Case Files in Family Medicine Flashcards
1
Q
Pregnancy category C
A
Animal studies have shown adverse fetal effects and there are no adequate studies in humans
OR
no animal studies have been conducted and there are no adequate studies in humans
2
Q
Pregnancy category D
A
Human studies have shown potential adverse fetal effects; however, the benefits of therapy may outweigh the potential risks
3
Q
Five A’s of tobacco cessation counselling
A
ASK the patient at each visit about tobacco use
ADVISE to quit through clear personalized messages.
ASSESS willingness to quit
ASSIST to quit
ARRANGE follow up and support
4
Q
5 Rs motivation to quit strategy
A
RELEVANCE RISKS REWARDS ROADBLOCKS REPETITION
5
Q
Bupropion (Zyban) Mechanism
A
(non-nicotine, For smoking cessation)
Blocks uptake of norepinephrine and/or dopamine
6
Q
Bupropion (Zyban) contraindications
A
(non-nicotine, For smoking cessation)
Contraindicated in patients with eating disorders,MAO inhibitor use in the last 2 weeks, or a history of seizure disorder.
7
Q
Bupoprion (Zyban) regimen
A
(non-nicotine, For smoking cessation)
-start 1-2 weeks before quit date
-150 mg for 3 days then 150 mg twice/day.
7-12 week course usual, can be used up to 6 months
8
Q
True/False: Bupropion (Zyban) can be used either alone or in combination with nicotine-based treatments
A
(non-nicotine, For smoking cessation)
True
9
Q
Bupropion (Zyban side effects
A
(non-nicotine, For smoking cessation)
Insomnia and dry mouth
10
Q
Varenicline (Chantix) mechanism
A
(non-nicotine, for smoking cessation)
Nicotinic receptor partial agonist that may reduce cravings and withdrawal symptoms as well as block some of the binding of nicotine from cigarettes
11
Q
True/false: Varenicline (Chantix) can be used in conjunction with nicotine based treatments.
A
(non-nicotine, for smoking cessation)
False: While this may be true, it has not been studied with nicotine supplementation
12
Q
Varenicline (Chantix) regimen
A
(non-nicotine, for smoking cessation)
- Start 1 week before quit date
- dose: 0.5 mg/day for 3 days, then 0.5 mg 2x/day for 4 days, then 1 mg/day for up to 6 months.
13
Q
When would you decrease dosage in a patient on Varenicline (Chantix)?
A
(non-nicotine, for smoking cessation)
When they are on hemodialysis or have a creatinine clearance
14
Q
What symptoms are Varenicline (Chantix) associated with?
A
(non-nicotine, for smoking cessation)
- Neuropsychiatric symptoms like changes in behavior, agitation, depression, suicidal thoughts
- therefore, should be used cautiously in anyone with psychiatric disorder history
15
Q
Varenicline (Chantix) side effects
A
(non-nicotine, for smoking cessation)
Nausea, trouble sleeping, and abnormal, vivid, or strange dreams
16
Q
4mg Nicotine gum is for who?
A
Those who smoke more than 25 cigs/day (2mg for less)
17
Q
Which nicotine replacement product has the highest peak nicotine level and therefore highest dependency potential?
A
nasal inhaler
18
Q
The nicotine inhaler, nasal spray, patch, and gum are pregnancy category ____ drugs
A
D (use when benefits outweigh potential risks)
19
Q
Buproprion and Varenicline are pregnancy category ______ meds
A
C (have not been studied, should only be used if absolutely necessary.
20
Q
What tests are necessary when testing for anemia?
A
CBC with peripheral smear, reticulocyte count, iron studies, B12, folic acid
21
Q
Anemia definition
A
hemoglobin level
22
Q
What population has the highest rates of anemia?
A
non-hispanic blacks. lowest is non-hispanic whites
23
Q
Anemia symptoms
A
fatigue, weakness, dyspnea
24
Q
What symptom is a reliable sign for anemia and commonly present in patients with hemoglobin
A
Conjuctival pallor
25
______ deficiency causes neurologic deficits. __________ deficiency does not
Vitamin B12
| Folate
26
Characteristics of iron deficiency anemia
Serum Iron: Low
TIBC: High
Transferrin saturation: Low
Serum Ferritin: Low
27
In the elderly, iron deficiency anemia is commonly caused by ____________
chronic GI blood loss
28
Anemia with a high MCV is usually indicative of what?
Folate or B12 deficiency
29
Elevated MMA (Methylmalonic acid) confirms what deficiency?
B12 deficiency
30
Elevated homocysteine levels indicate what type of deficiency?
folate deficiency
31
Folate deficiency anemia is usually seen in ________
alcoholics
32
B12 deficiency anemia is usually seen in _____________
pernicious anemia, malabsorption, veganism, history of gastrectomy
33
What happens in anemia of chronic inflammation with regards to the body's iron stores?
The body's iron stores (measured by serum ferritin) are normal, but the capability of using the stored iron in the reticuloendothelial system becomes decreased. (high ferritin helps differentiate form iron deficiency)
34
A hemoglobin less than ____________ is indicative for transfusion, and so is a co-morbid condition.
7 g/dL
35
Acute Diarrhea
Diarrhea present for less than 2-week duration
36
Chronic Diarrhea
Diarrhea lasting long than 4 weeks
37
Subacute diarrhea
Lasts between 2 and 4 weeks
38
What organisms can be found in undercooked chicken?
Salmonella and Shigella
39
What normally causes traveller's diarrhea during travel to mexico?
Entertoxigenic E. Coli
40
What commonly causes diarrhea in campers?
Giardia
41
What commonly causes diarrhea and is found in mayonnaise?
Staph aureus and Salmonella
42
What organism is commonly found in undercooked hamburger?
Enterohemhorragic E Coli
43
Raw seafood may harbor what organisms?
Vibrio, Salmonella, Hep A
44
Illness within 6 hours of eating a salad with mayonnaise indicates?
Staph aureus
45
Illness with 8-12 hours of eating a salad with mayonnaise indicates?
Clostridium perfringes (12-14 = E coli)
46
Daycare settings commonly transmit what?
Rotavirus, Shigella, Giardia
47
When antibiotics are indicated, what do you use?
- Quinolone antibiotics (commonly ciprofloxacin 500mg twice daily) are given for 1-3 days
- Azithromycin (1000-mg single does in adults or 10mg/kg daily for 3 days in children) Can be used in pregnant women
- Rifaximin (200mg 3 times/day for 3 days). Not effective when blood is in stool.
48
What are the primary sinopulmonary respiratory pathogens?
Strep pneumo
H influenzae
Moraxella catarrhalis
49
What are the primary oropharyngeal flora?
Staph Aureus
GAS (GBS in neonates)
Anaerobes
50
Best drug for retrophayngeal abscess and typical oropharyngeal flora?
Clindamycin
51
Dog bite treatment
Augmentin ("Dog" mentin)
52
Primary gut pathogens?
GNR (Klebsiella, E. Coli, Enterobacter), enterococcus, anaerobes
53
Best drug for primary gut pathogens?
Zosyn (piperacillin/tazobactam)
54
Cellulitus common causes
Staph and GABHS
55
Common MSK pathogens?
MSSA and MRSA most common, GABHS, Kingella, Lyme, Hib, GBS, Gonhorreae
56
The upper urinary tract can be imaged with what?
Either intravenous pyelogram (IVP) or computed tomography (CT) scan
57
The Lower urinary tract is most commonly evaluated by ____________
cytoscopy (an endoscopic procedure)
58
The incidence of cancer presenting as asymptomatic microscopic hematuria is ____________
low
59
What three etiologies is hematuria divided into?
Glomerular, renal (nonglomerular), and urologic
60
What is the difference between glomerular and renal heamaturia?
Glomerular is associated with significant proteinuria, erythrocyte casts, and dysmorphic RBCs. Renal hematuria is secondary to tubulointerstitial, renovascular, and metabolic disorders. It has significant proteinuria as well but without the dysmorphic RBCs or erythrocyte casts.
61
Routine screening of hematuria is/is not recommmended
is not
62
The initial finding of hematuria by the dipstick method should be confirmed by _______________
microscopic evaluation of the urinary sediment
63
Evaluation of the urinary sediment can distinguish between _______ and _______
glomerular disease and interstitial nephritis
64
What work up is required if hematuria resolves with treatment of UTI?
none
65
Further work up of idenitified thyroid nodules is indicated because the incidence of malignancy in solitary modules is ______
5-6%
66
Functional adenomas that present with hyperthyroidism are ______ malignant
rarely
67
Nonfunctioning nodules measuring greater than 1 cm by examination or ultrasonography do/do not require biopsy.
Do
68
What are the signs the could confirm rupture of placental membranes?
- Visualization of amniotic fluid leaking form the cervix
- The presence of pooling amniotic fluid in the posterior vaginal fornix
- Demonstration of a pH above 6.5 in fluid collected from the vagina using Nitrazine paper
69
What is the baseline fetal heart rate?
140 bpm
70
What is the ideal contraction interval?
Every 3 minutes
71
What is the recommended antibiotic prophylaxis for GBS colonization during labor?
- IV Penicillin 5 million units loading dose followed by 2.5 million units IV every 4 hours
- Alternative IV ampicillin, cephalothin, erythromycin, clindamycin, vancomycin
72
What is the first stage of labor?
onset of labor until the cervix is completely dilated. can be divided into latent phase (contractions become stronger, longer lasting, and more coordinated) and active phase (starts at 3-4cm dilation, when the rate of cervical dilation is at a maximum
73
What is the second stage of labor?
complete cervical dilation (10cm) through the delivery of the fetus
74
What is the third stage of labor?
Begins after delivery of baby and ends with the delivery of the placenta and membranes
75
normal fetal heart rate
110-160 bpm
76
What is short term (beat-to-beat) variability?
Change in fetal heart rate from one beat to the next. (N 6-25)
77
What is long term variability?
Waviness of baseline fetal heart rate of 1 minute (3-5 cycles/minute)
78
Which type of deceleration in fetal heart rate coincides with a contraction?
Early (compression of fetal head)
79
What is a late deceleration a sign of?
uteroplacental insufficiency
80
Four cardinal movements fetal head goes through during birth
- flexion
- internal rotation
- Extension
- External rotation
81
Overweight definition
BMI =25 to 29.9 kg/m2
82
Obesity definition
BMI > 30
83
Obesity screening
Recommended by USPSTF. Measure height, weight, calculate BMI. Measure waste circumference in those with BMI between 25 and 35 kg/m2
84
What waist circumference indicates increased cardiometabolic risk?
>40 in men and >35 in women
85
What tests can you perform on obese patients?
Fasting glucose, Fasting lipid, TSH, Liver enzyme
86
who qualifies for bariatric surgery?
Patients with BMI > 40 or patients with BMI > 35 and significant commorbidities.
87
Treatment for thyroid storm?
3 Ps propanolol PTU and ......idk
88
Normal TSG for thyroid nodule next step?
Fine needle aspiration (FNA) (adenoma)
89
Low TSH for thyroid nodule next step?
Radio uptake scan
Hot = benign/ablation
Cold = malignant, FNA
90
What is the screening recommendation for hyperlipidemia?
Grade A: Men 35 and odler
Grade B: Men 20-35
Grade A: women 45+
Women 20-45 = B
91
LDL goals:
92
Statins mechanism
HMG-CoA reductase inhibitor
- Increases LDL receptor synthesis
- decreases LDL
93
Bile acid sequestrant mechs
decrease LDL by forcing liver to consume cholesterol
94
Primary prevention
Intervention designed to prevent a disease before it occurs
| Example: statin to reduce LDL to lower risk of CAD.
95
Secondary prevention
An intervention intended to reduce the recurrence of exacerbation of a disease
Example: use of a statin after a person has had a MI to reduce the risk of a second heart attack
96
Effective screening criteria
"PASS-C AI" - "I want an AI to do my stupid PASS-C assignment."
- Prevalence high
- Asymptomatic time frame
- Sensitivity adequate
- Specificity adequate
- Cost effective
- Acceptable to patients
- Intervention available to reduce morbidity/mortality
97
USPSTF Grade A
Provide service - High certainty that net benefit of intervention is substantial
98
USPSTF Grade B
Provide service - High certainty that net benefit of intervention is moderate
or
moderate certainty that the net benefit is moderate to substantial
99
USPSTF Grade C
Offer to provide service if additional considerations encourage
100
USPSTF Grade D
Discourage service- Moderate certainty that there is no net benefit or that harms outweigh benefits
101
USPSTF Grade I
If offered, inform patients on uncertainty of benefit/harm balance - insufficient evidence or poor quality evidence that benefit/harm balance merits recommendation
102
Adult CVD screening recommendations
Level A:
-hypertension - BP measurement
-lipid disorders (M35+/F40+ y.o./at risk 20+) - non-fasting total cholesterol and HDL or fasting lipid panels that include LDL.
Level B:
-AAA for those who have smoked (M65-75 y.o.)
Level C:
none
Level D:
-AAA for women, regardless of smoking status
-Coronary artery disease screening in low risk adults (Level I for high risk)
-peripheral arterial disease in asymptomatic adults
103
Adult cancer screening recommendations
```
Level A:
-Colorectal cancer (M and F 50+) - Fecal occult blood testing using guaiac cards on 3 consecutive bowel movements (annual), flexible sigmoidoscopy (every 3-5 years), or colonoscopy (every 10 years). +sigmoidoscopy or FOBT leads to colonoscopy.
Level B:
None
Level C:
None
Level D:
-Bladder, testicular, pancreatic cancer
Level I:
-prostate cancer with DRE or PSA.
-Lung cancer
```
104
Adult obesity screening recommendations
```
Level A:
-Identify/promote tobacco use cessation
Level B:
-BMI (all adults)
-Type 2 diabetes (adults with hypertension/Hyperlipidemia)
-Depression
-alcohol abuse/prevention
```
105
Pneumoccocal Polysaccharide recomendations
Recommended as single does for all 65+ y.o. adults
AND
65- adults who are alcoholics or smokers, or have chronic diseases/immunodeficiency
106
Hep B vaccine recommendations
```
"everything involving a needle (penis counts as needle for MSM and promiscuos)"
Give to those at high risk of exposure:
health-care workers
Those exposed to blood
dialysis patients
IV drug users
promiscuous people or people w/ STDs
MSM (aka gay)
```
107
Hep A vaccine recommendations
Chronic liver disease people/all Hep B stuff
108
Varicella vaccination recommendations
-unreliable immunization history
109
Meningococcal vaccine recommendations
"West pointers (college/military/travel) and immunocompromised (asplenia/complement def)"
- college dormitory
- military recruits
- asplenia
- travel to countries where disease is endemic
- complement deficiencies
110
First line treatment for rhinosinusitis
Amoxicillin and trimethoprim/sulfamethoxazole for 10-14 days
111
Second line treatment for rhinosinusitis
Augmentin, 2nd/3rd gen cephalosporins, fluoroquniolones, macrolides
112
What therapy do you give to a patient when you suspect angina pectoris?
```
MONA therapy:
Morphine
Oxygen
Nitroglycerin
Aspirin
(B adrenergic antagonist too)
```
113
All patients who rule in for myocardial infarction should receive what?
aspirin and an antithrombotic treatment (heparin)
114
Ne York Heart Association functional classification of angina
Class I: Angina only with unusual strenuous activity
Class II: Angina with slightly more prolonged or slightly more vigorous activities than usual
Class III: Angina with usual daily activity
Class IV: Angina at rest
115
What does the combination of nitroglycerin and a B-adrenergic antoagnoist due for a myocardial infacrtion?
Reduces risk of subsequent myocardial infarction
116
Risk factors for MI
Diabetes, dyslipidemia, age, hypertension, tobacco abuse, family history of premature CAD, male gender, postmenopausal status, left ventricular hypertrophy, homocystinemia
117
Pericarditis symptoms
Sharp pain rather than dull,aching pressure. Pain exacerbated by inspiration, global ST-segment elevation on ECG
118
ESRD
The irreversible loss of kidney function such that the patient is permanently dependent on renal replacement therapy (Dialysis or transplantation). Also defined as a GFR of less than 15 mL/min
119
What are the 3 most common etiologies of CKD?
Diabetes, hypertension, and glomerulonephritis
120
What is normal GFR?
90 and 120 mL/min
121
Stage 1 CKD
A GFR more than 90 mL/min in the presence of signs of kidney disease, such as proteinuria, hematuria, or abnormal renal structure
122
Stage 2 CKD
GFR from 60-89
123
Stage 3 CKD
GFR from 30-59
124
Stage 4 CKD
GFR 15-29
125
Stage 5 CKD
GFR less than 15 mL/min
126
How should all patients with CKD be evaluated?
Renal imaging and microscopic evaluation of urine
127
Goals of treatment for CKD
BP less than 130/80 and protein excretion less than 500 to 10000 mg/d
128
What is the most important measure in the prevention of end-stage renal disease?
Glycemic control
| Tight glycemic control can prevent the microvascular complications of diabetes such as diabetic nephropathy.
129
First line treatment for CKD signs?
ACE inhibitor or ARB
| can also use dilitiazem, verapamil, or B-blockers
130
A history of recent antibiotic use may predispose to a __________ vaginitis
Candida
131
Women with diabetes mellitus are more prone to developing _______ infections
yeast
132
Vulvovaginal candidiasis
- Thick, whitish discharge that has no odor
- patient complains of priuritus
- physical exam: vaginal area is edematous with erythema present
- discharge has pH between 4.0 and 5.0
- Wet mount of KOH shows budding yeast or pseudohyphae
133
Vulvovaginal candidiasis treatment
- fluconazole 150mg for simple
| - more serious 10-14 days
134
Trichimoniasis
- STD
- Risk factors: Multiple sexual partners, pregnancy, menopause
- Copious amounts of a thin, frothy, green, yellow, or gray malodorous vaginal discharge
- "Strawberry cervix"
- wet mount demonstrates motile trichimonads
135
Trichimoniasis treatment
oral metronidazole, given in a single, 2-g oral dose or 1-week regimen of 500 mg twice a dayto patient and partner. Screen partner and for other STDs
136
Bacterial vaginosis BV
- overgrowth of anaerobic G vaginalis associated with mulitple sexual partners
- Diagnosis based on 3 of 4 criteria:
1. a thin, homogenous vaginal discharge
2. vaginal pH more than 4.5
3. Positive KOH "whiff" test
4. The presence of clue cells on wet mount prep
137
Bacterial vaginosis BV treatment
oral/topical preparations of metronidazole pr clindamycin
138
Mucopurulent cervicitis
- Characterized by purulent or mucopurulent discharge from endocervix
- test for N. gonorrheae or Chlamydia
- Gold diagnostic standard is culture of cervical discharge
- Treat Gonnorheae with 125 mg ceftriaxone intramuscularly.
- Quinolones resisted and NOT recommended
- Doxycyline 100mg orally 2/day or a 1-g azithromycin for Chlamydia
- Treat partners
139
PID presenting symptoms
Lower abdominal tenderness with both adnexal and cervical motion tenderness without other explanaiton of illness
140
Hematochezia
Bright red blood visible in the stool
141
What is criticial in intial evaluation of unstable patients with GI bleeding?
ABC's (airway, breathing, circulation)
142
The test of choice for the determination of the source of lower GI bleeding is _________________
colonoscopy
143
Ulcerative collitis
continuous inflammation of the large bowel, starting from rectum and extending proximally
144
Crohn's disease
Areas of focal inlfammation, can occur anywhere in GI tract
145
Crohn's disease and Ulcerative collitis can cause _______ in joints
arthritis
146
Who is colon cancer screening recommended for?
All patients over the age of 50 and at risk individuals who are younger
147
What is the gold standard for diagnosis of pneumonia?
Presence of an infiltrate on chest x-ray
148
Pneumonitis
Inflammation of the lungs from a variety of noninfectious causes such as cheicals, blood, radiation, and autoimmune processes
149
Community-acquired pneumonia
- People who are not in a hosptial
- Strep pneumoniae (acute onset, rust-sptutm, fever, shaking, chilss, lobar infiltrate)
- Haemophilus influnenzae (seen in patients iwth underlying COPD)
- Moraxella catarrhalis, mycoplasma, Chlamydia, Legionella: Atypical
150
Atypical pneumonia
Moraxella catarrhalis, mycoplasma, Chlamydia, Legionella: Atypical and some viruses
- Very yung and older patient
- Bilateral, diffuse infiltrates
151
Fun fact about legionella pneumonia
Causes diarrhea as well
152
recommended epmpiric therapy for pneumonia
```
a macrolide (calrithromycin or azithromycin) or doxycycline
-fluoroquinolone (new) or blactam and inhibitor combination in areas of high macrolider resistance
```
153
Who is pneumococcal vaccine recommended for?
All persons aged 65 years and older, all adults with Cardiopulmonary diease, cigarrette smokers, and all immunocompromised persons.
154
Depression diagnosis
```
Symptoms for depression must include at least 5 of the 9 following symptoms, must occur during the same 2-week period, must represent a change from previous functioning, and must include either depresssed mood or loss of interest or pleasure:
S leep changes: increase during day or decreased sleep at night
I nterest (loss): of interest in activities that used to interest them
G uilt (worthless): depressed elderly tend to devalue themselves
```
E nergy (lack): common presenting symptom (fatigue)
C ognition/C oncentration: reduced cognition &/or difficulty concentrating
A ppetite (wt. loss); usually declined, occasionally increased
P sychomotor: agitation (anxiety) or retardations (lethargic)
S uicide/death preocp.
155
When should a diagnosis of depression be considered?
When a patient presents with multiple unrelated physical symptoms
156
What are the SSRIs?
First Person Shooter, FaCE = FPS FACE
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Fluvoxaminee (Luvox)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
157
What are the SNRIs
Venlaxafine (Effexor)
Duloxetine (Cymbalata)
Mirtazapine (Remeron)
Desvenlafaxine (Pristiq)
158
What are the Atypical antidepressants?
Buproprion
Amoxapine
Trazodone
159
What are the MAOi inhibitors?
Phenelezine
Tranylcypromine
Selegiline
160
How do TCAs work?
Affect reuptake of norepinephrine and serotonin
161
How do MAOIs work?
increased amounts of serotonin and NE released during nerve stimulation
162
All patients with depression should be quesitoned about ______
mania (Antidepressants can exacerbate manic episode and uncover bipolar disorder)
163
Maternal benefits of breast feeding
- more rapid return of uterine tone with reduced bleeding and quicker return to nonpregnant size
- body weight stabilizaiton more rapid
- reduced incidence of ovarian and breast cancer
- convinience/cost
164
Lochia
Yellow-white discharge, consisting of blood cells, decidual cells, and fibrinous products, that occurs following delivery
165
In women who are not breast-feeding, menstruation usually restarts by what time?
Third post partum month (longer in those who are breast feeding
166
"Four Ts" of postpartum hemorrhage
- Tone: Uterine atony
- Trauma: Cervical, vaginal, or perineal lacerations; uterine inversion
- Tissue: Retained placenta or membranes
- Thrombin: Coagulopathies
167
What is the initial management of uterine atony after ABCs?
IV administration of oxytocin and binmanual uterine massage
168
What is given in uterine atony of oxytocin and massage fail? What are other options?
```
Methylergonovine (Contraindicated in patients with hypertension)
Prostaglandin F2 (hemabate) is next. Another option is misoprostol (Cytotec)
```
169
Postpartum fever, especially if associated with uterine tenderness and foul-smelling lochia, is often a sign of _______
endometritis
170
When does "baby blues" typically resolve?
10th post-partum day
171
When is the onset of postpartum depression?
at least 4 weeks post partum, but up to a year. Same symptoms as major depression
172
First line therapy for post-partum depression?
SSRIs (saffe in breast feeding)
173
Contraindications to breast-feeding
- HIV
- Acute, active HepB
- Breast reduction surgery with nipple transplant
174
Most women resume sexual activity by _______ months post partum
3
175
In breast-feeding women, what type of contraception is preferred?
progestin only (mini pill)
176
how long is it recommended to wait before starting oral contraceptives?
6 weeks (same for depo-provera)
177
Non-breastfeeding women should wait ______ weeks after delivery to start combined OCPs
3
178
What is the first priority in managing congestive heart failure?
optimizing oxygen exchange by administering oxygen via nasal cannula, dilating pulmonary vasculature, and decreasing cardiac preload and afterload.
179
Most cases of CHF are caused by what?
CAD or hypertension, so serial cardiac enzymes right away are important
180
What can be administered to reduce anxiety induced catecholamine release that causes tachycardia and increased PV resistance in CHF? What is the preffered diuretic?
- morphine sulfate acts as an anxiolyitc and vasodilator
- Furosemide (Lasix) is the diuretic of choice because its a diuretic that has immediate vasodilatory action on bronchial vasculature.
181
What medications decrease preload and afterlaod in CHF?
ACE inihbitors and B-Blockers
182
What does the sputum of the cough from CHF look like?
pink, forthy sputum
183
Framingham Heart Study CHF diagnostic criteria
- Must have two major OR one major and 2 minor
- Major: paroxsysmal nocturnal dyspnea, JVD, rales, cardiomegaly, pulmonary edema, S3 gallop, central venous pressure greater than 16 cm H20, circulation time of 25 seconds, hepatojugular reflex, weight loss of 4.5 kg over 5 days of treatment.
- Minor: bilateral ankle edema, nocturnal cough, dyspnea on exertion, hepatomegaly, pleural effusions, decreased vital capacity by one-third of max, and tachycardia
184
First priority in CHF patient
ABCs, starting see a trend here?
185
What are the initial tests for a suspected CHF patient?
blood tests (for anemia and infection), radiographic studies, electrocardiography, echocardiography
186
Neurohumoral responses to a failing heart result in _______ and _______ retention and ______ excretion
water, sodium retention and pottassium excretion
187
BNP can be used to assist in diagnosis of ____
CHF (BNP>500 pg/mL
188
_______________________________ is the gold-standard diagnostic modality in the presence of CHF
Echocardiography
189
Initial management of CHF patient
- ABCs!
- supplemental oxygen (possibly with CPAP or BiPAP or mechanical
- IV access obtained and cardiac/pulse oximetry monitors
190
Initial CHF outpatient sodium intake reduction
2 to 4 g/d restriciton
191
____________________ should be considered first line therapy in patients with CHF and reduced left ventricular function
ACE inhibitors
192
The administration of ______________________, especially in high doses, can worsen acute CHF symptoms. initial doses should be slow and titrated over several weeks
B-Blockers
193
What type of medication is contraindicated in CHF?
calcium channel blockers, with exception of mlodipine (Norvasc).
194
What type of calcium channel blockers can be used in diastolic dysfunction CHF?
nondihydropyridine calcium channel blockers (Diltiazem, verapamil)
195
One last thing about CHF:
cardiac resynchronizaiton therapy
196
Sexually active, symptomatic, and high risk females should be screened for _______ and ______ by urine nucleic acid amplification
Gonorrhea and Chlamydia
197
Describe the murmur of hypertrophic cardiomyopathy
Best heard along the left sternal border and accentuates with activities that decrease cardiac preload and end-diastolic volume of the left ventricle. Standing or straining with a Valsalva manuever would increase the murmmur. 3/6 systolic murmur is indicative, or any diastolic murmur
198
Gonorrhea and Chlamydia screening test?
Urine for nucleic acid amplification
199
Prehypertension
Blood Pressure between 120 and 139 mm Hg systolic and 80 and 89 mm Hg diastolic
200
Which is a greater risk for cardiovascular disease complications: systolic or diastolic?
Systolic
201
For persons with diabetes or kidney disease, the goal BP is to achieve what?
below 130/80
202
Stage 1 hypertension
Systolic: 140-159
Diastolic: 90-99
203
Stage 2 Hypertension
Systolic: >160
Diastolic: >100
204
What is the first line primary treatment of hypertension?
Thiazide diuretics
205
what is the treatment for a stage 2 hypertension/someone who is above the recommended goal by less than or equal to 20/10 mm Hg?
Combination therapy with two medications
206
What is the most common cause of hypertension in pediatric patients? What tests should be ordered?
Renal parenchymal disease.
| Order urinalysis, urine culture, and renal ultrasonography for all children presenting with hypertension
207
"Sausage shaped mass", "Currant Jelly"
Intussusception
208
"Olive shaped mass", "double track sign", waves across abdomen moments before emesis
Pyloric stenosis
209
When intussusception is suspected, what are the first steps?
IV fluid stabilization, surgery consultation, plain film of the abdomen to rule out perforation.
210
What test is diagnostic and therapeutic for intussusception?
barium enema
211
What is the differential diagnosis for intestinal obstruction?
Hypertrophic pyloric stenosis, malrotation with volvulus/obstruction, foreign-body ingestion, and poisoning.
212
What is the most common cause of GI obstruction in infants?
Hypertrophic pyloric stenosis
213
If malrotation is suspected, what is the test of choice?
Upper GI series
214
Lab studies/screening for suspected dementia
- "Anything that can alter mental status" Blood count, electrolytes, glucose, calcium, liver function tests, folate, B12, TSH.
- Syphilis screening for tertiary syphilis
- CT or MRI
- Depression
215
What is the most widely used tool in screening for dementia?
Folstein Mini-Mental status exam (MMSE) has 87% sensitivity and 82% specifcity
216
What is "pseudodementia"?
Depression in the elderly that mimicks dementia
217
Medications used in treatment of Alzheimer's dementia
```
Donepezil
Galantamine
Rivastagmine
Tacrine
NMDA antoginist
Memantine
"DONE GALloping Near The RIVer, mah man (MEMAN)"
```
218
Which type of dementia has a sudden onset and progresses in a stepwise fashion?
Vascular dementia
219
What type of dementia presents with vivid hallucinations, fluctuation in cognition, and often parkinsonian extrapyramidal signs and postural instability?
Lewy Body
220
What is delirium?
Acute change in mental status characterized by fluctuations in levels of consciousness.
221
What is caused by normal pressure hydrocephalus in the elderly?
Triad: dementia, incontinence, gait disturbance
222
Pharmacotherapy can be used in obesity patients with a BMI over __________
30 (or 27 with comorbid conditions)
223
For obesity, only ________ is approved for long-term use of up to 2 years by the US food and drug administration
orlistat (inhibits absorption of dietary fat)
224
aside from orlistat, all obesity medications are __________
anorexiants (increase satiety and satiation by affecting the monoamine oxidase system in the hypothalamus)
225
Weight loss medications not called orlistat
```
"Do PPD"
Dextroamphetamine
Phendimetrazine
Diethylproprion
Phentermine
```
226
What type of patient is a potential candidate for bariatric surgery?
Patients with a BMI greater than 40 who have failed diet and exercise (with or without drug therapy), or greater than 35 with comorbid conditions
227
Migraine headache diagnostic criteria
moderate to severe headache with pulsating quality, unilateral location, nausea and/or vomiting; photophobia, phonophobia, worsening with activity, multiple attacks lasting 3-4 days, absence of history or physical exam findings.
228
Common migraine triggers
Menses, fatigue, hunger, stress
229
Tension headache
pericranial muscle tenderness and a description of bilateral bandlike distribution of pain
230
Cluster headache
Unilateral headaches that may have a high male predominance, can be located in the orbital, supraorbital, or temporal region. Deep, excruciating pain lasting from 15 minutes to 3 hours. Usually episodic, but can be chronic.
231
What figures increase the likelihood of finding an abnormality on an imaging test for headache?
rapidly increasing headache frequency or a history of either lack of coordination, focal neurologic symptoms, or headache awakening the patient from sleep.
232
What drugs can be used for migraine headache prevention?
amitryptiline, propranolol, timolol, divalproex
233
What is initial pharmacologic therapy for atension headache?
Aspirin, acetaminophen, NSAIDs
234
Cluster headache treatment
O2 at 6 mL/min (100%), triptans, dihydroergotamine, verapamil, lithium, divalproex, ergotamine, prednisone.
235
Someone with known CHD or a CHD equivalent has a greater than _________ risk of having another CHD. These people will have the lowest cholesterol targets.
20% in 10 years
236
In terms of lipids, the main risk factor for CHD is _______
LDL
237
What are the guidelines on lipid screening?
Every adult over the age of 20 every 5 years, Can be fasting lipid panel or nonfasting total HDL cholesterol with subsequent fasting lipid panel if HDL200
238
What are the 5 factors that determine the LDL in an individual?
1. Cigarette smoking
2. Hypertension (BP>140/90 or on antihypertensives)
3. Low HDL
4. Age >45 for men, >55 years for women
5. Family history of premature CHD (male first dgree relative
239
What is the LDL goal for risk category "CHD or CHD equivalent"? When should medication be considered?
LDL should be less than 100. Medication should be considered when LDL >130
240
What is the LDL goal for patients with 2 or more risk factors? When should medication be considered?
LDL goal is less than 130. Medication should be considered when LDL >160 for 10 year risk between 10%-20% and >190 for 10 year risk between 0% and 9%
241
What is the LDL goal for patients with 0-1 risk factors? When should medication be considered?
LDL goal is less than 160. Medication should be considered when LDL is greater than 190
242
What is the LDL goal for patients who have a CHD and multiple risk factors?
LDL goal is less than 70
243
What are the secondary causes of dyslipidemia?
Diabetes, hypothyroidism, obstructive liver disease, and chronic renal failure
244
What is the cornerstone for all treatments for hyperlipidemia? What specific guidelines are given for fat and cholesterol intake?
Therapeutic lifestyle changes. Specific recommendations include a reduction of saturated fat to less than 7% of total calories and an intake of less than 200 mg/d of cholesterol?
245
The first line pharmacotherapy for LDL cholesterol reduction is __________
a statin
246
What are the USPSTF's recommendations regarding intimate partner violence?
All clinicians should be alert to physical and behavioral signs and symptoms associated with abuse and neglect, and direct questions about abuse are justifiable due to high levels of undetected abuse in women
247
Neglect is a form of __________
child abuse
248
hip pathology will frequently present with pain where?
Groin, thigh, or even knee
249
What is an antalgic gait?
Gait that occurs when the stance phase of gait is shortened, usually because of pain during weight bearing.
250
____________ is the most sensitive marker of hip pathology in children, followed by __________
Restricted internal rotation, lack of abduction
251
Common causes of limping in infants and toddlers
arthritis, fractures, and complications of congenital hip dysplasia
252
How will children wit ha septic hip joint lay?
with their hip flexed, abducted, and externally rotated.
253
Definitive diagnosis of septic arthritis comes from
aspiration of the joint
254
How does undiagnosed congenital dysplasia of the hip present?
painless lump that is present form the time the child learns to walk
255
What will septic joint aspirate look like?
A septic joint will have purulent aspirate with a WBC greater than 50,0000/uL
256
What will transient synovitis joint aspirate look like?
Transient wynovitis will have a clear/ellow aspirate with lower WBC (
257
What is Legg-Calce-Perthes?
Disease of avascular necrosis of the femoral head that typically occurs in children aged 4-8 years
258
What type of hip injury is common in overweight adolescent boys?
Slipped capital femoral epiphysis (treatment is surgical pinning of the neck) Can complicate to avascular necrosis of the hip
259
Drug fever
Fever that coincides with the administration of a particular drug and cannot be otherwise explained by clnicial and laboratory findings.
260
Malignant hyperthermia
A rare autosomal disorder characterized by a fever greater than 104 (40C) tachycardia, metabolic acidosis, rhabdomyolysis, and calcium accumulation in skeletal muscle leading to rigidity. May occur up to 24 hours after exposure to anesthetic agents halothane and succinylcholine.
261
Surgical Sight infection (SSI)
infection that occurs in the site of surgery within 30 days of an operative procedure or 1 year of implants.
262
The "5Ws" pneumonic for posteroperative fever causes
- Wind: pneumonia
- Water: UTI
- Wound: (SSI)
- walk: DVT
- wonder drugs: (Drug fever)
263
What are two important infectious etiologies to keep in mind if fever occurs within 36 hours postlaparotomy?
1. Bowel injury with leakage of GI contents into peritoneum
2. Invasive soft-tissue wound infection caused by invasive streptococci and clostridium species.
(TSS from staph aureus possible but less likely)
264
Homan sign
Pain in the calf on foot dorsiflexion
265
Bronchiolitis
- The most common acute cause of wheezing in children younger than 2 years of age, especially in infants who are 1-3 months old.
- It is a viral infection causing nonspecific inflammation of the small airways and peaks during the winter months.
- RSV accounts for 70% of cases
266
What is the progression of Cronchiolitis?
- Initially, the child develops rhinorrhea and wheezing followed by low grade fever.
- dyspnea eventually occurs, and fever
267
When is supplemental oxygen recommended for patients with bronchiolitis?
if SpO2
268
What is the most common cause of airway obstruction in children aged 6 months to 6 years?
Croup
269
What is Croup?
It is a viral infection of the subglottic region or the larynx that produces the characteristic barking cough, hoarseness, stridor, and different degrees of respiratory distress that are more severe at night.
270
When does croup usually occur?
Fall and winter
271
A croup score > ____ indicates severe croup
8
272
Moderate croup (westley socre 3-7) requires what?
epinephrine and other additional measures
273
What are the current cornerstones in treatment of croup?
Inhaled corticosteroids and epinephrine
274
What is Epiglottitis?
A bacterial infection of the supraglottic tissue and surrounding areas that causes rapidly progressive airway obstruction
275
What vaccine has caused epiglottitis rates to go down?
Hib
276
Epiglottitis visible on X-ray is called _________
thumb sign
277
Irritable bowel syndrome (IBS)
A functional GI disorder characterized by chronic abdominal pain and altered bowel habits
278
Lubirprostone (amitizia)
Pharmacologic agent that selectively activates intestinal chloride channels and increases fluid secretion is FDA approved for IBS in women with constipation, but has a side effect of nausea in a significant number of patients
279
In patients with typical features of IBS, what testing is recommended?
CBC and stool hemoccult.
280
IBS treatment for abdominal pain: Antispasmotics
dicyclomine and hysocycamine
281
IBS treatment for abdominal pain: TCAs
Amitryptiline
282
IBS treatment for abdominal pain: SSRIs
These can be used. Just remember that
283
IBS treatment for abdominal pain: antibiotics
Rifaximin
284
IBS treatment for Constipation: Natural
Fiber (Psyllium)
285
IBS treatment for diarrhea
loperamide and alosetron for 6 months of symptoms
286
Classic triad of ectopic pregnancy
Missed menses, pain, and bleeding
287
Most common sign of uterine rupture
Fetal distress with prolonged, variable, or late decelerations and bradycardia is the most common, and often only, sign of uterine rupture.
288
Treatments for opiod addiction
Methadone (long acting synthetic opiod), buprenorphine (parital opiod receptor agonist), naltrexone (long acting opiod antagonist)
289
Treatments for tobbacco addiction
Niotine replacement therapies (gums, patch, spray, lozenges), Buproprion (blocks norepinephrine reuptake), varenicicline (partial nicotinic agonist
290
Alcohol addiciton treatment
- Naltrexone
- Acamprosate (Acts on GABA and glutamate pathway
- Disulfiram (makes you sick with acetaldehyde
- Topiramate (probably does GABA and glutamate)
- Chlordiazepoxide, diazepam, lorazepam (benzos)
- Atenolol, propanolol (improve withdrawal symptoms)
- Clonidine (alpha antagonist)
291
Stimulant addiction treatment
- methylphenidate, amantidine (dopamine antagonists(
- Propanolol
- Despiramine, buprpion (antidepressants)
292
What is the treatment for acute opiod intoxication?
IV naloxone
293
Long QT syndrome
caused by mutations in multiple genes and is autosomal dominant, seen more commonly in females
294
Lab screening tests for noncardiac causes of palps
CBC, chemistry panel, TSH
295
A _______ Should be done prior to cardioversion for chronic atrial fibrillation in order to rule out presence of a thrombus that might dislodge
Transesophogeal echocardiogram (TEE)
296
Treatment for atrial fib?
Beta blockers (slow hear rate below 100) and anticoagulation with warfarin
297
What is the most common cause of palpiations?
Primary rhythm disturbance
298
The presence of delta waves on an ECG indicate what?
Wolff-Parkinson White (WPW) syndrome, AKA the presence of an accessory track that can be ablated by an electrophysiologist
299
What is a PVC?
Premature ventricular contraction
300
What is the confirmatory test for hypertrophic cardiomyopathy?
echocardiogram
301
What is appropriate in a patient with frequent (daily) palpitations?
A 24-72 hour Holter Monitor. A 30 day event monitor is a better test for someone with infrequent episodes
302
What are the charateristics of the hypertrophic cardiomyopathy murmur?
A systolic heart murmur that increases in intensity with Valsalva maneuver
303
Hymenoptera
Insect order that causes allergic reactions
304
How do you treat local insect sting reactions?
Ice, antihistamines, NSAId for pain relief. Tetanus prophylaxis needed in those not yet vaccinated or boosted.
305
Delayed reaction to insect bite
Larrge area (>10cm) of redness and warmth. not infectious, will not respond to antibiotics. Best treated with oral steroids. Tetanus prophylaxis must be updated if necessary.
306
Treatment of Anaphylaxis
- ABC assessment (intubate if necessary), fluid rescussitation of 10-20 mg/kg ASAP.
- Subcutaneous of intramuscular injection of 0.3 - 0.5 mL of 1:1000 solution of epinephrine given ASAP and repeated in 10-15 minutes if needed
307
Treatment of animal bite
- ABCs
- Local cleaning of the wound(s) with soap and water, irrigation with saline, and debridement of devitalized tissue should take place ASAP.
- update tetanus vaccination as needed
- contact animal control authorities for guidance regarding rabies vaccination
308
What is the current guidance for dog and cat bites?
Oral Augmentin prophylaxis for 5-7 days for patients with moderate to severe wounds from dog/cat/human. When cellulitis is present, do 7-14 days.
309
What organism is most common in human bite injuries?
Eikenella corrodens
310
What is the first diagnostic test in a suspected stroke patient?
CT without contrast to rule out hemorrhages
| MRI can come later
311
What are immediate precautionary treatments for suspected stroke patients?
ABC, Aspirin within 48 hours, DVT prophylaxis. No anticoagulation
312
Transient ischemic attack (TIA)
A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without infarction.
313
Transient symptoms with infarction (TSI)
A transient episode of neurologic dysfunction associated with irreversible ischemic brain injury
314
What assessment can be used to identify patients at high risk of ischemic stroke in the first 7 days after TIA
ABCD2 score:
- A: Age > 60 years (1 point)
- B: Blood pressure elevation (S>140 d>90) (1 Point)
- C: Clinical features (Unilateral weakness = 2 points, isolated speech disturbance = 1 point, other = 0)
- D: Duration (>60 min = 2 points, 10-59 min = 1 point,
315
____________ is the single most important risk factor for stroke
Hypertension
316
What is a crucial distinction to make when a stroke is diagnosed?
Differentiate between acute and hemorrhagic stroke
317
A _________ should be done in all stroke patients in order to detect acute myocardial infarctions
12-lead ECG
318
When would you administer recombinant tissue-type plasminogen activator (rtTPA)?
if the patient can be treated within 3 hours of the onset of ischemic stroke and the patient has no contraindications, like anticoagulant medications, MI, recent surgery, trauma
319
When a subarachnoid hemorrhage is suspected but not seen on CT, a _________ is indicated for diagnosis
lumbar puncture
320
Patients with a history of symptomatic cerebrovascular disease should be treated to an LDL goal of less than _______
100 mg/dL
321
If a patient has an ischemic stroke, ___________ will be a good management option
early mobilization of the patient
322
_______ is good initial pharmacotherapy for stroke patients with no detected sources of embolism
aspirin or clopidogrel (anti-platelet)
323
Be aware that ___________ can mimic stroke symptoms
hypoglycemia
324
Treatment of __________ should be cautious in stroke patients
Hypertensions
325
"ground glass" lung appearance on x-ray in suspected HIV patient
P. Jiroveci
326
Postexposure treatment of healthcare workers exposed to HIV includes what?
immediate and careful cleanming of the exposure/puncture sight with postexposure prophylactic (PEP) treatment with anti-retroviral therapy. (start within 2 hours)
327
Stages of AIDS
Stages of AIDS determined by CD4 count
1: >500
2: 20-499
3:
328
The standard screening test for HIV infection is ________
Detection of HIV antibodies using ELISA (enzyme-linked immunosorbent assay)
329
AIDS screening test samples that are repeatedly positive on ELISA must be confirmed with __________
Western Blot testing (electrophoresis that detects antibodies to HIV antigens of specific molecular weights)
330
___________ vaccines are contraindicated in AIDS patients and their close contacts
Live virus
331
P. jirovecci prophylaxis?
TMP-SMX when CD4
332
Mycobacterium avium-intracellulaire prophylaxis recommendation
CD4
333
Varicella vaccine is ________ in HIV patients
contraindicated (live vaccine)
334
conjugated bilirubin is excreted in the __________, while unconjugated bilirubin is bound to albumin and exempted from glomerular filtration
urine
335
A biliary obstruction leads to ___________ bilirubinemia
conjugated
336
What is Gilbert Syndrome?
Congential reduction of conjugation of bilirubin in the liver due to autosomal recessive gene involved in glucoronidation.
337
What type of bilirubinemia is caused by Hep A?
Conjugated
338
Hep A diagnosis
conjugatred bilirubinemia, elevated hepatic transaminases, and serology.
339
HBsAg
Hepatitis B surface antigen. present in both acute and chronic infections. It's presence is associated with contagiousness to tohers. Typically becomes detectable in 1-10 weeks following HBV exposure and disappears in 4-6 months in those who recover. Persistent detection of HBsAg after 6 months indicaters chronic infection.
340
HBeAg
Hepatitis e antigen. Marker for HBV replication and infectivity. patients with HBeAg are 100 times more infectious than those lacking it.
341
Anti-HBs
Antibody to the surface antigen in the absence of HBSaG is seen in resolved infections and is the serologic marker produced after HBV vaccination
342
anti-HBcAg IgM
diagnostic of acute infection. Only serological maker detectable during the window period.
343
A negligible level of HBsAg with a negative anti-HBcAg IgM is diagnostic of ________
chronic HBV infection
344
Hepatitis D requires what to thrive?
coinfection of Hep B because HepD uses the viral envelope of HepB to infect the host.
345
What happens to levels of liver enzyme markers in alcohol abuse?
Transaminase levels from alcohol abuse typically show the aspartate aminotransferase (AST) being elevated out of proportion to the Alanine aminotransferase (ALT), a ratio of 2 or greater
346
HCV effects?
Cirrhosis and edema
347
All pregnant women should be screened for what hep B thingy?
HBsAg. If positive, treat newborn with Hep B immunoglobulin (HBIg) and vaccination
348
__________ is one of the greatest risks for developing cirrhosis in Hep C patients
alcohol abuse
349
Asymptomatic chronic bilirubin elevation is a sign of
gilbert syndrome
350
The acute onset of painless jaundice in a patient older than age 50 years should prompt an examination for ___________
pancreatic cancer
351
Primary diagnostic tool for CHF
The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation.
352
Recommended intial cardiac study for palps?
It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval.
353
ST-segment depression
ischemia
354
Treat systolic hypertension in the elderly with
Thiazide diuretics. Thiazide diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance.
355
The ankle-brachial index (ABI)
The ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD). The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9-1.2 is considered normal.
356
Which cardiovascular parameter increases with normal aging?
Blood pressure
357
What changes does the heart undergo in normal aging?
As the body ages, the measured left ventricular ejection fraction, heart rate variability, and maximum heart rate trend downward, the walls of the major aorta and major arteries stiffen, and the vasodilator capacity of most smaller vessels is reduced (SOR A). The arterial wall changes increase peripheral resistance and result in an increase in blood pressure.
358
Which drug class is preferred for treating hypertension in patients who also have diabetes mellitus?
ACE inhibitors
359
Slipped capital femoral epiphysis
Slipped capital femoral epiphysis is the most common hip disorder between the ages of 8 and 15 and is more common in boys and overweight or obese children. It presents with limping and pain, and limited internal rotation of the hip is noted on physical examination.
360
For high risk of colorectal cancer patients (1st degree relative or 2 second degree relatives have it before age 60), what are the screening recommendations?
They should start colon cancer screening 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.
361
Who should early diagnostic upper GI endoscopy be considered for?
Patients with new-onset dyspepsia who are older than 55 years or who may have symptoms that may be associated with upper GI malignancy.
362
What testing should be done for patients with epigastric pain and no alarm symptoms?
H pylori, by IgG serology rather than 13-C urea breath test or stool antigen test, is recommended due to its low cost and ease of collection. Urea or stool antigen testing used to confirm a positive result.
363
How do H2 blockers work?
Competative antagonists of histamine binding to gastric parietal H2 receptors, which prevent activation of the pathway that mediates release of acid into the gastric lumen
364
How do PPIs work?
Suppress gastric acid production by irreversibly inhibiting H+K+ATPase proton pump in gastric parietal cells
365
Gastric ulcers are more common in _________ users
NSAID
366
Classic PUD (peptic ulcer disease) symptoms
Epigastric abdominal pain that is improved with ingestion of food, or pain that develops a few hours after eating. Nocturnal symptoms also common. Gradual onset of symptoms.
367
What is the gold standard for diagnosis for H pylori?
endoscopy with biopsy testing
368
Urea breath tests detects _______
Active h pylori infection
369
Serologic testing for anti-H pylori antibodies cannot distinguish between what?
Active and resolved infections
370
Which bloody stool patients should undergo a colonoscopy regardless of endoscopy findings?
Patients over 50
371
Roseola
- HHV-6
- 1-2 week incubation, mild fever, rash after fever goes away. Starts on trunk, spreads rapidly. Dissapear after 2 days. no treatment
372
Varicella
chicken pox,
rash, malaise, fever, anorexia.
-Papules or vesicles on an erythematous base (dew drops on rose petal).
-vaccination at 12-18 months with booster at age 4-6 years
373
fifth disease
- Parvovirus B-19
- AKA erythema infectiosum
- mild fever and upper respiratory symptoms followed by rash lasting 4-14 days. Starts on face, goes down. "slapped cheek" appearance.
374
Meningococcemia rash
Starts as erythematous maculopapular eruption that does not blanch with compression which prgroesses to form petechiae.
375
Menigococcemia immediate treatment
Empirical. do not wait for lumbar puncture. Ampicillin + gentamicin for children or vancomycin and ceftriaxone for adults. Penicillin for meningococcal meningitis.
376
Page 477
watch those sketchies
377
Acromegaly
A condition that results from excessive production of growth hormone by a pituitary adenoma. May cause menstrual irregularities and breast discharge
378
Duct Ectasia
Inflammation of a mammary duct below the nipple, which can lead to duct obstruction, a tender mass, and duct discharge
379
Intraductal papilloma
A benign tumor growth into a mammary duct, often with a resultant palpable small mass and duct discharge.
380
The identification of a new breast solid mass particularly in women older than 35 years should prompt __________
Triple assessment, which includes a clinical breast examination, imaging (mammography), and pathology assessment either by core biopsy or surgical excision.
381
For women younger than 35 years of age, suspected lesion characteristic of fibroadenoma or fibrocystic changes can be assess by ___________
ultrasonography
382
When is surgery indicated on a breast mass?
It is indicated if sterotactic biopsies show atypical ductal hyperplasia
383
Is breast pain a common complication of breast cancer?
No
384
What 3 categories can breast pain be split up into?
1. Cyclic mastalgia: diffuse, ilateral, often radiating to axilla and arm and related to menstrual cycle. resolves with menses
2. Noncyclic mastalgia: continuous or intermittent, but not associated with the menstrual cycle. More commonly unilateral and more prevalent in postmenopausal women.
3. Extra-mammary pain is breast pain secondary to another etiology. This is often chest wall pain, but sometimes, the underlying cause may be difficult to determine
385
What is the FDA approved treatment for breast pain?
- Danazol (but expensive)
| - Others include tamoxifen, torpemiphene, and bromocriptine.
386
Nipple discharge is usually caused by a __________ process
benign
387
What type of nipple discharge is more likely to represent a pathologic process?
Discharge that is spontaneous, persistent, from a single duct, associated with a mass, and occurs in women over 40 years of age is more likely to represent a pathologic process.
388
What is the treatment for most unilateral, spontaneous, or bloody nipple discharges?
Surgical excision of the terminal duct
389
What is the treatment of choice for most patients with hyperprolactinemic disorders?
Dopamine agonists (bromocriptine if infertility is involved).
390
Amenorrhea
Absence of menstrual bleeding for 6 months or more without pregnancy
391
Menometrorrhagia
Heavy menstrual flow or prolonged duration of flow occurring at regular intervals
392
Monorrhagia
Excessive menstrual flow, or prolonged duration (>7 d)occurring at regular intervals
393
Metrorrhagia
Bleeding occurring at irregular intervals
394
Asherman syndrome
Scarring within the uterine cavity caused by trauma for uterine curettage.
395
Risk factors for endometrial carcinoma
History of anovulatory menstrual cycles, obesity, nulliparity, age older than 35, the use of tamoxifen, or of unopposed exogenous estrogen
396
Dysfunctional uterine bleeding age of concern?
>35
397
Nonketotic hyperosmolar syndrome
Occurs in type II diabetics when blood sugar levels become highlyelevated, often approaching 1000 mg/dL..This elevates the serum osmolarity, giving the patient a large fluid deficit (up to 9 L).
398
What causes gestational diabetes?
increased insulin resistance caused by elevated chorionic somatomammotropin, progesterone, and estrogens all of which act as insulin antagonists.
399
Maternal complications of gestational diabetes
DKA, hyperglycemia, increased UTI risk, increased pregnancy induced hypertension/preeclampsia, and retinopathy.
400
Fetal effects of gestational diabetes
Congential malformation, macrosomia, polycythemia, hydramnios.
401
Gestational diabetes screening
50-g 1 hour glucose challenege test (GCT) administered to high risk pregnant women at intitial visit and rescreened at 24-28 wks. Greater than 130 mg/DL leads to 100g 3 hour test. Diagnosis made with greater than 2 positive results
402
Diabetes diagnosis: fasting glucose greater than
126 mg/dL
403
Diabetes diagnosis: 2 hour pasma glucose or _____ or more after 75 mg glucose load
200 mg/dL
404
Diabetes diagnosis: HA1C of _____ or greater
6.5%
405
Diabeetes diagnosis:: Random glucose of ______ or more along with classic symptoms
200 mg/dL
406
Metformin disadvantages
GI side effects, contraindiacted in patients with renal insufficiency
407
Sulfonylurea disadvantages
Weight gain, hypoglycemia
408
TZDs for diabetes disadvantages
fluid retention, CHF, weight gain, MI risk
409
Metformin mechanism
Biguanides act on liver to decrease output during gluconeogenesis. Secondary actions include increased insulin sensitivity in the liver and muscle and hypothesized decrease in intestinal absorption of glucose
410
Metformin contraindicatoins?
Creatinine of greater than 1.5/1.4 in men/women
411
Principal action of thiazolidinediones (TZDs)
improving insulin sensitivity in muscle and adipose tissue. Secondary actions are decreased hepatic gluconeogenesis and increased peripheral glucose utilization
412
Exenatide
GLP-1 agonist, incretin mimetic. Synthetic peptide that stimulates insulin releasse
413
DPP-4 inhibitors
Gliptins. Inhibit GLP-1 and GIP and decrease glucose production in liver
414
BP goal in diabetes ptients?
Less than 130/80
415
Creatinine clearance
((140-age) x (ideal body weight in kg) x (0.85 for women))/(72xserum creatinine)
416
Max bed rest for back pain?
2 days
417
Length of time herniated disk can be treated conservatively before imaging is of benefit?
MRI4 weeks
418
Cauda equina syndrome should be immediately evaluated by ____
MRI
419
Age by which a child should use single words?
Most children will say "mama/dada" indiscriminately by 9 months of age and use two other words by 12 months of age. No single words by 16 are a red flag of autisim spectrum disorder
420
Impairments for autism diagnosis
- Social interaction: deficient nonverbal behavior, peer relationships, spontaneous seeking of relatedness with others
- Communication: Spoken language development, conversation, play
- Restricted, repetative, and stereotyped patterns of behavior, interests, and activites
421
When shoud all children be screened with the Modified Checklist for Autism in Toddlers (M-CHAT)?
18- and 24-month visits
422
What do you do when a child has a positive autism screening or demonstrates 2+ risk factors?
- Refer the child for comprehensive ASD evaluation
- Refer child to early intervention/early childhood education services
- Obtain an audiologic evaluation
423
Chorea
Unpredictable, involunatry, irregular, brief movement that is jerky, writhing, or flowing
424
Hyperkinesias
Movement disorders characterized by extra or exaggerated
425
hypokinesias
movement disorders characterized by overall slowness of movement (bradykinesia), lack of movement (akinesia), or difficulty in initiating movement
426
Are laboratory and radiologic testing useful in diagnosis of movement disorders?
nope!
427
What happens in Parkinson's?
Neurons and dopamine are lost from the substantia nigra (part of basal ganglia) and intra-cytoplasmic inclusions (lewy bodies) proliferate. Dopamine depletion in the substantia nigra ultimately leads to increased inhibition of the thalamus and decreased excitation of the motor cortex.
428
Cardinal physical signs of Parkinson's
Distal resting tremor, rigidity, bradykinesia, postural instability, and assymetric onset
429
First line treatment for parkinsons?
Levodopa for motor impairment, dopamine agonists such as pramipexole and ropinirole to lower risk of motor complications, and MAO-B inhibitors.
430
First line treatment for Tourrette's?
Clonidine helps iwth comorbind ADHD and OCD
431
Huntington disease is inherited in an ______ pattern
AD
432
Haloperidol helps in what tic disorder?
Tourrette's
433
Too much levodopa causes _____
Dyskinesia
434
Intermittent asthma
- Symptoms 2x per week
- Night time awakenings 2 times per month
- Short acting B agonist used less than 2 days per week
435
Mild asthma
- symptoms more than 2 days/week
- nighttime awakenings 3-4x/month
- B agonist used greater than 2 days/week
- Minor limitation of normal acitvity
436
Moderate asthma
- Daily symptoms
- nighttime awakenings greater than 1x/week but not nightly
- daily use of B agonist
- Some limitation of normal activity
- FEV 60-80, FEV/FVC 75-80
437
Severe asthma
- Symptoms throughuought day
- Nighttime awakenings 7x/week
- B agonist used several times/day
- Normal activity extremely limited
- FEV less than 60, FEV/FVC less than 75
438
Asthma diagnostic studies
- accurate spirometry 5 yrs or older at time of diagnosis.
- Allergy testin
- Chest radiography
439
Treatment for asthma always begins with _______
education and counseling, environmental controls, and management of coexisting conditions
440
Treatment for AFib?
Rate and coagulation
| Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation
441
Preeclampsia criteria
The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count
442
How is osteoporosis diagnosed?
Central DEX T score of -2.5 or more of the hip, femoral neck, and lumbar spine is the standard radiographic diagnostic test.
443
What is the agent of choice for osteoporosis?
Oral bisphosphonates, like alendronate, risendronate, and ibandronate, which inhibit osteoclastic activity and therefore have anti-resorptive properties.
444
Best SERM for osteoporosis
Raloxifene, also decreases risk of breast cancer
445
Teriparatide
Recombinant human parathyroid hormone that causes bone density growth through its effect on osteoblasts.
446
Denosumab
Used for osteoporosis, prevents osteoclast differentiation and limits bone turnover.
447
Who does the USPSTF recommend osteoporosis screening for?
Women 65+ years old without previous known fractures or secondary causes of osteoporosis. Tey also recommend routine screening for women
448
Delayed gastric emptying in diabetic patient can be caused by
exenatide
449
Gabapentin is a good drug for relieving _______ pain
neuropathic
450
Patients using narcotics should be considered for additional prescription of _______
A stool softener. Constipation is a common side effect of narcotic use
451
In older people, __________ is the most common cause of lower extremity swelling
Chronic venous insufficiency
452
Lower leg swelling differential
- Venous insufficiency
- Pulmonary hypertension
- CHF
453
Venous edema
An excess of low viscosity, protein poor interstitial fluid resulting in pitting in affected area of the body
454
lymphedema
An excess of protein rich interstitial fluid within the skin and subcutaneous tissue. Primary forms are rare and often genetically related. Secondary lymphedema is more common and often related to previous malignancies, surgery, radiation, and infections.
455
Lipidema
A form of fat maldistribution that can appear to be leg swelling with foot sparing
456
Myxedema
A dermal edema secondary to increased deposition of connective tissue components (mucopolysaccharides) seen in various forms of thyroid disease
