comquest- family med shelf Flashcards
reactive non-stress test (NST)
A reactive non-stress test is defined by the presence of 2 accelerations within 20 minutes with or without fetal movement detected by the patient. NST is routinely performed in patients who present with decreased fetal movement. Reactive = reassuring.
acceleration on non-stress test (NST)
an acceleration is defined as a period during which fetal heart rate increases by at least 15 bpm for a duration of 15 to 120 seconds
what happens if a non-stress test (NST) is non-reactive after 20 minutes?
the NST is extended to 40 minutes and if still non-reactive then further eval.
what is a non-reassuring NST
the presence of repetitive variable decelerations or decelerations that last over 1 minute during an NST often necessitates c-section.
if a NST is considered reactrive in the first 20 minutes, but has no fetal movement ?
fetus is “sleeping”
if a NST is considered reactive in the first 20 minutes, but has no fetal movement ?
fetus is “sleeping”
Infant presents with bilious, non-bloody, non-projectile vomiting within the first days to months of life, in the setting of intermittent progressive food intolerance, and failure to thrive.
think malrotation with possible volvulus until proven otherwise.
Malrotation leads to —- which is the complete twisting of a loop of bowel around its mesenteric attachment site resulting in—–
volvulus; bowel ischemia
infants with volvulus present with…
distended abdomen, tenderness and rigidity on palpation, currant jelly stool (blood/mucus), and general clinical instability with possible shock (lethargy, fever, tachy, hypotension, and/or hypovolemia)
patients with signs of volvulus and/or are hemodynamically unstable should be…
sent for immediate exploratory surgery
hemodynamically stable infants with suspected volvulus should …
undergo an upper GI barium contrast series (reveals proximal duodenal dilation, “birds-beak” obstruction, spiral or corkscrew duodenal configuration)
“double-bubble” sign on abdominal x-ray
means gastric and duodenal dilation seen in any etiology of duodenal obstruction:
- duodenal atresia (down syndrome)
-duodenal stenosis
-annular pancreas
-malrotation
definitive dx imaging for pyloric stenosis
antropyloric ultrasound - shows thickened pylorus muscle
pyloric stenosis
non-bilious, projectile vomiting, palpable “olive shaped” mass in the RUQ
why shouldn’t barium contrast enema be used for the dx of malrotation?
many newborns have a mobile cecum (final colonic fixation occurs at term) which can mimic malrotation.
when is barium contrast enema effective and potentially therapeutic?
for pts with:
- intussusception
- duodenal atresia
- Hirschsprung disease
- meconium ileus
CT for malrotation (not-preffered)
“whirlpool sign” which is created by blood vessels twisting around the mesenteric peduncle; will confirm dx if performed for another reason - upper gi barium contrast series is first choice
what is the greatest risk factor for periductal mastitis?
smoking cigarettes - smoking damages mammary ductal tissue causing inflammation of the subareolar ducts which can then become infected.
periductal mastitis
inflammatory condition of the breast most commonly seen in cigarette smokers.
“young female smoker with unilateral breast tenderness and purulent nipple discharge”
first-line and second-line tx for periductal mastitis
first-line = amox-clav; clindamycin for penicillin hypersensitivity
patients who develop abscesses and or fistulas require surgical mgmt (needle aspiration, incision and drainage, and or ductal excision)
primary risk factor for mammary duct ectasia
age
BRCA 1 and 2 increase the risk for
breast and ovarian cancer
recent trauma of the breast is a risk factor for
Mondor disease or thrombophlebitis of the superficial veins of the breast. Responds to NSAIDs but is self-limited.
gradually painful and tender RIGHT posterior scrotum in a young male (teens- 35yo) with swelling, dysuria, +/- urethral discharge (g/c in younger men, e.coli and pseudomonas in older men and children) and fever.
epididimytis
epididymitis results from…?
retrograde passage of urine from the prostatic urethra into the spermatic duct.
may be caused by: infection, trauma, exercise
epididimytis physical exam signs
-tender/ swollen right posterior scrotum
- positive prehn sign
-positive cremasteric reflex
- tender spermatic cord
- leukocytes on UA w/ pyuria
-inc inflammatory markers
younger male with sudden/acute onset unilateral painful testis/lower abdomen and nausea and vomiting
testicular torsion
testicular torsion physical exam
- swollen, erythematous and tender testis
- abnormal position of testis (transverse lie, scrotal elevation)
negative prehn sign
-absent cremasteric reflex
-non-tender spermatic cord
male with slowly progressing (weeks to months), usually painless mass +/- dull ache; “heavy” testis, possible increase in serum markers (alpha-fetoprotein)
testicular tumor
testicular tumor physical exam
-palpable solid mass
- signs of metz (distant LAD, chest pain, GI symptoms, b-symptoms)
- possible swelling of ipsilateral lower limb (venous engorgement due to obstruction)
insidious onset of unilateral scrotal pain in boys 3-5 yo
torsion of testicular appendage (hydatid of morgagni)
torsion of testicular appendage (hydatid of morgagni) - physical examination
-tender testis
-blue dot sign on scrotal skin (infarcted appendage)
ortolani maneuver
grip the infant’s femur, flex leg at hip to 90 deg and ABD while lifting or pushing the trochanter anteriorly
barlow maneuver
grip the infant’s femur, flex leg at hip 90 deg and ADD hip, and the head of the femur is palpated for any movement out of the acetabulum
positive barlow negative ortolani
observation and repeat examination
positive ortolani maneuver + positive barlow
pts have a reducible dislocated hip.
- refer to orthopedist to determine course of treatment/dx
when are infants with developmental hip dysplasia warranted an immediate ultrasound (dx of choice for less than six months of age)
- infants who are 4 wks of age or older with suble or nonspecific findings
- infants 4-6 wekks of age w/ a normal exam with risk factors (breech at 34+ weeks of gestation or a FHx)
when is plain x-rays used for developmental hip dysplasia dx?
imaging modality of choice after 6 months of age. Prior to this the femoral head and acetabulum are cartilaginous
mechanism of action of ezetimibe
inhibits dietary cholesterol absorption in the intestine by binding to Niemann-Pick C1-like protein in the jejunal brush border.
- no proven benefit as monotherapy; usually used in combo with statins/fibrates to further lower LDL cholesterol; or if patient does not tolerate the other meds
what medications are used in pediatric patients with hyperlipidemia?
-Statins (first-line)
- bile acid sequestrants (cholestyramine and colesevelam)- lack of toxicity
- SE: flatulence and loose bowel movements
What is the only time on a Family Medicine exam when bile acid sequestrants should be considered as an answer choice?
-treatment of pruritis due to hyperbilirubinemia in liver failure patients.
-treat diarrhea in pts who have Crohn’s disease status post-ileum resection
Bile acid sequestrants and resins MOA
bind to bile acids in the gut and prevent reabsorption of bile acids that would otherwise be placed back into the cholesterol synthesis pathway
Fibrates (fenofibrate, gemfibrozil) MOA
-lower triglycerides by inducing lipoprotein lipase –> dec hepatic production of APO C3 via peroxisome proliferator activated receptors (PPARs) alpha activity –> enhances catabolism of triglycerides
- also enhance acyl-CoA synthetase and other enzymes involved in FA oxidation –> dec triglycerides and inc HDL
when are fibrates used as first line?
severe hypertriglyceridemia (>1000mg/dL) –> high risk of developing pancreatitis
MOA of statins
inhibit HMG-CoA reductase (rate limiting step of cholesterol synthesis) –> inc cholesterol metabolism
the most common reason for statin noncompliance?
muscle cramping
Statin toxicity profile
hepatotoxic (assess liver function before starting therapy and continue to monitor)
- discontinue if myositis or signs of liver injury.
- if just myalgia –> switch to other statin or lower dose
- if rhabdomyolysis (myalgias, general weakness, myoglobinuria) - discontinue
niacin (nicotinic acid) MOA
inhibits peripheral mobilization of FA
- dec amount of substrates needed for hepatic synthesis of triglycerides and VLDLs.
- helps inc HDL (niacin is the strongest lipid med to help improve HDL)
Generalized anxiety disorder
excessive worry about multiple areas of their lives on most days for at least 6 months; +/- physical symptoms (restlessness, muscle tension, fatigue, insomnia)
GAD first-line
SSRI
- not considered major teratogens, may have mild inc risk of post-partum hemorrhage and mildly dec birth weight
buspirone indications
-serotonergic agent, often used as an augmentation to SSRI in GAD
clonazepam indications
- panic disorder (sudden, unexpected onset of severe anxiety, tachycardia, SOB, palpitations)
dialectical behavioral therapy indications
- form of CBT for borderline personality disorder (unstable relationships, emotional dysregulation, recurrent suicidal thoughts)
when is CBT a first line for GAD?
- when GAD pts opt out of meds
