CCFP Exam Flashcards
3 things that can precipitate Hyperparathyroidism
- thiazides
- lithium
- Multiple Endocrine Neoplasia 1 & 2
3 Symptoms of Hyperparathyroidism
bone pain fragility # psychosis nephrolithiasis gout constipation
2 Management options for Hyperparathyroidism
Parathyroidectomy
Volume replete for high calcium
List components of CHADs Score
- CHF hx
- HTN hx
- age >75
- DM hx
- Stroke/TIA symptom hx
2 medication classes for GIB Prevention?
- H2 receptor antagonist
- Proton Pump Inhibitor
10 Symptoms of Hyperthyroidism
- tremor
- anxiety
- palpitations
- heat intolerance
- hair thinning
- goitre
- exophthalmos
- weight loss
- anemia
- lid lag
What test should be ordered if High TSH & High fT4?
MRI
think secondary hyperthyroidism from TSH secreting pituitary adenoma
What test should be ordered if Low TSH & High fT4?
Thyroid Uptake Scan
- look for Graves/Nodular vs. Thyroiditis
List 3 treatments for Hyperthyroidism?
Beta-Blockers
Methimazole
Subtotal Thyroidectomy
3 Symptoms of Thyroid Storm
Fever
CNS Agitation
Precipitant Trigger
How to treat thyroid storm?
- slow thyroid synthesis –> methimazole 60-120mg
- inhibit hormone release –> potassium iodide drops
- lower HR –> propranolol 60-80mg q4h
- support circ –> glucocorticoids, fluids, cooling & O2
3 Risk Factors for Hypothyroidism
Female trying to conceive or >45 yo
Postpartum
Medications - Amiodarone/Lithium/Iodine
10 Symptoms of Hypothyroidism
- weight gain
- cold intolerance
- hair thinning
- constipation
- depression
- goitre
- edema
- fatigue
- myalgia
- dry skin
Definition of subclinical hypothyroidism
TSH <10, Normal fT4, not pregnant, asymptomatic
When to treat Hypothyroidism
TSH >10 + symptomatic OR TSH 5-10 AND: - increased TPO antibodies - goitre - fam hx of autoimmune disease - pregnant
How often do we titrate Synthroid?
q4-6w until target range
What are the diagnostic values for Diabetes?
8hr FPG >7.0
2hr 75g OGTT >7.0 or 2hr >11.1
Random Glucose >11.1
HgA1c >6.5%
What are the target FPG levels pre & post prandial?
pre 4-7
post 5-10
What yearly investigations should be done in a patient with DM?
optometry fasting lipids Albumin/Cr ratio Monofilament/foot exam ECG
10 Risk Factors for DM?
- abdominal obesity
- asian/african
- low SES
- 1st relative with T2DM
- HTN
- smoking
- PCOS
- statins, steroids, atypical antipsychotics
- hx of pre-diabetes
- hx of GDM
- hx of delivering macrosomic infant
Who IS eligible for tPA?
age =/> 18
clinical dx of ischemic stroke causing neurological deficit
time of onset <4.5 hours
Absolute Contraindications for Thrombolysis?
- intracranial hemorrhage on Head CT
- clinical presentation suggests Subarachnoid hemorrhage
- NeuroSx, head Trauma or Stroke in last 3 months
- Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)
- Hx of intracranial hemorrhage
- Known intracranial arteriovenous malformation, neoplasm, or aneurysm
- Active internal bleeding
- Suspected/confirmed endocarditis
- Known bleeding risk (INR >1.7, etc.)
- Abnormal blood glucose
Relative Contraindications for Thrombolysis?
- Only minor or rapidly improving stroke symptoms
- Major surgery or serious non-head trauma in the previous 2 weeks
- History of gastrointestinal or urinary tract hemorrhage within 3 weeks
- Seizure at stroke onset
- Recent arterial puncture at a non-compressible site
- Recent LP
- Post myocardial infarction pericarditis
- Pregnancy
Red Flag Symptoms for Back Pain
B - bowel/bladder dysfunction A - anesthesia (saddle) C - constitutional symptoms (fever) K - chronic dz (cancer/OP) P - paresthesia A - age >65 I - immunosuppressed/IVDU N - neurological deficit >12 weeks
Cervical Cancer screening
ages 25-69, q3years
Colorectal Cancer screening
FIT ages 50-74 q2years
OR
Flexible Sigmoidoscopy q10years
Breast Cancer screening
mammogram q2-3years ages 50-74 IF average risk
Pancreatic Cancer screening
ONLY if high risk:
- family hx
- peutz-Jeghers syndrome
- BRCA1 with affected relative
H Pylori Treatment & Duration
14 day QUAD treatment:
- PPI
- Bismuth
- Metronidazole
- Tetracycline
Long term PPI side effects?
- Clostridium Difficile
- Pneumonia
- Dementia
- Fractures
- B12 Deficiency
Greatest risk factor for barrett’s esophagus?
reflux
How to prevent barrett’s esophagus?
high dose PPI AND ASA
When a pt presents with abdominal pain, what 1 test and 1 exam are commonly missed by the MD?
- BHCG
- Pelvic exam
Definition of acute vs. chronic diarrhea
acute <14 days
chronic >4 weeks
What are the pediatric resuscitation guidelines in Pediatrics?
bolus - 20ml/kg NS or LR
hourly maintenance 4:2:1 rule
Risk factors for C. Diff?
- elderly
- immunocompromised
- Healthcare associated
- recent course of antibiotics (Esp. fluoroquinolones i.e. Ciprofloxacin)
- previous C. Diff infection
1st line treatment for C. Diff?
Vancomycin PO as of 2018 - no longer Metronidazole
Workup for chronic diarrhea?
Test Blood AND Stool:
- Hgb, Ferritin, TSH, TTG
- C. Diff, O&P, Calprotectin
- dont do FIT –> straight to colonoscopy
List 4 Crohns Tx:
- sulfasalazine
- steroids
- MTX
- Biologics
IBS Therapies to try
- TTG
- FODMAP diet
- Psyllium
- Peppermint oil
- Probiotics
- CBT & hypnotherapy
- Colonoscopy if >50 OR if alarm features
What NOT to do for IBS?
- CRP, Calprotectin, Food Allergy Testing
- GF Diet
- Wheat bran
- Herbal therapies
- Acupuncture
- Colonoscopy if <50 & no alarm features
IBS Medications
Antidepressants (TCAs, SSRIs) Antispasmodics NOT loperamide (imodium) NOT osmotic laxatives NOT cholestyramine
Restless Leg Syndrome Non-prescription Treatments:
- Iron
- Magnesium
- stretch calves
- exercise
- massage
- heat
- avoid caffeine
Restless Leg Syndrome Prescription Tx:
- non-ergot dopamine agonist: pramipexole
- alpha 2 delta calcium channel ligand: gabapentin
Questions to diagnose Obstructive Sleep Apnea?
STOP S - snoring T - tired O - observed apnea P - high blood pressure
How to treat OSA?
Positive airway pressure (CPAP)
List 3 strategies in CBT
- goalification
- scalification
- reward chart
How do we treat subclinical hypothyroidism?
we don’t
What are the 2 treatment options for Hyperthyroid on labs, or having a thyroid nodule and then finding hyperthyroidism on labs?
- RAIU
- Beta-Blocker
What investigation do you order 1st after finding a thyroid nodule?
TSH & Thyroid US
What size of thyroid nodule is high risk?
> 1 cm
What investigation do you do after Thyroid US if high risk?
Fine needle aspiration for cytology
What are features of a suspicious thyroid nodule that would lead you to biopsy?
> 1cm
irregular surface
taller than wide
calcifications within
What are the treatments for Thyroid storm?
- Block synthesis (methimazole, PTU)
- block release (iodine)
- beta blocker (propranolol)
- block bile (cholestyramine)
What are the treatments for Graves Disease?
- block synthesis (methimazole/PTU)
- block release (iodine)
- beta blocker (propranolol)
- radiation
- removal of thyroid gland
What is the starting dose of Insulin in T2DM?
10 units NPH @ HS
Things to consider re: SGLT2 inhibitors
- don’t use in T1DM
- can cause vaginitis/balinitis
- can lower eGFR
- used in Heart failure without DM
- watchout for normoglycemic DKA
Diabetes Driving Guidelines?
2-4-6 rule
check blood sugar q2hours if hypoglycemic unawareness
check sugar q4h, if low, treat & wait 40 min
keep 6 lifesaver candies in the car for lows
Management of Hepatitis B?
- refer to hepatology
- treat if severe (cirrhosis, fibrosis, HBV DNA >2000 IU/mL & ALT elevated for 3-6months
- Tx with Tenofovir or Interferon
- Monitor
Management of Hepatitis C?
- refer to hepatology
- treat if severe
- Tx with Interferon or Antiretroviral Meds (Sofosbuvir)
- Monitor & Quit risks
Monitoring for Hep B/C
- liver US q6-12 months
- monitor varices with scope q1-3 years
- alcohol use, monitor by taking hx
- cirrhosis/fibrosis; no single blood test
4 important parts of exam for Back Pain?
- pedal pulses
- neurological exam
- weakness?
- numbness?
Recommended Therapies for Back Pain?
- not drugs
- teach lifting habits
- quit smoking & IVDU
- yoga
- acupuncture
- CBT
- osteopathy
4 joint pain alarm features?
- night pain
- boggy (soft) joint
- hot (fever, warm joint)
- AM stiffness >30 minutes
Who should I refer a child with behavioural problems to?
- pediatrics, SLP, psychology
- autism clinic
- hearing & vision assessment
- occupational therapy
List 3 things on the differential for autism?
- global developmental delay
- epilepsy
- hearing impairment**
Define Conduct Disorder
repetitive/persistent, violation of rights of others, rule breaking, VIOLENCE against people/animals, running away from home/school
- **PROPERTY/PEOPLE/ANIMALS DAMAGED
- **THEFT
Define Oppositional Defiant Disorder
irritable, defiant, vindictive
Therapies to try to minimize bed wetting
- make toilet accessible
- pee before bed
- training pants
- use bedwetting alarms
- can use desmopressin (short term ex. sleepovers)
- imipramine LAST RESORT
- no caffeine/chocolate
- no fluid before bed
- don’t punish child
- don’t put child in diapers
Treatment for Phimosis?
Topical steroids (Betamethasone)
What can be caused by undescended testes (cryptorchidism)?
torsion trauma tumor infertility inguinal hernia
How to examine for torsion?
TWIST score
- absent cremasteric reflex?
- nausea/vomiting?
- high riding testicle?
- testicular swelling?
- hard testicle?
which vaccines can someone get if they are allergic to chicken/eggs?
Influenza & MMR
which vaccines should you NOT give if someone is allergic to chicken/eggs?
yellow fever, tick borne encephalitis, rabies
Tips on making infant immunizations less painful?
- don’t aspirate
- do the most painful last
- breastfeed during
- skin-to-skin
- topical anesthetic
- oral sugar
Shingrix info?
non-live recombinant
- 2 doses
- 2 months (up to 6 months apart)
- 2x as effective as Zostavax
- $150 each shot
- recommended in patients >50 years old
HPV vaccine info?
- 2 doses
- 9 valent
- all genders
Who should get the Meningitis C vaccine?
- ALL canadian adolescents ~12yo
- military recruits
- asplenia & sickle cell
- travelers to Hajj & Meningitis belt of Africa
Which vaccines are live?
Polio
Varicella
MMR
Which vaccines can’t immunocompromised people have?
live vaccines - polio, varicella, MMR
Which vaccine is contraindicated if pt is pregnant?
most live vaccines
BCG
Flu vaccine is OK
Which vaccine is contraindicated if pt has active TB?
MMR, varicella, herpes zoster, bcg
which vaccine is contraindicated if pt has severe asthma/wheeze 7d prior?
live attenuated flu shot
which vaccine is contraindicated if pt has a congenital GI malformation?
rotavirus (risk of intussception)
which vaccine is contraindicated if pt has HIV?
live vaccines - varicella, polio & MMR
What are the common organisms causing sinusitis & ear infections?
Hemophilus influenza
Moraxella cattarhalis
Strep pneumoniae
Rhinosinusitis Signs & Symptoms
CPODS: Congestion/fullness Pain (facial pressure/fullness) Obstruction Drainage (purulent) Smell (anosmia)
Acute vs. Chronic Sinusitis Timeline
acute <4w
chronic >12w
When to refer for sinusitis?
> 4 episodes in 1 year
refractory to treatment
complications (immunosuppressed, severe pain, fungal)
Acute Sinusitis Management
- saline nasal rinse
- analgesia/antipyretics
- decongestant
- inhaled steam/warm compresses
- intranasal steroids x 3d (if no improvement, then abx)
When is chronic rhinosinusitis diagnosed?
> 2 CPODS for 8-12 weeks + inflammation of sinus mucosa
can confirm with CT (NOT xray)
When is acute sinusitis diagnosed?
> 2 PODS for >7d or w/ biphasic fever
Bacterial Sinusitis Treatment:
- Amoxicillin 80mg/kg or 500mg po TID
- Cefuroxime if allergic to PCN
** Amox/Clav 500mg po TID if Amox doesn’t work
Tx for 10-14d
Most are viral and do NOT need antibiotics
consider saline rinse, oral decongestants, IN steroids
Diagnostic Criteria for IBS:
recurrent abdo pain at least 1 day/week in the last 3 months associated with >2 of:
- related to defecation
- change in frequency of stool
- change in form of stool
Alarm Symptoms of IBS
unexplained weight loss vomiting GIB abdominal mass dysphagia anemia
Imp Hx for IBS:
- family hx of GI Cancer/IBD/celiac
- new symptoms in pt >45
- nocturnal defecation
Investigations for IBS:
- CBC, TSH, Stool C&S, lactulose hydrogen breath test, Giardia, albumin, fecal calprotectin, +/-O&P, +/- endoscopy/colonoscopy
IBS Management
- reassurance
- FODMAP diet
- Probiotics
- Peppermint oil/antispasmodic
- TCA (diarrhea prominent)
- SSRI (constipation prominent)
- adequate oral hydration
- bowel training
- exercise
- adequate oral fiber
- avoid fatty diet/caffeine/etoh
- CBT/hypnotherapy
S&S peptic ulcer disease
- upper abdo pain, bloating, nausea, early satiety, fullness, dyspepsia, belching, heart burn
Red flags of PUD
- vomiting
- bleeding/anemia
- unexplained weight loss
- abdominal mass
- dysphagia
- fam hx of GI cancer
- previous peptic ulcer
how to prevent peptic ulcer disease?
**H2 blockers & PPI
- no smoking
- no etoh
- no NSAIDs/ASA
- no bisphosphonates or CCB
- no caffeine or fatty diet
What is treatment if H Pylori test positive?
Quadruple therapy:
- PPI po BID
- Tetracycline QID
- Bismuth QID
- Metronidazole 500mg po BID QID
When do we do a test of cure for PUD?
if complicated patient or still symptomatic, 30d after completion of 14d treatment - order repeat urea breath test
Risk factors for Sinusitis?
- anatomy
- asthma
- smoking
- allergic rhinitis
Red Flag Features of Sinusitis
- persistent fever >39C
- proptosis
- periorbital edema
- vision changes
- cranial nerve palsies
- severe headache
- altered mental status
- abnormal EOM
- meningismus
Best treatment for GAS Pharyngitis?
Penicillin V 800mg po QID x 5 days (NOT 10)
S&S of Mono?
lymphadenopathy fever fatigue pharyngitis myalgia headache
What labs to order for Mono?
Lymphocyte count, AST/ALT, Monospot
Treatment for Mono?
NO ANTIBIOTICS
Hand washing & rest
How long to avoid contact sports after Mono?
At least 3 weeks
What can increase risk of neonatal sepsis?
chorioamnionitis fever <37w GA rupture >18 hours GBS + mother
neonatal sepsis bugs & meningitis =
Listeria
E Coli
GBS
Management of Neonatal Sepsis?
- CXR
- Ampicillin/Gentamicin +/- Acyclovir
- Consult NICU
- Blood Cultures/Urine Cultures/CSF
- Hgb, Lactate, WBC, CRP, Glucose
What is the cutoff for neonatal hypoglycemia?
<2.6
S&S of neonatal Hypoglycemia?
- lethargy
- jittery
- hypotonic
- sweating
- weak cry
- tachypnea
- seizures
Investigations for Hyperbilirubinemia?
Conjugated Bilirubin Hgb Group & Screen PBS Coombs test
Risks of Hip Dysplasia?
First born feet first female fluid (oligo) family hx
Differential for pediatric limp? (LIMPS)
- leg calve perthes disease
- infection/inflammation
- malignancies (Ewings sarcoma/osteosarcoma)
- pain from a # (abuse?)
- slipped capital femoral epiphysis (SCFE)