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Family Medicine > Common presenting problems > Flashcards

Common presenting problems Flashcards

1
Q

What must you rule out in patients 50+ years old presenting with abdominal pain?

A

AAA

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2
Q

What is allergic rhinitis

A

Inflammation of the nasal mucosa that is triggered by an allergic reaction

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3
Q

What are different classifications of allergic rhinitis

A

seasonal
◆ symptoms during a specific time of the year
◆ common allergens: trees, grass and weed pollens, airborne moulds

perennial
◆ symptoms throughout the year with variation in severity
◆ common allergens: dust mites, animal dander, moulds

• persistent allergic rhinitis may lead to chronic rhinosinusitis

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4
Q

Allergic rhinitis differential diagnosis

A
  • Acute viral infection
  • Vasomotor rhinitis
  • Deviated septum
  • Nasal polyps
  • Acute/chronic sinusitis
  • Drug-induced rhinitis
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5
Q

What is rhinitis medicamentosa

A

Rebound nasal congestion.

Occurs with prolonged use (>5-7 d) of vasoconstrictive
intranasal medications.

Patient may become dependent, requiring more frequent dosing to achieve the same decongestant effect

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6
Q

What is the pathophysiology of allergic rhinitis

A

increased IgE levels to certain allergens
→ excessive degranulation of mast cells
→ release of inflammatory mediators (e.g. histamine) and cytokines
→ local inflammatory reaction

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7
Q

What other conditions is allergic rhinitis associated with

A

asthma

eczema

sinusitis

otitis media

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8
Q

Allergic rhinitis management

A
  1. Conservative - minimize exposure, hygiene, saline nasal rinses
  2. Oral antihistamines (first line therapy for mild symptoms)
    Cetirizine (Reactine)
    Fexofenadine (Allegra)
    Loratadine (Claritin)
  3. Intranasal corticosteroids for moderate/severe or persistent symptoms (>1 mo of consistent use to
    see results)
  4. Intranasal decongestants (use must be limited to <5 d to avoid rhinitis medicamentosa)
  5. Allergy skin testing
    ■ for patients with chronic rhinitis
    ■ symptoms not controlled by allergen avoidance, pharmacological therapy
    ■ may identify allergens to include in immunotherapy treatment
  6. Immunotherapy (allergy shots)
    ■ reserved for severe cases unresponsive to pharmacologic agents
    ■ consists of periodic (usually weekly) subcutaneous injections of custom prepared solutions of one or
    more antigens to which the patient is allergic
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9
Q

Symptoms of generalized anxiety disorder

A 
AND I C REST
Anxious, nervous, or worried
No control over the worry
Duration >6 mo
Irritability
Concentration impairment
Restlessness
Energy decreased
Sleep impairment
Tension in muscles
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10
Q

What is the precursor to asthma

A

cannot be diagnosed at first presentation; called reactive airway disease until recurrent presentations

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11
Q

When can a child begin to do PFTs

A

pulmonary function tests (PFTs) can be done from age 6 or when child able to follow instructions to
do PFTs

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12
Q

What can be used to monitor asthma in the outpatient setting

A

Peak flow meter

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13
Q

When someone has a cough in asthma when is it typically exacerbated

A

Worse in cold, at night, and in early AM

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14
Q

COPD management ladder

A

Mild
Step 1: SABA prn (salbutamol)
Step 2: SABA prn + LAAC (i.e. tiotropium)
or + LABA (e.g. salmeterol)

Moderate
Step 3: SABA prn + LAAC + low-dose combined
ICS/LABA
consider inhaled vs. oral steroids

Severe
Step 4: ± theophylline
Pneumococcal vaccination, annual influenza
immunization

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15
Q

Asthma management ladder

A

Ongoing patient education, and environmental
control

SABA taken prn as rescue medication + maintenance meds

Maintenance medications
Step 1: Low-dose ICS

Step 2: Medium/high dose ICS
or low-dose ICS plus either LABA, LT modifier, or long-acting theophylline

Step 3: Medium/high-dose ICS plus either LABA, LT
modifier, or long-acting theophylline

Step 4: As above plus immunotherapy ± oral
glucocorticosteroids
+ pneumococcal vaccination, annual influenza immunization

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16
Q

What is the benefit of using aerosol puffers with spacers

A

Aerosols (puffers=MDI, MDI + spacer)

MDIs should be used with spacers to:
• Reduce side effects
• Improve amount inhaled
• Increase efficiency of use

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17
Q

In what population is dry powder inhalers often not used and why

A

Dry Powder Inhalers (discus, turbuhaler,
and diskhaler) require deep and fast
breathing (may not be ideal for children)

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18
Q

What is your differential diagnosis for wheezing

A 
• Allergies, anaphylaxis
• Asthma, reactive airway disease
• GERD
• Infections (bronchitis, pneumonia)
• Obstructive Sleep Apnea
• COPD
• Less common: congestive heart disease,
foreign body, malignancy, cystic fibrosis,
vocal cord dysfunction
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19
Q

What electrolyte abnormality is associated with Salbutamol and how does it present

A

lethargy, irritability

paresthesias, myalgias, weakness

palpitations, N/V, polyuria

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20
Q

What is the pathophysiology of BPH

A

hyperplasia of the stroma and epithelium in the periurethral transition zone

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21
Q

What is the meaning of different PSA values

A

◆ <4.0 ng/mL: normal, but must take into account patient’s age and velocity of PSA increase

◆ 4-10 ng/mL: consider measuring free/total PSA
◆ >10 ng/mL: high likelihood of prostate pathology

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22
Q

When is PSA testing inappropriate

A

PSA testing is inappropriate in men with a life expectancy less than 10 yr or patients with prostatitis,
UTI

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23
Q

What investigations should be completed for BPH

A

■ Urinalysis - exclude UTI and for microscopic hematuria (common sign)
■ Cr, BUN
■ post-void residual volume by ultrasound
■ urodynamic studies, renal ultrasound
■ patient voiding diary

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24
Q

What are late complications of BPH

A

Hydronephrosis

Loss of renal concentrating ability

Systemic acidosis

Renal failure

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25
Q

Management for mild or non bothersome BPH

A

■ fluid restriction (avoid alcohol and caffeine)

■ avoidance/monitoring of certain medications (e.g. antihistamines, diuretics, antidepressants,
decongestants)

■ pelvic floor/Kegel exercises

■ bladder retraining (scheduled voiding)

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26
Q

Pharmacological therapy for moderate/severe BPH symptoms

A

■ α-receptor antagonists (e.g. terazosin [Hytrin®], doxazosin [Cardura®], tamsulosin [Flomax®],
alfuzosin [Xatral®])
◆ relaxation of smooth muscle around the prostate and bladder neck

■ 5-α reductase inhibitor (e.g finasteride [Proscar®])
◆ only for patients with demonstrated prostatic enlargement due to BPH
◆ inhibits enzyme responsible for conversion of testosterone into dihydrotestosterone (DHT) thus
reducing growth of prostate

■ phytotherapy (e.g saw palmetto berry extract, Pygeum africanum)
◆ more studies required before this can be recommended as standard therapy (considered safe)

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27
Q

Surgical management options for BPH

A

TURP (transurethral resection of the prostate)

TUIP (transurethral incision of the prostate, for
prostates <30 g)

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28
Q

Absolute indications for surgical management of BPH

A

failed medical therapy

intractable urinary retention

benign prostatic obstruction leading to renal insufficiency

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29
Q

Surgical management of BPH potential complications

A

impotence

incontinence

ejaculatory difficulties (retrograde ejaculation)

decreased libido

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30
Q

What is the definition of acute bronchitis

A

acute infection of the tracheobronchial tree causing inflammation leading to bronchial edema and
mucus formation

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31
Q

Clinical triad of pericarditis

A

Pleuritic chest pain (increases with inspiration or when
reclining, and is lessened by leaning forward)

Pericardial friction rub

ECG changes (diffuse ST segment elevation and PR interval depression without T wave inversion

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32
Q

How can MI present in elderly females?

A

Elderly women can often present with dizziness, lightheadedness, back pain, or weakness, in the absence of chest pain

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33
Q

How can MI present in diabetic patients?

A

May present with dyspnea, syncope, and

fatigue in the absence of chest pain

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34
Q

Management of angina/ischemic heart disease?

A

nitroglycerin (NTG): wait 5 min between sprays and if no effect after 3 sprays, send to ED

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35
Q

Management of myocardial infarction?

A

■ ASA (160-325 mg, chewed stat), clopidogrel (Plavix®), LMWH (enoxaparin)

■ morphine, oxygen, NTG

■ ± reperfusion therapy with fibrinolytics if within 12 h (ideally <30 min)
or percutaneous intervention (cath lab) if <90 min

■ start β-blocker (e.g. metoprolol starting dose 25 mg PO q6h or bid, titrating to HR goal of 55-60 bpm)

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36
Q

Flu vs cold?

A

Onset
Sudden vs slow

Fever
High vs none

Exhaustion
Severe vs mild

Cough
Dry, severe or hacking vs might have

Throat
Fine vs sore

Nose
Dry vs runny

Head
Achy vs headache free

Appetite
Decreased vs normal

Muscles
Achy vs fine

Chills
Yes vs no

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37
Q

What is the role of echinacea in preventing and treating the common cold?

A

Echinacea products have not been shown to
provide benefits for treating colds, although it is possible
here is a weak benefit from some Echinacea products.

Individual prophylaxis trials consistently show positive (if
no -sign ficant) trends, although potential effects are of
questionable clinical relevance

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38
Q

What is the definition of the common cold (acute rhinitis)

A

viral URTI with inflammation

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39
Q

Most common organism that causes acute rhinitis

A

Rhinovirus

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40
Q

Clinical features of acute rhinitis

A

symptoms
■ local: nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough
■ general: malaise, headache, myalgias, mild fever

signs
■ erythematous nasal/oropharyngeal mucosa, enlarged lymph nodes
■ normal chest exam

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41
Q

Complications of acute rhinitis

A

■ secondary bacterial infection: otitis media, sinusitis, bronchitis, pneumonia

■ asthma/COPD exacerbation

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42
Q

Acute rhinitis management

A

• patient education
■ symptoms peak at 1-3 d and usually subside within 1 wk
■ cough may persist for days to weeks after other symptoms disappear
■ no antibiotics indicated because of viral etiology
■ secondary bacterial infection can present within 3-10 d after onset of cold symptoms

• prevention
■ frequent hand washing, avoidance of hand to mucous membrane contact, use of surface disinfectant
■ yearly influenza vaccination

• symptomatic relief
■ rest, hydration, gargling warm salt water, steam, nasal irrigation (spray/pot)
■ analgesics and antipyretics: acetaminophen, ASA (not in children because risk of Reye’s syndrome)
■ cough suppression: dextromethorphan or codeine if necessary (children under 6 yr of age should
not use any cough/cold medications)
■ decongestants, antihistamines

• patients with reactive airway disease will require increased use of bronchodilators and inhaled steroids

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43
Q

When can hormonal emergency contraception be used to be effective

A

If taken within 72 h of unprotected intercourse (reduces chance of pregnancy by 75-85%)

Most effective if taken within 24 h

Does not affect an established pregnancy

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44
Q

When can copper IUD emergency contraception be used to be effective

A 
Copper IUDs inserted within 5 d of unprotected intercourse are significantly more effective than
hormonal EC (reduces chance of pregnancy by ~99%)
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45
Q

What are the leading causes of dementia (major neurocognitive disorder)

A

Alzheimer’s dementia (40-50%)

Mixed dementia (20-25%)

Lewy-Body dementia (5-15%)

Vascular dementia (5-10%)

Frontotemporal dementia (5-10%)

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46
Q

What percentage of Canadians live with dementia and what is the risk rate

A

15% of Canadians ≥65 yr are living with dementia

risk for dementia doubles every 5 years after age 65

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47
Q

What types of dementia have a higher prevalence of depression

A

Vascular and mixed dementias have a higher prevalence of depression

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48
Q

Dementia quick screen procedure and scoring

A

Dementia quick screen = mini cog + animal naming

Mini Cog = 3-word recall + clock drawing
• Clock Drawing – including numbers and
hands so time shows 10 min past 11
(normal = correct number/hand placing
or only minor spacing problems)
• 0 word recall = impairment
•1-2 words and clock drawing abnormal = impairment
•3-word recall = normal.

• Naming animals in 1 min (normal = >15
in one min)

  • Interpretation: If all 3 results within normal range, cognitive impairment unlikely
  • Return for further evaluation if:
  • <15 animals named
  • 0-1 words recalled
  • Clock Drawing Abnormal
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49
Q

Pharmacological management for dementia

A

NMDA receptor antagonists and cholinesterase inhibitors slow rate of cognitive decline

low-dose neuroleptics and antidepressants can be used to treat behavioural and emotional symptoms (20% develop clinical depression)

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50
Q

Criteria for depression

A

Criteria for Depression (≥5/9 with at least one
of anhedonia or depressed mood for ≥2 wk)

M-SIGECAPS
M Depressed Mood
S Increased/decreased Sleep
I Decreased Interest
G Guilt
E Decreased Energy
C Decreased Concentration
A Increased/decreased Appetite and weight
P Psychomotor agitation/retardation
S Suicidal ideation
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51
Q

You start a patient on antidepressant therapy. When would you expect improvement/when would you take different action for management?

A

reassessment and referral recommended if no improvement after 6-8 wk of treatment

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52
Q

Examples of SSRIs

A 
paroxetine (Paxil®)
fluoxetine (Prozac®)
sertraline (Zoloft®)
citalopram (Celexa®)
fluvoxamine (Luvox®)
escitalopram (Cipralex®)
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53
Q

SSRI MOA

A

Block serotonin reuptake

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54
Q

SSRI side effects

A

Sexual dysfunction

Headache

GI upset, weight loss

Tremors

Insomnia, fatigue

Increase QT interval (baseline ECG is suggested)

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55
Q

Which SSRIs are generally used or avoided in youth

A

First line therapy for youth is fluoxetine

Paroxetine is not recommended for youth (controversial)

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56
Q

What are examples of SNRIs

A

venlafaxine (Effexor®)

duloxetine (Cymbalta®)

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57
Q

SNRI MOA

A

Block serotonin and NE reuptake

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58
Q

SNRI side effects

A

Insomnia, tremors, tachycardia,

sweating

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59
Q

SDRI examples

A

bupropion

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60
Q

SDRI MOA

A

Block dopamine and NE reuptake

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61
Q

SDRI side effects

A

Headache, insomnia, nightmares

Seizures

Less sexual dysfunction than SSRIs

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62
Q

What is the usual indication for using an SDRI

A

Often chosen for lack of sexual side effects, can be used for augmentation of anti-depressant effects with other classes of medication

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63
Q

TCA examples

A

Amitriptyline

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64
Q

TCA MOA

A

Block serotonin and NE reuptake

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65
Q

TCA side effects

A

Sexual dysfunction

weight gain

tremors, tachycardia, sweating

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66
Q

What is an important consideration when prescribing TCAs

A

Narrow therapeutic window, lethal in overdose

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67
Q

What is the prognosis of depression

A
  • up to 40% resolve spontaneously within 6-12 mo

* risks of recurrence: 50% after 1 episode; 70% after 2 episodes; 90% after 3 episodes

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68
Q

Hyperglycemia symptoms

A

Polyphagia, polydipsia, polyuria

Weight change

Blurry vision

Yeast infections

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69
Q

DKA symptoms

A

fruity breath

anorexia, N/V, abdominal pain

fatigue

Kussmaul breathing

dehydration

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70
Q

Hypoglycemia symptoms

A

Hunger

anxiety, tremors, palpitations, sweating, headache

fatigue

confusion, seizures, coma

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71
Q

Diabetes mellitus definition

A

metabolic disorder characterized by the presence of hyperglycemia due to defection insulin secretion,
defective insulin action or both

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72
Q

Micro and macrovascular complications of diabetes

A
  • Microvascular: nephropathy, retinopathy, neuropathy

* Macrovascular: CAD, CVD, PVD

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73
Q

What are medications that are risk factors for diabetes mellitus

A

glucocorticoids

atypical antipsychotics

HAART

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74
Q

Who should be screened for T2DM

A

■ FBG in everyone ≥40 q3yr, or at high risk using the CANRISK calculator
■ more frequent and/or earlier testing if presence of ≥1 risk factor (see above)

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75
Q

How to calculate total insulin units required per day

A

type 1 DM: 0.5-0.7 units/kg/d

type 2 DM: 0.3 units/kg/d

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76
Q

When should ophthalmology consult occur for patients with diabetes

A

type 1 DM within 5 yr

type 2 DM at diagnosis

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77
Q

By how much can diet affect HBA1c

A

Decrease HbA1c by 1-2%

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78
Q

How often should patient be monitoring their sugars

A

type 1 DM: 3 or more self-tests/d is associated with a 1% reduction in HbA1c
• type 2 DM: recommendations vary based on treatment regimen

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79
Q

What to do if FBG >14 mmol/L

A

perform ketone testing to rule out DKA

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80
Q

What to do if bedtime sugar level is <7 mmol/L

A

have bedtime snack to reduce risk of nocturnal hypoglycemia

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81
Q

Management of T2DM with monitoring by HBA1C

A
  1. Diagnosis - Start lifestyle intervention (nutrition therapy and physical activity) ± Metformin
  2. If A1C <8.5% - start or increase Metformin if do not hit glycemic target in 2-3 months
  3. If A1C 8.5% + start metformin immediately
    Conside initial combination with another antihyperglycemic agent
  4. If symptomatic or metabolic decompensation then start insulin +/- metformin immediately
  5. For all of these above, if not at glycemic targets add another agent based on patient characteristics

Clinical cardiovascular disease –> add SGLT2 inhibitor with demostrated CV outcome benefit

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82
Q

Insulin side effects

A

Risk of hypoglycemia

Weight gain

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83
Q

Insulin secretagogue (Meglitinide, sulfonylureas) side effects

A

Risk of hypoglycemia

Some weight gain

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84
Q

Examples of sulfonylureas

A

Gliclazide

Glyburide

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85
Q

acarbose side effects

A

gi side effects

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86
Q

SGLT2 inhibitors side effects

A

Genital infections, UTI

hypotension

dose related changes in LDL-C

caution with renal dysfunction and loop diuretics

dapagliflozin not to be used if bladder cancer

rare diabetic ketoacidosis (may occur with no
hyperglycemia)

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87
Q

Thiazolidediones side effects

A

CHF, edema

fractures

rare bladder cancer (ploglitazone)

cardiovascular controversy (rosiglitazone)

6-12 wk required for max effect

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88
Q

What are ototoxic drugs that can cause dizziness

A

Aminoglycosides (gentamicin, streptomycin, tobramycin)

Erythromycin

ASA

antimalarials

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89
Q

Screening tools for domestic violence

A 
Woman Abuse Screening Tool
 (WAST)-SHORT
1. In general how would you
describe your relationship?
a. A lot of tension
b. Some tension
c. No tension
2. Do you and your partner work out
arguments with . . .?
a. Great difficulty
b. Some difficulty
c. No difficulty

Endorsing either question 1 (“a lot of tension”)
or question 2 (“great difficulty”) makes
intimate partner violence exposure likely

B) HITS
How often does your partner:
1. Physically hurt you?
2 Insult you?
3 Threaten you with harm?
4. Scream or curse at you?

Each question on HITS to be answered on a 5
point scale ranging from 1
(= never) to 5 (= frequently)
A total score of 10.5 is significant

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90
Q

What are the medicolegal guidelines for dealing with partner and child abuse

A

reporting suspected or known child abuse is mandatory

spousal abuse is a criminal act, but not reportable without the woman’s/man’s permission

DOCUMENT all evidence of abuse-related visits for medico-legal purposes

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91
Q

H. Pylori eradication treatment with quadruple therapy

A

1) PPI 1 tablet 2x/d for 10 d and
2) Amoxicillin 1 g twice a day for 5 d (day 1-5)

Followed by

3) Clarithromycin 500 mg 2x/d (day 6-10) and
4) Metronidazole 500 mg 2x/d (day 6-10

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92
Q

What is the cardiovascular risk of Rosiglitazone

A

Rosiglitazone continues to demonstrate
increased risk of MIs, though it is not associated
with increased risk of CV or all-cause mortality

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93
Q

Pharmacological management of dyspepsia

A

■gastric acid suppression: H2 blockers, PPI’s
both are effective for PUD and GERD

■ prokinetics: e.g. Metoclopramide
effective for functional dyspepsia

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94
Q

What needs to be done to keep a patient on a PPI

A

do not keep patients on PPI without at least 1 trial off the medication per year

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95
Q

Investigations in dyspepsia

A

for new onset dyspepsia, test for H. pylori using the urea breath test or serology

upper endoscopy (preferred), upper GI series (not in patients with alarm symptoms)

for non-responders, gastroscopy should be considered

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96
Q

Indications for treatment for urinary symptoms

A
  • Dysuria
  • +Leukocytes
  • +Nitrites

If 2 or more criteria MET, then treat without culture, otherwise culture required prior to treatment

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97
Q

Most common etiology of UTI/cystitis

A 
KEEPS bacteria (Klebsiella, E. coli, Enterobacter,
Proteus mirabilis, Pseudomonas, S. saprophyticus)
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98
Q

vardenafil (Levitra®) dosing, routine, side effects, contraindications

A

2.5-20 mg/dose

Take 1 h prior to intercourse

As above

As above

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99
Q

Most common etiology of urethritis

A

C. trachomatis, N. gonorrhoeae, Trichomonas,

Candida, herpes

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100
Q

Urethritis presentation

A

Initial dysuria, urethral/vaginal discharge, history of STI

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101
Q

Vaginitis most common etiology

A

Candida, Gardnerella, Trichomonas, C. trachomatis,

atrophic, herpes, lichen sclerosis

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102
Q

Vaginitis presentation

A

External dysuria/pain, vaginal discharge, irritation,

dyspareunia, abnormal vaginal bleeding

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103
Q

Prostatitis most common etiology

A

E. coli, C. trachomatis, S. saprophyticus, Proteus

mirabilis, Enterobacter, Klebsiella, Pseudomonas

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104
Q

Prostatitis presentation

A

Dysuria, fever, chills, urgency, frequency, tender prostate,

rectal pain

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105
Q

Headache red flags

A

SNOOP

Systemic symptoms of illness
• fever
• anticoagulation
• pregnancy
• cancer
Neurologic signs/symptoms
• impaired mental status
• neck stiffness
• seizures
• focal neurological deficits

Onset
• sudden and severe
• new headache after age 50

Other associated conditions
• following head trauma
• awakens patient from sleep
• jaw claudication
• scalp tenderness
• worse with exercise, sexual activity or
Valsalva

Prior headache history
• different pattern
• rapidly progressing in severity/frequency

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106
Q

Tips for prevention of UTIs

A

•Maintain good hydration (especially with
cranberry juice) (recommendation level I)

• Wipe urethra from front to back to avoid
contamination of the urethra with feces
from the rectum

• Avoid feminine hygiene sprays and scented
douches

• Empty bladder immediately before and after
intercourse

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107
Q

Follow up for pregnant patients with UTI/cystitis

A

need to follow with monthly urine cultures and retreat if still infected

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108
Q

Indications for prophylactic antibiotics in UTI/cystitis

A

patients with recurrent UTIs (>3/yr) should be considered for prophylactic antibiotics

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109
Q

Follow up for urethritis

A

■ when swab or PCR is positive for chlamydia or gonorrhea must report to Public Health

■ all patients should return 4-7 d after completion of therapy for clinical evaluation

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110
Q

Erectile dysfunction definition

A

consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual
performance of ≥3 mo duration

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111
Q

Erectile dysfunction etiology

A

• organic:
vascular (90%) (arterial insufficiency, atherosclerosis)
endocrine (low testosterone, DM)
anatomic (structural abnormality, e.g. Peyronie’s)
neurologic (post-operative, DM)
medications (clonidine, antihypertensives, psychotropics)

• psychogenic (10%)

PENIS
Psychogenic
Endocrine (type 2 DM, testosterone)
Neurogenic (type 2 DM, post-operative)
Insufficiency of blood (atherosclerosis)
Substances
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112
Q

Examples of hypoglycemic agents used in T2DM

A

oral
■ biguanide: metformin (Glucophage®)
■ thiazolidinedione: troglitazone (Rezulin®), rosiglitazone (Avandia®)
■ α-glucosidase inhibitor: acarbose (Precose®)
■ nonsulfonylureas: nateglinide (Starlix®), repaglinide (Gluconorm®)
■ sulfonylureas: glyburide (DiaBeta®), glimepiride (Amaryl®), gliclazide (Diamicron®)
■ DPP-4 inhibitor: sitagliptin (Januvia®)

injectable
■ GLP-1 analogue: liraglutide (Victoza®)

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113
Q

Indications for ACEi/Arb use in DM2 patients

A

■ clinical macrovascular disease
■ age ≥55
■ age <55 and microvascular complications

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114
Q

Indications for statin use in DM2 patients

A 
■ clinical macrovascular disease
■ age ≥40
■ age <40 and any of the following:
- diabetes duration >15 yr and age >30 yr
- microvascular complications
- other cardiovascular risk factors
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115
Q

Indications for low dose ASA (81-325 mg) in DM2 patients

A

For secondary prevention in people with established CVD (NOT to be used routinely for primary
prevention)

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116
Q

What is the cardiovascular risk of Rosiglitazone

A

Rosiglitazone continues to demonstrate
increased risk of MIs, though it is not associated
with increased risk of CV or all-cause mortality

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117
Q

What are pharmacological treatments for erectile dysfunction

A

■ phosphodiesterase type 5 inhibitors

■ α-adrenergic blockers (eg yohimbine)

■ serotonin antagonist and reuptake inhibitor (e.g. trazodone)

■ testosterone

118
Q

What are absolute contraindications to testosterone supplementation

A

Breast/postate cancer are absolute contraindications

119
Q

What is indication for testosterone administration

A

currently only indicated in patients presenting with hypogonadism and testosterone deficiency

120
Q

Sildenafil (Viagara) dosing, routine, side effects, contraindications

A

25-100 mg/dose

Take 0.5-4 h prior to intercourse
May last 24 h

Flushing, headache, indigestion

Not to be used in patients taking nitrates

121
Q

Taldalafil (Cialis) dosing, routine, side effects, contraindications

A

5-20 mg/dose

Effects may last 36 h

As above

As above

122
Q

vardenafil (Levitra®) dosing, routine, side effects, contraindications

A

2.5-20 mg/dose

Take 1 h prior to intercourse

As above

As above

123
Q

Chronic fatigue syndrome criteria

A

must meet both criteria

  1. new or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not
    relieved by rest, which results in occupational, educational, social, or personal dysfunction
  2. concurrent presence of ≥4 of the following symptoms for a minimum of 6 mo
    ■ impairment of short-term memory or concentration, severe enough to cause significant decline in
    function
    ■ sore throat
    ■ tender cervical or axillary lymph nodes
    ■ muscle pain
    ■ multi-joint pain with no swelling or redness
    ■ new headache
    ■ unrefreshing sleep
    ■ post-exertion malaise lasting >24 h

• exclusion criteria: medical conditions that may explain the fatigue, certain psychiatric disorders
(depression with psychotic or melancholic features, schizophrenia, eating disorders), substance abuse,
severe obesity (BMI >45)

124
Q

Role of exercise therapy in chronic fatigue syndrome

A

Exercise therapy may be beneficial
to overall health and may decrease fatigue in CFS
patients, and is not associated with worsening
outcomes. Therapy may also have a positive impact
on sleep, physical function and self-perceived
general health. In general, exercise therapy appears
more effective than pacing strategies, and similar
to CBT.

125
Q

When can tympanic membrane temp be used

A

• TM not accurate for measurement until child is >5 yr

126
Q

Route of temperature measurement for children <2

A

fever in children under 2 must be a rectal temperature for accuracy

127
Q

Definition of a fever

A

oral temperature >37.2°C (AM), 37.7°C (PM)

128
Q

Migraine screen history

A 
POUND
Pulsatile quality
Over 4-72 h
Unilateral
Nausea and vomiting
Disabling intensity

if ≥4 present then a diagnosis is likely

129
Q

Headache red flags

A

SNOOP

Systemic symptoms of illness
• fever
• anticoagulation
• pregnancy
• cancer
Neurologic signs/symptoms
• impaired mental status
• neck stiffness
• seizures
• focal neurological deficits

Onset
• sudden and severe
• new headache after age 50

Other associated conditions
• following head trauma
• awakens patient from sleep
• jaw claudication
• scalp tenderness
• worse with exercise, sexual activity or
Valsalva

Prior headache history
• different pattern
• rapidly progressing in severity/frequency

130
Q

Migraine duration

A

4-72 hours

131
Q

Symptoms of HTN

A

Symptoms of HTN are usually NOT PRESENT
(this is why it is called the “silent killer”)

May have occipital headache upon awakening
or organ-specific complaints if advanced
disease

132
Q

Cluster h/a duration

A

<3 h at same time of day

133
Q

Caffeine withdrawal h/a duration

A

Begins 12-24 h after last caffeine intake, can last ~1 wk

134
Q

Migraine pain description

A

Classically unilateral and pulsatile, but 40% are
bilateral

moderate-severe intensity

N/V, photo-/phonophobia

135
Q

Migraine triggers

A 
Numerous (e.g. food, sleep
disturbance, stress,
hormonal, fatigue, weather,
high altitude)
Aggravated by physical
activity
136
Q

Acute migraine management

A

1st line: acetaminophen, NSAIDs, ASA ± caffeine

2nd line: NSAIDs

3rd line: 5-HT agonists± antiemetic

137
Q

Migraine prophylactic therapy

A

1st line: β blockers
2nd line: TCAs
3rd line anticonvulsants

138
Q

Tension h/a pain description

A

Mild to moderate pain

bilateral, fronto-occipital or generalized pain, band-like
pain

± contracted neck, scalp muscles

associated with little disability

139
Q

Tension h/a triggers

A

Stressful events NOT
aggravated by physical
activity

140
Q

Tension h/a acute treatment

A

Rest and relaxation

NSAIDs or acetaminophen

141
Q

Tension h/a prophylactic therapy

A

Rest and relaxation, physical activity, biofeedback

142
Q

Cluster h/a pain description

A

Sudden, unilateral, severe, usually centred around eye

frequently awakens patient

Associated conjunctival injection and tearing

“Suicide” headache

143
Q

Cluster h/a triggers

A

Often alcohol

144
Q

Cluster h/a acute treatment

A

Sumatriptan

Dihydroergotamine

High-flow O2

Intranasal lidocaine

145
Q

What investigations should a patient with a suspected pheochromocytoma causing hypertension undergo

A

24 h urine for metanephrines and creatinine

146
Q

Caffeine withdrawal h/a pain description

A

Severe, throbbing

associated with drowsiness, anxiety, muscle stiffness, nausea, waves of hot or cold sensations

147
Q

Caffeine withdrawal h/a acute treatment

A

Caffeine

Acetaminophen or ASA ± caffeine

148
Q

Caffeine withdrawal h/a prophylactic therapy

A

Cut down on caffeine

149
Q

Role of acupuncture in migraine prophylaxis

A

Adding acupuncture to symptomatic treatment of attacks reduces frequency of headaches. Acupuncture is more effective than sham, and is similarly effective to pharmacological interventions for migraine prophylaxis.

150
Q

Appropriate screening for hearing impairment in elderly patients

A

Elderly patients acknowledging a hearing impairment require audiometry, while those
who indicate they do not have hearing impairment
should be screened with a whispered voice-test

A normal whispered voice-test requires no further
workup

Those unable to perceive the whisper require audiometry

Weber and Rinne tests are not suitable for general hearing impairment screening

151
Q

How to complete whipered voice test

A

Whisper 6 test words 6 in-2 ft away from the patient’s ear out of the visual field, ask patient to
repeat the words (with non-test ear distraction)

152
Q

What investigations should be conducted in patients with unexplained sensorineural hearing loss

A

blood sugar

CBC and differential

TSH

syphilis testing

153
Q

Management of sudden sensorineural hearing loss

A

High dose oral steroids and urgent ENT referral

154
Q

Management of progressive assymetrical sensorineural hearing loss

A

MRI/CT scan to exclude vestibular schwannoma (acoustic neuroma)

155
Q

Symptoms of HTN

A

Symptoms of HTN are usually NOT PRESENT
(this is why it is called the “silent killer”)

May have occipital headache upon awakening
or organ-specific complaints if advanced
disease

156
Q

What antihypertensive combinations are not recommended

A

■ caution with combination of non-DHP CCB and β-blocker

■ combination of ACEI and ARB is not recommended

157
Q

Hypertension definition

A

BP ≥140/90 mmHg, unless DM (≥130/80 mmHg), or age ≥80 yr (≥150/90 mmHg)

158
Q

Hypertensive urgency definition

A

BP >210 or dBP >120 with minimal or no target organ damage

159
Q

Hypertensive emergency definition

A

severe HTN (dBP > 120) + acute target-organ damage

160
Q

Accelerated HTN definition

A

significant recent increase in BP over previous hypertensive levels associated with evidence of
vascular damage on fundoscopy, but without papilledema

161
Q

Malignant HTN definition

A

sufficient elevation in BP to cause papilledema and other manifestations of vascular damage
(retinal hemorrhages, bulging discs, mental status changes, increasing creatinine)

162
Q

When should you suspect hyperaldosteronism

A

Suspect Hyperaldosteronism when

  • HTN refractory to treatment with ≥3 drugs
  • Spontaneous hypokalemia

• Profound diuretic-induced hypokalemia
(<3.0 mmol/L)

• Incidental adrenal adenomas

163
Q

Types of hypertensive emergencies

A

• Malignant HTN

• Cerebrovascular
Hypertensive encephalopathy
Stroke
Intracerebral hemorrhage
SAH
• Cardiac
Acute aortic dissection
Acute refractory LV failure
Myocardial infarction/ischemia
Acute pulmonary edema

• Renal failure

164
Q

Causes of secondary hypertension

A

Renal

  • Renovascular HTN
  • Renal parenchymal disease, glomerulonephritis, pyelonephritis, polycystic kidney

Endocrine

  • 1º hyperaldosteronism
  • Pheochromocytoma
  • Cushing’s syndrome
  • Hyperthyroidism/hyperparathyroidism
  • Hypercalcemia of any cause

Vascular

  • Coarctation of the aorta
  • Renal artery stenosis

Drug-Induced

  • Estrogens/OCP
  • MAOIs
  • Cocaine
  • Steroids
  • Lithium
  • Amphetamines
  • NSAIDs
  • Decongestants
  • Alcohol
165
Q

What investigations should all patients with hypertension undergo

A 
electrolytes
Cr
fasting glucose and/or HbA1c
lipid profile
12-lead ECG
urinalysis

■ self-measurement of BP at home is encouraged

■ echocardiography for left ventricular dysfunction assessment if indicated

166
Q

What investigation should a patient with DM or chronic kidney disease and hypertension undergo

A

Urinary protein excretion

167
Q

What investigations should a patient with suspected renovascular hypertension undergo

A

Renal ultrasound

captopril renal scan (if GFR >60 mL/min)

MRA/CTA (if normal renal function)

168
Q

What investigations should a patient with a suspected endocrine cause of hypertension undergo

A

◆ plasma aldosterone, plasma renin (aldosterone-to-renin ratio)

◆ measured from morning samples taken from patients in sitting position after resting 15 min

◆ discontinue aldosterone antagonists, ARBs, β-blockers and clonidine prior to testing

169
Q

What investigations should a patient with a suspected pheochromocytoma causing hypertension undergo

A

24 h urine for metanephrines and creatinine

170
Q

HTN management in asthma medications to avoid

A

BB unless angina or post MI

171
Q

In what patient population should beta blockers be avoided when managing hypertension

A

Not recommended as first line for patients

of age ≥60

172
Q

In what patient population are ACEi avoided when managing hypertension

A

Not recommended as monotherapy in people

of African descent

173
Q

Examples of calcium channel blockers

A

Dihydropyridine CCBs (FAN)
• amlodipine
• nifedipine
• felodipine

Non-Dihydropyridine CCBs (Very Dull)
• diltiazem
• verapamil

174
Q

What is the premise of the DASH diet

A

reduced cholesterol and saturated fat

175
Q

Na limit for patients with hypertension

A

◆ limit daily sodium intake to 5 g or 87 mmol per day

176
Q

Role of electrolyte supplementation in patients with hypertension

A

potassium/magnesium/calcium supplementations are NOT recommended for HTN but an increase in dietary potassium may help

177
Q

When might lifestyle modification be sufficient hypertension treatment

A

may be sufficient in patients with stage 1 HTN (140-159/90-99)

178
Q

Indications for pharmacological treatment for hypertension patients

A

indications regardless of age (caution with elderly patients)

◆ dBP ≥90 mmHg with target organ damage or independent cardiovascular risk factors
◆ sBP ≥140 with target organ damage

◆ dBP ≥100 mmHg or sBP ≥160 mmHg without target organ damage or cardiovascular risk factors

179
Q

What are first line pharmacological agents for managing hypertension

A

Thiazide/thiazide-like diuretic

ACEI (for non African patients), ARB

long-acting CCB

β-blocker (if age <60)

180
Q

What antihypertensive combinations are not recommended

A

■ caution with combination of non-DHP CCB and β-blocker

■ combination of ACEI and ARB is not recommended

181
Q

You have a patient on thiazide/thiazide like diuretic monotherapy for their hypertension management, what investigations do you want to follow up on

A

be cautious of hypokalemia in patients treated with thiazide/thiazide-like diuretic monotherapy

182
Q

How to combine antihypertensives in general

A

A and B
C and D
do not go together

Every other combination of A, B, C, D
ACEi, beta blocker, CCB, diuretic

183
Q

Isolated diastolic HTN recommended treatment

A 
ACEI, ARB
β-blocker,
long-acting CCB
Thiazide diuretic
(consider ASA and statin in select patients)
184
Q

Isolate systolic HTN recommended treatment

A

ARB
long acting dihydropyridine CCB
Thiazide diuretic

185
Q

HTN treatment for patients with CAD

A

ACEI or ARB

β-blocker for patients with stable angina

186
Q

HTN treatment for patients with prior MI

A

ACEI or ARB

β-blocker

187
Q

HTN treatment for patients with LVH

A

ACEI, ARB

long-acting CCB
Thiazide diuretic

188
Q

What medications should be avoided in LVH

A

Hydralazine and minoxidil can increase LVH, thus not recommended

189
Q

HTN treatment for patients with CVA

A

ACEI, ARB

Thiazide diuretic

190
Q

HTN treatment for patients with heart failure

A

ACEI, ARB
β-blocker
Spironolactone for patients with NYHA class II - IV

191
Q

HTN treatment for patients with DM with albuminuria

A

ACEI, ARB

192
Q

Non diabetic CKD with proteinuria HTN treatment

A

ACEI, ARB

Thiazide diuretic

193
Q

HTN management in asthma

A

K sparing or thiazide diuretic for patients on Salbutamol

194
Q

HTN management in asthma medications to avoid

A

BB unless angina or post MI

195
Q

Antihypertensives to avoid in gout

A

Thiazide diurectics

196
Q

HTN management in patients that smoke

A

ACEI, ARB

Thiazide diuretic

197
Q

HTN medications to use in pregnancy

A

Hydralazine

Methyldopa

198
Q

HTN medications contraindicated in pregnancy

A

ACEi

199
Q

Management for BP >160/90

A

Labetalol

Nifedipine

200
Q

Indications for loop diuretic in HTN treatment

A

DM with albuminuria - Cr >150 use loop instead of thiazide

Non diabetic CKD with proteinuria for volume overload

201
Q

What are seropositive spondyloarthropathies

A 
RA 
SLE
Scleroderma 
Polymyositis/Dermatomyositis 
Sjögren’s syndrome
202
Q

What are seronegative spondyloarthropathies

A

Ankylosing spondylitis
Inflammatory bowel disease
Psoriatic arthritis
Reactive arthritis

203
Q

What are crystal arthropathies

A

Gout
Pseudogout
Hydroxyapatite

204
Q

Back pain red flags

A

Bowel or bladder dysfunction
Anesthesia (saddle)
Constitutional symptoms/malignancy
Chronic disease

Paresthesias
Age >50 and mild trauma
IV drug use/Infection
Neuromotor deficit

205
Q

Indications for lumbar xray in low back pain

A
  • No improvement after 6 wk
  • Fever >38oC
  • Unexplained weight loss
  • Prolonged corticosteroid use
  • Significant trauma
  • Progressive neurological deficit
  • Suspicion of ankylosing spondylitis
  • History of cancer (rule out metastases)
  • Alcohol/drug abuse (increased risk of osteomyelitis, trauma, fracture)
206
Q

What is the timeline for characterization of back pain

A

Acute <6 weeks
Subacute 6-12 weeks
Chronic >12 weeks

207
Q

Low back pain prognosis

A

90% resolve in 6 wk, <5% become chronic

208
Q

Role of spinal manipulative therapy for low back pain

A

SMT is not more effective than inert interventions, sham SMT or as an adjunct to another intervention for patients with acute low back pain, and does not appear any better than other recommended therapies either. Decision to refer patients for SMT should be based on costs, patient and provider preferences, and the relative safety of SMT relative to other reatment options.

209
Q

Role of massage in low back pain

A

Massage may be beneficial for subacute and chronic non-specific low back pain, especially in combination with exercise and education; it is more effective than classic massage.

210
Q

Acute (within 12 weeks of pain onset) management of low back pain

A
  • Educate patient that low back pain typically resolves within a few weeks (70% in 2 wks, 90% in 6 wks)
  • Prescribe self-care strategies including alternating cold and heat, continuation of usual activities as tolerated
  • Encourage early return to work
  • Recommend physical activity and/or exercise
• Consider analgesics in this order: 
» Acetaminophen (1st line) 
» NSAIDs (2nd line) 
» Short course muscle relaxants 
» Short-acting opioids (rarely, or severe pain)
  • Spinal traction, TENS not recommended
  • f/u in 1-6 weeks (symptoms and red flags) and refer if not returning to normal functioning or worsening
211
Q

Chronic (>12 weeks since pain onset) management of low back pain

A

• Prescribe physical or therapeutic exercise

• Analgesic Options 
» Acetaminophen 
» NSAIDs (consider PPI) 
» Low dose tricyclic antidepressants 
» Short term cyclobenzaprine for flare-ups

• Referral Options
» Community-based active rehabilitation program
» Community-based self management/cognitive behavioural therapy program

• Additional Options 
» Progressive muscle relaxation 
» Acupuncture 
» Massage therapy, TENS as adjunct to active therapy 
» Aqua therapy and yoga

MODERATE TO SEVERE PAIN
• Opioids

• Referral Options
» Multidisciplinary chronic pain program
» Epidural steroids (for short-term relief of radicular pain)
» Prolotherapy, facet joint injections, and surgery in carefully selected patients

212
Q

Patterns of Back Dominant pain (Pain greatest above gluteal fold)

A

Pattern 1

  • Worse with flexion
  • Constant/intermittent

Pattern 2

  • Worse with extension
  • Never worse with flexion
  • Always intermittent
213
Q

Pattern 1 back pain physical exam

A

Normal neuro exam
Fast responder - Improves with extension
Slow responder - No change or worsens with extension

214
Q

Pattern 2 back pain physical exam

A

Normal neuro exam ± improves with flexion

Worse with extension

215
Q

Pattern 1 back pain likely pathology

A

Arising from intervertebral discs or adjacent ligaments

216
Q

Pattern 2 back pain likely pathology

A

Posterior joint complex (associated ligaments and capsular structures)

217
Q

Pattern 1 back pain management

A

Scheduled extension
Lumbar roll
Night lumbar roll
Medication as required

218
Q

Pattern 2 back pain management

A

Scheduled flexion
Limited extension
Night lumbar roll
Medication as required

219
Q

Patterns of Leg Dominant (Pain greatest below gluteal fold) pain

A

Pattern 3
Pain changes with back movement/ position Currently/previously constant

Pattern 4
Worse with activity
Improves with rest and posture change
Intermittent/short duration

220
Q

Pattern 3 leg pain physical exam

A

Leg pain can improve but not disappear
Positive straight leg raise ± conduction loss
Fast responder - Improves with specific back position Slow responder - Not better with position changes

221
Q

Pattern 4 leg pain physical exam

A

No irritative findings ± conduction loss

222
Q

Pattern 3 likely diagnosis

A

Sciatica

223
Q

Pattern 4 likely diagnosis

A

Neurogenic claudication

224
Q

Pattern 3 leg pain management

A 
Prone extension
Supine “Z” lie 
Lumbar roll 
Night lumbar roll 
Medication as required
225
Q

Pattern 4 leg pain management

A 
Abdominal exercises 
Night lumbar roll 
Sustained flexion 
Pelvic tilt 
Medication as required
226
Q

Mean age of menopause

A

51.4 yr

227
Q

What are the clinical features of menopause

A

associated with estrogen deprivation

  • urogenital tract: atrophy, vaginal dryness/itching, urinary frequency/urgency/incontinence, bleeding
  • blood vessels and heart: vasomotor instability (e.g. hot flashes), increased risk of heart disease
  • bones: bone loss, joint/muscle/back pain, fractures, loss of height
  • brain: depression, irritability, mood swings, memory loss
228
Q

Menopause management

A

encourage physical exercise, smoking cessation, and a balanced diet with adequate intake/ supplementation of calcium (1,200-1,500 mg/d) and vitamin D (800-2,000 IU/d)

• hormone replacement therapy (HRT)
■ prescribe for moderate to severe symptoms for no longer than 5 yr; routine use is not recommended
■ regimens: cyclic estrogen-progestin, continuous estrogen-progestin, estrogen only (if no uterus), estrogen patch/gel/cream/ring/vaginal tablet
■ decreases risk of osteoporotic fractures, colorectal cancer
■ increases risk of breast cancer, coronary heart disease, stroke, DVT, and PE
■ initiation of HRT requires a thorough discussion of short- and long-term benefits and risks

• consider venlafaxine, SSRIs, or gabapentin to ease vasomotor instability

229
Q

Pharmacological management of osteoarthritis

A

Note: medications do not alter natural course of OA

1st line: acetaminophen up to 4 g/d (OA is not an inflammatory disorder)

2nd line: NSAIDs in the lowest effective dose for the shortest duration of time, along with gastroprotection; COX-2 selective inhibitors (celecoxib/Celebrex®, Meloxicam/Mobicox®) are recommended if long-term treatment or if high risk for serious GI problems

combination analgesics (e.g. acetaminophen and codeine)

intra-articular hyaluronic acid injections

intra-articular corticosteroid injections (no more than 3-4x/yr) may be helpful in acute flares (benefits last 4-6 wk, can be up to 6 mo)

topical NSAID (diclofenac/Pennsaid®)

capsaicin cream (Zostrix®)

oral glucosamine

230
Q

Surgical indications and management of osteoarthritis

A

Consider if persistent significant pain and functional impairment despite optimal pharmacotherapy (eg. debridement, osteotomy, total joint arthroplasty

231
Q

What are basic bone health tips that should be provided to everyone over the age of 50

A

Regular active weight-bearing exercise

Calcium (diet and supplements) 1,200 mg daily

Vitamin D 800-2,000 IU (20-50 µg) daily

Fall-prevention strategies

232
Q

What are disorders strongly associated with osteoporosis

A

Primary hyperparathyroidism

Type 1 DM

Osteogenesis imperfecta

Uncontrolled hyperthyroidism

Hypogonadism or premature menopause (<45 yr)

Cushing’s disease

Chronic malnutrition or malabsorption

Chronic liver disease

COPD

Chronic inflammatory conditions (e.g IBD)

233
Q

Who should receive initial BMD testing

A 
Age <50 years 
• Fragility fractures 
• Use of high-risk medications 
• Hypogonadism 
• Malabsorption syndromes 
• Chronic inflammatory conditions 
• Primary hyperparathyroidism 
• Other disorders strongly  associated with rapid bone  loss or fractures

Age 50-64 years
• Fragility fracture after age 40
• Prolonged use of glucocorticoids or other high-risk medications
• Parental hip fracture
• Vertebral fracture or osteopenia identified on radiography
• High alcohol intake or current smoking
• Low body weight (<60 kg) or major weight loss (>10% of body weight at age 25)
• Other disorders strongly associated with osteoporosis

All men and women 65 years +

234
Q

Management of low fracture risk (10 year <10%) in osteopenia

A

Unlikely to benefit from pharmacotherapy

Reassess risk in 5 yr

235
Q

Management of moderate fracture risk (10 year fracture risk 10-20%) in osteopenia

A

Lateral thoracolumbar radiography (T4- L4) or vertebral fracture assessment may aid in decision-making by identifying vertebral fracture

Factors warranting pharmacotherapy
• Additional vertebral fracture(s) (by vertebral fracture assessment or lateral spine radiograph)
• Previous wrist fracture in individuals aged >65 and those with T-score ≤-2.5
• Lumbar spine T-score &laquo_space;femoral neck T-score
• Rapid bone loss
• Men undergoing androgen-deprivation therapy for prostate cancer
• Women undergoing aromatase inhibitor therapy for breast cancer
• Long-term or repeated use of systemic glucocorticoids (oral or parenteral) not meeting conventional criteria for recent prolonged use
• Recurrent falls (≤2 in the past 12 mo)
• Other disorders strongly associated with osteoporosis, rapid bone loss, or fractures

Repeat BMD in 1-3 years and reassess risk

236
Q

High risk (10 yr fracture risk >20% or prior fragility fracture of hip or spine or >1 fragility fracture)

A

Good evidence of benefit from pharmacotherapy

237
Q

Alcohol intake considered at risk for osteoporosis

A

≥3 units per day

238
Q

Physical examination for osteoporosis

A

◆ height annually (prospective loss >2 cm or historical loss >6cm) and weight (weight loss >10% since age 25)

◆ rib-to-pelvis distance ≤2 fingers’ breadth

◆ occiput-to-wall distance >5 cm

◆ assess fall risk by ability to get up from chair without support with arms, and walking several steps and return

239
Q

Efficacy of human papillomavirus vaccine

A

Prophylactic vaccination can prevent HPV infection in women aged 9 to 26 years not previously infected with HPV subtypes covered by the vaccines.

240
Q

What are the 3 most common infections associated with vaginal discharge in an adult woman

A

Bacterial vaginosis

Vulvovaginal Candidiasis

Trichomoniasis

241
Q

What are STIs that require mandatory reporting

A

chlamydia, gonorrhea, hepatitis B, HIV, syphilis

242
Q

Bacterial STI or trichomonal infection return to sexual activity

A

should abstain from sexual activity until treatment completion and for 7 d after treatment for both partners, or until test of cure completed

243
Q

Gonnococcal cervicitis/urethritis signs and symptoms

A

M: urethral discharge, unexplained pyuria, dysuria, irritation, testicular swelling, Sx of epididymitis

F: mucopurulent endocervical discharge, vaginal bleeding dysuria, pelvic pain, dyspaurenia

M and F: often asymptomatic, can involve rectal symptoms in cases of unprotected anal sex

244
Q

Gonnococcal cervicitis/urethritis investigations

A

M: urethral swab for gram stain and culture

F: urine PCR, endocervical swab for Gram stain and culture, vaginal swab for wet mount (to rule out trichomonas)

M and F: urine PCR, rectal/ pharyngeal swabs if indicated

245
Q

Gonococcal cervicitis/urethritis treatment

A

Ceftriaxone 250 mg IM single dose

If risk factors for treatment failure (e.g. pregnancy, pharyngeal/rectal infection, potentially reduced susceptibility) Test of cure: culture 4 d post-treatment (preferred) or urine PCR 2 wk post treatment (alternative)

If no risk factors, rescreen 6-12 months post treatment

246
Q

Gonococcal cervicitis/urethritis complications

A

M: urethral strictures, epididymitis, infertility

F: PID, infertility, ectopic pregnancy, perinatal infection, chronic pelvic pain

M and F: Arthritis, increased risk of acquiring and transmitting HIV

247
Q

Non gonococcal cervicitis/urethritis (usually chlamydia) signs and symptoms

A

~70% asymptomatic

If symptoms appear (usually 2-6 wk after infection) then similar to gonococcal symptoms

248
Q

Non gonococcal cervicitis/urethritis (usually chlamydia) investigations

A

same as gonorrhea

249
Q

Non gonococcal cervicitis/urethritis (usually chlamydia) treatment

A

Azithromycin 1 g PO single dose + gonococcal treatment

Same follow up as gonococcal treatment

250
Q

Non gonococcal cervicitis/urethritis (usually chlamydia) complications

A

Same as gonococcal

251
Q

HPV signs and symptoms

A

Most are asymptomatic

M: cauliflower lesions (condylomata acuminata) on skin/mucosa of penile or anal area

F: cauliflower lesions and/or pre-neoplastic/neoplastic lesions on cervix/vagina/vulva

252
Q

HPV investigations

A

None needed if simple condylomata
Potential biopsy of suspicious lesions

F: screening for cervical dysplasia through regular Pap smears

253
Q

HPV treatment

A

For condylomata: cryotherapy, electrocautery, laser excision, topical therapy (patient-applied or office-based)

For cervical dysplasia: colposcopy and possible excision, dependent on grade of lesion

254
Q

HPV complications

A

M and F: anal cancer

MSM and F who have receptive anal sex: rectal cancer

F: cervical/vaginal/vulvar cancer

255
Q

Genital herpes signs and symptoms

A

1° episode: painful vesicoulcerative genital lesions ± fever, tender lymphadenopathy, protracted course

Recurrent episodes: less extensive lesions shorter course may have “trigger factors”

256
Q

Genital herpes investigations

A

Swab of vesicular content for culture, type-specific serologic testing for HSV-1 vs. HSV-2 antibodies and to determine 1° vs. recurrent episode

257
Q

Genital herpes treatment

A

1° Episode
Acyclovir 200 mg PO 5x/d x 5-10 d
or Famciclovir 250 mg PO tid x 5 d
or Valacyclovir 1,000 mg PO bid x 10 d

Recurrent Episode
Acyclovir 200 mg PO 5x/d x 5d or 800 mg PO tid x 2 d or Famciclovir 125 mg PO bid x 5 d
or Valacyclovir 500 mg PO bid x 3 d or 1,000 mg PO OD x 3 d

258
Q

Genital herpes complications

A

Genital pain, urethritis, cervicitis, aseptic meningitis, increased risk of acquiring and transmitting HIV

259
Q

Syphilis signs and symptoms

A

1°: chancre (painless sore), regional lymphadenopathy

2°: rash and flu-like symptoms, meningitis, headache, uveitis, retinitis, condyloma lata, mucus lesions, alopecia

Latent Phase: asymptomatic

3°: neurologic, cardiovascular, and tissue complications

260
Q

Syphilis investigations

A

Specimen collection from 1° and 2° lesions, screen high risk individuals with serologic syphilis testing (VDRL), universal screening of pregnant women

261
Q

What can present with a false positive syphilis screen

A

Endocarditis

262
Q

Syphilis treatment

A

Benzathine penicillin G IM (dose depends on stage and patient population. Check Public Health Canada guidelines )

Notify partners (last 3-12 mo)

Continuous follow-up and testing until patients are seronegative

263
Q

Syphilis complications

A

Chronic neurologic and cardiovascular sequelae, increased risk of acquiring and transmitting HIV

264
Q

Common etiologies of sinusitis

A

viral etiology is more common

  • viral: rhinovirus, influenza, parainfluenza
  • bacterial: S. pneumoniae, H. influenzae, M. catarrhalis
265
Q

Management of acute sinusitis

A
  1. may provide symptom relief:
    oral analgesics (acetaminophen, NSAIDs),
    nasal saline rinse,
    short-term use of topical or oral decongestants
    • do not prescribe antihistamines
  2. • intra-nasal corticosteroids if diagnosed with mild to moderate acute bacterial sinusitis
  3. • antibiotics and intra-nasal corticosteroids if diagnosed with severe acute bacterial sinusitis
266
Q

Acute sinusitis antibiotics

A

■ first-line antibiotic is amoxicillin

second line is amoxicillin-clavulanic acid or a fluoroquinolone

267
Q

When is an ENT referral warranted in patients with acute sinusitis

A

Anatomic defect (e.g. deviated septum, polyp, adenoid hypertrophy)

Failure of second-line therapy

≥4 episodes/yr

Refer urgently when there is development of complications (e.g. orbital extension, meningitis, intra-cranial abscess, venous sinus thrombosis), altered mental status, headache, systemic toxicity, or neurological finding

268
Q

You have a patient with recurrent sinusitis or acute bacterial rhinosinusitis. What are the next actions you take?

A

With multiple recurrent episodes, consider radiology (standard 3 view sinus x-ray or CT) to confirm ABRS during episode or to eliminate other causes

Refer for expert assessment

269
Q

How do you diagnose acute bacterial rhinosinusitis

A

For diagnosis of ABRS, patient must have:

  1. nasal obstruction or nasal purulence/discoloured postnasal discharge
    AND
  2. at least one other PODS symptom
    P Facial Pain/pressure/fullness
    O Nasal Obstruction
    D Nasal purulence/discoloured postnasal Discharge
    S Hyposmia/anosmia (Smell)
270
Q

What presentations should raise your suspicion of ABRS (acute bacterial rhinosinusitis)

A

Consider ABRS under any one of the following conditions:

Worsening after 5-7 d (biphasic illness) with similar symptoms

Symptoms persist more than 7 d without improvement

Presence of purulence for 3-4 d with high fever

271
Q

When do you consider a diagnosis of chronic rhinosinusitis

A

When symptoms persist for 4+ weeks

272
Q

Primary insomnia management

A

1st line - CBT

2nd line -
Pharmacologic treatment (used to supplement CBT; short-term prescription of <14 d with appropriate follow-up in 7-14 d):
◆ short-acting benzodiazepines (e.g. lorazepam, oxazepam, temazepam) at the lowest effective dose should be used <7 consecutive nights to break cycle of chronic insomnia or to manage an exacerbation of previously controlled primary insomnia
◆ non-benzodiazepines: zoplicone (Imovane®), zolpidem (Sublinox®), melatonin, low dose antidepressants with sedating properties (amitriptyline, trazadone, mirtazapine)
◆ if no progress or limited improvement, consider referral to sleep medicine program

273
Q

Apnea definition

A

no breathing for ≥10 s

274
Q

Diagnosis of OSA

A

Based on nocturnal polysomnography: >15 apneic/hypopneic episodes per hour of sleep with arousal recorded

275
Q

Consequences of OSA

A

◆ daytime somnolence, non-restorative sleep
◆ poor social and work performance
◆ mood changes: anxiety, irritability, depression
◆ sexual dysfunction: poor libido, impotence
◆ morning headache (due to hypercapnia)
◆ HTN (2x increased risk), CAD (3x increased risk), stroke (4x increased risk), arrhythmias
◆ OSA is an independent risk factor for CAD
◆ p lmonary HTN, right ventricular dysfunction, cor pulmonale (due to chronic hypoxemia) memory loss, decreased concentration, confusion

276
Q

OSA treatment

A

◆ modifiable factors: avoid sleeping supine; weight loss; avoid alcohol, sedatives, opioids; inhaled steroids if nasal swelling present; dental appliances to modify mandibular position
◆ primary treatment of OSA is CPAP: maintains patent airway in 95% of OSA cases
◆ surgery: somnoplasty, uvulopalatopharyngoplasty (UPPP), tonsillectomy, and adenoidectomy (in children)
◆ report patient to Ministry of Transportation if OSA is not controlled by CPAP

277
Q

OSA investigations

A

◆ evaluate BP, inspect nose and oropharynx (enlarged adenoids or tonsils)
◆ blood gas not helpful, TSH if clinically indicated
◆ nocturnal polysomnography

278
Q

Risk factors for OSA

A
  • 2% of women, 4% of men between ages 30-60
  • Obesity (due to upper airway narrowing). BMI >28 kg/m2 present in 60-90% of cases
  • Children (commonly due to large tonsils and adenoids)
  • Aging (due to decreased muscle tone)
  • Persistent URTIs, allergies, nasal tumours, hypothyroidism (due to macroglossia), neuromuscular disease
  • Family history
279
Q

Most common bacterial cause of sore throat

A

GABHS (Group A β Hemolytic Streptococcal Infections)

280
Q

Coxsackie virus presentation

A

– primarily late summer, early fall
– sudden onset of fever, pharyngitis, headache, abdominal pain, and vomiting
– appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharynx
– ulcers are pale grey and several mm in diameter, have surrounding erythema, and may appear on hands and feet

281
Q

EBV (infectious mononucleosis) presentation

A

pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash

282
Q

Herpes simplex virus presentation

A

Like coxsackie virus but ulcers are fewer and larger – pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash

283
Q

Investigations for sore throat due to suspected GABHS

A

■ gold standard for diagnosis is throat culture

■ rapid test for streptococcal antigen: high specificity (95%) but low sensitivity (50-90%)

284
Q

Investigations for sore throat due to suspected EBV (infectious mononucleosis)

A

◆ peripheral blood smear, heterophile antibody test (i.e. the latex agglutination assay or “monospot”)

285
Q

Approach to Diagnosis and Management of GABHS

A 
Modified Centor Score 
Cough absent?  1 
History of fever >38ºC?  1 
Tonsillar exudate?  1 
Swollen, tender anterior nodes?  1 
Age 3-14  1 
Age 15-44  0 
Age >45 –1
286
Q

Management of Centor score 0-1

A

Suggested action NO culture or antibiotic

287
Q

Management of Centor score 2-3

A

Culture all, treat with antibiotics only if culture is positive

288
Q

Management of Centor score 4+

A

Culture all, treat with antibiotics if clinically unwell, discontinue antibiotics if culture comes back negative

289
Q

Viral pharyngitis management

A

■ antibiotics not indicated

■ symptomatic therapy: acetaminophen/NSAIDs for fever and muscle aches, decongestants

290
Q

Management of GABHS

A

■ antibiotic treatment decreases severity and duration of symptoms, risk of transmission (after 24 h of treatment), and risk of rheumatic fever and suppurative complications

■ incidence of glomerulonephritis is not decreased with antibiotic treatment

■ no increased incidence of rheumatic fever with 48 h delay in antibiotic treatment; if possible, delay antibiotic treatment until culture confirms diagnosis

■ routine F/U and/or post-treatment throat cultures are not required for most patients

■ F/U throat culture only recommended for: patients with history of rheumatic fever, patients of family member(s) with history of acute rheumatic fever, suspected streptococcal carrier

291
Q

Infectious mononucleosis management

A

■ self-limiting course; antibiotics are not indicated

■ symptomatic treatment: acetaminophen/NSAIDs for fever, pharyngitis, malaise

■ avoid heavy physical activity and contact sports for at least one month or until splenomegaly resolves because of risk of splenic rupture

■ if acute airway obstruction, give corticosteroids and consult ENT

Family Medicine (2 decks)

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