnancy
-there is no contraindication to using a diaphragm but she should have a new fitting
recommended oral contraception after pregnancy
-In breast-feeding women, the progestin-only “minipill” is recommended, as combined hormonal contraceptives can interfere with milk supply
The post partum period is defined as the time starting after the delivery of the placenta lasting how long
6 to 12 weeks
What is lochia
-normal postpartum vaginal discharge which is initially reddish in color and consists of blood, decidua and epithelial cells, then becomes thicker and yellow-white as leukocytes predominate
In women who are not breast-feeding, when does menstruation usually restart postpartum
by the third postpartum month
The causes of most cases of postpartum hemorrhage can be remembered with the mnemonic “The Four Ts”
- Tone: uterine atony
- Trauma: cervical, vaginal, or perineal lacerations; uterine inversion
- Tissue: retained placenta or membranes
- Thrombin: Coagulopathies
What is the best way to prevent postpartum hemorrhage?
- Active management of the third stage of labor
- This involves administration of a uterotonic agent, such as oxytocin or misoprostol, coinciding with delivery of the anterior shoulder, gentle cord traction, and uterine massage
Uterine atony causes approximately 70% of postpartum hemorrhage. Describe the initial management of uterine atony
- initiating bimanual uterine compression and massage
- administration of oxytocin, which may be given IV or IM
Postpartum fever, especially if associated with uterine tenderness and foul-smelling lochia, is often a sign of what
endometritis
about 30 to 70% of women develop a temporary state known as the “maternity blues” or “baby blues”. describe the time frame for this
develops within the first week after delivery and typically resolves by the 10th postpartum day
Postpartum depression occurs following 10 to 20% of pregnancies. Describe the time frame
-onset occurs within 4 weeks postpartum but may occur as late as 1 year postpartum
What are the few contraindications to breast feeding
- HIV infx
- military TB
- acute hep B
- herpetic breast lesions
- chemo
- substance abuse
Non-breast feeding women should wait how long after delivery to start combined OCPs? and why?
- 3 weeks after delivery
- risk of thromboembolic disease is higher in those who start at earlier times
One of the earliest chest x-ray findings in CHF is what
cephalization of the pulmonary vasculature
What is the gold-standard diagnostic modality in the presence of CHF
Echocardiography
What should be considered first-line outpatient therapy in patients with CHF and reduced left ventricular function
ACEis or ARBs
The administration of Beta blockers, especially in high doses, in the setting of acute CHF, can do what
worsen symptoms
A 38 y/o parous woman presents for counseling regarding her contraceptive options. She is in a monogamous relationship. She reports that she is dissatisfied with using OTC options and she is not ready for permanent sterilization. She smokes half-pack of cigarettes daily. What are her available contraceptive options?
- IUD
- Progestin implants
- Injectable progestins
- Progestin only orals
- barriers
- natural family planning
A 38 y/o parous woman presents for counseling regarding her contraceptive options. She is in a monogamous relationship. She reports that she is dissatisfied with using OTC options and she is not ready for permanent sterilization. She smokes half-pack of cigarettes daily. What are her contraindicated contraceptive options?
-Combined estrogen-progesterone : orals, patches, vaginal rings
Combined hormonal contraceptives are to be used with caution in what situations?
-women who smoke cigarettes and are not recommended for smokers over the age of 35 because of increased risk of MI and stroke
Combo oral contraceptives offer significant protection against what? (besides getting pregnant)
- ovarian cx
- endometrial cx
- iron deficiency anemia from menstrual blood loss
- PID
- fibrocystic breast dx
what are the absolute contraindications to combined hormonal contraception
- previous thromboembolic event
- cerebral vascular dx
- coronary occlusion
- impaired liver function
- known or suspected breast cancer
- smokers
- congenital hyperlipidemia
What are the relative contraindications to combined hormonal contraception
- Severe vascular headache (classic migraine, cluster)
- Severe HTN
- DM
- Gallbladder dx
- obstructive jaundice in pregnancy
- Epilepsy (antiepileptic drugs may decrease effectiveness of OCPs)
- morbid obesity
another name for progestin-only pill
minipill
a healthy 16 year old adolescent girl presents for a routine checkup and sports preparticipation examination. She is noted incidentally to have a heart murmur. What are the recommended immunizations
- Tdap booster
- Meningococcal vaccine
- catch up immunization for the HPV vaccine
What is the hallmark physical exam finding in Hypertrophic cardiomyopathy?
How does this contrast with functional outflow murmurs common in athletes?
- a systolic murmur that DECREASES in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction); INCREASES with the Valsalva (decreased ventricular filling, increased obstruction)
- in athletes outflow murmurs INCREASE upon lying down
- any athlete who has a systolic murmur with an intensity of 3/6 or greater should be held from participation and referred to a cardiologist
A 47 y/o man is found to have an elevated BP when seen for an unrelated problem visit. on follow-up, his BP remains elevated. He is obese and leads a sedentary lifestyle, but does not have other high risks based on his personal or family history. Dx?
HTN and obesity
A 47 y/o man is found to have an elevated BP when seen for an unrelated problem visit. on follow-up, his BP remains elevated. He is obese and leads a sedentary lifestyle, but does not have other high risks based on his personal or family history. Necessary further evaluation?
- Blood glucose
- serum potassium
- fasting cholesterol panel
- estimated GFR
- creatinine
- calcium levels
- Hct
- urinalysis
- ECG
A 47 y/o man is found to have an elevated BP when seen for an unrelated problem visit. on follow-up, his BP remains elevated. He is obese and leads a sedentary lifestyle, but does not have other high risks based on his personal or family history. Nonpharmacological interventions?
- Dietary approaches to stop HTN (DASH) diet
- alcohol limitation to no more than 2 drinks per day
- increase physical activity
- weight reduction
A 47 y/o man is found to have an elevated BP when seen for an unrelated problem visit. on follow-up, his BP remains elevated. He is obese and leads a sedentary lifestyle, but does not have other high risks based on his personal or family history. Recommended initial medications?
-Thiazide diuretics or calcium channel blockers
What is the goal blood pressure
- less than 140/90 in adults up to age 59
- less than 150/90 in patients over 60
- in pts with DM or kidney dx, less than 140/90
What should be ordered in all children presenting with HTN
- The most common cause of HTN is renal parenchymal dx
- a urinalysis, urine culture, and renal US should be ordered
Depression in the elderly can present with symptoms of memory disturbance. This is known as what?
pseudodementia
A 20 y/o obese woman presents for a routine examination. Along with her abdominal obesity, she has irregular menstrual cycles, acanthosis nigricans, and hirsutism. Clinical issues to address?
- Obesity
- Possible polycystic ovarian disease
A 20 y/o obese woman presents for a routine examination. Along with her abdominal obesity, she has irregular menstrual cycles, acanthosis nigricans, and hirsutism. Next steps in evaluation?
- Calculate BMI
- Measure waist circumference
- repeat blood pressure
- order labs to measure fasting glucose, lipids, TSH, and liver enzymes
What are the major features of metabolic syndrome
- central obesity
- hypertriglyceridemia
- low HDL cholesterol
- Hyperglycemia
- HTN
BMI cutoff for overweight
25
BMI cutoff for obesity
30
BMI cutoff for morbid obesity
40
BMI cutoff for super obesity
50
What are the criteria for metabolic syndrome?
- 3 or more of the following
- Waist circumference > 102 cm (M) or 88 cm (F)
- triglycerides > 150
- HDL < 40 if male, < 50 if female
- BP > 130 systolic or > 85 diastolic
- Fasting plasma glucose > 100 or previousl dx DM2
BMI is NOT as accurate a measure of overweight/obesity in what pts?
- those with heart failure
- pregnant
- body builders
- professional athletes
- elderly pts
- certain ethnic groups
What are the BMIs in which bariatric surgery should be recommended
- BMI > 40 who have failed diet and exercise
- greater than 35 with serious comorbid conditions
Which weight loss medication is indicated for LONG TERM management of obesity
Orlistat
a 33-y/o woman presents with headaches that are throbbing and over her right eye. Her headaches have occurred since she was a teenagers and have progressively worsened. She has not found relief from OTC preparations. Most likely dx?
Migraine w/o aura
a 33-y/o woman presents with headaches that are throbbing and over her right eye. Her headaches have occurred since she was a teenagers and have progressively worsened. She has not found relief from OTC preparations. Most appropriate imaging study?
No imaging is indicated at this time as there are no “red flag” symptoms
a 33-y/o woman presents with headaches that are throbbing and over her right eye. Her headaches have occurred since she was a teenagers and have progressively worsened. She has not found relief from OTC preparations. Most appropriate therapy
-a “triptan” medication given in a means that does not have to be swallowed (e.g. SQ, intranasal, or orally dissolving)
simplified diagnostic criteria for migraine
- at least 2 of: unilateral, throbbing pain, aggravation by movement, moderate or severe intensity
- Plus at least 1 of the following: N/V, photo/phonophobia
What are the “red flag” symptoms and signs in the evaluation of headaches
- sudden onset maximum severity “worst headache” or new and different headaches
- HAs increasing in severity and frequency, brought on by Valsalva or physical exertion
- HA beginning after age 50, especially if jaw pain on chewing
- New onset HA in pt with risk factors for HIV infection or cancer
- HA with signs of systemic illness (fever, stiff neck, rash)
- Focal neurologic signs or symptoms of disease
- Papilledema
- HA subsequent to head trauma
What is first line treatment of cluster headache
100% oxygen at 6 L/min and triptans
When high blood cholesterol is identified, an investigation should be performed to evaluate for secondary causes of dyslipidemia. what causes should be investigated?
- Diabetes: fasting blood glucose
- Hypothyroidism; TSH
- Obstructive Liver disease: liver enzymes
- chronic renal failure: creatinine
What medications can elevate cholesterol
- progestins
- anabolic steroids
- corticosterioids
what is recommended as the second therapy for patients who cannot tolerate any level of statin
Ezetimibe
A 20 month old girl is brought to the office for evaluation of crying and not walking. On examination, she is found to have multiple bruises and circular wounds that are suspicious for cigarette burns. Her knee x-ray shows a metaphyseal corner fracture, an injury that is inconsistent with the stated history of “falling off the sofa”. Most likely mechanism of injuries?
-Inflicted injuries, including leg injury from forceful pulling, bruising from hitting the child’s leg’s, and cigarette burns
A 20 month old girl is brought to the office for evaluation of crying and not walking. On examination, she is found to have multiple bruises and circular wounds that are suspicious for cigarette burns. Her knee x-ray shows a metaphyseal corner fracture, an injury that is inconsistent with the stated history of “falling off the sofa”. Further evaluation at this time?
- complete, unclothed physical examination of child (including ophthalmoscopic and neurologic examinations
- radiographic skeletal survey
A 20 month old girl is brought to the office for evaluation of crying and not walking. On examination, she is found to have multiple bruises and circular wounds that are suspicious for cigarette burns. Her knee x-ray shows a metaphyseal corner fracture, an injury that is inconsistent with the stated history of “falling off the sofa”. Legal obligation of physician
-Report of suspected child abuse to the appropriate child protective services
An overweight 12 y/o boy presents for evaluation of a limp and thigh pain. There is no Hx of injury or trauma. He is found to have pain on internal rotation of the hip and his hip externally rotates when passively flexed. He bears weight more on his left than his right while walking. Most Appropriate test to order?
X-ray of the right hip
An overweight 12 y/o boy presents for evaluation of a limp and thigh pain. There is no Hx of injury or trauma. He is found to have pain on internal rotation of the hip and his hip externally rotates when passively flexed. He bears weight more on his left than his right while walking. Most likely Dx?
Slipped capital femoral epiphysis
An overweight 12 y/o boy presents for evaluation of a limp and thigh pain. There is no Hx of injury or trauma. He is found to have pain on internal rotation of the hip and his hip externally rotates when passively flexed. He bears weight more on his left than his right while walking. Complication for which he is at risk?
Avascular necrosis of the hip
Describe an Antalgic gait
this occurs when the stance phase of gait is shortened on the side of pain, usually because of pain during weight bearing
What is the most common nontraumatic hip pathology in adolescents
Slipped capital femoral epiphysis (SCFE)
Hip pathology will frequently present with pain where
groin, thigh, or even the knee
Describe the pain with specific movements in SCFE
- pain with internal rotation of hip
- finding of external rotation on passive flexion
What appears to be the most sensitive marker of hip pathology in children?
Restricted internal rotation, followed by a lack of abduction
common orthopedic causes of limp WITHOUT pain in children
- Congenital dislocation (developmental dysplasia) of the hip
- Spastic hemiplegia (cerebral palsy)
- Legg-Calve-Perthes
- Leg-length discrepancy
- Proximal focal femoral dysplasia
- Congenital short femur
- Congenital Bowing of the tibia
Children with a septic hip joint will often lay how?
-with their hip flexed, abducted, and externally rotated
A “toddler’s fracture” is one example of an unsuspected fracture that may present primarily as a limp or a refusal to walk. What is the fracture?
-A spiral fracture of the tibia that results from twisting while the foot is planted
Undiagnosed congenital developmental dysplasia of the hip (DDH) may present as what
a painless limp that is present from the time that the child learns to walk
What is Legg-Calve-Perthes (LCP) disease
an avascular necrosis of the femoral head that typically occurs in children ages 4 to 8
What drugs are usually implicated in Drug Fever
-Beta-lactams
-Sulfa derivatives
-Anticonvulsants
-allopurinol
Heparin
-Amphotericin B
Fever is defined as what
> 100.4
What is the most common postoperative complication, occurring in 50% of major surgery in the immediate postoperative period?
Fever
What are the PREoperative strategies to reduce the risk of postoperative fever
- Optimize nutritional status
- smoking cessation
- Treat any existing active infections
- Optimize management of existing medical conditions (e.g. diabetes)
- Reduce dosage of immunosuppressive therapies
What are the PERIoperative strategies to reduce the risk of postoperative fever
- Administer perioperative antibiotics
- Use noninvasive ventilation
- If intubation necessary, use pneumonia prevention protocols
- Remove catheters, IV lines, tubes, and drains as soon as safe
- Change lines after 72-96 hours if they are still needed
- DVT prophylaxis using early mobilization, sequential compression devices, subcutaneous heparin, or low-molecular weight heparin
What mnemonic helps in remembering the most common causes of postoperative fever
- “5 W’s”
- Wind (pneumonia)
- Water (UTI)
- Wound (SSI: Surgical Site infection)
- Walking (DVT)
- Wonder drugs (drug fever)
If fever occurs within 36 hours postlaparotomy, what are the 2 important infections to keep in mind
- Bowel injury with leakage of GI contents into the peritoneum
- invasive soft-tissue wound infections
Within the first 48 to 72 postoperative hours, What causes 90% of pulmonary complications of surgery, particularly following abdominal and thoracoabdominal procedures?
Atelectasis (partial collapse of peripheral alveoli)
What needs to be covered in aspiration pneumonia
Gram-negative (Pip/Tazo, meropenem, or cefepime with metronidazole)
pain in the calf on foot dorsiflexion
Homan sign (DVT)
What is the most important therapy for a surgical site infection
incision and drainage
-antibiotics are used solely in cases of significant systemic involvement
what accounts for 50 to 80% of Bronchiolitis cases in children
RSV
What is the single best indicator of severity in bronchiolitis?
- Low pulse oximetry
- mild is > 94
- Recommend supplemental oxygen if SpO2 is less than 90%
What is the most important therapy in the supportive care of bronchiolitis
humidified oxygen
What are the current cornerstones for croup
-glucocorticoids and nebulized epinephrine
What medications should be avoided in croup
- sedatives
- opiates
- expectorants
- antihistamines
In a child with epiglottitis, they are usually noticeably anxious and assume the sniffi position. What is this position?
-leaning forward on outstretched arms with chin thrust forward and neck hyperextended (tripod position) so as to increase the airway diameter
What radiographic finding in epiglottitis
- “thumb sign”
- protrusion of the enlarged epiglottis from the anterior wall of the hypopharynx seen on a lateral neck x-ray
After a Dx of IBS without complicated or alarming symptoms, what would be the next step in therapy?
- Trial of insoluble fiber supplementation
- relaxation techniques
- exercise
Describe the ROME III diagnostic criteria for IBS
- recurrent abd pain or discomfort at least 3 d/mo for the past 3 mo, associated with two or more of the following:
- Improvement with defacation
- onset associated with a change in frequency of stool
- onset associated with a change in form (appearance) of stool
- Criterion fulfilled for the previous 3 mo with symptom onset at least 6 mo prior to dx
When considering a dx of IBS, What are the “alarm features” what warrant further workup
- Unintentional or unexplained weight loss
- unexplained fever
- Family Hx of colon or ovarian cx
- Melena/blood in stool
- Age >60 with change in bowel habits to looser/increase frequency > 6 wk
- Anemia
- Abdominal or rectal mass
- Markers of inflammatory bowel disease
- markers of celiac disease
IN all pts wit IBS and the absence of alarm features, what are appropriate initial tests?
- CBC
- age appropriate colon cancer screening
In IBS cases with diarrhea or mixed, what testing is recommended
- testing for inflammation (CRP)
- celiac disease testing (IgA tissue transglutaminase antibody or antiendomysial antibody)
