Cases Flashcards
Factors associated with increased breast cancer risk (11 things)
Family history, menarche before 12 or menopause after 45, BRCA 1 or 2, advanced age, female, increased breast density, advanced age at first pregnancy, exposure to diethylstilbestrol, hormone therapy, therapeutic radiation, obesity
Four factors associated with decreased breast cancer rates
pregnancy at early age, late menarch/early menopause, high parity, medications like SERMs and NSAIDS and Aspirin
Does the practice of regular breast self-exam by trained women reduce breast cancer mortality?
no
Does the USPTSF recommend breast self exams?
NO
Does the American Cancer society recommend breast exams?
women should know how their breasts normally feel and report any changes. Breast self exam is an option of women starting in their 20s
American cancer society recommendations for clinical breast exams?
part of periodic health exam every three years for women in 20s and 30s, every year for 40 and over.
5 factors associated with increased risk of cervical cancer
early onset of intercourse, greater # of sexual partners, DES exposure, cigarette smoking, immunosuppresion
difference between gardasil and cervarix
gardasil: types 6, 11, 16, 18 approved for ages 9-26. Cervarix: types 16, 18, 31, and 45 for ages 10-25.
average age of menopause
51
smoking affect on menopause
smokers go through menopause a few years earlier than nonsmokers
hallmark of perimenopause
menstrual irregularity
8 risk factors for osteoporosis
low estrogen, lack of physical activity, inadequate calcium intake, family history, history of previous osteoporotic fractures, dementia, cigarette smoking, white
USPSTF osteoperosis screening in postmenopausal women younger than 60
insufficient evidence
USPSTF DEXA recommendations
recommends screening DEXA in all women 65 years and older and 60-64 who have increased fracture risk.
How often to get Td and when to replace with Tdap
Td every ten years. Tdap should replace a single dose of Td for adults 19-64 if they’ve never had a Tdap
Which type of Pap allows for later HPV testing if pap is abnormal?
the liquid based system
how much earlier can mammography detect cancer than self exam
1 or 2 years earlier
does mammography decrease breast cancer mortality?
yes
sensitivity of mammography
60-90%
is there a radiation risk with mammography
negligible
Mammography in women younger than 40
not indicated unless they fall into high risk category such as known BRCA mutation
women btwn 40 and 50 of average risk mammogram suggestions
individualized
upper age at which mammography screening should be discontinued
no specific- as long as woman is in good health and would be candidate for breast cancer treatment she should be screened.
when should pap smears be performed
cerivcal cancer screening starts at 21 every 2 years btwn 21 and 29 and every 3 years btwn 30 and 65. HIV positive and compromised immunity or history of CIN 2, 3, or cancer or DES need more frequent screening. women btwn 65 and 70 who have had 3+ normal paps within ten years may stop screening.
what makes a pap smear ‘adequate’
must contain over 5,000 squamous cells and have sufficient endocervical cells in order to be a sample of the transformation zone
Categories of epithelial abnormalities in PAPs
Atypical squamous cells (ASC): some abnormal cells. may be infection, irritation, precancerous.
Low grade squamous intraepithelial lesion (LSIL)- may progress to high grade lesion but most regress.
High grade squamous intraepithelial lesion (HSIL)- significant precancerous lesion.
Squamous cell carcinoma
Factors of a breast lump that increase likelihood of malignancy
presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular borders
breast lump-> suspected cystic lesion- what are next steps?
aspiration can be attempted and fluid sent of cytology.
breast lump-> solid lesion- what are next steps?
mammography.
What diagnostic test is helpful for distinguishing a solid mass from a cystic lesion in the breast?
ultrasound
Physiological causes of nipple discharge
pregnancy, excessive breast stimulation
Pathologic causes of nipple discharge
prolactinoma, breast cancer
work up of nipple discharge
imaging studies like mammogram, ultrasound, ductogram, and/or biopsy. consider hormonal testing to exclude endocrinological reasons. review and d/c any meds that may be the cause.
Osteoporosis prevention
postmenopausal women need to take between 1200 and 1500 mg of calcium and 800 IU of Vitamin D a day. Calcium tablets can be combined with Vitamin D in the form of cholecalciferol. Calcium in more than 500mg doses should be divided for absorption
losing 5-10% of body weight, patients can significantly reduce risk of what three diseases
diabetes, HTN, and Cardiovascular disease
The key aspects of the preventive exam
RISE: Identifying risk factors for serious medical conditions, updating Immunizations, ordering appropriate screening tests, Educating patients about living a healthy lifestyle and reducing risk of disease
Screening should be considered for conditions that are ___ and ____
important and treatable
Major modifiable risk factors for heart disease
Sedentary lifestyle, tobacco use, excess alcohol. high stress, poor diet, obesity,
Three known cardiovascular risk factors
older age, male gender, family history
Tobacco addiction characterized by the 3 Cs
compulsion to use, lack of control, and continued use despite adverse consequences.
four stages of behavior change
pre contemplative (not aware of need to change or not interested in changing), contemplative- currently interested in changing behavior. active- currently making change, relapse- attempted but no longer
possible protection from moderate alcohol consumption
cardiovascular protection- small increase in HDL, may contain other chemicals that act as anti oxidants or inhibit platelet aggregation
The CAGE questions
felt you needed to Cut down? felt Annoyed by criticism? had Guilty feelings? taken a morning Eye opener?
A brief nutritional history should include:
number of meal and snacks eaten in a 24 hour period, dining-out habits, frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy, desserts.
WAVE pocket card tool
dialogue about Weight, Activity, Variety, and Excess. eating appropriate number of servings of each food group and whether he or she is eating too much fat/sugar etc
Food frequency questionnaire
covers food intake over period of a month. often used in combination with 24 hour recall, it is the quickest way to determine nutritional deficiencies and excesses.
Rapid eating and activity assessment for patients (REAP)
brief validated questionnaire that assesses diet related to the food guide pyramid. questions about patient shopping and preparing their own food, trouble shopping/cooking, diet, limits foods, how willing they are to change.
BMI calculation
weight in kg/height in meters squared
Normal BMI range
18-25
Overweight BMI range
25-30
Obese BMI range
> 30
Very Obese BMI range
35-40
Morbidly Obese range
> 40
What measurements can you use to further determine risk and need for weight loss
body fat distribution, waist circumference, and waist-hip ratio
Three clinical findings associated with dyslipidemia and atherosclerosis
arcus corneus, acanthosis nigricans, xanthelasmas
ABCDE of skin lesions
Asymmetry, border irregularity, color non uniform, diameter >6mm, evolution or change over time
USPSTF on PSA
recommends against it.
ACS and AUA on PSA
recommend testing be offered to men starting at age 50 but that physician should discuss with patient the harm and benefit of screening
Potential benefits of PSA
prolonged life from early detection and tx of prostate cancer, psychological reassurance of a negative screen or detecting at treatable stage
Potential harms of PSA
pain and discomfort associated with prostate biopsy, psychological effects of false-positive test results, complications (including erectile dysfunction, urinary incontinence, bowel dysfunction, even death) from treatment of prostate cancer they may have never caused symptoms
Available methods of colon cancer screening
Colonoscopy (preferred), annual testing of three stools for blood and a flexible sigmoidoscopy test every five years, double contrast enemas every five years, CT colography (virtual colonoscopy) is experimental
Lung cancer screening (USPSTF)
screening with CT, CXR, or sputum cytology can detect lung cancer at an earlier stage than lung cancer would be detected in an unscreened population. However- poor evidence that any screening strategy for lung cancer decreases mortality. invasive and high false positive risk-> significant harms
4 steps of assessing an ECG
- look at rate, PR, QRS, and QT interval
- look for abnormalities in P waves
- assess axis, R wave progression, presence of Q waves, levels of voltage.
- look for ST depression or elevation and inverted T waves
Labs to assess risk for diabetes and CVD
draw glucose and a lipid panel. drawn in fasting state at least 8 hours after last food
5 As when counseling for behavior change
- Ask or Address behavior needing change
- Assess for interest in behavior change
- Advise on methods to change
- Assist with motivation
- Arrange for follow up
are oral meds successful for smoking cessation
oral meds somewhat effective (12 month quit rates 1.5-3 times the placebo)
Annual quit rate for smokers without any medical interventions
2-3% a year
Three things to do when a patient is ready to quit smoking
set a quit date, have patient call 1-800-QUIT-NOW or www.smokefree.gov, instruct pt to start bupropion one week before quit date
Bupropion dosing schedule
start with one pill a day for first three days, then increase to one pill twice a day, after four days, stop smoking and continue on pills twice a day. may add nicotine gum for bad cravings, if needed. after about two months on the pills- gradually stop
initial management of obesity, hyperlipidemia, elevated blood pressure, and glucose (6 things)
- educate pt about increased CVD and cerebrovascular risk
- obtain stress test
- initiate 81 mg aspirin daily
- f/u in one month
- repeat fasting lipid panel in 3 months, initiate meds if necessary
- counsel to reduce calories consumed and increase exercise
Exercise prescriptions should include what specific recommendations
type of exercise, precautions, specific workloads, duration and frequency, intensity guidelines
Calculation of target heart rate
(220-age) x 0.7
Borg rating of perceived exertion scale
6- no exertion, 9- very light, 11- light, 13- somewhat hard, 15- hard, 17- very strenuous/fatigued, 19- extremely hard
follow up of tubular adenoma with low grade dysplasia
repeat colonoscopy in 5-10 years
What percentage of population has hypothyroidism
5%
medical conditions associated with depression (3)
hypothyroidism, parkinsons, dementia
what percentage of parkinson’s patients experience depressive symptoms
60%
which is more sensitive- mini cog or MMSE?
mini-cog (99%) . the MMSE is only 91%
Diagnostic criteria for major depressive disorder
depressed mood or anhedonia and at least five of the following 8: sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal ideation.
Major depressive disorder vs. bereavement
MDD only if symptoms are present two months after the loss. Guilt about other things, thoughts of death, morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged funtional impairment, hallucinatory experiences other than hearing deceased person.
In what ethnic group is depression identified less frequently?
hispanics
how do hispanic patients tend to present with depression?
somatic complaints like myalgias or fatigue
which group has a lower rate of depression- US born hispanics or immigrants?
immigrants have up to 50% lower rate of depression
Factors that increase a patient’s likelihood of completing a suicide attempt
white male, previous attempt, suicide in elderly
most common means of suicide in elderly
drug overdose
SSRI examples
citalpram (celexa), fluoxetine (prozac), fluvoxamine (luvox), paroxetine (paxil), sertraline (zoloft), escitalopram (lexapro)
Venlafaxine (effexor)
serotonin and NE reuptake inhibitor
Bupropion (wellbutrin)
NE and dopamine reuptake inhibitor
nefazodone (serzone) and trazodone (desyrel)
serotonin antagonist and reuptake inhibitors
mirtazapine (remeron)
NE and serotonin antagonist, antihistaminic effects
duloxatine (cymbalta)
serotonin and NE reuptake inhibitor
TCA antidepressants
nortriptyline (pamelor), amitriptyline clomipramine, doxepin (sinequan). block reuptake of NE, 5HT
MOA-Is
Phenelzine (nardil), tranylcypromine (parnate). block pre-synaptic catabolism of NE and 5HT
SSRI/SNRI side effects
headaches, sleep disturbances, GI problems, hyponatremia due SIADH, serotonin syndrome, increased GI bleeding, elderly- increased risk for falls, possible adverse effects on bone density.
TCA side effects
cardiac arrhythmias
common causes of insomnia in elderly
environmental (noise or bedding), drugs/alcohol/caffeine, sleep apnea, parasomnias (restless leg syndrome, period leg movement and rapid eye movement sleep behavior disorder), disturbances in cycle (shift work), psychiatric disorders (Depression and anxiety), cardiorespiratory disorders, pain or pruritis, GERD, hyperthyroidism.
risk factors for elder abuse
dementia, shared living situation of elder and abuser (except $ abuse), caregiver substance abuse or mental illness, heavy dependence of caregiver on elder, social isolation of elder from people other than abuser
Geriatric depression scale- short form (GDS-SF)
over the past week: are you satisfied with your life? have you dropped many of your activities and interests? do you feel that your life is empty? bored easily? good spirits? afraid something bad will happen? happy? helpless? stay at home or go out and do things? memory problems?
screen for common causes of insomnia, fatigue, depression
comprehensive metabolic panel- electrolyte, renal, hepatic problems. TSH, CBC (anemia and vitamin def.), ESR (rheumatologic disease), EKG (if on TCAs etc)
What two behavioral treatments for insomnia have met evidence based criteria for efficacy?
sleep restriction-sleep compression therapy and multi component cognitive behavioral therapy for insomnia.
pharmacologic treatment of insomnia
side effects are prolonged sedation and dizziness. non benzodiazepines (i.e. zolpidem (ambien) and melatonin receptor agonists) are safest.
first line pharm approach to major depress. disorder
SSRI or SNRI
fluoxetine (prozac)
long half life. can cause agitation, restlessness, decreased libido in women, insomnia
sertraline (zoloft)
used in pregnancy. approved for OCD, panic, and PTSD. more GI side effets
paroxetine (paxil)
strong anti anxiety effects, best studied SSRIs in children, side effects include significant weight gain, impotence, sedation, and constipation. due to short half life, paroxetine is most likely of all ssris to cause antidepressant discontinuation syndrome
fluvoxamine (luvox)
particularly useful in OCD, greater frequency of emesis compared to other SSRIs
citalopram (celexa)
most common side effects include nausea, dry mouth, and somnolence
escitalopram (lexapro)
approved specifically for generalized anxiety disorder, fewer side effects than citalopra
for first episode of major depressive disorder- tx duration
9-12 months of meds, stopping sooner is high risk for recurrence.
recurrent episodes of depression are treated for how long
2-3 years
allow how long for depression meds to be fully effective, but follow up in how long?
4-6 weeks to be effective, but f/u in 2 weeks to monitor side effects
for patient who is seriously considering suicide, a tool to assess severity of the situation is the ___ scale (acronym)
SAD PERSONS: sex (male), age (under 19 or over 45), depression, previous attempts, ethanol or other substance abuse, rational thinking impaired, social supports lacking, organized plan, no significant other, sickness (7 out of 10 suggests hospitalization)
differential diagnosis for ankle pain
sprain, fracture of distal fibular, fracture of talus, peroneal tendon, subtalar injury
what percent of ankle injuries are clinically significant fractures?
less than 15%
compartment syndrome
serious life and limb-threatening complication of extremity trauma. rising pressure in a muscle compartment impairs perfusion to that same muscle compartment.
causes of compartment syndrome
fractures, crush injuries, burns, arterial injuries
signs and symptoms of compartment syndrome
Pain, Pallor, Pulselessness, paresthesias (burning, itching, prickling, or tingling), poikilothermia (can’t regulate body temp), paralysis
what is the most reliable sign of compartment syndrome
paresthesias
most common mechanism of injury for ankle sprain
plantarflexion and inversion
Medial ankle sprain mechanism of action
forced eversion and dorsiflexion.
why are medial ankle sprains less common than lateral?
bony articulation btwn the medial malleolus and the talus
history of a snap or tear is diagnostically significant in what injury
knee injury
is a history o fa snap or tear diagnostically significant in ankle injuries?
no
which ligaments are most often damaged in ankle injuries caused by plantarflexion and inversion
lateral stabilizing ligaments- anterior talofibular, calcaneofibular, posterior talofibular).
Anterior drawer test
assesses integrity of the anterior talofibular ligament (most easily injured). knee flexed 90 degrees. one hand holds tibia and exerts a slight posterior force while the other brings calcaneus and talus forward on tibia.
inversion test
when ankle i inverted it does not appear lax, indicating calcaneofibular ligament is intact
what ligament is the strongest of the lateral complex
posterior talofibular
crossed-leg test
detects high ankle tibiofubular syndesmotic sprain. while patient is sitting with one leg crossed over the other, pressure is applied to the medial side of the knee. high ankle sprain will produce pain in the syndesmosis area.
Grade I ankle sprain
stretching and/or small tear of a ligament. slight/no functional loss. mild tenderness, mild swelling. usually no ecchymosis. no mechanical instability: no streatching or opening of the joint with stress.
Grade II ankle sprain
incomplete tear. moderate functional impairment, loss of some motor function. difficulty bearing weight. tenderness and pain. mild to moderate swelling. ecchymosis common. moderate instability, stretching of the joint with stress, but a definite stopping point.
Grade III ankle sprain
complete tear and loss of integrity of ligament. inability to bear weight. severe swelling, ecchymosis. mechanical instability. significant stretching of the joint with stress, without stopping point.
most common acute ankle injury
lateral ankle inversion sprain
Medial ankle stability is provided by
the strong deltoid ligament, the anterior tibiofibular ligament, and bony mortise.
Peroneal tendon tear
usually due to an inversion injury or reptitive trauma. may occur in conjunction w/ankle sprain. persistent pain posterior to the lateral malleolus.
Talar dome fracture
may occur in conjunction with an ankle sprain, and initial x rays may miss a talar dome fracture.
ankle tendonitis
inflammatory condition, usually involving the posterior tibialis tendon. swelling/warmth may be present in the affected area. worsens initially with aggravating activity only. may then progress to discomfort at any time. chronic. worse during the day and after exercise.
subtalar injury
often due to a high-energy injury. a dislocation involves the talocalcaneal and talnavicular joints. pain, swelling, deformity, are present.
tarsal tunnel syndrome
entrapment of the tibial nerve. pain, tingling, and burning sensations along the sole of the foot. pain along the inside of the ankle and/or bottom of the feet and shooting pain.
syndesmotic injury
generally involves the interosseus membrane and the anterior inferior tibiofibular ligament. pain and disability are often out of proportion to the injury. one would expect a positive ankle squeeze test.
infection of the ankle joint
less common. appropriate history and physical exam neede. symptoms include painful range of active and passive motion, edema, erythema, warmth, and fever.
arthritis of ankle
less common than in some other joints. chronic process, more commonly seen in older people. the tibiotalar joint is generally involved and condition may occur as result of prior injury, obesity, or history of rheumatoid disease.
ottawa rules
decision tool designed to help in evaluation of adults w/acute ankle and midfoot injuries. 97-100% sensitive. also used to exclude fractures in children under 5.
according to ottawa rules, radiographs of ankle needed if:
pain in malleolar zone AND either bony tenderness along distal 6cm of posterior edge of either malleolus OR inability to bear weight both immediately and in the emergency department
according to ottawa rules, radiographs of foot needed if:
there is pain in the midfoot region AND bony tenderness at either the navicular bone or base of fifth metatarsal OR inability to bear weight both immediately and in emergency department.
management of ankle sprain
RICE: (rest for first 72 hours only, Ice several times throughout the day for ten minutes at a time, Compression with tape, elastic wrap, or semi rigid ankle support, Elevation.) Ibuprofen TID PRN. Daily ankle exercises- inversion, eversion, plantar and dorsi flexion, calf stretching, single leg balancing. proprioceptive exercises help prevent and reduce the likelihood of re-injury.
dysuria Rx
if pt has no hx of allergy to sulfa, trimethoprim-sulfamethoxazole may be used for empirical tx for uncomplicated lower UTIs. a quinolone like cipro may be used if high uropathogen resistence to trimethoprim-sulfamethoxazole.
DDx of heart palpatations
cardiac dysrhthmias, anxiety/panic disorder, anemia, hyperthyroidism, drug/caffeine abuse
hyperthyroidism causes increased heart rate and cardiac output due to
increased peripheral oxygen needs, and increased cardiac contractility
weight loss in hyperthyroidism is due to
increased calorigenesis (heat produced by consumption of food), and increased gut motility and the associated hyperdefecation and malabsorption
exercise intolerance and fatigue in hyperthryoidism is caused by
oxygen consumption and CO2 production, respiratory muscle weakness
60-80% of hyperthyroidism is caused by
toxic diffuse goiter (graves’)
hypervascularity of thyroid may result in a bruit or thrill upon auscultation in what disease
graves’
worldwide most common cause of goiter
lack of iodine.
ankle clonus
elicited by rapidly dorsiflexing the foot, causing alternate contraction and relaxation of the gastrocnemius and soleus muscles.
lid lag
elicited by hasving pt follow with his eyes your finger moving slowly from their upper to lower field of vision. if lid lag- upper eyelid lags behind the upper edge of the iris as teh eye moves downward.
how to differentiate btwn hyperthyroidism and anxiety
in anxiety, peripheral manifestations of excess thyroid hormones are absent- the skin is cold and clammy. panic attacks. ask about brief periods of overwhelming terror
why does anemia cause palpaitations?
tachycardia from hypovolemia. heart responds to low blood volume by speeding up to increase the exposure of blood to oxygenation in the lungs. anemia can cause dyspnea on exertion bc of the lack of oxygen carrying capacity of the blood. A common source of anemia in menstruating women is heavy periods.
tests to order on a patient with palpitations
TSH, T4, ECG, CBC (anemia), Radioactive iodine uptake test and scan (RAIU)
thyroid ultrasound
evaluation of thyroid nodules and thyroid enlargement. US characteristics of a nodule can be used to stratify risk of malignancy and US can guide the fine needle aspiration of nodules that are not easily palpated.
Management of hyperthyroidism
propranolol can be used for symptomatic relief of adrenergic symptoms (tachycardia, tremor, heat intolerance)
management of hypothyroidism
easier to manage than hyperthyroidism. can be managed with one or two blood tests a year.
levothyroxine
increase dose slowly, especially in elderly. aim for dose of 1.5-1.8mcg per kg. check TSH one month after starting. in primary- once a stable TSH level is achieved, blood work can be checked annually.
At risk populations for DM
Native Americans, African, and Asian Americans, Latin Americans, Pacific Islanders.
how many people in US have undiagnosed diabetes
7 million
preferred method for diagnosing diabetes
HbA1c (>6.5%)
American Diabetes Association screening recommendations
overweight or obese (BMI over 25) pts who have 1+ :sedentary lifestyle, race, 1st degree relative w/DM, previously impaired fasting glu, HTN, HDL 250, history of gestational DM or baby >9lbs, PCOS, CVD. If none of those risks- screening begins at 45 yo. If results normal, testing repeated at 3 year intervals- more frequent if risk factors or borderline results.
USPSTF screening recommendations for DM
screen for type 2 DM in asymp adults w/sustained BP greater than 135/80.
leading cause of death in DM patients
cardiovascular disease (i.e. coronary heart disease and stroke)
most common cause of new cases of blindness among adults of working age
diabetes
do diabetics on insulin or oral hypoglycemics have greater chance of retinopathy
40% in insulin, 24% w/oral hypoglycemic agents
how likely is glaucoma in diabetics
40%
prevalence of neuropathy in DM
7% at one year, increasing 50% at 25 years for type 1 and 2
what % of DM patients have nephropathy
20-40%
Fatalismo
holding to a belief that control over one’s DM is external to self.
utility of EMR
templates increase likelihood the pt will receive the recommended care. Assists in evaluating how the physician is caring for specific patient populations. helps the physician improve reimbursement by creating reports of pt care data for specific measures of care, such as HbA1c or blood pressure control for medicare and medicaid
why is examining the thyroid in diabetics important?
thyroid disease can lead to diabetes and hyperlipidemia
Diabetic foot exam should include:
testing for loss of protective sensation: sensory testing can be conducted with a 10g monofilament, tuning fork, pinprick, ankle reflexes. Assessment of pedal pulses: evaluate for peripheral vascular disease, strongest risk factor for delayed ulcer healing and amputation in diabetes patients. Inspection- inspect of breaks in skin.
what is the strongest risk factor for delayed ulcer healing and amputation in diabetes patients
peripheral vascular disease (test pedal pulse)
four reasons for ordering lab tests in DM patients
monitoring diabetic control, assessing end organ damage, monitoring side effects of treatment, uncovering management complications
recommended lab tests for DM patient
HbA1c (4-12 week period. measure at dx and at least 2x a year in pts who are stable and meeting goal. quarterly when therapy is changing or goal not being met), electrocardiogram (die from CVD. test at baseline), Sport urine albumin:creatinine ratio (screening for microalbuminuria. many rx like metformin are renally excreted. annual monitoring is required to identify renal insuff and avoid drug tox). Serum B12 (metformin can cause asymp subnormal b12), TSH, fasting lipids, fingerstick blood sugar
how often to test spot urine albumin:creatinine ratio in DM?
annually
when to test B12 in DM?
if patient exhibits signs of neuropathy
ADA and USPSTF recommendations for TSH testing in DM
do not recommend for or against ordering TSH.
how often to do fasting lipid profile in DM
at diagnosis, every three months until control is achieved, annually once lipids are well controlled.
when to do a fingerstick blood sugar in DM
only if pt is experiencing acute symptoms of hyperglycemia or hypoglycemia at time of visit
ADA/European Association for the Study of Diabetes (EASD) Consensus Algorithm for Management of DM II [FIRST TIER]
Step 1: Diagnosis. If HbA1c > 6.5%. lifestyle change + metformin.
Step 2: Assessment: If HbA1c >8%, continue lifestyle and metformin and add sulfonylurea (glyburide, glipizide, or glimepiride) or basal insulin (glargine, detemir, or protamine hagedorn NPH).
Step 3: Reassessment: If HbA1c >8, continue lifestyle and metformin, add basal insulin or (if already on insulin) intensify insulin regimen, consider discontinuing sulfonylurea to avoid hypoglycemia.
ADA/European Association for the Study of Diabetes (EASD) Consensus Algorithm for Management of DM II [SECOND TIER]
Explore other Tx options: adding rapid acting insulin with meals, thiazolidinediones: pioglitazone (actos) or rosiglitazone (avandia) may be useful for those who cannot tolerate the GI effects of metformin or have hypoglycemia with sulfonylureas. Can increase risk of heart failure, edema, and bone fractures. Meglitinides, GLP 1 analogs, DPP4 inhibitors, amylin analog, alpha glucosidase inhibitors
in the diabetes prevention program (DPP) what was the most successful method to prevent diabetes?
lifestyle alteration
what improves cardiovascular risk improvement more- BP and lipid control or glycemic control?
BP and lipid
barriers to insulin tx
pts opposed to injecting (need education), drawing up insulin if visually impaired or poor dexterity (insulin pens), misconception that it causes complications, physicians reluctant to rx insulin cause don’t have time to teach pts how to use it.
first line therapy for CHF in DM patients
ARBs.
when should a statin be used regardless of lipid level?
for patients with known CVD or over 40 with one risk factor for CVD
NCEP ATP III guidelines for dyslipidemia
target non HDL cholesterol as a second goal after lowering LDL. Non HDL cholesterol may be a stronger predictor of CVD bc it represents the atherogenic VLDL remnants as well as the LDL.
when to use aspirin therapy
secondary prevention in diabetes patients with history of CVD or in those deemed at moderate or high risk of CVD. primary prevention in DM pts with increased CV risk (over 40 who have HTN, smoking, dyslipidemia, fam history, or albuminuria).
what can be used instead of aspirin for CVD if pt has aspirin allergy
clopidogrel (75mg)
what is the most important modifiable cause of premature death in DM
smoking
DM I patients should have their first eye exam when
five years after dx
immunizations in DM pts
annual vaccination for influenza, pneumococcal polysaccharide vaccine for all diabetes patients over two years old. one time revaccination is recommended for pts over 64 if first received greater than 5 years ago or have nephrotic syndrome, CKD or immunocomp.
DDx for leg swelling
cellulitis, DVT, venous insufficiency, lymphangitis, peripheral arterial disease
single greatest contributor to mortality in US
smoking
three leading specific causes of smoking attributable death
lung cancer, ischemic heart disease, COPD
known health risks of obesity
HTN, dyslipidemia, DM, coronary heart disease, stroke, gall bladder disease, osteoarthritis, sleep apnea, respiratory problems, endometrial cancer, breast cancer, colon cancer,
Wagner Ulcer grading system
Grade 1: superficial ulcer, involves full skin thicnkess. outpatinet management.
Grade 2: deep ulcer. penetrating down to ligaments and muscle, no bone involvement or abscess formation.
Grade 3: deep ulcer, cellulitis or abscess formation, often osteomyelitis (evaluate for myelitis. may need hospitalization(
Grade 4: localized gangrene. surgery/amputation.
Grade 5: extensive gangrene/whole foot.
organism in small skin break cellulitis vs. large skin break.
small = strep, large = staph.
homan’s sign
classic sign of DVT. pain on passive dorsiflexion of the foot
most robust risk factors in development of DVT
smoking and obesity
ankle brachial index
ABI. can be done to determine the presence of PAD. an ABI <0.9 is consistent with the disease.
doppler ultrasound of lower extremity
confirms w/good sensitivity and specificity if DVT is present. Best predictive value for a DVT. can be overused.
D dimer
small protein fragment present in blood after a clot is degraded by fibrinolysis, sensitive but not specific.
Well’s Criteria For Dx of DVT
active cancer =1pt, paralysis/paresis/immobilization cast=1pt, bedridden 3+ days or surg=1pt, localized tenderness=1pt, entire leg swollen=1pt, calf swelling more than 3cm compared to asymp leg= 1pt, pitting edema= 1pt, collateral superficial veins=1pt, alt dx as likely = -2pts. 3points is high probability, 1-2 is moderate,
management of DVT- criteria to treat on an outpatient basis
hemodynamically stable, good kidney function, low risk for bleeding, stable and supportive home environment, daily access to international normalized ratio (INR) monitoring
warfarin tx duration for DVTs
isolated calf thrombophelbitis: 6-12 weeks. first time event from surg or trauma - 3 months, first episode of idiopathic thromboembolic disease= 6 months. recurrent= 12 months to indefinitely
titration of warfarin
half life is 40 hours, so 5-7 days to reach stable state. check INR three days after warfarin initiation to make sure its not too high. if INR is >5 and 9, hold warfarin and give an oral dose of vit k
screening for inherited thrombophilia
no absolute indications. initial thrombosis occurring prior to age 50 w/out immediate risk factor. family history. recurrent, starting in unusual vascular beds- portal, hepatic, mesenteric, cerebral.
definition of high blood pressure
systolic > 140, diastolic > 90
official diagnosis of HTN
must be at least two elevated measurements- at least 5 minutes apart, one in each arm, on two or more visits- in order to accurately diagnose a patient with HTN. a patient cannot be diagnosed with HTN if patient is acutely ill or in acute pain.
USPSTF HTN screening recommendations
screen for high BP in pts without known HTN starting at age 18.
JNC guidelines- evaluation of pt w/possible new dx of HTN has three goals
- assess presence or absence of target end organ disease (heart, brain, kidneys, PVD, eyes), 2. assess lifestyle and identify other CV risk factors or concomitant disorders that may affect prognosis and guide tx. (metabolic synd, fam history of CVD, smoking, etoh, cocaine, age, sedentary, microalbuminuria) 3. reveal identifiable causes of high BP (apnea, CKD, hyperaldosteronism, pheochrom, coarctation, rx, OTC, herbals, cocaine,)
studies recommended for a new dx of HTN
ECG, urinalysis, H/H (low hematocrit can mean anemia in HTN and makes major CV event more likely), serum potassium, serum creatinine or corresponding GFR, fasting serum cholesterol panel, urinary albumin excretion or albumin/creatinine ratio (optional except for those with DM or kidney disease), serum Ca
Tx for stage 1 HTN without compelling indications
Thiazide. may consider ACEI, ARB, BB, CCB or combo
Tx for stage 2 HTN without compelling indication
2 drug combo (thiazide and ACE, ARB, BB, or CCB)
Tx for HTN + heart failure
thiazides, BB, ACEI, ARB, aldosterone antagonists
Tx for HTN + post MI
BB, ACEI, Aldo antagonist
Tx for HTN + CAD risk
thiazides, BBs, ACEIs, ARBs, CCBs
Tx for HTN + DM
Thiazides, BBs, ACEIs, ARBs, CCBs
Tx for HTN + CKD
ACEIs, ARBs
Tx for recurrent stroke prevention
thiazides, ACEIs
most cost effective antiHTN drug on market
Hydrochlorothiazide (4.30 for a month)
possible problems with hydrochlorothiazide
may cause hyponatremia, avoid in gout pts, problem if urine incontinent
what 2 ethnic groups have lowest rates of BP control
mexican americans and native americans
causes of resistant HTN
improper BP measurement, excess sodium intake, inadequate diuretic therapy, medication issues (inadequate doses, drug interactions, excess alcohol, secondary HTN
ATP III dyslipidemia therapy recommendations
- CHD pts (or w/ CAD, PAD, AAA, DM) should start lifestyle modifications and an LDL lowering drug simultaneously
- determine major risk factors (cigarette smoking, HTN, low HDL (under 40), fam history of premature CHD, age)
- If 2+ risk factors present w/out CHD, assess 10 year CHD risk. take LDL drug after 3 months of lifestyle changes if LDL is still above 130.
- almost all ppl with 0-1 risk factor have 10 year risk of less than 10%
palpatations ddx (5)
dysrhthmia, CHD, valvular heart disease, anxiety/panic, vasomotor symptoms of menopause.
Framingham risk score Risk Factors for CHD
total cholesterol, DM, smoking, Age, HTN, elevated LDL, male gender
NCEP ATP III Risk factors for CHD
smoking, age, HTN, elevated LDL, fam history of CHD
USPSTF screening recommendations for CHD
screen adults over 18 for high BP, routinely screen men over 35 and women over 45 for lipid disorders adn treat abnormal lipids in people who are at increased risk for coronary heart disease. recommends AGAINST routine screening with resting ECG, treadmill test, or EBCT in adults at low risk.
Typical CHD chest pain
radiates to one or both shoulders or arms. precipitated by exertion. more likely ACS or ischemic.
The three Ps of pain- characteristics that decrease the likelihood of ACS
Pleuritic- worsened by respiration, exacerbated when lying down. causes of pleuritic chest pain include pulm embolism, pneumothorax, viral or idiopathic pleurisy, pneumo, and pleuropericarditis.
Positional pain
Reproduced by Palpation
Characterizing chest symptoms using PQRST
Provocation/palliation, Quality, region/radiation, severity, temporal elements, associated symptoms
most common structural heart disease presenting with palpitations
mitral valve prolapse
mitral valve prolapse on auscultation
midsystolic click followed by crescendo-decrescendo murmur. best heard at apex. enhanced by valsava and decreased by squatting
in patients at low risk for CHD, the test most helpful in exluding disease is
exercise stress electrocardiography
USPSTF aspirin therapy recommendations
initiate aspirin in men 45-79 to reduce MI risk. initiate in women 55-79 to reduce ische1mic stroke risk. benefit weighed against risk of GI hemorrhage.
causes of lower back pain
lumbar strain/sprain (70%), age related degenerative joint changes in the disks and facets (10%), herniated disc (4%), osteoporotic fracture (4%)
risk factors for lower back pain
prolonged sitting, with truck driving having highest rate (then desk jobs), deconditioning, suboptimal lifting and carrying habits, obesity (maybe)
lifetime prevalence of LBP
60-80%
congenital causes of LBP
scoliosis, kyphosis, spondylolysis
traumatic causes of LBP
lumbar strain, compression fracture
metabolic causes of LBP
osteoporosis, hyperparathyroidism, paget’s disease, osteomalacia
infectious causes of LBP
pyelonephritis, osteomyelitis, discitis, herpes zoster, spinal or epidural abscess
inflammatory causes of LBP
ankylosing spondylitis, sacroiliitis, rheumatoid arthritis
neoplastic causes of LBP
multiple myeloma, metastatic disease, lymphoma, leukemia, osteosarcoma
degenerative causes of LBP
disc herniation, osteoarthritis, facet arthropathy, spinal stenosis
Vascular causes of LBP
aortic aneurysm, diabetic neuropathy
visceral causes of LBP
prostatitis, PID, ovarian cyst, endometriosis, kidney stones, cholecystitis, pancreatitis
Radiologic findings associated with LBP
spondylolysis, disc-space narrowing, spinal instability, spina bifida occulta
what percentage of LBP resolve within one month
90%
for patients who are out of work greater than 6 months, what % chance is there returning to work?
50%
classic signs of disc herniation
exacerbated when sitting or bending and relief while lying or standing, increased pain with coughing and sneezing, pain radiating down leg/foot, parasthesias, muscle weakness like foot drop
what position makes scoliosis more easily visualized
lumbar flexion
what is the best measure of spine mobility?
lumbar flexion
restriction and pain during flexion are suggestive of…
herniation, osteoarthritis, or muscle spasm
pain with lumbar extension is suggestive of
degenerative disease or spinal stenosis
with lateral motion, pain on the same side as bending is suggestive of
bone pathology such as osteoarthritis or neural compression
pain on the opposite of lateral bending is suggestive of
muscle strain
difficulty with heel walk is associated with
L5 herniation
difficulty with toe walk is associated wtih
S1 herniation
if pain is reduced by squatting, suggests
central spinal stenosis
most neuropathic back pain is due to impingement of which three nerve roots
L4, L5, S1
decreased patella reflex implies
impingement at L3-L4
decreased achilles reflex implies
impingement of L5-S1
decreased rectal tone with back pain can indicate
disc herniation and/or cauda equina syndrome
passive straight leg raise/Lasegue’s sign
leg raised less than 80 degrees, lower and then dorsiflex. positive if there is pain with dorsiflexion- radiates down posterior/lateral thigh. stretching of S1 or L5
Pain with straight leg raise earlier than 30 degrees
malingering
pain in opposite leg during a straight leg raise is suggestive of
root compression due to complete disc herniation
crossed leg raise
positive if pain is increased in contralateral leg- not sensitive but very specific
FABER test
flexion, abduction, external rotation. pathology of hip joint or sacrum.
pelvic compression test
performed by forcibly pressing together hips. positive test elicits pain in the sacroiliac joint
Pain worse with movement and sitting that improves while lying down. Dx
lumbar strain
pain worse with movement and sitting that improves while lying down, and radiation down the leg
disc herniation
cauda equina syndrome
spinal compression resulting from a large mass effect (such as acute disc herniation or tumor) causing pain radiating down the leg and numbness of the leg. decompression within 72 hours needed.
red flags signaling cauda equina syndrome
urinary incontinence or retention, saddle anesthesia, anal sphincter tone decreased or fecal incontinence, bilateral lower extremity weakness or numbness, progressive neurological deficits
red flags signaling LBP is from cancer
history of cancer, weight loss, age over 50 or under 17, failure to improve with therapy, pain more than 4-6 weeks, night pain or pain at rest
red flags signaling vertebral fractures
corticosteroid use, trauma over age 50, age over 70, history of osteoporosis, recent car accident, previous vertebral fracture
two red flags of herniated nucleus pulposus
major muscle weakness (strength 3 of 5) and foot drop
spondylolisthesis
anterior displacement of vertebra or the vertebral column in relation to the vertebrae below. aching back and posterior thigh that increases with activity of bending
when to do diagnostic testing (imaging etc) in LBP
after 4-6 weeks of conservative treatment
guidelines for plain x ray films in LBP (AHCPR)
age under 20 and over 70, trauma, strenuous lifting + osteoporosis, prolonged steroid use, cancer, fever/chills, pain worse when supine or severe at night
criteria for lumbar films (deyo series)
age over 50, trauma, neuromotor defect, weight loss of 10lbs, ankylosing spondylitis, drug/etoh abuse, history of malignancy, 100 degree fever, revisit w/out improvement
Is CT recommended in back pain?
no
indications for MRI in LBP
neurological deficit, radiculopathy, progressive motor weakness, cauda equina compression, suspected systemic disorder, failed 6 weeks conservative treatment,
differential diagnosis for knee pain
osteoarthritis, rheumatoid arthritis, SLE< gout, pseudogout, psoriatic arthritis, knee strain
causes of knee pain in children and adolescents
patellar subluxation, tibial apophysitis (osgood-schlatter), patellar tendonitis
causes of knee pain in adults
patellofemoral pain syndrome, overuse, traumatic injuries, inflammatory arthropathies,
locking or popping symptoms in knee pain
ligament or menisci injuries
PHQ-2 Depression screen
during the past month: have you often been bothered by feeling down, depressed or hopeless? Have you often been bothered by little interest or pleasure in doing things?
Lachman’s test
assess ACL.
valgus and varus stress tests
assess functioning of medial and lateral collateral ligaments.
McMurray test
assess the medial and lateral medisci. positive ive click is felt or causes pain.
Phalen’s test
flex wrist by having patient place dorsal surfaces of hands together in front of him for 30-60 seconds to reproduce symptoms
The three most helpful findings in predicting the electrodiagnosis of carpal tunnel syndrome are
hand symptom diagrams, hypoalgesia, weak thumb abduction strength testing
discoid lesions
discrete erythematous plaques with scaling
theater sign
mild to moderate pain after prolonged sitting. patellofemoral pain syndrome
anterior knee pain, no trauma, overuse, mild pain after prolonged sitting
patellofemoral pain syndrome
lateral knee pain, no trauma, pain aggravated with activity
iliotibial band tendonitis
general knee pain, trauma/noncontact deceleration forces. moderate to severe joint effusion, swelling within 2 hours of pop
ACL sprain
medial joint line pain, trauma, misstep or collision, immediate onset of pain/swelling after trauma
MCL sprain
lateral joint line pain, trauma. varus stress. immediate onset of lateral knee pain.
lateral collateral ligament sprain
medial or lateral joint line, trauma/sudden twisting injury. can occur with chronic degenerative process. mild effusion. possible atrophy of the vastus medialis obliquus portion of the quadriceps
meniscal tear
generalized extreme pain with any movement. elevated WBCs. elevated ESR. abrupt onset of pain/swelling
septic arthritis
generalized or joint line tenderness, pain aggrevated by weight bearing activities relieved by rest. not acute trauma. crepitus on exam
osteoarthritis
extreme pain with any movement, also painful to touch. acute pain and swelling without prior trauma. arthrocentesis with clear or slightly cloudy synovial fluid
gout
synovial fluid findings: clear straw colored transudative fluid
OA, degenerative meniscal injury. simply joint effusion
synovial fluid findings: dark, discolored bloody aspirate
Acute meniscal tear, anterior or posterior cruciate ligament tear (knee sprain).hemarthrosis
synovial fluid findings: dark, discolored w/fat globules
Osteochondral fracture. hemarthrosis w/ fat globules
synovial fluid findings: turbid to very turbid fluid, high white cell count (15k to >200k)
septic arthritis
synovial fluid findings: slightly turbid, crystals
inflammation. SLE, gout, RA
is knee x ray required to diagnose OA?
no
a ‘merchant’s view’ on x ray
top view of the knee obtained with knee bent at a 45 degree angle, showing the alignment of the patella in the groove of the femur (evaluates the patellofemoral joint)
Major radiographic features of OA
joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
what radiographic feature best predicts disease progression in OA
joint space narrowing
preferred test to dx meniscal or ligamentous damage
MRI
what test to order in setting of locking, popping, or joint instability (knee)
MRI
Intra-articular steroid injections
no more than 3 injections per year, no more than 1 injection per month. long acting triamcinolone preferred over methylprednisolone. combine 1ml of steroid with 3-4ml local anesthetic.
three OA treatments that are A level evidence
water exercise, NSAIDs ad corticosteroid injections.
when to do nerve conduction velocity study on carpal tunnel pts
if symptoms don’t improve w/conservative tx, motor dysfunction, thenar atrophy
breast cancer screening in ages 50-74
biennial mammography
cervical cancer screening for women over 65
should not be screened if they have adequat normal pap smears.
Lipid disorder screening (USPSTF)
screen women over 45 if they are increased risk for coronary heart disease, no recommendation for women over 20, strongly recommends women over 35
AAA Screening recommendation
one time US to screen for AAA for men 65-75 who have any history of smoking. recommended against for women
USPSTF recommendation for carotid artery stenosis screening
against if aysmpt
zoster vaccine
60 and older
tetanus booster every _ years
10
pneumococcal vaccine
once at 65 years old
most common sexually transmitted bacterial infection in the US
chlamydia
USPSTF chlamydia screening recommendations
Strongly recommends (A): all sexually active non/pregnant 24 and younger. Non-preg women 25 and older at increased risk. Recommends (B) all preg women 24 and younger, preg women over 25 at increased risk, advises against screening women age 25 and older if not at increased risk. Insuff evidence for or against screening men
USPSTF folic acid recommendation
all women planning or capable of pregnancy take a daily supplement containing 400-800 mcg of folic acid.
when to increase folic acid dose beyond 400-800mcg
1mg in pts with DM or epilepsy, 4mg in pts who bore a child w/previous neural tube defect.
HTN drugs to avoid during pregnancy
ACEIs, ARBs, thiazide diuretics
bleeding can occur in early pregnancy around time of missed menses as a result of…
invasion of trophoblast into the decidua (implantation bleed)
gestational age 5 weeks- findings
embryo is 1/8 inch in size. has heartbeat. brain/spinal cord rapidly developing.
gestational age 8 weeks- findings
enlargement of uterus detected on bimanual exam
gestational age 10-12 weeks- findings
fetal heart tones elicited by hand-held doppler
gestational age 12 weeks- findings
uterine fundus palpated above symphysis pubis
gestational age 18-20 weeks- findings
fetal movement (quickening) detected by mother
gestational age 20-36 weeks- findings
uterine enlargement, measure in centimeters, approximates gestational age and will become a routinely elicited physical exam finding.
Naegele’s Rule
start w/first day of last normal period, then add 1 year, subtract 3 months, add 1 week.
abortion is legal up to ___ weeks of pregnancy
22
Adolescent interview: HEEADSSS
Home, education/employment, eating, activities, drugs, sex, suicide, safety
goodell’s sign
softening of cervix
hegar’s sign
softening of the uterus
chadwick’s sign
bluish-purple hue on the cervix and vaginal walls is caused by hyperemia
cervical os dilated w/obvious bleeding lends support to dx of…
spontaneous abortion
1st trimester bleeding DDx
spontaneous abortion syndrome (loss of preg before 20 weeks), ectopic pregnancy, idiopathic bleeding in normal pregnancy
inevitable abortion
dilated os
incomplete abortion
some but not all of intrauterine contents have been expelled
missed abortion
fetal demise w/out cervical dilation and or uterine activity
septic abortion
w/intrauterine infection
complete abortion
products of conception have been completely expelled from uterus
threatened abortion
simply a pregnancy complicated by bleeding before 20 weeks gestation
Rh D negative women should receive
50mcg dose of Rho(D) Immune Globulin (i.e. RhoGAM) to prevent hemolytic disease of newborn
Kleihauer-Betke testing
to estimate the quantitative amount of fetal Hg in the maternal circulation to help with dosing RhoGam
what four measurements are taken in the second trimester
biparietal diameter, head circumference, abdominal circumference, femur length.
DDx for cough and wheezing
upper airway cough syndrome (post nasal drip), asthma, non asthmatic eosinophilic bronchitis, vocal cord dysfunction, COPD, CHF, GERD
serious, less common causes of persistent cough
pulmonary conditions (bronchogenic carcioma of lung, sarcoidosis, TB), cardiac conditions like CHF
etiologies of wheezing
asthma (most common cause), upper airway cough syndrome, COPD, CHF, foreigh body aspiration, persistent bronchitis, vocal cord dysfunction, PE
co-morbidities- conditions that may require tx to improve the control of asthma
GERD, obesity, obstructive sleep apnea, rhinitis or sinusitis, stress and depression
pathophysiology of asthma
chronic inflammatory disease of the airways. involves mast cells, eosinophils, t lymphocytes, macrophages, neutrophils, and epithelial cells. Chronic inflammation leads to airway hyperresponsiveness and limitation of airway flow (obstruction). persistent inflammation can lead to airway edema, long term inflammation can lead to airway remodeling and permanent loss of lung function
fever, colored nasal drainage, headaches, face pain, toothache, failure to respond to decongestants, failure to improve after viral URI, nasa congestion of obstruction. initial improvemen,t then reoccurence of worsening sympt
acute sinusitis
nasal congestion and drainage, mild headache, symptoms less than 10 days and not worsening
viral rhinosinusitis
at least 2: nasal obstruction, mucopurulent drainage, face pain, decreased smell, some pts may have only minimal symptoms such as worsening nasal congestion, more than 12 weeks
chronic sinusitis
distinctive diagnostic abnormalitiy in patients with asthma
reversible obstructive findings on spirometry
patients who respond to inhaled steroids like asthma patients but have normal spirometry and normal CXR
non asthmatic eosinophilic bronchitis
flattening of inspiratory loop on spirometry
vocal cord dysfunction
tx for intermittent asthma
SABA PRN
step 2 asthma tx
low dose ICS
step 3 asthma tx
low dose ICS + LABA or medium dose ICS
step 4 asthma tx
medium dose ICS + LABA
asthma exacerbation management
oral corticosteroids
what immunizations to asthma pts need
influenza vaccine and pneumococcal polysaccharide (23 valent), up to date tetanus-diptheria
when is chadwicks sign usually visible and what is it
venous congestion–> bluish discoloration of cervix. visible by 8-10 weeks
calculating due date
40 weeks after beginning of last menstrual period
when does hCG peak?
10-12 weeks
gestational sac often visualized by ___ weeks gestation
4-5
a fetal pol is visualized by ___weeks
5-6
presence of ____ indicates infection with Hep B and warrants further investigation
Surface antigen
if positive for Hep B surface antigen, test for ___
hep B core antigen (active infection)
high risk groups for gonorrhea and chlamydia screening in pregnant women
under 25, not married, black, history of STDs or multiple sexual partners, communities w/high infection rates
Hep C antibody testing should be offered to pregnant women with risk factors such as:
contact w/prison inmates, IV drug use, HIV positive, multiple sexual partners, tattoos, elevated liver enzymes
HIV screen in pregnant women
recommended for all.
rubella and syphilis screen in pregnant women
universal screening recommended
how much weight is normal to gain in pregnancy
20-25 lb gain
prenatal visit schedule
every 4 weeks until 28 weeks, every 2 weeks from 28-36 weeks, weekly from 36 weeks until delivery
at 10 weeks, fundus is palpable at
pelvic brim
at 20 weeks, top of fundus is at level of
umbilicus
all pregnant women should be screened for asymptomatic bacteriuria at ___ weeks
12-16
flu vaccine in pregnancy
recommended (IM preparation, killed and safe). mist/attenuated is not recommended
triple or quad screen
second trimester. AFP, hCG, unconjugated estriol, dimeric inhibin A. not performed until 15-21 weeks gestation
women should be offered routine US scanning for structural anomalies between ___ weeks
18-20
risk of spontaneous abortion in amniocentesis
1:400-1:200
screening for Gestational diabetes.
at risk - screen at 24-28 weeks. measure serum glucose 1 hour after oral ingestion of a 50g glucose solution. normal if fasting is <140.
most common cause of life threatening infection in newborns
GBS (sepsis, meningitis, and pneumonia)
what four signs of labor should patient be alerted to
vaginal bleeding, vaginal discharge, gush of fluid, regular contractions
DDx of vaginal discharge and potential bleeding in third trimester
placenta previa, bacterial vaginosis, vaginal candidiasis, UTI, cervical trauma, placental abruption, PROM, preterm labor, uterine rupture
risks for placenta previa
prior pregnancy, over 35 yo, smoker, previous twins, uterine surg (including prior c section)
standard tx for bacterial vaginosis
metronidazole, 500mg BID, 7 days
tx for vaginal candidiasis
clotrimazole
uterine contractions, vaginal bleeding, abdominal tenderness, non-reassuring fetal heart tracing
placental abruption. placenta peels away from inner wall of uterus.
PROM
premature rupture of membranes- large gush or steady trickle of clear vaginal fluid. 8-10% of term pregnancies
Rhogam immunization
if pt is Rh negative, Rhogam immunization should be given at 28 weeks, within 72 hours after delivery, with any episodes of bleeding
eclampsia
describes the occurrence of one or more convulsions in the presence of preeclampsia without the presence of another underlying neurologic disorder
most common skin eruptions in pregnancy
pruritic urticarial papules and plaques of pregnancy (PUPPP), prurigo of pregnancy, pruritic folliculitis [serious conditions- cholestasis of pregnancy, pustular psoriasis, pemphigoid gestationis]
tx of skin eruptions in pregnancy
relief of symptoms. topical emollients and glucocorticoids.
most infants with down’s have between 4 and 6 of following signs
flat facial profile, excessive skin at nape of neck, slanted palpebral fissures, hypotonia, hyperflexibility of joints, dysplasia of pelvis, anomalous ears, dysplasia of midphalanx of fifth finger, transverse palmar simian crease, poor moro reflex
postpartum follow up
2 weeks for c section (wound healing), 6 weeks for vaginal delivery
postpartum blues
mild, often rapid fluctuations in mood within first two weeks. peaks around day 5. resolve with time
postpartum depression
occurs in 5% of women. onset of clinical depression within first four weeks post partum.
Ddx of pain radiating to back ,N/v
cholecystitis, biliary colic, duodenal ulcer, hepatitis, pancreatitis
alcohol dependence
3 or more: tolerance, withdrawal, larger quantity, desire to cut down, significant time spent obtaining or recovering, social/recreational tasks are sacrificed, use continues despite physical problems
CAGE
cut down? annoyed by questions? guilt? eye opener?
physical exam techniques to rule out appendicitis
psoas sign (passive extension of patient’s thigh as the y lie on side with knees extended or asking the patient to flex thigh and hip causes abdominal pain). obturator sign (examiner has patient supine with right hip flexed to 90 degree, take right ankle in right hand with left hand rotate patients hip by moving knee back and forth)
difference between cholecystitis and biliary colic
cholecystitis is similar to biliary colic but is a stone that cannot be dislodged so symptoms last longer than 4-6 hours
biliary colic
RUQ pain, epigastric pain or chest pain that is constant, alsts less than 4-6 hours, radiates to back. follows fatty meal.
two classic (rare) physical exam signs of pancreatitis
grey-turner’s sign: ecchymotic discoloration in flank. Cullen’s sign: ecchymotic discoloration of perumbilical region
preferred study to evaluate RUQ
Abdominal ultrasound.
untreated symptomatic gallstones biliary colic- risk of progression ___% to complications such as:
70%. cholangitis, panreatitis, cholecysitis, choledocholitiasis, gallstone ileus, mirizzi synrome
mirizzi syndrome
gallstone compression of hepatic duct
Ursodiol
atypical symptoms of biliary colic with visible stones. if symptoms resolves, may have been from gallstones
HIDA scan
functional study of gallbladder. may reproduce pain. do if not visible stones on gallbladder US
ERCP indication
jaundice and/or gallstone pancreatitis suggestive of common duct stone. postoperative patient who did not have an intraoperative cholangiogram and who presents with repeat episode of biliary colic
MRCP
similar diagnostic modality that sues magentic resonance. unlike ERCP, is diagnostic only.
Ddx for erythematous patch of skin on 68 year old man
squamous cell carcinoma, basal cell carcinoma, melanoma, actinic keratosis, eczema, fungal
macule
close your eyes and run fingers over it, don’t know its there. completely flat.
patch
macule >1cm in diameter
papule
solid, raised, distinct border, <1cm
plaque
solid, raised, flat topped >1cm
nodule
raised, solid, may be epidermis, dermis, or subcut.
tumor
solid mass of skin or subcut. larger than nodule
vesicle
raised lesion <1cm, filled with clear fluid
Bulla
circumscribed, fluid filled lesion >1cm in diameter
pustule
circumscribed, elevated lesion containing pus
wheal
an area of elevated edema in upper epidermis
annual skin cancer screening by full body skin examination by health care provider is what recommendation by USPSTF
I
tinea pedis
athlete’s foot. ubiquitous dermatophyte infection.
5 things a consent form must have
nap of the procedure, diagnosis, risks, benefits, alternatives
sun exposure increases risk of what three things
squamous cell carcinoma, actinic keratosis, basal cell carcinoma
international prostate symptom score
ask pt- over the past month or so, how often have you: had sensation of not emptying bladder, had to urinate again soon, stop and start, difficult to postpone, weak stream, push or strain to begin, nocturia
punch biopsy procedure and wound care
disinfect biopsy area with povidone solution. use disposable sterile gown and gloves. infiltrate area with 1% lidocaine w/out epinephrine using 23 guage. drape. disposable punch to obtain a biopsy from periphery. put in formalin jar. place steri-strip to approximate the edge of the skin at site. compressive dressing. keep dry for 3 days
dx: scaly lesion, thick, pink macular to papular area, edges are fleshy. borders often bleed
squamous cell carcinoma
dc: plaque like or nodular with waxy/translucent appearance, ulceration and telangiectasia. no itching or color change.
basal cell carcinoma
dx: growing, spreading, pigmented lesions.
melanoma
60: of primary skin cancers
basal cell
single greatest risk factor for non melanoma skin cancer
percent of lifetime sun exposure obtained before 18 years of age
lichen planus
common in middle age. primary lesion is a 2 to 10mm flat topped papule w/irregular angulated border commonly on flexor surfaces of wrists and legs above ankles.
seborrheic keratoses
usually elevated, hyperpigmented lesions on face and trunk. stuck on appearance.
other conditions w/symptoms similar to BPH
UTI, prostatitis, medication side effects, overactive bladder, prostate cancer
complications of untreated BPH
UTIs, acute urinary retention, obstructive nephropathy
obtain PSA if:
life expectancy is >10 years, PSA level will influence BPH treatment
tx for actinic keratosis
5-FU
two BPH drugs
alpha adrenergic antagonists (tamsulosin, alfuzosin, terazosin) and 5-alpha reductase inhibitors (finasteride and dutasteride)
tx for tinea capitis
oral therapy is required. Griseofulvin. 20-25mg/kg/day, for 6-12 weeks
Tx for Tinea unguium (onychomycosis)
griseofulvin. Terbinafine (250mg/day for 12 weeks if toes, 6 weeks if fingernails). itraconozaole 200mg BID as pulse therapy (1 weeks of iraconazole, 3 weeks off)
two drug families effective against dermatophytes
azoles and allylamines
Group I (strongest) topical steroids
augmented betamethasom dipropionate, halobetasol propionate. for psoriasis, lichen planus, severe eczema, alopecia areata,
Group II topical steroids
desoximetason fluocinonide. for psoriasis, lichen planus, severe hand eczema, alopecia areata
Group III topical steroids
betamethasone diproprionate, triamcinolone acetonide.
group IV topical steroids
fluocinolone acetonide, traiamcinolone acetonide.
Group VII (weakest) topical steroids
hydrocortisone 1%, 2.5%
most common site of osteoporosis fractures
vertebrae, hip, distal radius, proximal humerus.
USPSTF v. ACOG v. ACS breast cancer recommendations
USPSTF: biennal for 50-74. ACOG: mamm every 1-2 years women 40-49, annually after. ACS: annual mamm for all 40+
colon cancer screening
everyong 50-75
ACOG cervical cancer screening recs
first pap at 21, biennial pap from 21-30, over 30 w/three consecutively normal paps- every 3.
risk factors for endometrial cancer
any increased exposure to estrogen. tamoxfen, obesity, anovulatory cycles, estrogen secreting neoplasms, early menarche, late menopause, nulliparity
protective factors for endometrial cancer
smoking and OCPs
Ddx for abnormal bleeding in postmenopausal woman
cervical polyps, endometrial hyperplasia, endometrial cancer, proliferative endometrium, iatrogenic, systemic disorders, genital tract pathology
most cost effective initial test in women with abnormal uterine bleeding at low risk for endometrial cancer
transvaginal ultrasound
osteoporosis tx
biphosphoanates. inhibit bone resorption and reduce bone turnover, increasing bone mineral density. decrease risk of vertebral and non vertebral fractures. generic (more affordable): alendronate (fosamax) and risedronate (actonel). Parathyroid hormone (forteo)- approved by FDA for those w/osteoporosis and high risk for fracture. given subcutaneously. decreases fracture risk by 50-65%. no demonstrated efficacy and safety beyond two years.
pulsating moderate to severe headache, nausea, vomiting, photophobia, phonophobia, unilateral, 4-72 hours.
migraine
mild to moderate, pressing headache. photo/phonophobia, bilateral, occipital tenderness,
tension
severe headache with rhinorrhea, lacrimation, facial sweating, miosis
cluster headache
potentially life threatening diagnoses to consider with headache
bacterial meningitis (fever, chills, stiff neck, URI, new rash), intracranial hemorrhage (trauma, acute change in pattern of headaches, first or worst headache, HTN), brain tumor (first headache in pt over 50yo, abnormal thinking, weight loss)
depedence: syndrome characterized by maladaptive pattern of opioid use causing impairment. at least three:
tolerance, withdrawal, increasing doses, desire or inability to cut down, sig. time spend searching, interferes with activities, continued use despite problems
mental status exam
appearance, psychomotor, speech, affect, mood, thought process, thought content, level of awareness, attention
only recommend neuroimaging a headache if
patient has migraine with atypical headache patterns or neurologic signs, patient is at higher risk of a significant abnormality, study results would alter management
side effects of triptans
dizziness, sleepiness, nausea, fatigue, paresthesias, throat tightness or closure, chest pressure
side effects of ergot alkaloids
MI, tachyarrhythmias, stroke HTN, Rash, nausea, vomiting, diarrhea, dry mouth
prophylactic therapies for headaches
beta blockers, neuristabilizers (divalproex, topiramate), TCAs, CCBs, feverfew, Mg, B2
Ddx of epigastric pain
GERD, PUD, Anxiety, abdominal muscle strain, gastritis
differentiating btwn GERD and PUD
GERD: classic heartburn and regurg (burning chest with bitter taste), occurs after meals, pregnancy, obesity, girdles. PUD: episodic or recurrent aching. gnawing, or hunger like pain. gastric ulcer 5-15 min after eating until stomach empties, duodenal ulcer pain relieved by eating
complications of GERD
esophagitis, peptic strictures from fibrosis and constriction, barrett’s esophagitis, 2-5% may further -> adenocarcinoma
complications of PUD
hemorrhage, perforation into the peritoneal cavity or adjacent organs, ulcer scar healing or inflammation with impaired gastric emptying can lead to gastric outlet obstruction syndrome.
onset of heartburn and regurg in patient over 55yo
refer to GI. increased chance of cancer
most common cause of lower GI bleeding in patients over 50yo
diverticulitis
most common cause of non cardiac chest pain
GERD
is FIT or FOBT more sensitive and specific for detecting occult lower GI bleed
FIT
medications that may potentiate GERD symptoms
CCBs, beta agonists, alpha adrenergic agonists, theophylline, nitrates, and some sedatives.
therapies used for dyspepsia after H pylori infection is ruled out
TCAs, capsaicin, peppermint oil, caraway oil, artichoke leaf.
first line regimes for H pylori
PPI triple therapy for 10-14 days (PPI BID + clarithromycin BID + Amoxicillin QD), ALternative PPI therapy for 14 days (if PCN allergy. PPI BID, clarith BID, metrodnidazole BID), Quadruple therapy for 10-14 days (PPI QD OR Ranitidine BID, tetracycline TID, metronidazole , bismuth subsilacylate)
accepted indications for testing to prove H pylori eradication after antibiotic therapy
patients with H pylori associated ulcers, persistent dyspeptic symptoms despite the test and treat strategy, individuals with H pylori associated MALD lymphoma, post resection of early gastric cancer
to evaluate eradication of H pylori:
perform fecal antigen testing, if positive- retreat with salvage therapy, upper endo/EGD to rule out ulcer disease, prolonged PPI therapy for symptoms. if fecal antigen testing negative, perform urease test.
RUQ pain ddx
cholecystitis, biliary colic, congestive hepatomegaly, hepatitis, perforated duodenal ulcer, retrocecal appendicitis
LUQ pain ddx
gastritis, splenic disorders (abscess, rupture)
RLQ pain ddx
appendicitis, cecal divertiulitis, meckels’ diverticulitis, mesenteric adenitis.
LLQ pain ddx
sigmoid diverticulitis
red flag signs of severe or life threatening abdominal pathology
abrupt onset of severe pain, shock with hypotension and tachy, distension, peritoneal irritation signs, absent bowel sounds, fever, vomiting, diarrhea, weight loss, menstrual changes, trauma, prior surgeries, blood in emesis or stool, severity of pain, rigid abdomen, rebound tenderness, mass, ascites
red flags for women who may have been victimized by intimate partner
migraines, frequent headaches, chronic pain syndrome, heart and BP, arthritis, stomach ulcers, pain during sex, cervical cancer, depression, unexplained findings
domestic violence screening
ACOG suggests screening all patients at all visits
Obstetrical history (GTPAL)
G: number of pregnancies, T number of term, P number of preterm, A number of abortions, L number of living
strongest risk factor for elevated cholesterol
elevated BMI
metabolic syndrome
at least three: hypertriglyceridemia, low HDL, elevated blood glu, excessive waist circumference, HTN
lung sounds that indicate consolidation
egophany, tactile fremitus, dullness to percussion, crackles, whispered pectroliloquy
lung sounds that do not indicated consolidation
wheezes, rhonchi
BMI screening
AAP and AAFP recommend universal screening, USPSTF= insufficient evidence
focal crackles in febrile child without underlying lung disease
pneumonia.
fine crackles at mid inspiration v. coarse late inspiratory crackles
fine/mid insp: acute pneumonia. coarse/late = resolving
McIsaac score-
indicates whether to evaluate for Group A beta hemolytic stretococcal pharyngitis with a strep antigen test or culture. Fever, no cough, tonsillar exudate, tender cervical adenopathy, less than 15yo. if greater than 45, -1pt. if total is 2-3pts, order rapid strep test. if total is greater than or equal to 4, order culture or start abx
for children 3 months to adolescence, 1st line tx for uncomplicated pneumonia is
amoxicillin. covers strep
school aged children with symptoms more concerning for atypical pneumonia, tx is
macrolide. azithromycin
most common pneumonia pathogen in infants <3weeks and tx
e coli, GBS, listeria. Tx: ampicillin and gentamicin
most common pathogen of pneumonia in 3 week-6 months and Tx
strep pneumo, chlamydia, adenovirus, influenza, RSV, parainfluenza. Tx: erythromycin, cefotaxime, or cefuroxime. Azithromycin if outpatient
pneumonia pathogens if 3 months to 5years old, tx
strep pneumo, mycoplasma, chlamydia, adenovirus, influenza virus, parainfluenza, rhinovirus, RSV. tx PCN or ceftriaxone
pneumonia pathogens in children > 5 years old, tx
chlamydia, mycoplasma, strep pneumo. Tx: IV antibiotic
recommend diabetes screening fro al 10 year olds with
BMI>85%ile and risk factors, and BMI>96%ile w/out risk factors. re-check every two years
check fasting lipid profile on every child with:
BMI over 85%ile
drug tx for children with hyperlipidemia if
older than 10 who are either tanner stage 2 or post menarche and LDL over 190 or 160 w/risks
define A fib
rapid irregular and chaotic atrial activity without definable p waves on electrocardiogram
presentation of A fib
dizziness, syncope, dyspnea, or palpitations
etiology of a fib
fever, myocarditis, volume contraction, thyrotoxicosis, endogenous catcholamines, AV nodal dysfunction
USPSTF recommendations for screening cerebrovascular disease
screen all adults over 18 for HTN. screen adults over 20 for hyperlipidemia if at increased CAD risk (i.e. diabetic, HTN, fam history), ask all adults about tobacco use, discuss aspirin chemoprevention in all men uncer 45 for primary prevention of MI
left hemiplegia, spatial and perceptual dificulties, inattention to ppl in left visual field, denial of stroke disability. Where is infarct
Right middle cerebral infarct affecting right parietal hemisphere
impairment of BP, respiratory function, heartbeat, and consciousness. where is infarct?
brainstem
expressive and receptive aphasia, left facia weakness
left MCA
what fraction of stroke survivors develop depression
1/3
FAST test for stroke
Face: can they smile, Arms: can they raise both, Speech: can they repeat a sentence. Time: call 911
LP in stroke pts if
meningitis suspicion, endocarditis, CNS vasculitis or if possibility of subarachnoid hemorrhage.
management of A fib
IV diltiazem, IV BBs or verapamil to slow rate. cardioversion via electrical shock or meds
ticlopidine
marginally better than aspirin alone for preventing stroke
most states require what vaccines for school entrance
hep B, DTaP, polio, MMR, varicella
immunization contraindications
allergy or sensitivity to specific vaccine, immunodeficienct states such as HIV or chemo, postpone vaccines when patients have moderate to severe illness- fever, otitis, diarrhea, vomiting. if illness is mild, get vaccine. tx with antimicrobials will not interfere with vaccines
ADHD diagnosis
not made until child is>6 years old. Symptoms must be more frequent or severe compared to others same age, present in at least two settings, at least 6 months
AAP and AAFP recommendations on childhood BMI screening
universal screening using percentile score
most common cause of a sore throat
viral pharyngitis
what distinguishes infectious mononucleosis from other causes of viral pharyngitis (but not from group A strep)
palatal petechiae of posterior oropharynx
presentation of group A strep pharyngitis
high fever, cervical lymphadenopathy, tonsillar exudate, palatal petechiae, strawberry tongue.
pertonsillar abscess presentation
fever, difficulty swallowing, neck or ear pain, muffled hot potato voice.
Tx of group A pharyngitis
PCN po, PCN iv, amoxicillin, first gen cephalosporin, macrolides
fussy infant ddx
colic, pyloric stenosis, intussusception, allergy to breast milk, GERD, infection
APGAR score
appearance, pulse, grimace, activity, respiration
normal pattern of infant weight gain and loss
normal infants lose up to 10% of birth weight in first several days. by 2 weeks of age, return to birth weight. milk production begins 48-72 hours after delivery.
4 week old milestones
more alert, smoother movements, listen to voices, respond to mother, eyes wander, recognizes sounds
fever in infant under 2 months of age
potentially serious sign of infection. thorough lab eval and cultures of blood, CSF, and urine. admit to hospital for observation and possibly abx
USPSTF recommendations for postpartum depression screening
all adults in practices that have systems in place to ensure accurate dx, tx, and follow up- most primary care don’t have that in place.
PHQ-2
shortest and most readily utilized rapid screen for depression. if both questions are positive, follow up with PHQ-9
PHQ-9
little interest, feeling down, trouble sleeping, tired, appetitie, bad about yourself, concentration problems, fidgety, thoughts of being dead
edinborough postnatal depression scale
i have been able to laugh and see funny side, looked forward with enjoyment, have blamed myself for wrong things, anxious, scared, unhappy, sad, crying, harming myself.
wessel definition of colic
unexplained paroxysmal bouts of fussing and crying that lasts at least three hours a day, at least three times a week, for longer than three weeks.
Ddx for shoulder pain
impingement syndrome/subacromial bursitis, shoulder instability, rotator cuff tendonitis, torn rotator cuff, labral pathology
anatomic stabilizers of the shoulder joint
labrum, glenohumeral ligaments, rotator muscle group
non musculoskeletal causes of referred shoulder pain
myocardial infarction, lung cancer, cholecystitis, ruptured ectopic pregnancy
musculoskeltal scauses of shoulder pain that restrict passive ROM
adhesive capsulitis (contracture of capsule. DM and following injury), glenohumeral arthritis (less common site of OA than hip)
tx for tinea pedis
tolnaftate (tinactin) BID
pt carrying arm in adducted and internally rotated position may indicate
posterior dislocation
poor posture or rounded shoudlers may indcate what shoulder injury
impingement syndrome
boney deformity in the area of the clavicle or AC joint may indicate
fractured clavicle or sprain of AC joint
what muscle does empty can test examine
supraspinatous
what does apley scratch test indicate?
if there is pain/decreased ROM- rotator cuff tendonitis. unable to raise arm above head: rotator cuff tear. significant pain/decreased ROM: impingement, bursitis
neer test
subacromial space impingement
hawkins kennedy test
supraspinatous tendon impingement
yergason’s test
bicepts tendonitis
USPSTF breast cancer screening recs
mammo every 2 years if 50 and older.
cancer screenings NOT recommended by USPSTF
PSA, chest x ray, total body skin exam for skin cancer, pancreatic cancer screening, testicular cancer screening
6 steps of the SPIKES strategy for delivering bad news
setting up interview, perception, invitation, knowledge, address Emotions, strategy and summary.
Tx iron deficiency anemia in adult male
ferrous sulfate 325 TID, docusate sodium 100mg BID for constipation, colonoscopy
USPSTF screening tests and recs for adolescents
rubella for females of child bearing, chlamydia and gonorrhea- women under 25, HIV and syphillis- sexually active men at increased risk
ddx of SOB
COPD, asthma, lung cancer, pneumonia, acute bronchitis, CHF
four items predictive of presence of COPD
smoking more than 40 pack-years, self reported history of chronic obstructive airway disease, max laryngeal height of 4cm or less, age > 45 years
findings on chest x ray that are not diagnostic but may be suggestive of advanced COPD
hyerpinflation, hyperlucency, rapid tapering of vascular markings
when to add inhaled glucocorticosteroids to COPD regimen
if FEV1 <50% of predicted
immunizations for COPD patients
influenza (every adult over 50), pneumococcal polysaccharide vaccine (all adults 65 and older), TdaP (Td every 10 years following TdaP)
abx should be given to people with exacerbations of COPD if they:
have increased dyspnea, increased sputum, and increase sputum purulence, require mechanical ventilation
DSM IV criteria for dementia
acquired impairment in memory with: exec function loss, language loss, praxis loss, gnosis loss
USPSTF screening dementia
insufficient evidence
movements of labor: engagment
widest part of fetus entered pelvic inlet
movements of labor: descent
wisest part of fetus is btwn ischial spines
movements of labor: flexion
when fetus is in the occiput anterior position the fetal head is flexed
movements of labor: internal rotation
fetal head must rotate in order to further descend
movements of labor: extension
occurs as the fetal head passes under the symphysis pubis, which occurs during crowning
movements of labor: external rotation
head realigns with shoulders
movements of labor: expulsion
anterior shoulder of fetus pushed out first, then posterior shoulder
normal fetal heart rate baseling
110-160
reassuring fetal heart rate tracing
two heart rate accelerations at least 15 secs, peaks at least 15 beats per min above base line, moderate varriability
how to manage late decelerations in fetal heart rate
continuous monitoring, place pt on her side to decrease pressure on vena cava
use of Aspirin in women v men
in women- preventive for stroke, given to all patients with identified CAD
systolic heart failure management
ACEIs, ARBs, Digoxin, Loops, BBs (can initially worsen failure), spironolactone
what common HTN med does not have role in heart failure management
CCBs. TZDs worsen
DDx for dysmenorrhea
adenomyosis, cervical stenosis, chronic PID, endometriosis, fibroids, ovarian cysts
uterine leiomyoma (fibroids)
most common benign tumors of the uterus. risks- early menarch, fam history, alcohol
study of choice for pelvic path
Ultrasound
when to tx otitis media with abx
children under 6 months. wait if btwn 6mo and 2 years. dont treat if over 2
