cases

Question 1

breast self exam

Answer 1

• does not reduce br ca or all cause mortality

- may increase # of biopsies performed

Question 2

cervical ca screening

Answer 2

• 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

Question 3

risk factors for cervical ca

Answer 3

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

Question 4

good screening test

Answer 4

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

Question 5

tests for breast lump

Answer 5

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

Question 6

pathologic causes of nipple dischg

Answer 6

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

Question 7

mammography sensitivity

Answer 7

• bw 60 and 90%

- lower sensitivity in younger women (dense breasts)

Question 8

br ca risk factors

Answer 8

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

Question 9

factors assoc with decreased br ca risk

Answer 9

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

Question 10

does smoking affect br ca risk

Answer 10

NO!

Question 11

menopause timing

Answer 11

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

Question 12

calcium intake for women

Answer 12

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

Question 13

risk factors for osteoporosis

Answer 13

• 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

Question 14

BMI increases risk of:

Answer 14

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

worse with older age, sedentary lifestyle, cigarettes

Question 15

gardasil

Answer 15

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

Question 16

cervarix

Answer 16

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

Question 17

RISE mnemonic

Answer 17

• risk factors
• immunizations
• screening tests
• education

Question 18

most frequent causes of death for 55 yo male

Answer 18

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

Question 19

risk factors for CVD and ASCVD

Answer 19

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

Question 20

three Cs of addiction

Answer 20

• compulsion
• lack of control
• continued use

Question 21

stages of behavior change

Answer 21

• pre-contemplative
• contemplative
• (planning)
• active
• (maintenance)
• relapse

Question 22

interventions that help improve smoking cessation

Answer 22

• 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)

Question 23

effects of moderate etoh intake

Answer 23

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

Question 24

etoh and chronic dz

Answer 24

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

Question 25

how to get complete nutrition hx

Answer 25

- 24 hr recall - food diary - food frequency questionnaire - usual diet hx - observed intake - weighted intakes

Question 26

BMI categories

Answer 26

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

Question 27

US lifetime risk of obesity

Answer 27

25%

Question 28

pe findings of dyslipidemia

Answer 28

- corneal arcus - xanthelasmas - acanthosis n

Question 29

pe findings of atherosclerosis

Answer 29

- decreased peripheral pulses | - carotid bruit

Question 30

skin ABCDE

Answer 30

- asymmetry - border irregularity - color non-uniform - diameter >6mm - evolution over time

Question 31

tetanus recommendations

Answer 31

- Td booster every 10 years | - one time TdaP replaces Td between 11-64

Question 32

when to get zoster vaccine

Answer 32

60! only one dose needed

Question 33

USPSTF levels of evidence

Answer 33

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

Question 34

lung ca screening

Answer 34

- annual with low dose CT IF: | age 55-80 with 30 pack-year smoking hx; currently smokes or quit in past 15 yrs

Question 35

colon ca screening options

Answer 35

- colonoscopy q10y - FOBT q1y + flex sig q5y - double contrast enema q5y

Question 36

ECG changes suggesting CAD

Answer 36

- ST depression (cardiac ischemia) - convex ST elevation (acute MI) - Q waves (infarction)

Question 37

U waves

Answer 37

- bradycardia, electrolyte imbalance, drug effect, CNS dz, hyperthyroidism, LVH, MVP

Question 38

diet to lower heart dz risk

Answer 38

- fish 2x/week - esp fatty fish higher in omega 3 - tofu, soybeans, canola, walnuts, flaxseed

Question 39

common causes of insomnia in elderly

Answer 39

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

Question 40

tx of insomnia in elderly

Answer 40

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

Question 41

medical conditions assoc with depression

Answer 41

- hypothyroidism - parkinson's - dementia

Question 42

factors that increase risk of suicide

Answer 42

- male gender - older age - previous suicide attempt

Question 43

MDD vs bereavement

Answer 43

- 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

Question 44

assessing for severity of SI

Answer 44

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

Question 45

common SEs of SSRI/SNRI

Answer 45

- 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

Question 46

tx of depression

Answer 46

- SSRI/SNRI - CBT - exercise - ECT (later option)

Question 47

SSRIs and preg

Answer 47

- most category C | - Paxil is category D

Question 48

fluoxetine

Answer 48

- long T1/2, no d/c syndrome | - SEs: agitation, motor restlessness, decreased libido, insomnia

Question 49

sertraline

Answer 49

- freq in preg and breast feeding - OCD, panic, PTSD - more GI SEs

Question 50

paroxetine

Answer 50

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

Question 51

fluvoxamine

Answer 51

- OCD | - increased emesis

Question 52

citalopram

Answer 52

- SEs: nausea, dry mouth, somnolence

Question 53

escitalopram

Answer 53

- GAD | - fewer SEs than citalopram

Question 54

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

Answer 54

- CMP - TSH - CBC

Question 55

depression in Hispanics

Answer 55

- 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

Question 56

risk factors for elder abuse

Answer 56

- 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

Question 57

adherence to antidepressants in elderly

Answer 57

- only about 50% - inability to afford - SE concerns - worry about stigma - not understanding how to take it

Question 58

acute ankle injury stats

Answer 58

- 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

Question 59

compartment syndrome

Answer 59

- causes: fx, crush, burn, arterial - high clinical suspicion - tx: fasciotomy - pain pallor pulselessness paresthesias poikilothermia paralysis

Question 60

most common MOI for ankle sprain

Answer 60

- lateral sprain: plantarflexion and inversion | - medial ankle sprain less common (dorsiflexion and eversion)

Question 61

how to assess ankle ligs

Answer 61

- 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

Question 62

asses for high ankle sprain

Answer 62

- crossed-leg test: high ankle tibiofibular syndesmotic sprain

Question 63

grade I ankle sprain

Answer 63

- stretch/small tear of ligament - slight to no fnal loss - mild tenderness and swelling - usually no ecchymosis - no mechanical instability

Question 64

grade II ankle sprain

Answer 64

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

Question 65

grade III ankle sprain

Answer 65

- complete tear of ligament - inability to bear weight - severe swelling - ecchymosis - mechanical instability

Question 66

ddx of ankle injury

Answer 66

- sprain (lateral ankle inversion sprain most likely) - peroneal tendon tear - talar dome fracture - fibular fracture - tendonitis - subtalar injury

Question 67

peroneal tendon tear

Answer 67

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

Question 68

talar dome fracture

Answer 68

- may be missed on initial XR | - if sx persist, get repeat imaging to detect avascular necrosis

Question 69

fibular fx

Answer 69

- usually due to fall/athletic injury or high veolicty mechanism

Question 70

ankle tendonitis

Answer 70

- 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

Question 71

subtalar injury

Answer 71

- high energy injury - dislocation: talocalcaneal and talonavicular joints - pain swelling and deformity

Question 72

tarsal tunnel syndrome

Answer 72

- entrapment of tibial n | - pain/tingling/burning along sole of foot

Question 73

syndesmotic injury

Answer 73

- interosseus membrane and anterior inferior tibiofibular ligament - pain out of proportion to injury - positive ankle squeeze test

Question 74

ankle arthritis

Answer 74

- tibiotalar jt | - stiffness, swelling, deformity, feeling of instability

Question 75

Ottawa rules

Answer 75

- 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)

Question 76

ankle sprain tx

Answer 76

- RICE - NSAIDs - daily ankle exercise - avoid reinjury - no flip flops!!!

Question 77

dysuria tx

Answer 77

- bactrim for empirical treatment for uncomplciated lower UTI - quinolone in communities with known bactrim resistance

Question 78

cardiac sx of hyperthyroidism

Answer 78

- arrhythmias | - cardiomyopathy

Question 79

sx of hyperthyroid in younger pts

Answer 79

- tachycardia (MOST common) - fatigue - weight loss, heat intolerance, tremor, increased sweating, depression, hyperreflexia, diarrhea, light periods

Question 80

sx of hyperthyroidism in older pts

Answer 80

- still get tachycardia, fatigue, weight loss - Afib - many other sx absent

Question 81

Graves dz

Answer 81

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

Question 82

eye findings in Graves

Answer 82

- 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

Question 83

toxic nodular goiter

Answer 83

- 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

Question 84

thyroiditis

Answer 84

- T3/T4 leaks from inflamed thyroid - usually short term - after viral illness, preg

Question 85

excess iodine

Answer 85

- via diet or amiodarone

Question 86

causes of goiter

Answer 86

- lack of iodine (most common owrldwide) - Hashimoto - Graves - nodules - thyroid ca - pregnancy - thyroiditis

Question 87

hypothyroid sx

Answer 87

- weight gain - cold intolerance - pedal edema - heavy periods - fatigue

Question 88

neurologic findings of hyperthyroidism

Answer 88

- increased DTRs - ankle clonus - tremor - lid lag

Question 89

differential dx of palpitations

Answer 89

- cardiac arrhythmia - anxiety/panic do - anemia - hyperthyroidism - drug/caffeine

Question 90

tests for dx hyperthyroid

Answer 90

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

Question 91

tx of hyperthyroid

Answer 91

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

Question 92

methimazole tx

Answer 92

- 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

Question 93

radioactive iodine tx

Answer 93

- 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

Question 94

hypothyroid tx

Answer 94

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

Question 95

medical hx for diabetes pt

Answer 95

- 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

Question 96

benefits of EMR

Answer 96

- templates that increase likelihood of pt receiving care - tools to evaluate pt care across population - documentation of improved physician performance

Question 97

end organ damage of DM

Answer 97

- 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)

Question 98

hyperosmolar hyperglycemic state

Answer 98

- 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

Question 99

DKA

Answer 99

- mortality 2% under 65yo, 22% above 65yo - pH <7.3 - glucose ~250 - ketosis

Question 100

LEARN model

Answer 100

for understanding pt experience of their illness - listen - explain your perceptions - acknowledge and discuss differences - recommend treatment - negotiate agreement

Question 101

dx criteria for DM

Answer 101

- 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

Question 102

screening of T2DM: American DM Assoc

Answer 102

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

Question 103

T2DM risk factors

Answer 103

- 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

Question 104

screening of T2DM: USPSTF

Answer 104

- asx adults with BP > 135/80

Question 105

DM fundoscopic findings

Answer 105

- retinal hemorrhage - cotton wool spots - microaneurysms - if proliferative: neovascularization

Question 106

DM foot exam

Answer 106

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

Question 107

DM lab tests

Answer 107

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

Question 108

management of cardiovascular outcomes in DM

Answer 108

- 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 -

Question 109

DM tx

Answer 109

- 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

Question 110

barriers to initiation of insulin tx

Answer 110

- 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

Question 111

DM vaccines

Answer 111

- flu - pneumococcal (revacc >64yo, esp if nephrotic syndrome/ESRD) - HBV

Question 112

ophtho referral in DM

Answer 112

ANNUAL dilated eye exams - T1DM: first eye exam 5 yrs after dx - T2DM: first exam AT time of dx

Question 113

DM daily foot care

Answer 113

- 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

Question 114

DM optimal glucose ranges

Answer 114

- fasting: 80-120 | - postprandial (1-2 hrs after): <180

Question 115

familismo

Answer 115

- family is 1ary source of support | - hard to make decision w/o family

Question 116

respeto/simpatia

Answer 116

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

Question 117

personalismo

Answer 117

- value warm friendly relationships | - balance with respeto

Question 118

fatalismo

Answer 118

- control over one's dz is external to self | - "it is out of my hands"

Question 119

body image in latino pts

Answer 119

- "clean and not too thin" - thinner not necessarily seen as healhtier - approach from perspective of balance

Question 120

latino alternative health practices

Answer 120

- illness, treatments, foods have hot and cold properties | - use principle of balance

Question 121

causes of mortality in US

Answer 121

- smoking (biggest) --> lung cancer, ischemic heart dz, COPD - obesity (2nd) - DM --> CVD and CRF - HTN --> CAD, cardiomyopathy, cerebroVD, CRF

Question 122

health risks of obesity

Answer 122

- HTN - dyslipidemia - T2DM - CAD - stroke - gallbladder dz - OA - sleep apnea - respiratory probs - endometrial ca, br ca, colon ca

Question 123

Wagner grade 1 ulcer

Answer 123

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

Question 124

Wagner grade 2 ulcer

Answer 124

- 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

Question 125

Wagner grade 3 ulcer

Answer 125

- deep, cellulitis/abscess, often osteomyelitis - eval for osteomyelitis, peripheral arterial dz - may require hospitalization

Question 126

Wagner grade 4 ulcer

Answer 126

- localized gangrene - emergent hosp and surgical consult - often amputation needed

Question 127

Wagner grade 5 ulcer

Answer 127

- extensive gangrene involving whole foot - emergent hosp and surgical consult - often amputation needed

Question 128

ddx of leg swelling

Answer 128

- cellulitis - DVT - venous insufficiency - lymphedema - peripheral arterial dz

Question 129

cellulitis

Answer 129

- small skin breaks: strep infx; larger wounds: staph - DM pts more susceptible - presence of fever supports dx

Question 130

DVT

Answer 130

- 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

Question 131

venous insufficiency

Answer 131

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

Question 132

lymphedema

Answer 132

- generally painless - early: soft and pitting - late: woody texture, fibrotic tissue

Question 133

peripheral arterial dz

Answer 133

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

Question 134

D-dimer

Answer 134

- sensitive but not specific test for DVT - negative result rules out DVT - useful in excluding when probability is low

Question 135

Wells criteria for DVT

Answer 135

- 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

Question 136

management of DVT

Answer 136

- 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)

Question 137

LMWH vs UFH

Answer 137

- 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

Question 138

DVT and warfarin prophyl

Answer 138

- 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

Question 139

warfarin titration

Answer 139

- 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

Question 140

screening of inherited thrombophilia: when?

Answer 140

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

Question 141

dx of HTN

Answer 141

- 2+ elevated measurements at least 5 min apart in each arm on 2+ visits - doesn't count if acutely ill or in pain

Question 142

causes of HTN

Answer 142

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

Question 143

BP classification

Answer 143

- normal: 160 / >100

Question 144

eval of pt with new HTN

Answer 144

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

Question 145

PE of pt with new HTN

Answer 145

- BP - BMI - fundoscope - vascular: bruits, pulses - thyroid - lung: CHF - heart - abdomen: AAA, kidneys - neurologic

Question 146

studies in pt with new HTN

Answer 146

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

Question 147

tx of stage 1 HTN

Answer 147

- thiazide for most | - ACE i, ARB, BB, CCB also possible

Question 148

tx of stage 2 HTN

Answer 148

- two drug combo: thiazide + other

Question 149

compelling indications for HTN meds

Answer 149

heart failure, post MI, high CAD risk, DM, CKD, stroke prevention - CKD: ACE/ARB only - stroke prevention: thiazide/ACE

Question 150

effects of lifestyle mod on HTN

Answer 150

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

Question 151

thiazides

Answer 151

- 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

Question 152

sociocultural factors in HTN tx

Answer 152

- 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

Question 153

resistant HTN

Answer 153

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

Question 154

mechanical causes of low back pain

Answer 154

- 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

Question 155

epidemiology of low back pain

Answer 155

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

Question 156

low back pain prognosis

Answer 156

- 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%

Question 157

disc herniation

Answer 157

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

Question 158

stoop test

Answer 158

- pt goes from standing to squatting | - pain reduced in central spinal stenosis

Question 159

range of motion tests

Answer 159

- hip flexion: L234 - hip abduction: L45S1 - hip adduction: L234 - knee extension: L234 - knee flexion: L5S12 - ankle dorsiflexion: L45 - ankle plantaflexion: S12

Question 160

straight leg raise

Answer 160

- 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

Question 161

crossed leg raise

Answer 161

- raise asx leg - positive test if pain increased in contralateral leg - high specificity, low sensitivity for disc herniation

Question 162

FABER test

Answer 162

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

Question 163

red flags signalling vertebral fx

Answer 163

- prolonged steroid use - mild trauma >age 50 - age > 70 - hx of OP - recent signif trauma - previous vertebral fracture

Question 164

ankylosing spondylitis

Answer 164

- chronic painful inflamm arthritis - affects spine and sacroiliac jts --> eventual spine fusion - pts 15-40 yo - morning stiffness

Question 165

spondylolisthesis

Answer 165

- anterior displacement of vertebra or vertebral column - any age - aching back and posterior thigh, increases iwth activity or bending

Question 166

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

Answer 166

- 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

Question 167

causes of knee pain to consider in children/adols

Answer 167

- patellar subluxation - Osgood Schlatter - patellar tendonitis

Question 168

causes of knee pain to consider in adults

Answer 168

- patellofemoral pain syndrome (dx of exclusion) - pes anserine bursitis (overuse) - ligament sprain - ligament/meniscus tear - inflammatory: RA, septic, Reiter's

Question 169

what does impaired squatting ability in knee pain mean

Answer 169

could be: - effusion - arthritis - ligament injury

Question 170

what does impaired waddle in knee pain mean

Answer 170

- ligament instability - joint effusion - meniscus damage

Question 171

accuracy of Tinel

Answer 171

- sensitivity 50% | - specificity 77%

Question 172

accuracy of Phalen

Answer 172

- sensitivity 68% | - specificity 73%

Question 173

best findings for predicting carpal tunnel

Answer 173

- 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

Question 174

OA

Answer 174

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

Question 175

RA

Answer 175

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

Question 176

gout

Answer 176

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

Question 177

psoriatic arthritis

Answer 177

- oligo arthritis or polyarthritis | - assoc with psoriatic plaques on extensor surfaces

Question 178

baker's cyst

Answer 178

- popliteal - posterior knee pain if large - difficulty with full flexing - symptomatic cysts can be palpated on PE

Question 179

IT band tendonitis

Answer 179

- lateral knee pain - usually overuse - repetitive flexion - no effusion - pain aggravated with activity

Question 180

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

Answer 180

- ACL - nope! | - LCL/MCL - yes!

Question 181

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

Answer 181

- osteochondral fracture

Question 182

OA knee XR

Answer 182

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

Question 183

OA management

Answer 183

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

Question 184

tramadol

Answer 184

- 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.

Question 185

carpal tunnel management

Answer 185

- 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

Question 186

lipid screening

Answer 186

- men >35 | - women >45 if at increased risk of CHD

Question 187

abdominal US screening

Answer 187

- 1x in men 65-75 with smoking hx | - no routine screening in women

Question 188

chlamydia risk factors

Answer 188

- 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

Question 189

chlamydia screening

Answer 189

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

Question 190

how long to wait after live vaccine to get preg?

Answer 190

3 months

Question 191

preconception genetic screening

Answer 191

- 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

Question 192

preconception infx dz testing/counseling

Answer 192

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

Question 193

management of chronic dz in preg

Answer 193

- 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

Question 194

PE/fetal US findings by GA

Answer 194

- 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

Question 195

Naegele's rule

Answer 195

for EDD - start with 1st day of last normal MP - add 1 year - subtract 3 months - add 1 week

Question 196

miscarriage

Answer 196

- 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

Question 197

1st tri bleeding

Answer 197

- 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

Question 198

HEEADSSS

Answer 198

- home - education/employment - eating - activities - drugs - sexuality - suicide/depression - safety/violence

Question 199

Goodell's sign

Answer 199

softening of cervix

Question 200

Hegar's sign

Answer 200

softening of uterus

Question 201

Chadwick's sign

Answer 201

blue-purple hue of cervix and vaginal walls | caused by hyperemia

Question 202

ectropion

Answer 202

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

Question 203

GTD

Answer 203

- usually benign but can be malignant - hCG >100,000 - snowstorm on US

Question 204

Rh type in preg

Answer 204

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

Question 205

congenital rubella

Answer 205

- perinatal death - premature delivery - low birth weight - congenital anomalies - active congenital syphylis

Question 206

tests in 1st tri bleeding

Answer 206

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

Question 207

quant HCG changes in preg

Answer 207

- 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

Question 208

progesterone testing in 1st tri bleeding

Answer 208

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

Question 209

US and EDD

Answer 209

- 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

Question 210

management of SAB

Answer 210

- need serial reading of qHCG every 48-72 hrs with clinical assessment

Question 211

management of inevitable ab

Answer 211

- 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

Question 212

alcohol abuse

Answer 212

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

Question 213

alcohol dependence

Answer 213

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

Question 214

higher rates of use relapse seen in?

Answer 214

- men - younger age - fewer social support - drank more before tx - poor compliance with drug tx

Question 215

alcoholism screening

Answer 215

- + 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

Question 216

ddx of RUQ pain

Answer 216

- cholecystitis - biliary colic - duodenal ulcer - hepatitis - pancreatitis less likely: PNA, MI, renal, pyelo, zoster

Question 217

cholecystitis

Answer 217

- 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

Question 218

biliary colic

Answer 218

- 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

Question 219

duodenal ulcer

Answer 219

- epigastric pain relieved by food or antacids - vomiting and radiation to back uncommon - significant variation and overlap with other conditions

Question 220

pancreatitis

Answer 220

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

Question 221

Grey-Turner's sign

Answer 221

ecchymotic discoloration of flank - from pancreatitis

Question 222

Cullen's sign

Answer 222

ecchymotic discoloration in the periumbilical region - from pancreatitis

Question 223

tests in RUQ pain

Answer 223

- CBC - electrolytes (for vomiting) - LFTs - EKG and TnI - amylase/lipase - urinalysis - Abdominal US

Question 224

tx biliary colic

Answer 224

- 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

Question 225

tx of risky drinking

Answer 225

- brief intervention by family physician - referral to MET or CBT - participation in AA

Question 226

primary skin lesion

Answer 226

- uncomplicated lesion representing initial pathologic chg | - uninfluenced by infx, trauma, therapy, etc

Question 227

secondary skin lesion

Answer 227

- change has occurred due to progression, scratching, infection, etc

Question 228

skin dz that affect specific surfaces

Answer 228

- psoriasis: extensor - eczema: flexor - erythema multiforme, 2ary syphilis, eczema: palms and soles

Question 229

recommendation for skin cancer screening

Answer 229

- insuff evidence | - discuss recommendations with pts and ask pref

Question 230

tinea pedis

Answer 230

- dermatophyte infection - most common superficial fungal infx - risks: local friction, warmth, moisture bw toes, DM, immunosuppression

Question 231

sun exposure increases risks of:

Answer 231

- squamous cell carcinoma - actinic keratosis - basal cell carcinoma

Question 232

squamous cell carcinoma

Answer 232

- 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

Question 233

basal cell carcinoma

Answer 233

- 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

Question 234

melanoma

Answer 234

- 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

Question 235

actinic keratosis

Answer 235

- scaly keratotic patches | - usually felt more than seen

Question 236

lichen planus

Answer 236

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

Question 237

seborrheic keratoses

Answer 237

- elevated hyperpigmented lesions on face and trunk - look "stuck on" - well-circumscribed border

Question 238

shave biopsy

Answer 238

only with elevated lesions

Question 239

ddx of BPH

Answer 239

- UTI and prostatic infx - prostatitis - mx SEs - overactive bladder - prostate ca

Question 240

complications of untreated BPH

Answer 240

- UTI - urinary retention - obstructive nephropathy

Question 241

when to get PSA

Answer 241

- if life expectancy > 10 yrs | - PSA will influence BPH tx

Question 242

what surgery done for squamous cell carcinoma

Answer 242

- surgical excision | - if <2cm, need 4mm margin

Question 243

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

Answer 243

MOHS

Question 244

how to treat actinic keratosis

Answer 244

5FU tx | - also used for Bowen's dz and superficial squamous cell if pt refuses surgery

Question 245

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

Answer 245

cryotherapy | - no histo confirmation of margins

Question 246

radiation tx is contraindicated in what skin lesions

Answer 246

- trunk and extremities (better for head and neck)

Question 247

BPH management

Answer 247

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

Question 248

tinea capitis tx

Answer 248

- griseofulvin for 6-12 weeks

Question 249

tx of tinea unguium

Answer 249

- 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

Question 250

regular tinea tx

Answer 250

- topical antifungals - --- clotrimazole, miconazole, etc - --- terbinafine, naftifine should resolve w/in 2-4 wks

Question 251

types of topical steroids

Answer 251

- 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

Question 252

SEs of topical corticosteroid tx

Answer 252

- skin atrophy - hypopigmentation - if very high potency: systemic SEs possible

Question 253

menopause

Answer 253

- 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

Question 254

hip fracture mortality and loss of independence

Answer 254

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

Question 255

OP risk factors

Answer 255

- family hx - previous low impact fx - smoking - heavy alcohol use - corticosteroid use - Caucasian - lower body weight

Question 256

OP screening

Answer 256

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

Question 257

dx of OP

Answer 257

DEXA! - T 0 to -1: normal - T -1 to -2.5: osteopenia - T <-2.5: OP

Question 258

OP prevention

Answer 258

- 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

Question 259

risk factors for endo ca

Answer 259

unopposed estrogen!! e.g.: - tamoxifen - obesity - anovulatory cycles - early menarche, late menoP, nulliparity - HTN - DM - hx of br ca or colon ca

Question 260

protective factors for endo ca

Answer 260

- smoking (decreases estrogen) | - OCPs

Question 261

ddx of abnl uterine bleeding in postMP woman

Answer 261

- cervical polyps - endometrial hyperplasia - endometrial ca - proliferative endometrium - iatrogenic - systemic disorders - genital tract pathology

Question 262

endometrial hyperplasia

Answer 262

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

Question 263

endometrial ca

Answer 263

- 4th most common cancer in women - 90% have AUB - MUST consider in postMP woman with bleeding

Question 264

iatrogenic causes of AUB

Answer 264

- anticoag, SSRIs, antipsychotics, corticosteroids, hormonal mx

Question 265

systemic disorders that can cause AUB

Answer 265

- thyroid - hematologic - hepatic - adrenal - pituitary - hypothalamic

Question 266

TVUS in AUB

Answer 266

- 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

Question 267

endometrial biopsy

Answer 267

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

Question 268

OP treatment

Answer 268

- 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

Question 269

menopause hormone therapy: pros and cons

Answer 269

- 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

Question 270

alternative menoP tx

Answer 270

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

Question 271

migraine H/A

Answer 271

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

Question 272

tension H/A

Answer 272

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

Question 273

cluster H/A

Answer 273

- 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

Question 274

medication overuse headache

Answer 274

- 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

Question 275

when to get neuroimaging in H/A

Answer 275

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

Question 276

mx/substances that can trigger H/A

Answer 276

- progesterone - tobacco - caffeine - alcohol - aspartame, phenylalanine

Question 277

dietary triggers for H/A

Answer 277

- ripened cheeses - cured meats, organ meats - pickled or fermented foods - MSG - chocolate - legumes, beans - onions, citrus fruits, bananas

Question 278

triptans

Answer 278

- 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

Question 279

ergot alkaloids

Answer 279

- 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

Question 280

non-specific abortive migraine tx

Answer 280

- aspirin, butalbital, caffeine (fiorinal) - acetaminophen, bultalbital, caffeine (fioricet) - acetaminophen/dichloralpehazone (midrin) - acetaminophen/aspirin/caffeine (excedrin)

Question 281

migraine prophylaxis

Answer 281

- beta blockers (propranolol, timolol) - neurostabilizers: depakote, topamax - TCAs: amitryptiline - CCBs: verapamil - feverfew, magnesium, B12

Question 282

potential barriers to medical care for latinos

Answer 282

- 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

Question 283

dyspepsia

Answer 283

- 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%)

Question 284

PUD risk factors

Answer 284

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

Question 285

GERD

Answer 285

- 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

Question 286

complications of GERD

Answer 286

- esophagitis - peptic strictures (10%) --> dysphagia, early satiety - Barrett's - adenocarcinoma (from Barrett's)

Question 287

H pylori infx

Answer 287

- 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

Question 288

diverticulitis

Answer 288

- 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

Question 289

upper GI series

Answer 289

- useful for complications of GERD, not GERD itself | - MAY show gastric/duod ulcer

Question 290

24 hr pH probe

Answer 290

- 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

Question 291

what causes false pos on FOBT/FIT

Answer 291

diets high in: - red meat - iron - vitamin C

Question 292

H pylori testing

Answer 292

- 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

Question 293

test and treat for GERD/PUD

Answer 293

- 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)

Question 294

when to refer for upper endoscopy/EGD

Answer 294

- alarm or extraesophageal sx - no response to test and treat - make sure to biopsy gastric body and antrum for HP testing

Question 295

GERD lifestyle modifications

Answer 295

- 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

Question 296

tx of functional dyspepsia

Answer 296

- PPI therapy - trial of H2RAs - 10% reduction in sx after HP eradication

Question 297

GERD/PUD tx w/o HP infx

Answer 297

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

Question 298

HP eradication tx

Answer 298

- triple therapy: PPI + clarithromycin + amoxicillin, 2x/d, 14 d - alternate triple: PPI + clarithromycin + metro, 2x/d, 14d - quadruple therapy: PPI, tetracucline, metronidazole, bismuth

Question 299

who to test for HP eradication

Answer 299

- 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

Question 300

how to test eradication of HP

Answer 300

- fecal antigen testing - --- if positive --> retreatment - --- if symptoms persist: EGD, prolonged PPI therapy - if negative --> urease breath testing - --- if negative: refer to GI

Question 301

risk factors for complications of flu

Answer 301

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

Question 302

common complications of flu

Answer 302

- otitis media (10-50% of children) - strep PNA other: - lower resp infx - neuro: aseptic mening, GBS, febrile sz - myositis, myocarditis

Question 303

obesity in children: epidem

Answer 303

- 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

Question 304

complications of obesity in children

Answer 304

- T2DM - high cholesterol - HTN - metabolic syndrome - MSK dos - GI dos - early menarche, PCOS - skin probs - psychosocial probs - OSA - asthma - pseudotumor

Question 305

metabolic syndrome (adults)

Answer 305

at least 3 of: - hyperTGemia - low HDL - elevated fasting blood gluc - excessive waist circumf - HTN increased risk for CVD, DM

Question 306

lung sounds indicating consolidation

Answer 306

- 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

Question 307

BMI ranges (children)

Answer 307

goes by BMI-for-age percentile - healthy: 5-85% - overweight: 85-95% - obese: 95+

Question 308

causes of typical vs atypical vs viral PNA

Answer 308

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

Question 309

viral PNA is more common in what age group?

Answer 309

younger children (4mos to 5 yrs)

Question 310

prodrome of typical vs atypical vs viral PNA

Answer 310

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

Question 311

sx of typical vs atypical vs viral PNA

Answer 311

- 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

Question 312

lung findings in typical vs atypival vs viral PNA

Answer 312

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

Question 313

what is the McIsaac/Centor score for?

Answer 313

- 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

Question 314

rapid influenza testing

Answer 314

- more predictive if increased prevalence of dz

Question 315

tx of flu

Answer 315

- 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

Question 316

bronchitis tx

Answer 316

- 90% nonbacterial: supportive tx only | - beta-2 ag if WHEEZING

Question 317

PNA tx

Answer 317

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

Question 318

most common PNA pathogens: infants <3wks

Answer 318

E coli GBS Listeria

Question 319

most common PNA pathogens: 3 wks to 6 mos

Answer 319

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

Question 320

most common PNA pathogens: 3 mos to 5 yrs

Answer 320

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

Question 321

most common PNA pathogens: >5yrs

Answer 321

S pneumo Chlamydia Mycoplasma

Question 322

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

Answer 322

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

Question 323

weight loss goals in children

Answer 323

- < 7 and BMI >95%: maintain weight | - --- if complications, get weight to 7: weight to < 85%

Question 324

stages of tx for obese children

Answer 324

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

Question 325

screening of diabetes in obese children

Answer 325

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

Question 326

screening for hyperlipidemia in obese children

Answer 326

- fasting lipid if BMI >85%, family hx or overweight/obese | - goal: total Chol <130

Question 327

tx of hyperlipidemia in children

Answer 327

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

Question 328

screening for steatosis in obese children

Answer 328

- 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

Question 329

Afib

Answer 329

- 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

Question 330

dz assoc with Afib

Answer 330

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

Question 331

classification of Afib

Answer 331

- 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

Question 332

complications of stroke

Answer 332

- aspiration PNA - malnutrition, dehydration - pressure sores - functional impairment - depression

Question 333

screening for cerebrovasc dz risk factors

Answer 333

- HTN, HL - ask about tobacco - discuss aspirin in men >45 for MI prevention

Question 334

post-stroke depression

Answer 334

- 1/3 of stroke survivors - impairs rehab progress, assoc with impaired fnal outcome - SSRIs!

Question 335

IADLs

Answer 335

not necessary for fundamental fn, but allow independent living in community - light housework - preparing meals - shopping - telephone - money management

Question 336

orthostasis

Answer 336

- decrease of 20 in SBP or 10 in DBP | - increase of 20 in HR (or 16 in elderly)

Question 337

timed up and go test

Answer 337

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

Question 338

ddx of stroke

Answer 338

- brain tumor - seizure - stroke - TIA - CAD - medication SE

Question 339

medications that can cause neurologic sx/stroke-like sx

Answer 339

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

Question 340

hypokalemic periodic paralysis

Answer 340

- episodes of general or focal weakness - begins in childhood/adolescence - paralysis often during rest period follow vigorous activity

Question 341

hemiplegic migraine

Answer 341

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

Question 342

AFib tx

Answer 342

- IV diltiazem, BBs, or verapamil | - cardioversion

Question 343

when to use tPA

Answer 343

- w/in 3 hrs: salvages brain tissues | - don't give if clinical suspicion of bleeding abnl, TCP; heparin/warfarin tx; unknown anticoag hx

Question 344

2ary stroke prevention mx

Answer 344

- for non-cardioembolic: daily antiplatelet: aspirin, aggrenox, ticlid, clopidogrel - for cardioembolic: warfarin

Question 345

goals for statin tx in stroke prevention

Answer 345

- LDL < 100 if CAD or symptomatic ASCVD | - LDL <70 if very high risk with multiple risk factors

Question 346

5 year old milestones

Answer 346

- 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

Question 347

when to screen children for anemia

Answer 347

- low-iron diet - environmental: poverty, limited food access - special health needs

Question 348

when to screen child for lead toxicity

Answer 348

- live/visit house built before 1950 - live/visit house built before 1978 that was recently remodeled - sibling/playmate with lead poisoning

Question 349

when to screen child for TB

Answer 349

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

Question 350

mononucleosis

Answer 350

- 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

Question 351

GABHS pharyngitis

Answer 351

- 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

Question 352

peri-tonsillar abscess

Answer 352

- fever - difficulty swallowing - neck/ear pain - hot potato voice - uvula deviation

Question 353

tx of GABHS pharyngitis

Answer 353

- 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

Question 354

stabilizers of shoulder jt

Answer 354

- labrum - glenohumeral ligaments - rotator mm

Question 355

supraspinatus

Answer 355

- sup/post scap --> greater tuberosity | - abducts shoulder

Question 356

infraspinatus

Answer 356

- inf/post scap --> greater tuberosity | - externally rotates shoulder

Question 357

teres minor

Answer 357

- inf/post scap --> greater tuberosity | - externally rotates shoulder

Question 358

subscap

Answer 358

- ant scap --> lesser tuberosity | - internally rotates shoulder

Question 359

non-MSK causes of shoulder pain

Answer 359

- MI - lung cancer - cholecystitis - ruptured ectopic preg

Question 360

tinea pedis: dx, tx

Answer 360

- dx: clinical, or scrapings + KOH | - tx: tinactin (tolnaftate) 2x/day

Question 361

what might poor posture/rounded shoulders indicate

Answer 361

impingement

Question 362

what is the apley scratch test

Answer 362

- hand behind back, try to reach shoulder blade | - may indicate rotator cuff tendonitis/tear/impingement

Question 363

what does the empty can test assess

Answer 363

supraspinatous

Question 364

what is the neer test

Answer 364

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

Question 365

what is the hawkins kennedy test

Answer 365

supraspinatous impingement test

Question 366

how do you test for shoulder instability

Answer 366

- anterior/posterior translate test - sulcus sign - apprehension test - relocation test

Question 367

how do you test for biceps tendonitis

Answer 367

- speed's test | - yergason's test

Question 368

what is the clunk test

Answer 368

- full passive ROM of shoulder with pressure into labrum/glenoid - assess labral pathology

Question 369

what is the OBrien test

Answer 369

- looks for SLAP lesion (superior labral tear) | - false pos with AC pathology or tendinitis

Question 370

tx of rotator cuff tendinitis and shoulder instab

Answer 370

- relative rest - PT - NSAIDs, acetaminophen - subacromial injection if other methods fail

Question 371

definition of fatigue

Answer 371

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

Question 372

barriers to screening tests

Answer 372

- 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

Question 373

risk factors for colorectal ca

Answer 373

- 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

Question 374

what is SPIKESS

Answer 374

used for delivering bad news - Setting up interview - Perception - Invitation - Knowledge - Emotions (pt's) - Strategy - Summary

Question 375

ddx of fatigue

Answer 375

- depression - OSA - anemia - occult malignancy - CAD

Question 376

anemia

Answer 376

- 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)

Question 377

chronic fatigue syndrome

Answer 377

- 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

Question 378

evaluation of fatigue

Answer 378

- blood: CBC, iron studies, ESR, serum glucose, TSH - --- DON'T GET EBV TITERS - sleep study - eval of GI blood loss?

Question 379

tx of iron deficiency anemia

Answer 379

- ferrous sulfate 325 - docusate as needed for constipation - colonoscopy etc if concern for GI cause

Question 380

tx of invasive adenocarcinoma of colon

Answer 380

- 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

Question 381

screening tests in adolescents

Answer 381

- 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

Question 382

chlamydia/gonorrhea

Answer 382

- 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

Question 383

trich

Answer 383

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

Question 384

epidem of testicular ca

Answer 384

- most common malig in males 15-35yo | - most common in AfAm

Question 385

testicular ca: classification

Answer 385

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

Question 386

risk factors for testicular ca

Answer 386

- genetics (klinefelter, Down, etc) - family hx - cryptorchidism - environmental hazards - testicular ca in contralateral testicle

Question 387

cremasteric reflex

Answer 387

- do AFTER inspection and BEFORE palpation | - absent in torsion (but can also be absent in nl exam)

Question 388

blue dot sign

Answer 388

- hard tender nodule in upper pole of testis w/ small blue discoloration - indicates torsion of testicular appendage

Question 389

Prehn's sign

Answer 389

- lifting of testicles relieves epididymitis pain but not torsion pain

Question 390

ddx of testicular pain

Answer 390

- trauma - torsion - epididymitis - hydrocele - torsion of testicular appendage - tumor - varicocele

Question 391

testicular torsion

Answer 391

- 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

Question 392

epididymitis

Answer 392

- 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

Question 393

varicocele

Answer 393

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

Question 394

imaging of testicular torsion

Answer 394

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

Question 395

tx of testicular torsion

Answer 395

- 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

Question 396

COPD causes

Answer 396

- long term cig smoke or air pollution | - sometimes A1AT deficiency: consider if pt <45yo has COPD, esp if Caucasian and family hx

Question 397

COPD dx

Answer 397

- 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

Question 398

asthma spirometry

Answer 398

- FEV1/FVC decreased or normal | - FVC always decreased

Question 399

pathophys of COPD vs asthma

Answer 399

- COPD: macrophages, killer T, neutrophils | - asthma: mast cells, helper T, eosinophils

Question 400

COPD exacerbation

Answer 400

- criteria: increased dyspnea, increased sputum volume and increased sputum purulence - most common causes: infection, air pollution (1/3 cannot be Id'ed)

Question 401

COPD and heart failure

Answer 401

- chronic hypoxia --> pulm vasoconstriction, increased pulm BP --> irreversible HTN due to damage --> RH failure --> increased preload, peripheral edema, JVD

Question 402

ddx of dyspnea

Answer 402

- asthma - bronchitis - CHF - COPD - lung cancer - PNA

Question 403

COPD exam findings

Answer 403

- 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

Question 404

CHF exam findings

Answer 404

- inspiratory crackles, dullness to percussion - S3 - laterally displaced PMI - peripheral edema, JVD, hepatojugular reflux

Question 405

COPD classification by spirometry

Answer 405

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

Question 406

CXR in COPD?

Answer 406

- 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

Question 407

bronchodilators for COPD pts?

Answer 407

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

Question 408

inhaled glucocorticoids for COPD

Answer 408

- only if FEV1 <50% and repeated exacerbation | - more effective with long-acting beta-ag

Question 409

systemic glucocorticoids for COPD

Answer 409

- useful during acute exacerbation - may improve lung function in 20% stable pts - risks!

Question 410

immunizations impt for COPD

Answer 410

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

Question 411

tx of COPD exacerbation

Answer 411

- 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

Question 412

CAD risk factors

Answer 412

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

Question 413

diastolic heart failure

Answer 413

- 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

Question 414

ddx of SOB

Answer 414

- acute MI - arrhythmia - CAD/ischemic cardiomyopathy - uncontrolled HTN/diastolic dysfn - non-ischemic cardiomyopathy - valvular disease

Question 415

causes of CHF

Answer 415

``` #1: significant CAD #2: chronic uncontrolled HTN ```

Question 416

causes of non-ischemic cardiomyopathy

Answer 416

- idiopathic - infectious - toxic - infiltrative (sarcoid) can be dilated, hypertrophic, arrhythmogenic RV dysplasia, restrictive

Question 417

studies in SOB

Answer 417

- CXR - EKG - echo/doppler (to establish dx and guide therapy) - stress testing - BNP

Question 418

stress testing

Answer 418

- intermediate risk: get exercise tolerance test (low negative predictive value) - or get stress echocardiography/nuclear stress testing

Question 419

interventions for CAD

Answer 419

- 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)

Question 420

management of new onset CHF

Answer 420

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

Question 421

management of systolic HF

Answer 421

- 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

Question 422

management of diastolic HF

Answer 422

- BB or CCB (diltiazem) | - excessive diuresis and preload reduction can WORSEN

Question 423

prevalence of 1ary dysmenorrhea

Answer 423

- 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

Question 424

risk factors for 1ary dysmenorrhea

Answer 424

- depression/anxiety - smoking - early onset of menarche - overall lower state of health, other social stressors

Question 425

menorrhagia vs metrorrhagia

Answer 425

- menorrhagia: increased blood loss | - metrorrhagia: irregular and frequent bleeding

Question 426

fibroids

Answer 426

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

Question 427

fibroids risk/protective factors

Answer 427

- protective: OCPs, increased parity, smoking | - risk: early menarche, family hx, alcohol

Question 428

adenomyosis

Answer 428

- 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

Question 429

cervical stenosis

Answer 429

- congenital or acquired (cryotherapy, LEEP) - uterus distended with blood - adolescent with signif dysmenorrhea + minimal menstrual flow

Question 430

endometriosis

Answer 430

- 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

Question 431

studies for dysmenorrhea

Answer 431

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

Question 432

tx of fibroids

Answer 432

- 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

Question 433

indication for hysterectomy in pt with fibroids

Answer 433

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

Question 434

tx of PMS

Answer 434

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

Question 435

head thrust test

Answer 435

- demonstrates likely peripheral lesion | - if normal in presence of vertigo --> lesion is central

Question 436

peripheral vertigo

Answer 436

- Meniere's, vestibular neuritis, BPPV - positive head thrust - unidirectional nystagmus, resolves with gaze fixation - dx: history, PE

Question 437

central vertigo

Answer 437

- stroke, TIA, vestibular migraine - normal head thrust - nystagmus changes direction, does not resolve with fixation - dx: MRI

Question 438

BPPV

Answer 438

- cause: CaCO3 in semicircular canals - dx: Dix Hallpike - tx: Epley

Question 439

Meniere's disease

Answer 439

- triad: unilateral hearing loss, tinnitus, vertigo | - tx: diuretics, low salt diet (decrease endolymphatic pressure)

Question 440

vestibular neuritis

Answer 440

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

Question 441

vestibular suppressant medications

Answer 441

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

Question 442

when to do peds developmental screens

Answer 442

- AAP: 9 mo, 18 mo, 30 mo - autism screening: 18 mo, 2 years - may involve parental reports and/or exam

Question 443

when to transition baby to cow's milk?

Answer 443

1 YEAR | - may develop colitis before that --> bleeding, anemia

Question 444

caloric requirements of 1-2 mo olds

Answer 444

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

Question 445

Moro reflex

Answer 445

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

Question 446

2 month milestones

Answer 446

- head up 45 - follow past midline - laugh - smile spontaneously

Question 447

4 month milestones

Answer 447

- roll over - follow to 180 - turn to rattling sound

Question 448

6 month milestones

Answer 448

- sit w/o support - look for dropped item - turn to voice, babbles - feed self, stranger recognition

Question 449

9 month milestones

Answer 449

- pull to stand - take 2 cubes - dada/mama - wave bye bye, point when want something

Question 450

when can you start solid foods

Answer 450

- rice cereal with a spoon: 4 months

Question 451

vitamin D in children

Answer 451

400 IU per day | - unless drinking 32oz + of formula/milk

Question 452

when do babies sleep through the night

Answer 452

4-6 months

Question 453

when double/triple birth weight?

Answer 453

- double 4-5 months | - triple: 1 year

Question 454

should babies use walkers?

Answer 454

NO! DANGER!

Question 455

can you take acetaminophen and get a vaccine?

Answer 455

- may cause lower Ab response for some vaccines | - use only if absolutely necessary

Question 456

hepatic neoplasm

Answer 456

- can cause asymptomatic RUQ abdominal tumor | - jaundice possible but not necessary

Question 457

hydronephrosis

Answer 457

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

Question 458

neuroblastoma

Answer 458

- 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

Question 459

teratoma

Answer 459

- painless abdominal mass w/ or w/o mass effect sx

Question 460

Wilms tumor

Answer 460

- 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

Question 461

initial testing for abdominal mass in child

Answer 461

- 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

Question 462

genetics of neuroblastoma

Answer 462

- familial forms: 1% of cases; usually AD with low penetrance - some cases due to somatic mutations

Question 463

genetic conditions that predispose to childhood obesity

Answer 463

- Prader Willi - Bardet Biedl - Cohen

Question 464

critical periods of excessive weight gain in children

Answer 464

- infancy: extent and duration of breastfeeding inversely assoc with obesity risk - adol: early puberty insulin resistance; early menarche

Question 465

sequelae of childhod obesity

Answer 465

- HTN - OSA - Pickwickian syndrome - restrictive lung dz - endocrine - GI: NASH, gallbladder dz - Blount dz - SCFE

Question 466

ADHD: epidem

Answer 466

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

Question 467

when to test for DM in children/adol

Answer 467

- 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

Question 468

when to screen for HTN in children

Answer 468

- start at age 3 | - measure yearly

Question 469

BP classification in children

Answer 469

sys and dias BP percentile: - normal < 90% - preHTN: 90-95 - Stage 1: 95-99th + 5 mmHg - Stage 2: > 99th + 5 mmHg

Question 470

causes of HTN in children

Answer 470

- 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

Question 471

flu vaccine in children

Answer 471

- 1st year of immunization, if <9: need 2 doses 1 month apart

Question 472

HAV vaccine in children

Answer 472

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

Question 473

ddx of ADHD

Answer 473

- sensory impairment - sleep problems - mood disorder - learning disability - oppositional defiant disorder

Question 474

stimulant medications: adverse effects

Answer 474

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

Question 475

obesity and increased cancer death rate

Answer 475

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

Question 476

CHD risk equivalents

Answer 476

place you at same risk of having cardiac event as someone who's already had one - DM - symptomatic carotid artery dz - PAD - AAA

Question 477

medical conditions that cause dyslipidemia

Answer 477

- DM - cholestatic or obstructive liver dz - nephrotic syndrome - hypothyroidism - acute hepatitis - alcoholism

Question 478

medications that cause dyslipidemia

Answer 478

- thiazides - BBs - oral estrogens - protease inhibitors

Question 479

how to estimate BMR

Answer 479

body weight * 10 * activity factor - 1.3 if sedentary - 1.5 if moderate - 1.7 if heavy - 1.9 if intense

Question 480

cholesterol screening

Answer 480

- USPSTF: all men 35+, all women 45+ | - younger adults with risk factors

Question 481

medications for dyslipidemia

Answer 481

- 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

Question 482

lifestyle interventions that raise HDL

Answer 482

- exercise - weight loss - smoking cessation - moderate alcohol consumption

Question 483

orlistat

Answer 483

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

Question 484

phentermine

Answer 484

- causes modest weight loss - SE: tachycardia, HTN, restlessness, insomnia, tremor - ONLY FOR SHORT TERM USE

Question 485

bariatric surgery

Answer 485

- pts with BMI >40 or BMI >35 with severe complications | - failed other treatment methods

Question 486

joint fluid colors

Answer 486

- straw: normal - pink/red: traumatic tap or injury - yellow/green: inflammatory or septic arthritis - cloudy: increased WBCs or crystals

Question 487

NSAIDs and warfarin

Answer 487

NSAIDs increase effect of anticoags; avoid!!

Question 488

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

Answer 488

- 1-2 jts involved: can do arthrocentesis with glucocorticoid injections - polyarticular: oral glucocorticoids

Question 489

initial pregnancy labs

Answer 489

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

Question 490

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

Answer 490

1 cm!!

Question 491

acral lentiginous melanoma

Answer 491

- seen more often in dark-skinned peop | - typically on the palms and soles of feet, including under the nails

Question 492

nodular melanoma

Answer 492

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

Question 493

indications for testing for H pylori eradication

Answer 493

- 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.

Question 494

when to give tamiflu

Answer 494

- 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.

Question 495

risk factors for complications of flu

Answer 495

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

Question 496

medications that cause HTN

Answer 496

- steroids - amphetamines - thyroid mx - some anti-depressants

Question 497

fastest rising cancer incidence in US

Answer 497

malignant melanoma!! | early detection and treatment very important

Question 498

who should get endometrial cancer screening

Answer 498

women with/at high risk for HNPCC | annual biopsy starting at age 35

Question 499

five As

Answer 499

counseling for behavior chg | ask, assess, advise, assist, arrange

Question 500

is body fat distribution important?

Answer 500

YES! | increased waist circumference and waist-hip ratio = central adiposity

Question 501

which are the live vaccines

Answer 501

zoster varicella MMR OPV

Question 502

depression in elderly

Answer 502

- increases risk of disabilities in mobility and ADLs - alcohol and drug abuse common comorbidities - completed suicide more common in older depressed pts

Question 503

depression screening

Answer 503

- all adults - esp pts with chronic dz - geri depression scale, zung depression scale, beck depression inventory

Question 504

pathophys of tachycardia and increased cardiac output in hyperthyroidism

Answer 504

- increased peripheral O2 needs | - increased cardiac contractility

Question 505

pathophys of weight loss in hyperthyroidism

Answer 505

- increased calorigenesis | - increased gut motility, hyperdefecation, malabsorption

Question 506

pathophys of exercise intolerance and fatigue in hyperthyroidism

Answer 506

- O2 consumption and CO2 production | - respiratory muscle weakness

Question 507

causes of high radioactive I uptake

Answer 507

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

Question 508

causes of low radioactive I uptake

Answer 508

- sub acute thyroiditis - silent thyroiditis - iodine induced - exogenous L-thyroxine - struma ovarii - amiodarone

Question 509

does HTN worsen the vascular dz seen in DM?

Answer 509

YES!

Question 510

DM prevalence

Answer 510

- 8.3% of US population - 11.3% of age 20+ - 26% of age 65+

Question 511

risk of ASCVD events in DM vs non-DM

Answer 511

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

Question 512

aspirin prophylaxis

Answer 512

- men 45-79: for MI | - women 55-79: for stroke

Question 513

dental care in DM

Answer 513

- very important! increased risk of cavities! - gum dz and fungal infx more common - regular dental care

Question 514

BMI and life expectancy

Answer 514

- BMI 30-35: 2-4 year reduction | - BMI > 40: 20 yr reduction for men, 5 yr reduction for women

Question 515

end organ dz in HTN

Answer 515

- heart - brain - kidneys - peripheral vascular dz - retinopathy

Question 516

HTN lab tests

Answer 516

- EKG - urinalysis - serum K, Ca - serum Cr or GFR - fasting lipids - urine albumin

Question 517

red flags for malignant cause of back pain

Answer 517

- 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

Question 518

lifestyle recommendations in preg

Answer 518

- 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

Question 519

diameter of skin lesion to biopsy?

Answer 519

> 6mm

Question 520

what size of squamous cell carcinoma has higher met rate?

Answer 520

> 2 cm

Question 521

maximal urinary flow rate

Answer 521

> 15 ml/s: excludes bladder outlet obstruction | < 15ml/s compatible with obstruction due to prostatic or urethral dz (but NOT DIAGNOSTIC)

Question 522

stroke risk factors

Answer 522

- age - smoking - HTN - HL - arrhythmia

Question 523

when to get CT of shoulder

Answer 523

- complicated fracture - suspected tumor - MRI contraindicated

Question 524

Beginning HRT after age 60 increases the risk of what?

Answer 524

coronary artery disease

Question 525

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

Answer 525

breast cancer

Question 526

how to confirm menopause?

Answer 526

Elevated FSH and LH levels

Question 527

smoking and estrogen

Answer 527

smoking decreases estrogen exposure | therefore decreases risk endometrial cancer, fibroids

Question 528

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

Answer 528

- NOT FluMist; just shot | - no fluMist for pts with respiratory dz either

Question 529

Beckwith Wiedemann

Answer 529

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

Question 530

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

Answer 530

- acupuncture | - TENS, thiamine, vit E supplementation