CME SAMPs Flashcards
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
What are common symptoms of endometriosis? List three.
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
Her symptoms are compatible with mild endometriosis. You complete your evaluation with a physical examination. It is normal. The patient would like to know if there is a way of confirming that she has endometriosis. What initial imaging is recommended to help diagnose endometriosis?
Transvaginal ultrasonography
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
What is the definitive method of diagnosing endometriosis?
Laparoscopy with biopsy
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
You decide to start treating your patient empirically. What is a first-line treatment for mild endometriosis?
Hormonal therapy: combined hormonal contraceptives, including oral pills, transdermal patches, and vaginal rings, are considered first-line therapies. Progestin-only methods (i.e., oral, depot, implant, or hormonal intrauterine systems) are other first-line options that may be considered for those who cannot tolerate or have contraindications to estrogen.
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
When is surgical treatment indicated?
Surgical management is indicated if :
- empiric therapy is ineffective
- medical management is not tolerated
- to immediately diagnose and treat the patient (adnexal mass or treatment of infertility)
A 26-year-old woman presents with recurrent pelvic pain during menstruation. She suspects endometriosis, as her mother also had this condition. She would like to discus the diagnosis and treatment options.
Your patient informs you that she has been trying to get pregnant for the past twelve months and fears that this suspected endometriosis is causing her infertility.
What treatment option could be considered in order to increase your patient’s chances of getting pregnant?
Laparoscopic surgery
Which two viruses cause most cases of infectious mononucleosis?
Epstein-Barr virus
Cytomegalovirus (10%)
How long is the incubation period?
EBV : 32-49 days
Which two initial lab tests should be ordered to confirm your diagnosis?
Complete blood count with differential.
Rapid heterophile antibody latex agglutination test (monospot test).
What follow-up test should be ordered if your initial test results are negative and if your clinical suspicion remains high?
Viral capsid immunoglobulin G (IgG) and IgM testing
Is routine imaging indicated following the diagnosis of infectious mononucleosis. Yes or no?
No.
How long may fatigue persist in some patients?
6 months or more
How long should she avoid all athletic activities to reduce the risk of splenic rupture?
3 weeks
Prior Epstein-Barr virus infection increases the risk of developing multiple sclerosis. True or false?
True.
List three conditions associated with bronchiectasis
Cystic fibrosis
Rheumatic diseases
Autoimmune diseases
Primary ciliary dyskinesia
Pulmonary infections
Allergic bronchopulmonary aspergillosis
Young syndrome
List three symptoms of bronchiectasis
Chronic cough
Increased sputum production
Dyspnea
Hemoptysis
Pleuritic chest pain
The radiologist reports suspected bronchiectasis. You initiate a referral to a respirologist.
List four other tests that should be ordered along with your referral to the respirologist
Complete blood exam
Biochemistry
C reactive protein
Aspergillus serology
Autoimmune screen
Immunoglobulins
Sputum sample for microscopy and culture
Lung function testing
6-minute walk test
Her chest x-ray is essentially normal. You order a high-resolution CT scan.
List two characteristics you might find on CT scan if she has bronchiectasis
Dilatation of the airways
Tree-in-bud pattern
Mucopurulent plugs or debris with post-obstructive air trapping
List three pharmacological modalities used in the long-term management of bronchiectasis?
Long term antibiotic treatment for patients with 3 or more exacerbations a year
Long term mucolytics
Inhaled antibiotics
List two non-pharmacological modalities used in treating bronchiectasis?
Chest physiotherapy
Avoidance of lung irritants
Optimized nutritional status
Pulmonary rehab
Should Patients with acute exacerbations should be treated with 14 days of antibiotics. True or false?
True.
What is the clinical diagnosis?
Uterine inversion
What is the next immediate step in management?
Uterine replacement/reversion OR transfer to operating room
Adolescents are two to four times more likely than adults to develop cannabis use disorder within two years of use. True or false?
True.
She has heard that regular cannabis use is associated with an increased risk of neurological or mental health problems. Name 3 such problems.
Neurological - lower IQ, poor educational outcomes, impaired executive function, avolition.
Psychiatric- increased risk of self-harm and suicidality, anxiety disorders, psychosis.
Large studies have shown clear benefits of pharmacotherapy for cannabis use disorder. True or false?
False.
Your patient is now concerned about using marijuana on a daily basis and would like your help to reduce her habit. She is afraid that if she stops suddenly she may experience withdrawal. What symptoms are associated with withdrawal? Name 3.
Irritability, anger, or aggression; nervousness or anxiety; sleep difficulty; decreased appetite or weight loss; restlessness; depressed mood; physical symptoms including abdominal pain, tremors, diaphoresis, fevers, chills, and headache
DRESS can be associated with a number of medications. List 3 of the most common medications or medication categories.
Allopurinol
Aromatic anticonvulsants (Lamotrigine, Phenytoin, Carbamazepine)
Vancomycin
Minocycline
Proton pump inhibitors
Sulfonamide
Apart from fever and rash, what are the most common clinical manifestations of DRESS? List 2.
Facial edema
Lymphadenopathy
Pleuritic involvement (including pleural effusions, pneumonitis)
——
Key Features of DRESS:
1) Skin Rash:
The rash is often widespread and can range from mild to severe, resembling measles or morbilliform eruptions (=90% of drug exanthems).
2) Eosinophilia:
Elevated levels of eosinophils (a type of white blood cell) are found in the blood, which is a key marker of the immune system’s response to the drug.
3) Systemic Symptoms:
Multiple organs are affected, including the liver, kidneys, lungs, and heart.
Common systemic symptoms include fever, lymphadenopathy (swollen lymph nodes), hepatitis, and nephritis.
4)Delayed Onset:
DRESS typically occurs 2-8 weeks after starting the offending drug, making it different from other drug reactions that happen more quickly.
Apart from eosinophilia and elevated LFTs, what diagnostic test abnormalities are commonly seen in DRESS? List 2.
Leukocytosis
Thrombocytosis
Elevated creatinine or proteinuria
Chest x-ray pulmonary infiltrate, pleural effusion, acute respiratory distress syndrome
The patient has been hydrated and given antipyretics and the offending agent has been stopped. What is the generally accepted treatment of choice?
Systemic corticosteroids (IV corticosteroids like methylprednisolone)
Empiric antibiotics should be provided to this patient who is suspected of having DRESS syndrome. True or false?
False
What additional pharmacotherapy can be considered if there is an inadequate response? List 2.
Intravenous immunoglobulin
Plasmapheresis
Immunosuppressive agents
N-acetyl cysteine
MODY is most often an autosomal dominant inherited disorder. True or false?
True.
MODY is a rare form autosomal dominant inherited disorder causing diabetes 2nd to a single gene mutation. NOT AUTOIMMUNE.
It is misdiagnosed as Type 1 or Type 2 diabetes in up to 80% of cases. True or false?
True.
Maturity Onset Diabetes of the Young (MODY) is distinct from type 1 and type 2 diabetes, occurring in younger individuals (typically under the age of 25).
What clinical clues could suggest the patient has MODY rather than type 2 diabetes? List three
Onset age less than 30 years
Not obese
Lacks signs of insulin resistance such as acanthosis nigricans, skin tags, androgenic alopecia or markers of metabolic syndrome.
Has a family history of diabetes in young, nonobese family members, a lack of response to metformin, a larger drop in serum glucose level with sulfonylureas and greater sensitivity to insulin.
Her initial history, exam and laboratory findings suggest MODY. What confirmatory test should be ordered?
Commercially available genetic testing
What laboratory testing results would suggest MODY? List two.
1) Absent pancreatic beta-cell autoantibodies
(in Db1, positie pancreatic beta-cell antibodies)
2) Fasting C-peptide level greater than 0.60 ng per mL
(in Db1, fasting c-peptide is
Her laboratory testing confirms MODY subtype 3. MODY subtype 3 is the most common subtype. True or false?
True.
Patients with MODY subtype 3 do not usually develop microvascular complications. True or false?
False.
MODY 2 (GCK mutation) is the least severe form, with mild, stable hyperglycemia that often does not require treatment.
MODY 1 (HNF4A mutation) is moderate in severity and requires treatment (sulfonylureas) to avoid diabetes complications (microvascular).
MODY 3 (HNF1A mutation) is the most severe of the three, with more aggressive disease progression and a higher risk of microvascular complications, often sulfonylureas not enough and need to switch to insulin.
Metformin is not a preferred pharmacologic agent. True or false?
True.
Sulfonylureas. They should be started at one-fourth of the typical starting dose to avoid hypoglycemia, then slowly titrated to achieve optimal glycemic control.
Ex:
glyburide 1.25mg po die
gliclazide 10mg po die
List 4 signs or symptoms of OIN.
Hypersomnolence, delirium, hallucinations, allodynia, hyperalgesia, myoclonus, tremor, and seizures.
OIN can be difficult to differentiate from a serotonin syndrome, especially if there has been an increase or the addition of a new serotonin agent within the last 24 hours. List 3 features that would lead you to suspect a serotonin syndrome instead of an OIN.
Autonomic hyperactivity (hyperthermia, tachycardia, mydriasis, diaphoresis, diarrhea) and neuromuscular abnormalities (tremor, hyperreflexia, muscle rigidity).
Renal failure increases the risk of OIN for this patient. List 3 other risk factors for this condition.
High dosage of opioids, dehydration, infection, end-stage disease and advanced age.
Which opioids are most commonly associated with OIN, considering that all opioids are at risk of causing OIN?
Drugs that form active metabolites such as meperidine, morphine, oxycodone, and hydromorphone.
Which drugs can increase morphine bioavailability? Name 1.
3A4 inhibitors (amiodarone, diltiazem, verapamil, grapefruit juice, antifungals).
If you choose to rotate the opioid, how would you reduce the equianalgesic dose of the new opioid?
It is recommended to reduce the calculated equianalgesic dose of the new opioid by 25 – 50% to minimize the risk of inadvertent overdose.
How would you manage this patient?
1) Dose reduction or discontinuation of opioids
2) opioid rotation (changing one opioid to another to improve pain control or reduce unwanted side effects)
3) Hydration and correction of underlying precipitants such as renal impairment.
Regarding HS, which one of the following statements is false?
A) It is a chronic immune-mediated inflammatory skin disease.
B) Prodromal systemic symptoms are uncommon.
C) The incidence is highest among those aged 18–29 years.
D) Incidence is highest for women.
B) Prodromal systemic symptoms are uncommon.
Although noninfectious, an HS abscess has many of the clinical hallmarks of an infection, such as erythema, warmth, swelling, and tenderness. This creates a challenge to differentiate it from infection without a history of multiple episodes. List 3 valuable clues to aid in differentiating HS from infection.
Localization in skin areas prototypical for HS (e.g., axillae, inframammary folds, pannus, groin, and buttocks)
Presence of comedones in these areas and a history of recurrence.
Signs of prior episodes.
Absence of lymphatic streaking.
List three other conditions you should consider in your differential diagnosis.
Cellulitis
Infected abscess
Epidermal inclusion cyst
Cystic acne
Patients with HS have higher risk of several comorbidities. List 3.
Metabolic syndrome
Polycystic ovary syndrome
Psychiatric disorders (e.g, depression, anxiety, and suicide)
Inflammatory bowel disease
spondyloarthritis
Weight loss is a consistently effective intervention to lessen HS disease activity.
False
Incision and drainage
Intralesional steroid injections
antibiotics
Tumor necrosis factor–a inhibitors (TNF-a inhibitors) (ex: humira/adalimumab)
Due to the patient’s unknown blood type, which test should be immediately performed on her child’s cord blood (or peripheral blood) to help determine the child’s risk for isoimmune hemolytic disease?
Direct antiglobulin test (Coomb’s test) –> detects IgG and complement 3 that are put on red blood cells by immune system, targeting them for destruction. Coomb’s reaggent agglutinates with IgG/complement 3.
The result for this test does not raise concern for an elevated risk for isoimmune hemolytic disease. The newborn’s complete physical examination is normal.
The female patient denies any known family history of glucose-6-phosphate dehydrogenase (G6PD) deficiency – although, she does not think anyone in her family has ever been tested for this.
Employing race-conscious medicine, is the child’s risk of G6PD deficiency greater than 1%?
Yes (13%)
At 12 hours of life, the newborn male appears jaundiced. Which test should be used to determine the severity of the child’s hyperbilirubinemia?
Transcutaneous bilirubin concentration or total serum bilirubin concentration
The test result exceeds the standardized threshold for initiating phototherapy treatment for neonatal hyperbilirubinemia. List two other laboratory tests can be done on the child at this time to help identify hemolysis?
End-tidal carbon monoxide concentration (measures CO2 breathed out that increases with hemolysis –> bilirubin is broken down in biliverdin and CO2)
AND
hemoglobin concentration, OR
hematocrit, OR
complete blood count (no acceptable as a CCFP answer)
These tests are completed; significant hemolysis is not identified.
Prior to initiating phototherapy on the newborn, the mother expresses hesitancy due to a fear that phototherapy may lead to an increased risk of childhood epilepsy. She enquires about the use of direct exposure to sunlight instead of using LED phototherapy.
Is there evidence that phototherapy may lead to an increase in the risk of subsequent childhood epilepsy?
Yes
Is direct exposure to sunlight a reliable therapeutic tool for treating neonatal hyperbilirubinemia?
No
Following your discussion with the mother, she consents to initiating LED phototherapy with her child.
Following 24 hours of “single-sided” (“standard”) phototherapy, the child’s bilirubin levels are below the standardized phototherapy treatment threshold. Nevertheless, you discuss continuation of phototherapy with the mother due to the risk of rebound hyperbilirubinemia.
Gestational age <38 weeks, OR
Age <48 hours at the start of phototherapy, OR
Hemolytic disease
What laboratory assessment should be done to determine if phototherapy is indicated?
Total serum bilirubin concentration
This test result reveals that phototherapy is indicated. The mother consents to initiation of LED phototherapy. Following 12 hours of “double-sided” (“intensive”) phototherapy, laboratory assessment of his bilirubin levels reveal increasing hyperbilirubinemia (>150µmol/L) higher than the prior laboratory assessment).
Assuming that only bilirubin levels have been assessed so far in the child, list three other laboratory assessments are indicated to assess for the cause and severity of hemolysis?
DAT (Direct antiglobulin test or Coomb’s Test)
G6PD activity (assess G6PD deficiency)
[End-tidal carbon monoxide concentration AND
hemoglobin concentration]
