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1
Q

breast self exam

A
  • does not reduce br ca or all cause mortality

- may increase # of biopsies performed

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2
Q

cervical ca screening

A
  • start at 21
  • every 3 yrs (21-29)
  • 30-65: every 3 years or every 5 with cotest
  • more frequent screening: immunocompromise, HIB, hx of CIN2/3/cancer, DES exposure
  • > 65 w/3 nl consecutive paps (or 2 nl cotests): stop
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3
Q

risk factors for cervical ca

A
  • early onset of intercourse
  • # lifetime sexual partners
  • DES exposure
  • cigarette smoking
  • immunosuppression
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4
Q

good screening test

A
  • accuracy (sensitivity/specificity)
  • dz is treatable
  • able to detect dz when asx
  • high prevalence of disease
  • minimal associated risk
  • reasonable cost
  • acceptable to patients
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5
Q

tests for breast lump

A
  • cystic: FNA + cytology
  • solid: mammogram
  • US helps tell bw solid and cystic
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6
Q

pathologic causes of nipple dischg

A
  • prolactinoma
  • br ca (intraductal papilloma, mammary duct ectasia, Paget’s, DCIS)
  • hormone imbalance
  • injury/trauma
  • breast abscess
  • medications (antidepressants, antipsychotics, antiHTN, opiates)
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7
Q

mammography sensitivity

A
  • bw 60 and 90%

- lower sensitivity in younger women (dense breasts)

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8
Q

br ca risk factors

A
  • 1st degree relative
  • estrogen exposure
  • genetics
  • advanced age
  • female
  • increased breast density
  • advanced age at first preg
  • DES
  • hormone therapy
  • therapeutic radiation
  • obesity
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9
Q

factors assoc with decreased br ca risk

A
  • pregnancy at early age
  • decreased estrogen exposure
  • SERM use
  • maybe NSAID/aspirin use
  • limited alcohol intake
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10
Q

does smoking affect br ca risk

A

NO!

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11
Q

menopause timing

A
  • avg age 51; range 40-60
  • smoking –> earlier menopause
  • definition: no menses 12 months
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12
Q

calcium intake for women

A
  • premenoP: 1000 mg
  • postmenoP: 1500 mg
  • increase dairy intake, weight bearing exercise
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13
Q

risk factors for osteoporosis

A
  • low estrogen states: early menoP, prolonged premenoP amenorrhea, low weight/BMI
  • lack of physical activity
  • inadequate Ca intake
  • family hx
  • personal hx of previous fx as adult
  • dementia
  • cigarette smoking
  • white race
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14
Q

BMI increases risk of:

A
  • HTN
  • CAD
  • stroke
  • OA
  • some cancers
  • T2DM

worse with older age, sedentary lifestyle, cigarettes

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15
Q

gardasil

A
  • HPV 6, 11 (warts)
  • HPV 16, 18 (cancer)
  • females 9-26 yo
  • 3 doses
  • before/around sexual debut
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16
Q

cervarix

A
  • HPV 16, 18 (cancer)
  • HPV 31, 45
  • females 10-25 yo
  • 3 doses
  • before/around sexual debut
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17
Q

RISE mnemonic

A
  • risk factors
  • immunizations
  • screening tests
  • education
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18
Q

most frequent causes of death for 55 yo male

A
  • malignant neoplasm
  • heart dz
  • unintentional injury
  • DM
  • chronic lung dz
  • chronic liver dz
  • cirrhosis
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19
Q

risk factors for CVD and ASCVD

A
  • SMOKING
  • sedentary lifestyle
  • stress
  • premature family hx
  • excess alcohol
  • obesity
  • poor diet
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20
Q

three Cs of addiction

A
  • compulsion
  • lack of control
  • continued use
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21
Q

stages of behavior change

A
  • pre-contemplative
  • contemplative
  • (planning)
  • active
  • (maintenance)
  • relapse
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22
Q

interventions that help improve smoking cessation

A
  • group setting
  • oral mx: quit rates 1.5-3x higher than placebo
  • mx + 1-on-1 counseling sessions
  • problem soving skills, social support, relaxation/breathing
  • mx: buproprion, varenicicline (if sz, fail buproprion)
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23
Q

effects of moderate etoh intake

A
  • small increase in HDL
  • some protection against heart dz
  • anti-oxidants, inhibition of platelet aggregation?
  • red wine: more polyphenols - less heart dz and cancer?
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24
Q

etoh and chronic dz

A
  • heart failure, cardiomyopathy, DM, HTN, arrhythmia, obesity, HL, mx: may have adverse effects
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25
Q

how to get complete nutrition hx

A
  • 24 hr recall
  • food diary
  • food frequency questionnaire
  • usual diet hx
  • observed intake
  • weighted intakes
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26
Q

BMI categories

A
  • underweight: below 18.5
  • normal: 18.5-24.9
  • overweight: 25-29.9
  • obese: 30+ (morbidly obese 40+)
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27
Q

US lifetime risk of obesity

A

25%

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28
Q

pe findings of dyslipidemia

A
  • corneal arcus
  • xanthelasmas
  • acanthosis n
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29
Q

pe findings of atherosclerosis

A
  • decreased peripheral pulses

- carotid bruit

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30
Q

skin ABCDE

A
  • asymmetry
  • border irregularity
  • color non-uniform
  • diameter >6mm
  • evolution over time
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31
Q

tetanus recommendations

A
  • Td booster every 10 years

- one time TdaP replaces Td between 11-64

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32
Q

when to get zoster vaccine

A

60! only one dose needed

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33
Q

USPSTF levels of evidence

A
  • A: recommend, substantial benefit
  • B: recommend, fair/substantial benefit
  • C: against routine provision of service
  • D: against service
  • I: insufficient evidence
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34
Q

lung ca screening

A
  • annual with low dose CT IF:

age 55-80 with 30 pack-year smoking hx; currently smokes or quit in past 15 yrs

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35
Q

colon ca screening options

A
  • colonoscopy q10y
  • FOBT q1y + flex sig q5y
  • double contrast enema q5y
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36
Q

ECG changes suggesting CAD

A
  • ST depression (cardiac ischemia)
  • convex ST elevation (acute MI)
  • Q waves (infarction)
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37
Q

U waves

A
  • bradycardia, electrolyte imbalance, drug effect, CNS dz, hyperthyroidism, LVH, MVP
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38
Q

diet to lower heart dz risk

A
  • fish 2x/week
  • esp fatty fish higher in omega 3
  • tofu, soybeans, canola, walnuts, flaxseed
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39
Q

common causes of insomnia in elderly

A
  • environmental problems
  • drugs/alcohol/caffeine
  • sleep apnea
  • parasomnias
  • sleep-wake disturbances
  • depression/anxiety
  • cardiorespiratory dz
  • pain or pruritus
  • GERD
  • hyperthyroidism
  • advanced sleep phase syndrome
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40
Q

tx of insomnia in elderly

A
  • CBT: sleep hygiene, stimulus control, etc
  • —- sleep restriction therapy, sleep compression therapy
  • zolpidem and melatonin receptor antagonists
  • no BZOs, antihistamines, antidepressants, etc
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41
Q

medical conditions assoc with depression

A
  • hypothyroidism
  • parkinson’s
  • dementia
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42
Q

factors that increase risk of suicide

A
  • male gender
  • older age
  • previous suicide attempt
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43
Q

MDD vs bereavement

A
  • MDD: sx still present 2 mos after loss
  • or sx not “characteristic” of “normal” rief rxn
  • — grief/thoughts of death unrelated to loved one’s death
  • — preoccupation with worthlessness
  • — marked PMR
  • — hallucinations unrelated to loved one
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44
Q

assessing for severity of SI

A

SADPERSONS (sex, age, depression, prev attempt, etoh/substance, rationality impaired, social support lacking, organized plan, no signif other, sickness)

  • 4-6: outpatient tx (+ no-harm contract)
  • 7-10: hospitalization
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45
Q

common SEs of SSRI/SNRI

A
  • HA
  • sleep disturbances/insomnia
  • GI: nausea, diarrhea
  • hyponatremia from SIADH
  • serotonin syndrome
  • increased risk GI bleed
  • increased risk for falls
  • adverse effects on bone density
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46
Q

tx of depression

A
  • SSRI/SNRI
  • CBT
  • exercise
  • ECT (later option)
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47
Q

SSRIs and preg

A
  • most category C

- Paxil is category D

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48
Q

fluoxetine

A
  • long T1/2, no d/c syndrome

- SEs: agitation, motor restlessness, decreased libido, insomnia

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49
Q

sertraline

A
  • freq in preg and breast feeding
  • OCD, panic, PTSD
  • more GI SEs
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50
Q

paroxetine

A
  • strong antianxiety
  • best studied in children
  • short T1/2- most likely to have d/c syndrome
  • SEs: weight gain, importence, sedation, constipation
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51
Q

fluvoxamine

A
  • OCD

- increased emesis

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52
Q

citalopram

A
  • SEs: nausea, dry mouth, somnolence
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53
Q

escitalopram

A
  • GAD

- fewer SEs than citalopram

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54
Q

lab tests to r/o other causes of depression/insomnia/fatigue

A
  • CMP
  • TSH
  • CBC
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55
Q

depression in Hispanics

A
  • depression ID’ed less frequently
  • frequently present for somatic complaints
  • rates of depression similar
  • sx of perceptual distortion (CELAJES) more common
  • less likely to receive adequate therapy
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56
Q

risk factors for elder abuse

A
  • dementia
  • shared living situation of elder and abuser
  • caregiver substance abuse or elder illness
  • heavy dependence of caregiver on elder
  • social isolation from people other than abuser
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57
Q

adherence to antidepressants in elderly

A
  • only about 50%
  • inability to afford
  • SE concerns
  • worry about stigma
  • not understanding how to take it
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58
Q

acute ankle injury stats

A
  • one of most common MSK injuries
  • 2 million per year; 20% of all sports injuries
  • most common presentation to ED, but less than 15% are clinically signif fx
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59
Q

compartment syndrome

A
  • causes: fx, crush, burn, arterial
  • high clinical suspicion
  • tx: fasciotomy
  • pain pallor pulselessness paresthesias poikilothermia paralysis
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60
Q

most common MOI for ankle sprain

A
  • lateral sprain: plantarflexion and inversion

- medial ankle sprain less common (dorsiflexion and eversion)

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61
Q

how to assess ankle ligs

A
  • anterior drawer: ant talofibular ligament (most easily injured)
  • inversion/talar tilt: if ankle is inverted, does it appear lax? calcaneofibular lig
  • posterior talofib: rarely injured
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62
Q

asses for high ankle sprain

A
  • crossed-leg test: high ankle tibiofibular syndesmotic sprain
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63
Q

grade I ankle sprain

A
  • stretch/small tear of ligament
  • slight to no fnal loss
  • mild tenderness and swelling
  • usually no ecchymosis
  • no mechanical instability
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64
Q

grade II ankle sprain

A
  • incomplete ligament tear
  • moderate functional impairment, difficulty weight bearing
  • tenderness over involved structure, mild to moderate pain/swelling
  • ecchymosis common
  • moderate instability
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65
Q

grade III ankle sprain

A
  • complete tear of ligament
  • inability to bear weight
  • severe swelling
  • ecchymosis
  • mechanical instability
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66
Q

ddx of ankle injury

A
  • sprain (lateral ankle inversion sprain most likely)
  • peroneal tendon tear
  • talar dome fracture
  • fibular fracture
  • tendonitis
  • subtalar injury
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67
Q

peroneal tendon tear

A
  • usually due to inversion inury or repetitive trauma
  • persistent pain posterior to lateral malleolus
  • +/- swelling
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68
Q

talar dome fracture

A
  • may be missed on initial XR

- if sx persist, get repeat imaging to detect avascular necrosis

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69
Q

fibular fx

A
  • usually due to fall/athletic injury or high veolicty mechanism
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70
Q

ankle tendonitis

A
  • usually PT tendon
  • swelling/warmth and stiffness
  • worsens initially with aggravating activity only –> discomfort at any time
  • chronic pain, worse during day and after exercise
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71
Q

subtalar injury

A
  • high energy injury
  • dislocation: talocalcaneal and talonavicular joints
  • pain swelling and deformity
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72
Q

tarsal tunnel syndrome

A
  • entrapment of tibial n

- pain/tingling/burning along sole of foot

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73
Q

syndesmotic injury

A
  • interosseus membrane and anterior inferior tibiofibular ligament
  • pain out of proportion to injury
  • positive ankle squeeze test
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74
Q

ankle arthritis

A
  • tibiotalar jt

- stiffness, swelling, deformity, feeling of instability

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75
Q

Ottawa rules

A
  • 97-100% sensitive
  • children >5 and adults
  • get ankle XR if: pain in malleolar zone AND (bony tenderness along distal 6cm of posterior malleolus OR inability to bear weight immediately and upon exam)
  • get foot XR if: pain in midfoot AND (bony tenderness at navicular/base of 5th metatarsal OR inability to bear weight)
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76
Q

ankle sprain tx

A
  • RICE
  • NSAIDs
  • daily ankle exercise
  • avoid reinjury - no flip flops!!!
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77
Q

dysuria tx

A
  • bactrim for empirical treatment for uncomplciated lower UTI
  • quinolone in communities with known bactrim resistance
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78
Q

cardiac sx of hyperthyroidism

A
  • arrhythmias

- cardiomyopathy

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79
Q

sx of hyperthyroid in younger pts

A
  • tachycardia (MOST common)
  • fatigue
  • weight loss, heat intolerance, tremor, increased sweating, depression, hyperreflexia, diarrhea, light periods
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80
Q

sx of hyperthyroidism in older pts

A
  • still get tachycardia, fatigue, weight loss
  • Afib
  • many other sx absent
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81
Q

Graves dz

A

aka toxic diffuse goiter

  • majority of hyperthyroidism
  • Ab –> TSH rcptr stimulation –> excess T3/T4 synthesis
  • females > males, 40-60 yo peak
  • family hx of thyroid dz and autoimmune
  • triggers: stressful life event, high iodine intake, recent pregnancy
  • may have thyroid bruit/thrill from hypervascularity
  • PRETIBIAL MyXEDEMA
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82
Q

eye findings in Graves

A
  • exophthalmos/proptosis
  • 50% have eye involvement by MRI; 20-30% clinically relevant
  • up to 10% of eye manifestations occur while pt is euthyroid
  • tx of Graves does NOT affect eye manifestations; may even progress after tx
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83
Q

toxic nodular goiter

A
  • 5% of hyperthyroidism
  • thyroid nodules: 4-5% are cancerous
  • more common in pts > 40yo, usually multinodular dz
  • younger pts more commonly have solitary nodule, usually related to iodine deficiency
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84
Q

thyroiditis

A
  • T3/T4 leaks from inflamed thyroid
  • usually short term
  • after viral illness, preg
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85
Q

excess iodine

A
  • via diet or amiodarone
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86
Q

causes of goiter

A
  • lack of iodine (most common owrldwide)
  • Hashimoto
  • Graves
  • nodules
  • thyroid ca
  • pregnancy
  • thyroiditis
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87
Q

hypothyroid sx

A
  • weight gain
  • cold intolerance
  • pedal edema
  • heavy periods
  • fatigue
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88
Q

neurologic findings of hyperthyroidism

A
  • increased DTRs
  • ankle clonus
  • tremor
  • lid lag
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89
Q

differential dx of palpitations

A
  • cardiac arrhythmia
  • anxiety/panic do
  • anemia
  • hyperthyroidism
  • drug/caffeine
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90
Q

tests for dx hyperthyroid

A
  • TSH (T4 can r/o pituitary cause)
  • ECG
  • CBC (anemia)
  • radioactive I uptake test/scan
  • thyroid US (nodules and enlargement)
  • TPO Abs (Graves)
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91
Q

tx of hyperthyroid

A
  • propranolol
  • ophthlamology referral
  • methimazole: block production of more T3/T4
  • oral radioactive iodine
  • surgery (not first line)
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92
Q

methimazole tx

A
  • small chance of low WBCs
  • clinical improvement after 1 mo, 3 mos to decrease T3/T4
  • several years of tx
  • requires regular monitoring of TSH levels
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93
Q

radioactive iodine tx

A
  • SEs: transient soreness of neck, brief worsening of sx, ophthalmopathy may worsen
  • 1-2 doses
  • may need replacement T3/T4
  • pregnancy test prior; don’t be around preggos or kiddos for several days
  • TSH checked Q2-3 mos until stable, then Q6 mos
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94
Q

hypothyroid tx

A
  • levothyroxine!
  • increase dose slowly, aim for 1.5-1.8 mcg/kg
  • check TSH q1 mo until stable, then Q12mo
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95
Q

medical hx for diabetes pt

A
  • age and characteristics at onset
  • previous tx, response to tx
  • current tx
  • nutrition hx, physical activity
  • diabetes education hx
  • hyperglycemic and hypoglycemic episodes
  • hypoglycemic awareness
  • microvascular and macrovascular complications
  • psychosocial
  • dental dz
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96
Q

benefits of EMR

A
  • templates that increase likelihood of pt receiving care
  • tools to evaluate pt care across population
  • documentation of improved physician performance
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97
Q

end organ damage of DM

A
  • cardiovascular: CAD and cerebrovascular; leading cause of death
  • retinopathy (after 15 yrs, all T1DM and 2/3 T2DM)
  • neuropathy
  • nephropathy (20-40% of DM pts)
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98
Q

hyperosmolar hyperglycemic state

A
  • physical findings: severe dehydration and high osmolality
  • precipitants: infections + decreased lfuid intake; also some acute conditions
  • mortality: increases with age and osmolality
  • pH usually >7.3, bicarb > 15
  • glucose > 600
  • ketones absent/mildly elevated
  • FLUID REPLACEMENT IS KEY
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99
Q

DKA

A
  • mortality 2% under 65yo, 22% above 65yo
  • pH <7.3
  • glucose ~250
  • ketosis
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100
Q

LEARN model

A

for understanding pt experience of their illness

  • listen
  • explain your perceptions
  • acknowledge and discuss differences
  • recommend treatment
  • negotiate agreement
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101
Q

dx criteria for DM

A
  • random glucose of 200 + sx of hyperglycemia
  • fasting glucose >126
  • HbA1C > 6.5
  • OGTT (not really recommended)
  • need fasting/HbA1C/OGTT result 2x unless sx of hyperglycemia
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102
Q

screening of T2DM: American DM Assoc

A
  • overweight/obese w/ 1+ risk factors
  • w/o risk factors, screen at 45 yo
  • repeat screen Q3y or more frequently if higher risk
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103
Q

T2DM risk factors

A
  • physical inactivity
  • ethnicity (Native Am, Asian Am, AfAm, Latin Am, Pacific Islander)
  • 1st degree relative
  • previous impaired fasting/glucose tolerance/A1C
  • HTN
  • low HDL or high TGs
  • hx of GDM or LGA baby
  • PCOS
  • hx of cardiovascular dz
  • acanthosis, obesity
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104
Q

screening of T2DM: USPSTF

A
  • asx adults with BP > 135/80
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105
Q

DM fundoscopic findings

A
  • retinal hemorrhage
  • cotton wool spots
  • microaneurysms
  • if proliferative: neovascularization
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106
Q

DM foot exam

A
  • testing for sensation (monofilament + vibration/pinprick)
  • ankle reflexes
  • pedal pulses
  • inspection of skin changes, ulceration, bony abnormalities
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107
Q

DM lab tests

A
  • HbA1C (control)
  • spot urine albumin to Cr
  • serum Cr and GFR calc
  • fasting lipids
  • B12 if neuropathy
  • screening TSH: T1DM, new dyslipidemia, women >50
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108
Q

management of cardiovascular outcomes in DM

A
  • quit smoking - cessation counseling (MOST important)
  • lower BP if >140/90; Acei/ARB/CaChB/thiazide as first line (thiazide or CaChB if black)
  • resting ECG
  • moderate intensity statin if 40-75yo; high intensity if ASCVD risk >7.5%
  • lifestyle modifications: weight, exercise, fat intake
  • aspirin (same recs as for pts w/o DM): men 45-79, women 55-79
  • ## HbA1c <7 prevents microvascular dz
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109
Q

DM tx

A
  • start with lifestyle + metformin
  • if HbA1c >8 –> add sulfonylurea or insulin
  • if HbA1c still >8 intensify regimen
  • if HbA1c still >8 many other drugs available
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110
Q

barriers to initiation of insulin tx

A
  • mindset that insulin is mx of last resort
  • fear of injection
  • physical limitations for drawing up insulin
  • perception that insulin causes DM comorbidities
  • lack of time/support to teach pts how to use
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111
Q

DM vaccines

A
  • flu
  • pneumococcal (revacc >64yo, esp if nephrotic syndrome/ESRD)
  • HBV
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112
Q

ophtho referral in DM

A

ANNUAL dilated eye exams

  • T1DM: first eye exam 5 yrs after dx
  • T2DM: first exam AT time of dx
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113
Q

DM daily foot care

A
  • inspect, wash, dry daily
  • report all injuries
  • moisturizer, no lotion b/w toes
  • socks and closed-toed shoes at all times
  • cut toenails straight across
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114
Q

DM optimal glucose ranges

A
  • fasting: 80-120

- postprandial (1-2 hrs after): <180

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115
Q

familismo

A
  • family is 1ary source of support

- hard to make decision w/o family

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116
Q

respeto/simpatia

A
  • respect to elders and authority figures
  • communication should be based on politeness and respect
  • pts may not question doctor even when disagree
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117
Q

personalismo

A
  • value warm friendly relationships

- balance with respeto

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118
Q

fatalismo

A
  • control over one’s dz is external to self

- “it is out of my hands”

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119
Q

body image in latino pts

A
  • “clean and not too thin”
  • thinner not necessarily seen as healhtier
  • approach from perspective of balance
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120
Q

latino alternative health practices

A
  • illness, treatments, foods have hot and cold properties

- use principle of balance

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121
Q

causes of mortality in US

A
  • smoking (biggest) –> lung cancer, ischemic heart dz, COPD
  • obesity (2nd)
  • DM –> CVD and CRF
  • HTN –> CAD, cardiomyopathy, cerebroVD, CRF
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122
Q

health risks of obesity

A
  • HTN
  • dyslipidemia
  • T2DM
  • CAD
  • stroke
  • gallbladder dz
  • OA
  • sleep apnea
  • respiratory probs
  • endometrial ca, br ca, colon ca
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123
Q

Wagner grade 1 ulcer

A
  • superficial, full skin thickness, NO underlying tissue involvement
  • outpt management
  • extensive debridement, local wound care, relief of pressure
  • may warrant tx of infx
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124
Q

Wagner grade 2 ulcer

A
  • deep, penetrate to ligaments and mm, NO bone involvement or abscess
  • outpt management
  • extensive debridement, local wound care, relief of pressure
  • may warrant tx of infx
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125
Q

Wagner grade 3 ulcer

A
  • deep, cellulitis/abscess, often osteomyelitis
  • eval for osteomyelitis, peripheral arterial dz
  • may require hospitalization
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126
Q

Wagner grade 4 ulcer

A
  • localized gangrene
  • emergent hosp and surgical consult
  • often amputation needed
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127
Q

Wagner grade 5 ulcer

A
  • extensive gangrene involving whole foot
  • emergent hosp and surgical consult
  • often amputation needed
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128
Q

ddx of leg swelling

A
  • cellulitis
  • DVT
  • venous insufficiency
  • lymphedema
  • peripheral arterial dz
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129
Q

cellulitis

A
  • small skin breaks: strep infx; larger wounds: staph
  • DM pts more susceptible
  • presence of fever supports dx
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130
Q

DVT

A
  • acute swelling, pain, discoloration
  • unilateral edema, warmth, superficial venous dilation
  • Homan’s sign!
  • smoking and obesity, DM, sedentary, OCPs, HTN, prolonged immobility/surgery, trauma, etc etc
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131
Q

venous insufficiency

A
  • from DVT and/or valvular incompetence
  • may be b/l
  • erythema, stasis dermatitis, hyperpigmentation at distal leg
  • skin ulceration at malleoli
  • obesity!
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132
Q

lymphedema

A
  • generally painless
  • early: soft and pitting
  • late: woody texture, fibrotic tissue
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133
Q

peripheral arterial dz

A
  • claudication
  • night pain, non-healing ulcers, skin color change
  • do ABI
  • cigarette smoking is biggest modifiable risk
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134
Q

D-dimer

A
  • sensitive but not specific test for DVT
  • negative result rules out DVT
  • useful in excluding when probability is low
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135
Q

Wells criteria for DVT

A
  • active cancer
  • paralysis/paresis/immobilization
  • bedridden for >3 days or major surg
  • localized tenderness in deep venous system
  • entire leg swollen
  • calf swelling 3 cm>other leg
  • pitting edema
  • collateral superficial vv
  • alternative dx as or more likely than DVT (-2)

3 pts = high prob
1-2 pts = moderate prob
<= 0 pts = low prob

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136
Q

management of DVT

A
  • outpt: hemodyn stable, good kidney fn, low bleed risk, support at home, daily INR monitoring
  • anticoag with LMWH/UFH
  • warfarin for prophylaxis (duration dependent on risk factors etc)
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137
Q

LMWH vs UFH

A
  • LMWH: subQ 1-2x/day, no monitoring reqd, TCP less likely, can be used outpt
  • UFH: IV based on body weight, PTT needed, TCP more likely, req’s hosp
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138
Q

DVT and warfarin prophyl

A
  • isolated calf: 6-12 wks
  • first time as result of surg or trauma: 3+ months
  • first of idiopathic event: 6+ months
  • recurrent dz or thrombophilia: 12+ months
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139
Q

warfarin titration

A
  • T1/2 = 40h - takes 5-7 d to reach stable state
  • INR 3 d after admin
  • INR > 5 and 9: hold warfarin and give oral vitK
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140
Q

screening of inherited thrombophilia: when?

A
  • initial thrombosis < 50yo w/o risk factor
  • family hx
  • reccurent venous thrombosis
  • thrombosis in unusual beds: portal, hepatic, mesenteric, cerebral
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141
Q

dx of HTN

A
  • 2+ elevated measurements at least 5 min apart in each arm on 2+ visits
  • doesn’t count if acutely ill or in pain
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142
Q

causes of HTN

A 
essential
secondary
- sleep apnea
- chronic renal dz
- renovascular
- drugs
- pheo
- 1ary aldo
- chronic steroids
- Cushing
- thyroid/parathyroid
- coarctation
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143
Q

BP classification

A
  • normal: 160 / >100
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144
Q

eval of pt with new HTN

A

1) assess end-organ dz (heart, brain, kidney, blood vessels, eye)
2) lifestyle/risk factors (metabolic syndrome, family hx, smoking, etoh, drugs, age, exercise, GFR)
3) eval for ID’able causes

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145
Q

PE of pt with new HTN

A
  • BP
  • BMI
  • fundoscope
  • vascular: bruits, pulses
  • thyroid
  • lung: CHF
  • heart
  • abdomen: AAA, kidneys
  • neurologic
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146
Q

studies in pt with new HTN

A
  • ECG
  • urinalysis (proteinuria, glycosuria)
  • blood glucose
  • hematocrit
  • serum K
  • Cr/GFR
  • lipids
  • urine albumin/creatinine
  • serum Ca
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147
Q

tx of stage 1 HTN

A
  • thiazide for most

- ACE i, ARB, BB, CCB also possible

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148
Q

tx of stage 2 HTN

A
  • two drug combo: thiazide + other
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149
Q

compelling indications for HTN meds

A

heart failure, post MI, high CAD risk, DM, CKD, stroke prevention

  • CKD: ACE/ARB only
  • stroke prevention: thiazide/ACE
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150
Q

effects of lifestyle mod on HTN

A

1) weight reduction (best)
2) DASH
3) Na restricted diet
4) physical activity
5) moderation of etoh

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151
Q

thiazides

A
  • may cause hypoNa
  • avoid in gout, urine incontinence
  • doses >25mg do not have increased effects on BP or morbidity/mortality
  • start at lower doses in elderly - increased risk of hypoT episodes
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152
Q

sociocultural factors in HTN tx

A
  • lifestyle issues and socioeconomic factors involved in BP control
  • control rates lowest in Mexican Am and Native Am
  • prevalence, severity, impact of HTN increased in AfAm
  • Af Am: reduced BP responses to monotherapy w/o diuretic/CCB
  • Af aM: 2-4x more likely to develop angioedema from ACEi
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153
Q

resistant HTN

A

failure to achieve goal BP in pts with full doses of 3 drug regimen (including diuretic)

causes:

  • improper BP measurement
  • excess sodium intake
  • inadequate diuretic tx
  • medication issue
  • excess etoh
  • 2ary HTN
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154
Q

mechanical causes of low back pain

A
  • 97% of low back pain
  • risks: prolonged sitting, deconditioning, suboptimal lifting/carrying
  • causes: lumbar strain/sprain, age-related degen jts, herniated disc, fx, spinal stenosis
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155
Q

epidemiology of low back pain

A
  • 5th most common reason for doctor visits
  • US lifetime prevalence: 60-80%
  • MOST cases resolve in 2-4 weeks
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156
Q

low back pain prognosis

A
  • most cases acute in onset and resolution: 90% resolve w/in one month, 5% disabled longer than 3 months
  • if out of work >6 mos, only 50% chance of returning
  • older or psychosocial stress: longer to recover
  • recurrence rate: 35-75%
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157
Q

disc herniation

A
  • exacerbation when sitting or bending, relief with lying or standing
  • increased pain with cough/sneeze
  • pain radiating down leg and foot
  • paresthesias
  • mm weakness
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158
Q

stoop test

A
  • pt goes from standing to squatting

- pain reduced in central spinal stenosis

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159
Q

range of motion tests

A
  • hip flexion: L234
  • hip abduction: L45S1
  • hip adduction: L234
  • knee extension: L234
  • knee flexion: L5S12
  • ankle dorsiflexion: L45
  • ankle plantaflexion: S12
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160
Q

straight leg raise

A
  • no pain with dorsiflexion: hamstrings are tight
  • positive: pain radiates down post/lat thigh
  • NO pain <30 degrees (if pain, malingering!)
  • pain in opposite leg: root compression from complete disc herniation
  • high sensitivity, low specificity for disc herniation
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161
Q

crossed leg raise

A
  • raise asx leg
  • positive test if pain increased in contralateral leg
  • high specificity, low sensitivity for disc herniation
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162
Q

FABER test

A

looks for hip jt pathology, sacroiliac pain

  • flex hip and place foot of tested leg on opposite knee
  • pressure on tested knee while stabilizing opposite hip
  • positive: pain at hip/sacral jt, leg can’t lower to parallel
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163
Q

red flags signalling vertebral fx

A
  • prolonged steroid use
  • mild trauma >age 50
  • age > 70
  • hx of OP
  • recent signif trauma
  • previous vertebral fracture
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164
Q

ankylosing spondylitis

A
  • chronic painful inflamm arthritis
  • affects spine and sacroiliac jts –> eventual spine fusion
  • pts 15-40 yo
  • morning stiffness
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165
Q

spondylolisthesis

A
  • anterior displacement of vertebra or vertebral column
  • any age
  • aching back and posterior thigh, increases iwth activity or bending
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166
Q

acute low back pain (0-3 mos): tx

A
  • general: local therapy, good posture
  • NSAIDs, acetaminophen, muscle relaxants
  • opiods: 2nd/3rd line
  • no support for steroids
  • avoid strenuous activity but remain active, bed rest not helpful
  • PT slightly more effective than staying active
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167
Q

causes of knee pain to consider in children/adols

A
  • patellar subluxation
  • Osgood Schlatter
  • patellar tendonitis
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168
Q

causes of knee pain to consider in adults

A
  • patellofemoral pain syndrome (dx of exclusion)
  • pes anserine bursitis (overuse)
  • ligament sprain
  • ligament/meniscus tear
  • inflammatory: RA, septic, Reiter’s
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169
Q

what does impaired squatting ability in knee pain mean

A

could be:

  • effusion
  • arthritis
  • ligament injury
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170
Q

what does impaired waddle in knee pain mean

A
  • ligament instability
  • joint effusion
  • meniscus damage
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171
Q

accuracy of Tinel

A
  • sensitivity 50%

- specificity 77%

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172
Q

accuracy of Phalen

A
  • sensitivity 68%

- specificity 73%

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173
Q

best findings for predicting carpal tunnel

A
  • hand sx: sx in at least 2 of digits 1,2,3 or palmar sx that are not only in unlar palm
  • hpalgesia
  • weak thumb abduction strength testing
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174
Q

OA

A
  • asymmetric involvement of jts
  • can be monoarticular in young adults if from trauma or congenital defect
  • stiffness worse after effort
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175
Q

RA

A
  • bilateral, polyarticular; usually hands and feet (smaller jts)
  • rheumatoid nodules: subQ nodules, firm and nontender, at pressure points
  • joint stiffness worse in morning
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176
Q

gout

A
  • monoarticular, usually big toe
  • tophi: visible, palpable nodules on ears or soft tissue
  • —- typically not painful, take years to appear
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177
Q

psoriatic arthritis

A
  • oligo arthritis or polyarthritis

- assoc with psoriatic plaques on extensor surfaces

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178
Q

baker’s cyst

A
  • popliteal
  • posterior knee pain if large
  • difficulty with full flexing
  • symptomatic cysts can be palpated on PE
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179
Q

IT band tendonitis

A
  • lateral knee pain
  • usually overuse - repetitive flexion
  • no effusion
  • pain aggravated with activity
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180
Q

does ACL tear get immediate swelling? what about LCL/MCL?

A
  • ACL - nope!

- LCL/MCL - yes!

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181
Q

what does a joint aspiration with blood and fat in it mean?

A
  • osteochondral fracture
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182
Q

OA knee XR

A
  • not good for early OA
  • findings do not correlate with degree of sx
  • findings: jt space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
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183
Q

OA management

A

good evidence:

  • exercise, quad strengthening, etc
  • NSAIDs/acetaminophen
  • steroid injections

mixed evidence:

  • glucosamine, chondroitin, SAM-e
  • tramadol
  • hyaluronic acid injections
  • acupuncture

referral to surgeon once knee replacement is in consideration

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184
Q

tramadol

A
  • centrally acting analgesic: acts at mu-opioid rcptr
  • stim release of 5HT, blocks reuptake of NE
  • alleviate mod to severe pain
  • lower abuse potential than opioids

dangerous SEs: seizures! 5ht syndrome, resp depression, copdema, bronchospasm, dependency.
Common SEs: constipation, nausea, dizziness, pruritis.

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185
Q

carpal tunnel management

A
  • wrist splint for 1 mo, then reassess

- NCS not needed for dx, but may use if sx don’t improve, motor dysfn present, or thenar atrophy

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186
Q

lipid screening

A
  • men >35

- women >45 if at increased risk of CHD

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187
Q

abdominal US screening

A
  • 1x in men 65-75 with smoking hx

- no routine screening in women

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188
Q

chlamydia risk factors

A
  • age <24 yo
  • hx of chlamydia or STI
  • new or multiple sexual partners
  • inconsistent condom use
  • exchanging sex for money or drugs
  • AfAm and Hispanic
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189
Q

chlamydia screening

A

NAAT!

  • all sexually active non-preg women =25 at increased risk
  • preg women: same but B level recommendation
  • insufficient evidence for men
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190
Q

how long to wait after live vaccine to get preg?

A

3 months

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191
Q

preconception genetic screening

A
  • folic acid (400-800 mcg in normal, 1mg if diabetes or epilepsy, 4mg if previous NTD)
  • sickle cell, thalassemia, Tay Sachs
  • CF, nonsyndromic hearing loss
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192
Q

preconception infx dz testing/counseling

A
  • HIV
  • syphilis
  • HBV immunization
  • rubella, varicella vaccination status (live vaccines, can’t give once preg)
  • toxo: avoid cat litter, raw meat
  • CMV: hand washing
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193
Q

management of chronic dz in preg

A
  • DM: optimize control, 1mg folic acid, no ACEis
  • HTN: no ACEis, ARBs, thiazides
  • epilepsy: optimize control, 1 mg folic acid
  • DVT: no warfarin, switch to heparin
  • avoid BZOs
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194
Q

PE/fetal US findings by GA

A
  • 5w: brain and spinal cord rapidly developing, fetus has heartbeat
  • 8w: uterus enlarged on bimanual
  • 10-12w: fetal heart tones on Doppler
  • 12 w: fundus above pubic symphysis
  • 18-20w: fetal movement felt by mother
  • 20-36w: uterine enlargement approximates GA
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195
Q

Naegele’s rule

A

for EDD

  • start with 1st day of last normal MP
  • add 1 year
  • subtract 3 months
  • add 1 week
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196
Q

miscarriage

A
  • 1/2 of 1st tri miscarriages are from chrom abnl
  • 1/3 of all preg end in miscarriage
  • 87% of women with miscarriage end up having normal preg/birth
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197
Q

1st tri bleeding

A
  • 1/4 preggos will have some
  • if signif in 1st tri: 25-50% chance of miscarriage
  • if exam benign, pulse stable, BP nl, Hgb nl: non-emergent
  • emergent bleed: pulse rise, BP drop, abd exam suggesting intraperitoneal bleeding
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198
Q

HEEADSSS

A
  • home
  • education/employment
  • eating
  • activities
  • drugs
  • sexuality
  • suicide/depression
  • safety/violence
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199
Q

Goodell’s sign

A

softening of cervix

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200
Q

Hegar’s sign

A

softening of uterus

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201
Q

Chadwick’s sign

A

blue-purple hue of cervix and vaginal walls

caused by hyperemia

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202
Q

ectropion

A
  • central part of cervix appears red from mucus producing endocervical epithelium protruding through cervical os
  • no clinical significance
  • common in women on OCPs
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203
Q

GTD

A
  • usually benign but can be malignant
  • hCG >100,000
  • snowstorm on US
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204
Q

Rh type in preg

A
  • if neg, get 50mcg RhoGAM to prevent hemolytic dz of newborn
  • usually not enough antigen to affect first gestation
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205
Q

congenital rubella

A
  • perinatal death
  • premature delivery
  • low birth weight
  • congenital anomalies
  • active congenital syphylis
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206
Q

tests in 1st tri bleeding

A
  • CBC
  • WBC (infx - but most preggos have leukocytosis)
  • wet mount: G/C/trich
  • type and screen
  • quant HCG (1-2) + pelvic US
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207
Q

quant HCG changes in preg

A
  • expected date of MP: >= 100
  • through first 6-7 weeks gestation: double every 48 hours
  • 1500-1800 for conclusive preg seen on TVUS
  • 5000 for preg seen on TAUS
  • hCG usually lower than nl and increase more slowly in ectopics and SAB
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208
Q

progesterone testing in 1st tri bleeding

A
  • > 25: sustainable IUP
  • <5: evolving SAB or ectopic
  • good pos and neg predictive values at these ranges; not so good in between
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209
Q

US and EDD

A
  • 1st tri: crown rump, accurate to +/- 1 week
  • if calc w/in 1 week of Naegele, then use Naegele
  • if >1wk from Naegele, use US dating
  • 2nd tri: accuracy to +/- 2 weeks
  • 3rd tri: 3 weeks
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210
Q

management of SAB

A
  • need serial reading of qHCG every 48-72 hrs with clinical assessment
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211
Q

management of inevitable ab

A
  • expectant: effective in up to 75% but can be emotionally distressing and long
  • surgical: D&C +/- aspiration
  • medical: misoprostol vaginally, possible repeat on day 3
  • confirm RhoGAM receipt if Rh neg
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212
Q

alcohol abuse

A

maladaptive pattern of use with 1+:

  • failure to fulfill obligations
  • recurrent use in hazardous situations
  • recurrent legal problems
  • continued use despite related social/interpersonal probs
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213
Q

alcohol dependence

A

3+ of:

  • tolerance
  • w/d
  • substance taken in larger quantity than expected
  • persistent desire to cut down or control use
  • significant time spent obtaining/using/recovering from use
  • social/occupational/recreational tasks sacrificed
  • use continues despite physical/psychol probs
214
Q

higher rates of use relapse seen in?

A
  • men
  • younger age
  • fewer social support
  • drank more before tx
  • poor compliance with drug tx
215
Q

alcoholism screening

A
    • answers to 2+ of CAGe
  • have you ever had a drinking prob + evidence of etoh consumption in last 24h
  • men: >14 drinks/wk or 4 drinks/occasion
  • women: >7 drinks/wk or 3 drinks/occasion
216
Q

ddx of RUQ pain

A
  • cholecystitis
  • biliary colic
  • duodenal ulcer
  • hepatitis
  • pancreatitis

less likely: PNA, MI, renal, pyelo, zoster

217
Q

cholecystitis

A
  • stone that can’t be dislodged from cystic duct
  • sx last longer than 4-6 hrs
  • may be assoc with inc severity, fever, leukocytosis
  • acute or chronic inflamm
  • acalculous cholecystitis: esp in elderly or ICU
218
Q

biliary colic

A
  • constant pain lasting <4-6 hrs, radiates to back under R shoulder blade
  • accomp by N/V, esp after heavy fatty meal
  • sx result from contraction of GB with stone obstructing duct
219
Q

duodenal ulcer

A
  • epigastric pain relieved by food or antacids
  • vomiting and radiation to back uncommon
  • significant variation and overlap with other conditions
220
Q

pancreatitis

A
  • top 2 causes: alcoholic and gallstone
  • pain is profound, onset is rapid, radiates to back
  • N/V common
221
Q

Grey-Turner’s sign

A

ecchymotic discoloration of flank - from pancreatitis

222
Q

Cullen’s sign

A

ecchymotic discoloration in the periumbilical region - from pancreatitis

223
Q

tests in RUQ pain

A
  • CBC
  • electrolytes (for vomiting)
  • LFTs
  • EKG and TnI
  • amylase/lipase
  • urinalysis
  • Abdominal US
224
Q

tx biliary colic

A
  • if sx, risk of progression 70%
  • surgical eval w/in a month
  • 3 month trial of ursodiol: if atypical sx with visible stones
  • HIDA scan: if typical sx but no visible stones
  • ERCP: if findings suggesting common duct stone
  • MRCP: like ERCP but diagnostic only
225
Q

tx of risky drinking

A
  • brief intervention by family physician
  • referral to MET or CBT
  • participation in AA
226
Q

primary skin lesion

A
  • uncomplicated lesion representing initial pathologic chg

- uninfluenced by infx, trauma, therapy, etc

227
Q

secondary skin lesion

A
  • change has occurred due to progression, scratching, infection, etc
228
Q

skin dz that affect specific surfaces

A
  • psoriasis: extensor
  • eczema: flexor
  • erythema multiforme, 2ary syphilis, eczema: palms and soles
229
Q

recommendation for skin cancer screening

A
  • insuff evidence

- discuss recommendations with pts and ask pref

230
Q

tinea pedis

A
  • dermatophyte infection
  • most common superficial fungal infx
  • risks: local friction, warmth, moisture bw toes, DM, immunosuppression
231
Q

sun exposure increases risks of:

A
  • squamous cell carcinoma
  • actinic keratosis
  • basal cell carcinoma
232
Q

squamous cell carcinoma

A
  • scaly erythematous raised base; irregular bleeding borders
  • heaped up edges are FLESHY
  • high risk for recurrence and mets if >2 cm
  • common on sun exposed extremities
  • 20% of all skin cancer
233
Q

basal cell carcinoma

A
  • plaque like or nodular; waxy translucent
  • often with ulceration and teleangiectasia
  • no itching, change in skin color
  • local invasion, slow growing; mets RARE
  • common on face but can happen anywhere
  • 60% of skin cancers
234
Q

melanoma

A
  • growing/spreading pigmented lesions
  • exposed areas of skin; women - >50% on legs
  • hx of intermittent intense sun exposure, blond/red hair, easy burning
  • 1% of skin cancer but 60% skin cancer deaths
235
Q

actinic keratosis

A
  • scaly keratotic patches

- usually felt more than seen

236
Q

lichen planus

A
  • common in middle age
  • 2-10 mm flat-topped papule with irregular angulated border
  • common on flexor surface of wrists and legs above ankles
237
Q

seborrheic keratoses

A
  • elevated hyperpigmented lesions on face and trunk
  • look “stuck on”
  • well-circumscribed border
238
Q

shave biopsy

A

only with elevated lesions

239
Q

ddx of BPH

A
  • UTI and prostatic infx
  • prostatitis
  • mx SEs
  • overactive bladder
  • prostate ca
240
Q

complications of untreated BPH

A
  • UTI
  • urinary retention
  • obstructive nephropathy
241
Q

when to get PSA

A
  • if life expectancy > 10 yrs

- PSA will influence BPH tx

242
Q

what surgery done for squamous cell carcinoma

A
  • surgical excision

- if <2cm, need 4mm margin

243
Q

what surgery done for non-melanoma skin cancer >2cm, or in cosmetically sensitive areas, or indistinct margins

A

MOHS

244
Q

how to treat actinic keratosis

A

5FU tx

- also used for Bowen’s dz and superficial squamous cell if pt refuses surgery

245
Q

what tx for small well defined low risk SCCs and Bowen’s

A

cryotherapy

- no histo confirmation of margins

246
Q

radiation tx is contraindicated in what skin lesions

A
  • trunk and extremities (better for head and neck)
247
Q

BPH management

A
  • behavior mod (fluids, caffeine/alcohol, salt/spices)
  • alpha-antag –> 5alpha reductase –> combo
  • surgical (if obstruction –> UTI risk or if mx don’t improve sx)
248
Q

tinea capitis tx

A
  • griseofulvin for 6-12 weeks
249
Q

tx of tinea unguium

A
  • griseofulvin: need long term tx
  • terbinafine 250mg/d for 12 wks (toes) or 6 wks (fingers)
  • itraconoazole 200mg 2x/d as pulse: 1 week on, 3 weeks off
  • —- fingers: 2 pulses, toes 3 pulses
250
Q

regular tinea tx

A
  • topical antifungals
  • — clotrimazole, miconazole, etc
  • — terbinafine, naftifine

should resolve w/in 2-4 wks

251
Q

types of topical steroids

A
  • Group I: strongest = halobetasol prpionate
  • Group II: desoximetasone
  • Group III: betamethasone, triamcinolone
  • Group IV/V: floucinolone, triamcinolone
  • Group VI: alclometasone, desonide
  • Group VII: weakest = hydrocortisone
252
Q

SEs of topical corticosteroid tx

A
  • skin atrophy
  • hypopigmentation
  • if very high potency: systemic SEs possible
253
Q

menopause

A
  • 12 mos w/o menses
  • median age 52
  • follicle depletion –> decreased E
  • sx: hot flashes, vasomotor, atrophic vaginitis, urinary sx, sexual dysfn, sleep probs, mood probs, concentration difficulties
254
Q

hip fracture mortality and loss of independence

A
  • avg 1 yr mortality rate after hip fx: 20-25%
  • 15-25% require nursing home for 1+ year
  • less than 30% regain original fn
255
Q

OP risk factors

A
  • family hx
  • previous low impact fx
  • smoking
  • heavy alcohol use
  • corticosteroid use
  • Caucasian
  • lower body weight
256
Q

OP screening

A
  • all women >65 with DEXA
  • younger women with risk of 65yo via FRAX calculator
  • not enough evidence for screening in men
257
Q

dx of OP

A

DEXA!

  • T 0 to -1: normal
  • T -1 to -2.5: osteopenia
  • T <-2.5: OP
258
Q

OP prevention

A
  • adequate intake of vitamin D and Ca in preteen and teen years: max bone density nlly reached in teens
  • 800 IU of vit D in adults >50yo; supplement, fortified milk/cereal, egg yolks, salt water fish, liver
  • 1000 mg Ca in adults; 1200 mg in >50yo
  • weight-bearing exercise and muscle strengthening
  • limit smoking and alcohol intake
259
Q

risk factors for endo ca

A

unopposed estrogen!! e.g.:

  • tamoxifen
  • obesity
  • anovulatory cycles
  • early menarche, late menoP, nulliparity
  • HTN
  • DM
  • hx of br ca or colon ca
260
Q

protective factors for endo ca

A
  • smoking (decreases estrogen)

- OCPs

261
Q

ddx of abnl uterine bleeding in postMP woman

A
  • cervical polyps
  • endometrial hyperplasia
  • endometrial ca
  • proliferative endometrium
  • iatrogenic
  • systemic disorders
  • genital tract pathology
262
Q

endometrial hyperplasia

A
  • may cause AUB
  • simple hyperplasia: <5% progression to cancer
  • atypical complex hyperplasia: 30-45% progression
263
Q

endometrial ca

A
  • 4th most common cancer in women
  • 90% have AUB
  • MUST consider in postMP woman with bleeding
264
Q

iatrogenic causes of AUB

A
  • anticoag, SSRIs, antipsychotics, corticosteroids, hormonal mx
265
Q

systemic disorders that can cause AUB

A
  • thyroid
  • hematologic
  • hepatic
  • adrenal
  • pituitary
  • hypothalamic
266
Q

TVUS in AUB

A
  • most cost-effective
  • highly sensitive for detection of endometrial cancer and endometrial abnormality
  • if >5mm on US, need more workup
  • shows fibroids, masses, ovarian pathology
267
Q

endometrial biopsy

A
  • gold standard for dx of AUB
  • sensitivity ~99% for endo ca in postMP
  • outpatient! give ibuprofen before procedure
268
Q

OP treatment

A
  • bisphosphonates: inhibit resorption and reduce turnover; decrease risk of fx (alendronate, resdronate; IV zoledronic acid avail if do not tolerate oral)
  • parathyroid hormone: if at high risk of fx; subQ admin; expensive!!
  • estrogen: only for short term tx
  • calcitonin: reduces vertebral fx only
269
Q

menopause hormone therapy: pros and cons

A
  • only for short term tx
  • improves vasomotor and atrophic sx, helps prevent OP
  • E+P > 3 yrs increases br ca risk
  • if begun after 60yo increases CAD risk
  • increases risk of stroke for first 2 yrs

LOWEST EFFECTIVE DOSE FOR SHORTEST PERIOD OF TIME

270
Q

alternative menoP tx

A
  • soy, black cohosh, flaxseed, St Johns wort
  • SSRIs, clonidine, gabapentin
  • exercise: good for hot flashes
  • smoking cessation, avoiding hot/alcoholic drinks
271
Q

migraine H/A

A
  • need 5 for dx
  • pulsating, unilateral, w/ or w/o aura
  • N/V, photophobia, phonophobia
  • last 4-72 hrs
  • aggravated by physical activity
272
Q

tension H/A

A
  • need 10 for dx
  • pressing, bilateral/occipital, no aura
  • photophobia, phonophobia possible
  • last 30 min to 7 days
  • not aggravated by phys activity
273
Q

cluster H/A

A
  • need 5 to dx
  • can be unilateral, orbital, periorbital, supraorbital, temporal
  • assoc with autonomic features (horners, rhinorrhea, etc)
  • last 15-180 minutes
  • not aggravated by phys activity
274
Q

medication overuse headache

A
  • following chronic use of analgesic
  • similar to 1ary H/As except occur daily, often on awakening, refractory to tx
  • tolerance to abortive mx, decreased response to prophylactic mx
  • assoc with restlessness, nausea, forgetfulness, depression
  • criteria: >15 per month, regular overuse of mx for >3 mos, development/worsening of H/A during mx overuse
  • tx: stop mx
275
Q

when to get neuroimaging in H/A

A
  • migraine with atypical H/A pattern or neurologic sign
  • pt at higher risk of signif abnormality
  • study results would alter management
276
Q

mx/substances that can trigger H/A

A
  • progesterone
  • tobacco
  • caffeine
  • alcohol
  • aspartame, phenylalanine
277
Q

dietary triggers for H/A

A
  • ripened cheeses
  • cured meats, organ meats
  • pickled or fermented foods
  • MSG
  • chocolate
  • legumes, beans
  • onions, citrus fruits, bananas
278
Q

triptans

A
  • abortive tx for migraines
  • contraind: use of ergotamine, MAOis, pregnancy, heart dz/stroke/uncontrolled HTN
  • may cause 5ht syndrome with SSRIs
  • SEs: dizziness, sleepiness, nausea, fatigue
279
Q

ergot alkaloids

A
  • abortive tx for migraines
  • contraind: use of triptans, heart dz/angina, HTN, periph vascular dz, pregnancy, breastfeeding
  • SEs: MI, Vtach, stroke, HTN. rash, N/V/D, dry mouth
280
Q

non-specific abortive migraine tx

A
  • aspirin, butalbital, caffeine (fiorinal)
  • acetaminophen, bultalbital, caffeine (fioricet)
  • acetaminophen/dichloralpehazone (midrin)
  • acetaminophen/aspirin/caffeine (excedrin)
281
Q

migraine prophylaxis

A
  • beta blockers (propranolol, timolol)
  • neurostabilizers: depakote, topamax
  • TCAs: amitryptiline
  • CCBs: verapamil
  • feverfew, magnesium, B12
282
Q

potential barriers to medical care for latinos

A
  • lack of documentation
  • holistic view of health
  • less likely to visit for preventive care
  • healthcare system is confusing, perception of discrimination/racism
  • emphasis of masculinity
283
Q

dyspepsia

A
  • upper abd pain (episodic or persistent); may be assoc with other sx
  • 25% of adults; 5% of visits to family docs
  • causes: functional (50%), PUD (15-20%), GERD (5-15%), gastric/esoph ca (2%)
284
Q

PUD risk factors

A
  • mx: aspirin, NSAIDs, warfarin, chronic corticosteroids
  • cigarette smoking reduces healing after insult
  • physiologic stress can contribute
  • H pylori infx
285
Q

GERD

A
  • abnormal LES pressure and reflux during transient LES relaxations are key to cause
  • atypical sx: asthma, cough, dental enamel loss, globus, hoarseness, non-cardiac chest pain, laryngitis, sore throat, subglottic stenosis
286
Q

complications of GERD

A
  • esophagitis
  • peptic strictures (10%) –> dysphagia, early satiety
  • Barrett’s
  • adenocarcinoma (from Barrett’s)
287
Q

H pylori infx

A
  • rare in developed countries; 80-90% adults worldwide
  • fecal-oral transmission in childhood
  • colonizes gastric epithelium –> more vulnerable to peptic acid damage, also local inflammatory response –> further damage
  • complications: can progress to atrophy, intestinal metaplasia, gastric carcinoma; can lead to gastric lymphoma
  • 90% of pts with duod ulcers have HP
288
Q

diverticulitis

A
  • LLQ pain, hematochezia, fever
  • most common cause of lower GI bleed in >50yo
  • outpt tx: bactrim/metronidazole or levofloxacin/metronidazole
  • may need admission to hosp
289
Q

upper GI series

A
  • useful for complications of GERD, not GERD itself

- MAY show gastric/duod ulcer

290
Q

24 hr pH probe

A
  • best when GERD dx is not easily determined
  • also used when pts want referral for Nissen
  • or when pts do not improve after PPI trials
291
Q

what causes false pos on FOBT/FIT

A

diets high in:

  • red meat
  • iron
  • vitamin C
292
Q

H pylori testing

A
  • IgG serology: good 1st time test if high prevalence of infx - shows immunologic response to past infx; CANNOT confirm eradication
  • urease breath test: detects ACTIVE infection, less accurate during PPI therapy
  • fecal antigen testing: accurate but expensive, used to evaluate eradication
293
Q

test and treat for GERD/PUD

A
  • PPI test: short PPI trial; stop after a successful 4-8 week course, or used when symptoms recur
    (pts often trial H2RAs/PPIs on their own before coming to doctor)
294
Q

when to refer for upper endoscopy/EGD

A
  • alarm or extraesophageal sx
  • no response to test and treat
  • make sure to biopsy gastric body and antrum for HP testing
295
Q

GERD lifestyle modifications

A
  • avoid large meals, acidic foods, alcohol, caffeine, chocolate, onions, garlic, peppermint
  • decrease dietary fat intake
  • don’t lie down 3-4 hrs after meal
  • avoid CCBs, beta-ag, alpha-ag, theophylline, nitrates
  • elevate head of bed
  • avoid clothing that is tight around waist
  • lose weight
  • stop smoking
296
Q

tx of functional dyspepsia

A
  • PPI therapy
  • trial of H2RAs
  • 10% reduction in sx after HP eradication
297
Q

GERD/PUD tx w/o HP infx

A
  • TCAs

- capsaicin, peppermint oil, caraway oil, artichoke leaf possible remedies

298
Q

HP eradication tx

A
  • triple therapy: PPI + clarithromycin + amoxicillin, 2x/d, 14 d
  • alternate triple: PPI + clarithromycin + metro, 2x/d, 14d
  • quadruple therapy: PPI, tetracucline, metronidazole, bismuth
299
Q

who to test for HP eradication

A
  • pts with HP ulcers
  • persistent dyspeptic sx after test and treat
  • HP associated MALT
  • post-resection of early gastric ca
  • if need to document for resumption of chronic NSAIDs
300
Q

how to test eradication of HP

A
  • fecal antigen testing
  • — if positive –> retreatment
  • — if symptoms persist: EGD, prolonged PPI therapy
  • if negative –> urease breath testing
  • — if negative: refer to GI
301
Q

risk factors for complications of flu

A
  • children <2)
  • COPD
  • congenital heart dz
  • increased aspiration risk
  • metabolic dz: DM
  • chronic renal dz
  • immunosuppression
  • long-term aspirin tx
302
Q

common complications of flu

A
  • otitis media (10-50% of children)
  • strep PNA

other:

  • lower resp infx
  • neuro: aseptic mening, GBS, febrile sz
  • myositis, myocarditis
303
Q

obesity in children: epidem

A
  • 15% of 6-19yo
  • non hisp AfAm: 13–>18%, hispanic: 9–>20%; white: 7–>14.5%
  • decreased activity, increased consumption of processed foods
  • at age 4, 80% chance of persisiting into adol, 20% chance of persisting into adultood
304
Q

complications of obesity in children

A
  • T2DM
  • high cholesterol
  • HTN
  • metabolic syndrome
  • MSK dos
  • GI dos
  • early menarche, PCOS
  • skin probs
  • psychosocial probs
  • OSA
  • asthma
  • pseudotumor
305
Q

metabolic syndrome (adults)

A

at least 3 of:

  • hyperTGemia
  • low HDL
  • elevated fasting blood gluc
  • excessive waist circumf
  • HTN

increased risk for CVD, DM

306
Q

lung sounds indicating consolidation

A
  • egophony
  • tactile fremitus (increased vibration = consol, decreased = effusion)
  • dullness to percussion (effusion or consolidation)
  • crackles (usually end-inspiratory - sign of fluid in lungs and/or consolidation)
  • whispered pectoriloquy
307
Q

BMI ranges (children)

A

goes by BMI-for-age percentile

  • healthy: 5-85%
  • overweight: 85-95%
  • obese: 95+
308
Q

causes of typical vs atypical vs viral PNA

A
  • typical: S pneumo
  • atypical: Mycoplasma, Chlamydia
  • viral: flu, RSV, adeno, rhino, paraflu
309
Q

viral PNA is more common in what age group?

A

younger children (4mos to 5 yrs)

310
Q

prodrome of typical vs atypical vs viral PNA

A
  • typical: none
  • atypical: H/A, GI sx, arthralgia, cough, fever
  • viral: rhinorrhea, myalgias
311
Q

sx of typical vs atypical vs viral PNA

A
  • typical: pleuritic chest pain, fever, chills, dyspnea, fever
  • atypical: PNA sx + constitutional sx, otalgia/otitis, etc
  • viral: chills, fever, dry cough, predominance of extra-pulm sx
312
Q

lung findings in typical vs atypival vs viral PNA

A
  • typical: pan-inspiratory crackles; 50% have pleural effusion
  • atypical: late inspiratory crackles, interstitial on CXR
  • viral: crackles
313
Q

what is the McIsaac/Centor score for?

A
  • whether to get rapid strep or culture to evaluate for GABHS pharyngitis
  • pts for fever, absent cough, tonsillar exudates, cervical LAN
  • extra pt if 45yo
  • if 4: throat culture, empiric ABx
314
Q

rapid influenza testing

A
  • more predictive if increased prevalence of dz
315
Q

tx of flu

A
  • antivirals: only w/in 1st 48 hrs of illness, decrease sx duration by 24 hrs
  • — start antivirals after 48hrs if mod to severe CAP or worsening sx
  • supportive: cough syrup, tea, ibuprofen, acetaminophen, fluids, rest
  • fever lasts 3-5 days, cough and tiredness 2 weeks
316
Q

bronchitis tx

A
  • 90% nonbacterial: supportive tx only

- beta-2 ag if WHEEZING

317
Q

PNA tx

A
  • 3mos to adol: amoxicillin
  • school age, worried about atypical: azithromycin
  • — (can also use erythro or clarithro, but more GI SEs)
318
Q

most common PNA pathogens: infants <3wks

A

E coli
GBS
Listeria

319
Q

most common PNA pathogens: 3 wks to 6 mos

A

S pneumo
Chlamydia
viral: adeno, flu, RSV, paraflu

320
Q

most common PNA pathogens: 3 mos to 5 yrs

A

S pneumo
Mycoplasma
Chlamydia
viral: adeno, flu, paraflu, rhino, RSV

321
Q

most common PNA pathogens: >5yrs

A

S pneumo
Chlamydia
Mycoplasma

322
Q

what is the 5-2-1-0 plan?

A
  • 5 fruit/vegetable servings per day
  • 2 hrs or less of TV
  • 1 hr physical activity
  • 0 sugary drinks in house
323
Q

weight loss goals in children

A
  • < 7 and BMI >95%: maintain weight

- — if complications, get weight to 7: weight to < 85%

324
Q

stages of tx for obese children

A

1) 5-2-1-0
2) #1 + reduced diet/TV + monthly visits + dietician etc
3) #1 + #2 + referral to multidiscip obesity care team
4) #1 + #2 + #3 + referral to pediatric tertiary weight management ctr

325
Q

screening of diabetes in obese children

A

all 10 year olds with:
1) BMI >85% and risk factors
2) BMI > 95% w/o risk factors
recheck every 2 years

326
Q

screening for hyperlipidemia in obese children

A
  • fasting lipid if BMI >85%, family hx or overweight/obese

- goal: total Chol <130

327
Q

tx of hyperlipidemia in children

A
  • initial: diet and exercise

- if >10yo, Tanner stage 2 or post menarche AND LDL >190 or >160 w/risk factors: drugs

328
Q

screening for steatosis in obese children

A
  • AST/ALT at age 10 if BMI>95%
  • or if >85% with risk factors
  • repeat every 2 years
  • refer to GI if lvls 2x ULN
329
Q

Afib

A
  • dizziness, syncope, dyspnea, palpitations
  • dx: EKG
  • most common arrhythmia, increases with age and severity of heart dz
  • causes: fever, myo/pericarditis, volume contraction, thyrotoxicosis, catecholamines, AV node dysfn
330
Q

dz assoc with Afib

A
  • cardiac: HTN, CAD, cardiomyopathy, mitral valve dz
  • pulm: COPD, OSA, PE
  • other: surgery, excess alcohol, hyperthyroidism, febrile illness
331
Q

classification of Afib

A
  • new onset: <72hrs total duration
  • chronic persistent
  • chronic paroxysmal: episodic - may need ambulatory EKG to dx
  • with rapid ventricular response: phys or electrical Vtach in presence of AFib
332
Q

complications of stroke

A
  • aspiration PNA
  • malnutrition, dehydration
  • pressure sores
  • functional impairment
  • depression
333
Q

screening for cerebrovasc dz risk factors

A
  • HTN, HL
  • ask about tobacco
  • discuss aspirin in men >45 for MI prevention
334
Q

post-stroke depression

A
  • 1/3 of stroke survivors
  • impairs rehab progress, assoc with impaired fnal outcome
  • SSRIs!
335
Q

IADLs

A

not necessary for fundamental fn, but allow independent living in community

  • light housework
  • preparing meals
  • shopping
  • telephone
  • money management
336
Q

orthostasis

A
  • decrease of 20 in SBP or 10 in DBP

- increase of 20 in HR (or 16 in elderly)

337
Q

timed up and go test

A
  • sit in chair, stand up (w/o arms), walk 10 ft, turn around, walk back to chair, sit down
  • 30s: impaired mobility
338
Q

ddx of stroke

A
  • brain tumor
  • seizure
  • stroke
  • TIA
  • CAD
  • medication SE
339
Q

medications that can cause neurologic sx/stroke-like sx

A
  • thiazides: electrolyte disturbance, arrhythmia, paresthesias/mm weakness
  • estrogen: increased stroke risk
  • antiHTN: lightheadedness, dizziness
  • neuroleptics: increased stroke risk
  • alpha-blockers: lightheadedness, dizziness, sudden syncope
340
Q

hypokalemic periodic paralysis

A
  • episodes of general or focal weakness
  • begins in childhood/adolescence
  • paralysis often during rest period follow vigorous activity
341
Q

hemiplegic migraine

A
  • H/A assoc with hemiparesis with sensory/motor weakness
  • most common in childhood and adolescence
  • sx cease by mid-adult
342
Q

AFib tx

A
  • IV diltiazem, BBs, or verapamil

- cardioversion

343
Q

when to use tPA

A
  • w/in 3 hrs: salvages brain tissues

- don’t give if clinical suspicion of bleeding abnl, TCP; heparin/warfarin tx; unknown anticoag hx

344
Q

2ary stroke prevention mx

A
  • for non-cardioembolic: daily antiplatelet: aspirin, aggrenox, ticlid, clopidogrel
  • for cardioembolic: warfarin
345
Q

goals for statin tx in stroke prevention

A
  • LDL < 100 if CAD or symptomatic ASCVD

- LDL <70 if very high risk with multiple risk factors

346
Q

5 year old milestones

A
  • dress yourself
  • name colors
  • person w/at least 6 body parts
  • copy square and triangle
  • hold pencil correctly
  • skip, hop, stand on one foot
  • talk in complete sentences
  • fully understandable speech
347
Q

when to screen children for anemia

A
  • low-iron diet
  • environmental: poverty, limited food access
  • special health needs
348
Q

when to screen child for lead toxicity

A
  • live/visit house built before 1950
  • live/visit house built before 1978 that was recently remodeled
  • sibling/playmate with lead poisoning
349
Q

when to screen child for TB

A
  • exposure to family member/contact with TB
  • family member with positive PPD
  • birth in or travel to high risk country
  • HIV+
  • incarcerated
350
Q

mononucleosis

A
  • EBV, CMV
  • low grade fever, pharyngitis, LAN
  • posterior cervical LAN common
  • palatal petechiae of posterior oropharynx distinguish mono from other viral pharyngitis (but NOT GABHS)
  • HSM
  • if treated with amox or amp, develop classic prolonged pruritic maculopapular rash
351
Q

GABHS pharyngitis

A
  • high fever
  • anterior cervical LAN
  • tonsillar exudates, palatal petechiae
  • strawberry tongue
  • no rhinorrhea, cough, conjunctivitis
  • scarlet fever!

complications: rheumatic fever, PSGN
- peri-tonsillar abscess, bacteremia, endocarditis, PNA, mastoiditis, etc etc

352
Q

peri-tonsillar abscess

A
  • fever
  • difficulty swallowing
  • neck/ear pain
  • hot potato voice
  • uvula deviation
353
Q

tx of GABHS pharyngitis

A
  • PCN VK; PCN G IM if unlikely to finish oral ABx course
  • amox liquid: tastes better
  • cephalexin and cefadroxil - if mild allergy to PCN
  • macrolides: if complete PCN allergy

pt should stay home until 24 hrs of ABx treatment

354
Q

stabilizers of shoulder jt

A
  • labrum
  • glenohumeral ligaments
  • rotator mm
355
Q

supraspinatus

A
  • sup/post scap –> greater tuberosity

- abducts shoulder

356
Q

infraspinatus

A
  • inf/post scap –> greater tuberosity

- externally rotates shoulder

357
Q

teres minor

A
  • inf/post scap –> greater tuberosity

- externally rotates shoulder

358
Q

subscap

A
  • ant scap –> lesser tuberosity

- internally rotates shoulder

359
Q

non-MSK causes of shoulder pain

A
  • MI
  • lung cancer
  • cholecystitis
  • ruptured ectopic preg
360
Q

tinea pedis: dx, tx

A
  • dx: clinical, or scrapings + KOH

- tx: tinactin (tolnaftate) 2x/day

361
Q

what might poor posture/rounded shoulders indicate

A

impingement

362
Q

what is the apley scratch test

A
  • hand behind back, try to reach shoulder blade

- may indicate rotator cuff tendonitis/tear/impingement

363
Q

what does the empty can test assess

A

supraspinatous

364
Q

what is the neer test

A

subacromial impingement test (supraspinatous tendon, long head of biceps, subacromial bursa)

365
Q

what is the hawkins kennedy test

A

supraspinatous impingement test

366
Q

how do you test for shoulder instability

A
  • anterior/posterior translate test
  • sulcus sign
  • apprehension test
  • relocation test
367
Q

how do you test for biceps tendonitis

A
  • speed’s test

- yergason’s test

368
Q

what is the clunk test

A
  • full passive ROM of shoulder with pressure into labrum/glenoid
  • assess labral pathology
369
Q

what is the OBrien test

A
  • looks for SLAP lesion (superior labral tear)

- false pos with AC pathology or tendinitis

370
Q

tx of rotator cuff tendinitis and shoulder instab

A
  • relative rest
  • PT
  • NSAIDs, acetaminophen
  • subacromial injection if other methods fail
371
Q

definition of fatigue

A

exhaustion/tiredness that is pervasive, not relieved by rest/worsened by exertion
(sleepiness: relieved by rest/exertion)

372
Q

barriers to screening tests

A
  • lack of awareness
  • denial of vulnerability
  • lack of insurance
  • not having received a recommendation for screening
  • fear of apin
  • fear of finding out bad results
373
Q

risk factors for colorectal ca

A
  • age >50
  • genetic conditions
  • personal hx of ca or adenomas
  • 1st degree relative with crc; 1st degree relative with adenoma s
  • personal hx of DM
374
Q

what is SPIKESS

A

used for delivering bad news

  • Setting up interview
  • Perception
  • Invitation
  • Knowledge
  • Emotions (pt’s)
  • Strategy
  • Summary
375
Q

ddx of fatigue

A
  • depression
  • OSA
  • anemia
  • occult malignancy
  • CAD
376
Q

anemia

A
  • pale conjunctivae better than skin pallor as indicator of anemia
  • adults: GI loss most common cause of Fe deficient anemia
  • — red blood: CRC, polyps, diverticuli
  • — guaiac positive: PUD, gastritis
  • chronic hematuria (rare)
  • jejunal dz, celiac sprue
  • poor dietary intake of iron (rare in US)
377
Q

chronic fatigue syndrome

A
  • lasting >6 mos, unrelieved by rest, worsened with exertion

dx criteria:

  • > = 6 mos of disabling fatigue
  • 4+ of: impaired memory/concentration, post-exertional malaise, tender LAN, sore throat, H/A, myalgia, arthralgia
378
Q

evaluation of fatigue

A
  • blood: CBC, iron studies, ESR, serum glucose, TSH
  • — DON’T GET EBV TITERS
  • sleep study
  • eval of GI blood loss?
379
Q

tx of iron deficiency anemia

A
  • ferrous sulfate 325
  • docusate as needed for constipation
  • colonoscopy etc if concern for GI cause
380
Q

tx of invasive adenocarcinoma of colon

A
  • colon ca: surgical removal and pathological staging
  • rectal ca: endorectal US
  • CT A/P and CXR for mets
  • CEA > 5ng/ml = worse prognosis
  • chemo, surg, radiation, or combo
381
Q

screening tests in adolescents

A
  • rubella for all females of childbearing age
  • gonorrhea/chlamydia: women <25yo and others at increased risk
  • HIV: sexually active men at increased risk
  • syphilis: sexually active men at increased risk
  • debate for G/C in males
382
Q

chlamydia/gonorrhea

A
  • dysuria, dischg, pain with sex, abd/testicular pain, breakthrough bleeding
  • may be asymptomatic
  • dx: NAAT of urine, endocervical sample, urethral sample
  • — gonorrhea: culture of rectal/pharyngeal specimen
383
Q

trich

A
  • vaginal dischg with odor and itching
  • may be asymptomatic
  • dx: saline wet mount, rapid antigen testing, trich culture
384
Q

epidem of testicular ca

A
  • most common malig in males 15-35yo

- most common in AfAm

385
Q

testicular ca: classification

A
  • germ cell tumor (95% of 1ary testicular tumors): seminoma > non-seminoma
  • Leydig/Sertoli: only 10% malignant
  • extragonadal: leuk, lymph, melanoma mets
386
Q

risk factors for testicular ca

A
  • genetics (klinefelter, Down, etc)
  • family hx
  • cryptorchidism
  • environmental hazards
  • testicular ca in contralateral testicle
387
Q

cremasteric reflex

A
  • do AFTER inspection and BEFORE palpation

- absent in torsion (but can also be absent in nl exam)

388
Q

blue dot sign

A
  • hard tender nodule in upper pole of testis w/ small blue discoloration
  • indicates torsion of testicular appendage
389
Q

Prehn’s sign

A
  • lifting of testicles relieves epididymitis pain but not torsion pain
390
Q

ddx of testicular pain

A
  • trauma
  • torsion
  • epididymitis
  • hydrocele
  • torsion of testicular appendage
  • tumor
  • varicocele
391
Q

testicular torsion

A
  • painful testicular swelling, often hrs after vigorous physical activity or minor trauma
  • uncommon, peaks in 1 yo and 14yo
  • causes: congenital anomaly, undescended testes, recent trauma/vigorous exercise
392
Q

epididymitis

A
  • possible preceding UTI or STI sx/dx
  • most frequent cause of sudden scrotal pain, but can be insidious onset also
  • most often in post-pubertal boys
393
Q

varicocele

A
  • asx or dull ache/fullness upon standing
  • more common on L side
  • 15% incidence in adolescence
  • impairs fertility - unknown mechanism
394
Q

imaging of testicular torsion

A
  • color Doppler: sensitivity 88 and specificity 90; fast and readily available
  • radionuclide scintigraphy: 100% sensitivity, may help when Doppler equivocal
395
Q

tx of testicular torsion

A
  • IMMEDIATE SURGERY!!! WITHIN 6 HOURS BEST
  • otherwise can get testicular loss
  • most common cause of delay of surg = delay in seeking medical attn > incorrect initial dx > delay in tx at hospital
  • 6hr duration –> 90% viability; >12 hrs –> 50%; >24 hrs –> 10%
  • may attempt manual detorsion but difficult bc of pain
  • avoid contact sports for 1 month after surg
396
Q

COPD causes

A
  • long term cig smoke or air pollution

- sometimes A1AT deficiency: consider if pt <45yo has COPD, esp if Caucasian and family hx

397
Q

COPD dx

A
  • middle age/older with dyspnea, chronic cough/sputum, hx of tobacco
  • confirm with spirometry pre- and post- bronchodilator tx
  • — post FEV1/FVC = 12% after tx = reversibility
398
Q

asthma spirometry

A
  • FEV1/FVC decreased or normal

- FVC always decreased

399
Q

pathophys of COPD vs asthma

A
  • COPD: macrophages, killer T, neutrophils

- asthma: mast cells, helper T, eosinophils

400
Q

COPD exacerbation

A
  • criteria: increased dyspnea, increased sputum volume and increased sputum purulence
  • most common causes: infection, air pollution (1/3 cannot be Id’ed)
401
Q

COPD and heart failure

A
  • chronic hypoxia –> pulm vasoconstriction, increased pulm BP –> irreversible HTN due to damage –> RH failure –> increased preload, peripheral edema, JVD
402
Q

ddx of dyspnea

A
  • asthma
  • bronchitis
  • CHF
  • COPD
  • lung cancer
  • PNA
403
Q

COPD exam findings

A
  • increased AP diam of chest
  • decreased diaphragmatic excursion
  • end-exp wheezing, prolonged exp phase
  • can also find max laryngeal height <= 4 cm at full inspiration
404
Q

CHF exam findings

A
  • inspiratory crackles, dullness to percussion
  • S3
  • laterally displaced PMI
  • peripheral edema, JVD, hepatojugular reflux
405
Q

COPD classification by spirometry

A

for ALL: FEV1/FVC < 70% predicted

  • mild: FEV1 > 80%
  • mod: FEV1 50-79%
  • severe: FEV1 30-49%
  • very severe: FEV1 <50% with chronic resp failure
406
Q

CXR in COPD?

A
  • does not rule in or out
  • does eval for other causes of dyspnea: get at first presentation
  • COPD CXR findings: hyperinflation, lung hyperlucency, rapid tapering of vascular markings
407
Q

bronchodilators for COPD pts?

A
  • if symptomatic, short acting beta-ag
  • add anticholinergic or long-acting if needed
  • maintenance of COPD: anticholinergic +/- short acting beta ag
408
Q

inhaled glucocorticoids for COPD

A
  • only if FEV1 <50% and repeated exacerbation

- more effective with long-acting beta-ag

409
Q

systemic glucocorticoids for COPD

A
  • useful during acute exacerbation
  • may improve lung function in 20% stable pts
  • risks!
410
Q

immunizations impt for COPD

A
  • flu (reduces illness/death by 50%)
  • pneumococcal (even if younger than 65) - if FEV<40
  • TdaP booster
411
Q

tx of COPD exacerbation

A
  • inhaled bronchodilators and oral steroids
  • ABx if have all three of: increased dyspnea, increased sputum volume, increased sputum purulence OR if require ventilation
  • noninvasive mechanical ventilation: improves acidosis, decreases need for ET tube, reduces RR, length of stay, mortality
  • medications and education to prevent future exacerbations
412
Q

CAD risk factors

A
  • DM, HTN
  • sedentary lifestyle, obesity
  • smoking
  • abnl lipid levels
  • older age (men 45+, women 55+)
  • male
  • family hx
  • HDL<40 (elevated HDL is protective)
413
Q

diastolic heart failure

A
  • signs and sx of heart failure present with preserved LV fn
  • exercise intolerance, pulm congestion, hepatic congestion, peripheral edema
  • possible to have w/o systolic dysfn
  • better prognosis than if have systolic dysfn too
414
Q

ddx of SOB

A
  • acute MI
  • arrhythmia
  • CAD/ischemic cardiomyopathy
  • uncontrolled HTN/diastolic dysfn
  • non-ischemic cardiomyopathy
  • valvular disease
415
Q

causes of CHF

A 
#1: significant CAD
#2: chronic uncontrolled HTN
416
Q

causes of non-ischemic cardiomyopathy

A
  • idiopathic
  • infectious
  • toxic
  • infiltrative (sarcoid)

can be dilated, hypertrophic, arrhythmogenic RV dysplasia, restrictive

417
Q

studies in SOB

A
  • CXR
  • EKG
  • echo/doppler (to establish dx and guide therapy)
  • stress testing
  • BNP
418
Q

stress testing

A
  • intermediate risk: get exercise tolerance test (low negative predictive value)
  • or get stress echocardiography/nuclear stress testing
419
Q

interventions for CAD

A
  • ACE-i for BP (also good BP med if diabetic)
  • A1C <100
  • aspirin (men) (in women, only for stroke prevention)
  • weight loss (but no rapid fluctuations)
420
Q

management of new onset CHF

A
  • SEND TO ER
  • do not admit directly to floor
  • urgent stabilization with IV lasix
  • admission to CCU if cardiac enzymes elevated
421
Q

management of systolic HF

A
  • ACE-is/ARBs (if ACEi not tolerated)
  • dig (watch for toxicity in renal insuff)
  • loop diuretics
  • BBs (don’t start during decompensated failure)
  • spironolactone (only class III and IV)
  • AVOID AMLODIPINE, THIOZOLADINEDIONES
422
Q

management of diastolic HF

A
  • BB or CCB (diltiazem)

- excessive diuresis and preload reduction can WORSEN

423
Q

prevalence of 1ary dysmenorrhea

A
  • most common in women in teens and twenties
  • 20-90% of women
  • 10-15% of women have sx severe enough to miss school or work
424
Q

risk factors for 1ary dysmenorrhea

A
  • depression/anxiety
  • smoking
  • early onset of menarche
  • overall lower state of health, other social stressors
425
Q

menorrhagia vs metrorrhagia

A
  • menorrhagia: increased blood loss

- metrorrhagia: irregular and frequent bleeding

426
Q

fibroids

A
  • 3x more common in AfAm
  • menorrhagia most common sx
  • 2ary anemia, dysmenorrhea, pressure sx, difficulty conceiving; normally no dyspareunia
427
Q

fibroids risk/protective factors

A
  • protective: OCPs, increased parity, smoking

- risk: early menarche, family hx, alcohol

428
Q

adenomyosis

A
  • more freq in parous vs nullips
  • US: boggy (MRI more specific)
  • NO TX AVAILABE
  • sx: menorrhagia, urinary/GI sx depending on uterine size
  • PE: uterus enlarged and diffusely boggy; symmetric, mobile
429
Q

cervical stenosis

A
  • congenital or acquired (cryotherapy, LEEP)
  • uterus distended with blood
  • adolescent with signif dysmenorrhea + minimal menstrual flow
430
Q

endometriosis

A
  • 75% have chronic pelvic pain or dysmenorrhea
  • dyspareunia more common
  • bowel/bladder sx cycle with menses; fatigue, AUB, fertility effects
  • PE: pain in cul-de-sac, immobile retroflexed uterus, nodules on uterosacral ligs, pain with uterine motion
431
Q

studies for dysmenorrhea

A
  • TVUS and TAUS: good initial eval if thinking 2ary dysmenorrhea
  • CBC
  • preg test
  • TSH
  • MRI can help dx pathology, not initial study tho
432
Q

tx of fibroids

A
  • ibuprofen
  • mirena IUD (reduces blood flow, overall uterine volume)
  • OCPs/nuvaring/ortho-evra patch
  • depo
  • hysterectomy: definitive tx if no longer desire childbearing
  • myomectomy
  • uterine artery embolization
433
Q

indication for hysterectomy in pt with fibroids

A
  • uterus >14-16 wks in size +/- sx
  • rapidly growing fibroid
  • failure of other management
434
Q

tx of PMS

A
  • SSRI
  • OCP
  • danazol (androgen w/ progesterone effects, inhibits ovulation)
  • GnRH agonist (leuprolide)
  • regular exercise, decreased carbs in luteal phase, relaxation therapy
435
Q

head thrust test

A
  • demonstrates likely peripheral lesion

- if normal in presence of vertigo –> lesion is central

436
Q

peripheral vertigo

A
  • Meniere’s, vestibular neuritis, BPPV
  • positive head thrust
  • unidirectional nystagmus, resolves with gaze fixation
  • dx: history, PE
437
Q

central vertigo

A
  • stroke, TIA, vestibular migraine
  • normal head thrust
  • nystagmus changes direction, does not resolve with fixation
  • dx: MRI
438
Q

BPPV

A
  • cause: CaCO3 in semicircular canals
  • dx: Dix Hallpike
  • tx: Epley
439
Q

Meniere’s disease

A
  • triad: unilateral hearing loss, tinnitus, vertigo

- tx: diuretics, low salt diet (decrease endolymphatic pressure)

440
Q

vestibular neuritis

A
  • assoc with recent URI
  • can have labyrinthitis as well
  • 2nd most common cause of vertigo in primary care practice
441
Q

vestibular suppressant medications

A
  • anticholinergics: meclizine, dimenhydrinate (also anti-emetics)
  • non-selective phenothiazine anti-emetics: metoclopramide, promethazine
  • AVOID IN ELDERLY: sedating!!!!
442
Q

when to do peds developmental screens

A
  • AAP: 9 mo, 18 mo, 30 mo
  • autism screening: 18 mo, 2 years
  • may involve parental reports and/or exam
443
Q

when to transition baby to cow’s milk?

A

1 YEAR

- may develop colitis before that –> bleeding, anemia

444
Q

caloric requirements of 1-2 mo olds

A
  • 100-120 kcal/kg/day
  • avg daily weight gain = 20-30 g
  • preterm: 115-130 kcal/kg/day
445
Q

Moro reflex

A

= startle

  • present at birth, gone by 4 months
  • used to detect peripheral problems - congenital MSK abnormalities or neural plexus injuries
446
Q

2 month milestones

A
  • head up 45
  • follow past midline
  • laugh
  • smile spontaneously
447
Q

4 month milestones

A
  • roll over
  • follow to 180
  • turn to rattling sound
448
Q

6 month milestones

A
  • sit w/o support
  • look for dropped item
  • turn to voice, babbles
  • feed self, stranger recognition
449
Q

9 month milestones

A
  • pull to stand
  • take 2 cubes
  • dada/mama
  • wave bye bye, point when want something
450
Q

when can you start solid foods

A
  • rice cereal with a spoon: 4 months
451
Q

vitamin D in children

A

400 IU per day

- unless drinking 32oz + of formula/milk

452
Q

when do babies sleep through the night

A

4-6 months

453
Q

when double/triple birth weight?

A
  • double 4-5 months

- triple: 1 year

454
Q

should babies use walkers?

A

NO! DANGER!

455
Q

can you take acetaminophen and get a vaccine?

A
  • may cause lower Ab response for some vaccines

- use only if absolutely necessary

456
Q

hepatic neoplasm

A
  • can cause asymptomatic RUQ abdominal tumor

- jaundice possible but not necessary

457
Q

hydronephrosis

A
  • obestruction at uretero-pelvic jct
  • multicystic kidney in newborn would cause
  • usually present with UTI
458
Q

neuroblastoma

A
  • most frequently dx neoplasm in infants
  • painless mass in neck/chest/abdomen
  • may be asx or may be chronically ill with bone pain from mets
  • fever, pallor, weight loss
459
Q

teratoma

A
  • painless abdominal mass w/ or w/o mass effect sx
460
Q

Wilms tumor

A
  • likely dx in asx RUQ mass in child w/o LAN or jaundice
  • often discovered by parents or routine exam
  • rarely cross midline
  • median age: 3 years
461
Q

initial testing for abdominal mass in child

A
  • CBC with diff
  • VMA/HVA (for neuroblastoma)
  • CXR (for mets to chest)
  • skeletal survey (for mets to bone)
  • abdominal US: BEST FIRST IMAGING STUDY; shows if purely cystic lesion
  • abdominal XR (not best first study)
  • abdominal CT: reveals calcifications, better anatomy than IS (for surgery), eval of lungs
462
Q

genetics of neuroblastoma

A
  • familial forms: 1% of cases; usually AD with low penetrance
  • some cases due to somatic mutations
463
Q

genetic conditions that predispose to childhood obesity

A
  • Prader Willi
  • Bardet Biedl
  • Cohen
464
Q

critical periods of excessive weight gain in children

A
  • infancy: extent and duration of breastfeeding inversely assoc with obesity risk
  • adol: early puberty insulin resistance; early menarche
465
Q

sequelae of childhod obesity

A
  • HTN
  • OSA
  • Pickwickian syndrome
  • restrictive lung dz
  • endocrine
  • GI: NASH, gallbladder dz
  • Blount dz
  • SCFE
466
Q

ADHD: epidem

A
  • 8-10% prev
  • not all children have behavioral problems
  • girls: more often inattentive type, may be more impaired academically/socially
467
Q

when to test for DM in children/adol

A
  • BMI >85% or weight:height >85%
  • weight >120% ideal AND 2+ risk factors
  • — family hx (1st or 2nd degree)
  • — race/ethnicity
  • — signs of insulin resistance
  • start at 10 or puberty onset; test every 2 years with fasting serum glucose
468
Q

when to screen for HTN in children

A
  • start at age 3

- measure yearly

469
Q

BP classification in children

A

sys and dias BP percentile:

  • normal < 90%
  • preHTN: 90-95
  • Stage 1: 95-99th + 5 mmHg
  • Stage 2: > 99th + 5 mmHg
470
Q

causes of HTN in children

A
  • most common cause = primary
  • 2ary: renal parenchymal dz, coarctation of aorta, renal vascular dz, caetcholamine excess (pheo, neuro) - consider in young pts with no family hx and substantial elevation
471
Q

flu vaccine in children

A
  • 1st year of immunization, if <9: need 2 doses 1 month apart
472
Q

HAV vaccine in children

A
  • children >23 mos in areas where programs target older children, increased risk, or need immunity
  • routine at 12 and 18 mos
473
Q

ddx of ADHD

A
  • sensory impairment
  • sleep problems
  • mood disorder
  • learning disability
  • oppositional defiant disorder
474
Q

stimulant medications: adverse effects

A
  • appetite suppression
  • <1%: tic disorders
  • insomnia (dose-related), worse in initial part of mx
  • slight decrease in growth velocity
475
Q

obesity and increased cancer death rate

A
  • non hodgkins lymphooma
  • multiple myeloma
  • esoph, colon, rectum. liver, gall bladder, pancreatic, stomach, kidney, prostate, breast, uterus, cervix, ovary
476
Q

CHD risk equivalents

A

place you at same risk of having cardiac event as someone who’s already had one

  • DM
  • symptomatic carotid artery dz
  • PAD
  • AAA
477
Q

medical conditions that cause dyslipidemia

A
  • DM
  • cholestatic or obstructive liver dz
  • nephrotic syndrome
  • hypothyroidism
  • acute hepatitis
  • alcoholism
478
Q

medications that cause dyslipidemia

A
  • thiazides
  • BBs
  • oral estrogens
  • protease inhibitors
479
Q

how to estimate BMR

A

body weight * 10 * activity factor

  • 1.3 if sedentary
  • 1.5 if moderate
  • 1.7 if heavy
  • 1.9 if intense
480
Q

cholesterol screening

A
  • USPSTF: all men 35+, all women 45+

- younger adults with risk factors

481
Q

medications for dyslipidemia

A
  • statins
  • bile acid sequestrants
  • nicotinic acid
  • fibric acid derivatives (1st line for TGs)
  • ezetimide (decreased absorption of cholesterol)

check lipids 6 wks after starting therapy, q1 yr when on stable dosage

482
Q

lifestyle interventions that raise HDL

A
  • exercise
  • weight loss
  • smoking cessation
  • moderate alcohol consumption
483
Q

orlistat

A
  • GI lipase inhibitor
  • only FDA approved drug for long-term tx of obesity
  • modest weight loss when in conjunction with diet and exercise
484
Q

phentermine

A
  • causes modest weight loss
  • SE: tachycardia, HTN, restlessness, insomnia, tremor
  • ONLY FOR SHORT TERM USE
485
Q

bariatric surgery

A
  • pts with BMI >40 or BMI >35 with severe complications

- failed other treatment methods

486
Q

joint fluid colors

A
  • straw: normal
  • pink/red: traumatic tap or injury
  • yellow/green: inflammatory or septic arthritis
  • cloudy: increased WBCs or crystals
487
Q

NSAIDs and warfarin

A

NSAIDs increase effect of anticoags; avoid!!

488
Q

tx of gout in pts who can’t take NSAIDs/colchicine

A
  • 1-2 jts involved: can do arthrocentesis with glucocorticoid injections
  • polyarticular: oral glucocorticoids
489
Q

initial pregnancy labs

A

CBC, RPR, HIV, Rubella, Blood type and Hepatitis B

490
Q

size of derm finding that differentiates between macule/patch, pustule/bulla, etc

A

1 cm!!

491
Q

acral lentiginous melanoma

A
  • seen more often in dark-skinned peop

- typically on the palms and soles of feet, including under the nails

492
Q

nodular melanoma

A

single dark brown or black nevus on a sun-exposed area that grows deep into the skin

493
Q

indications for testing for H pylori eradication

A
  • H. pylori-associated ulcer
  • persistent sx despite appropriate therapy for H. pylori
  • H. pylori-associated MALT lymphoma
  • hx of resection for early gastric cancer
  • planning to resume chronic NSAID therapy.
494
Q

when to give tamiflu

A
  • pts who show signs of flu like sx without further testing in communities with known flu outbreaks.
  • can reduce sx of the flu
  • only in patients who are still w/in a 48 hour window since symptoms began.
495
Q

risk factors for complications of flu

A
  • children < 2)
  • COPD/ability to handle respiratory secretions/increased risk of aspiration
  • CHD
  • metabolic conditions
  • Chronic Renal Disease
  • Immunosuppression
  • Long term aspirin therapy
496
Q

medications that cause HTN

A
  • steroids
  • amphetamines
  • thyroid mx
  • some anti-depressants
497
Q

fastest rising cancer incidence in US

A

malignant melanoma!!

early detection and treatment very important

498
Q

who should get endometrial cancer screening

A

women with/at high risk for HNPCC

annual biopsy starting at age 35

499
Q

five As

A

counseling for behavior chg

ask, assess, advise, assist, arrange

500
Q

is body fat distribution important?

A

YES!

increased waist circumference and waist-hip ratio = central adiposity

501
Q

which are the live vaccines

A

zoster
varicella
MMR
OPV

502
Q

depression in elderly

A
  • increases risk of disabilities in mobility and ADLs
  • alcohol and drug abuse common comorbidities
  • completed suicide more common in older depressed pts
503
Q

depression screening

A
  • all adults
  • esp pts with chronic dz
  • geri depression scale, zung depression scale, beck depression inventory
504
Q

pathophys of tachycardia and increased cardiac output in hyperthyroidism

A
  • increased peripheral O2 needs

- increased cardiac contractility

505
Q

pathophys of weight loss in hyperthyroidism

A
  • increased calorigenesis

- increased gut motility, hyperdefecation, malabsorption

506
Q

pathophys of exercise intolerance and fatigue in hyperthyroidism

A
  • O2 consumption and CO2 production

- respiratory muscle weakness

507
Q

causes of high radioactive I uptake

A
  • Graves (diffuse)
  • multi-nodular goiter
  • toxic solitary nodule
  • TRH-secreting pituitary tumor
  • HCG secreting tumor
508
Q

causes of low radioactive I uptake

A
  • sub acute thyroiditis
  • silent thyroiditis
  • iodine induced
  • exogenous L-thyroxine
  • struma ovarii
  • amiodarone
509
Q

does HTN worsen the vascular dz seen in DM?

A

YES!

510
Q

DM prevalence

A
  • 8.3% of US population
  • 11.3% of age 20+
  • 26% of age 65+
511
Q

risk of ASCVD events in DM vs non-DM

A
  • 2-4x more likely to have heart dz or stroke
  • worse outcomes with MI
  • DM dx = same as previous MI in terms of risk
512
Q

aspirin prophylaxis

A
  • men 45-79: for MI

- women 55-79: for stroke

513
Q

dental care in DM

A
  • very important! increased risk of cavities!
  • gum dz and fungal infx more common
  • regular dental care
514
Q

BMI and life expectancy

A
  • BMI 30-35: 2-4 year reduction

- BMI > 40: 20 yr reduction for men, 5 yr reduction for women

515
Q

end organ dz in HTN

A
  • heart
  • brain
  • kidneys
  • peripheral vascular dz
  • retinopathy
516
Q

HTN lab tests

A
  • EKG
  • urinalysis
  • serum K, Ca
  • serum Cr or GFR
  • fasting lipids
  • urine albumin
517
Q

red flags for malignant cause of back pain

A
  • hx of cancer
  • unexplained weight loss >10kg
  • age >50 or <17
  • failure to improve with therapy
  • pain longer than 4-6 wks
  • night pain or pain at rest
518
Q

lifestyle recommendations in preg

A
  • avoid vit A overuse (upper limit 3000 mcg)
  • avoid vit D overuse (upper limit 4000 mcg)
  • limit caffeine to 2 c coffee or 6 glasses soda
519
Q

diameter of skin lesion to biopsy?

A

> 6mm

520
Q

what size of squamous cell carcinoma has higher met rate?

A

> 2 cm

521
Q

maximal urinary flow rate

A

> 15 ml/s: excludes bladder outlet obstruction

< 15ml/s compatible with obstruction due to prostatic or urethral dz (but NOT DIAGNOSTIC)

522
Q

stroke risk factors

A
  • age
  • smoking
  • HTN
  • HL
  • arrhythmia
523
Q

when to get CT of shoulder

A
  • complicated fracture
  • suspected tumor
  • MRI contraindicated
524
Q

Beginning HRT after age 60 increases the risk of what?

A

coronary artery disease

525
Q

Use of combined estrogen and progesterone beyond three years increases the risk of what?

A

breast cancer

526
Q

how to confirm menopause?

A

Elevated FSH and LH levels

527
Q

smoking and estrogen

A

smoking decreases estrogen exposure

therefore decreases risk endometrial cancer, fibroids

528
Q

which flu shot can you give to people with egg allergies?

A
  • NOT FluMist; just shot

- no fluMist for pts with respiratory dz either

529
Q

Beckwith Wiedemann

A

genetic overgrowth syndrome
Other features: WILMS, omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.

530
Q

non-pharm management of dysmenorrhea (w/o uterine pathology)

A
  • acupuncture

- TENS, thiamine, vit E supplementation

fm cases (1 decks)

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