comquest- family med shelf

Question 1

reactive non-stress test (NST)

Answer 1

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.

Question 2

acceleration on non-stress test (NST)

Answer 2

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

Question 3

what happens if a non-stress test (NST) is non-reactive after 20 minutes?

Answer 3

the NST is extended to 40 minutes and if still non-reactive then further eval.

Question 4

what is a non-reassuring NST

Answer 4

the presence of repetitive variable decelerations or decelerations that last over 1 minute during an NST often necessitates c-section.

Question 5

if a NST is considered reactrive in the first 20 minutes, but has no fetal movement ?

Answer 5

fetus is “sleeping”

Question 6

if a NST is considered reactive in the first 20 minutes, but has no fetal movement ?

Answer 6

fetus is “sleeping”

Question 7

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.

Answer 7

think malrotation with possible volvulus until proven otherwise.

Question 8

Malrotation leads to —- which is the complete twisting of a loop of bowel around its mesenteric attachment site resulting in—–

Answer 8

volvulus; bowel ischemia

Question 9

infants with volvulus present with…

Answer 9

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)

Question 10

patients with signs of volvulus and/or are hemodynamically unstable should be…

Answer 10

sent for immediate exploratory surgery

Question 11

hemodynamically stable infants with suspected volvulus should …

Answer 11

undergo an upper GI barium contrast series (reveals proximal duodenal dilation, “birds-beak” obstruction, spiral or corkscrew duodenal configuration)

Question 12

“double-bubble” sign on abdominal x-ray

Answer 12

means gastric and duodenal dilation seen in any etiology of duodenal obstruction:
- duodenal atresia (down syndrome)
-duodenal stenosis
-annular pancreas
-malrotation

Question 13

definitive dx imaging for pyloric stenosis

Answer 13

antropyloric ultrasound - shows thickened pylorus muscle

Question 14

pyloric stenosis

Answer 14

non-bilious, projectile vomiting, palpable “olive shaped” mass in the RUQ

Question 15

why shouldn’t barium contrast enema be used for the dx of malrotation?

Answer 15

many newborns have a mobile cecum (final colonic fixation occurs at term) which can mimic malrotation.

Question 16

when is barium contrast enema effective and potentially therapeutic?

Answer 16

for pts with:
- intussusception
- duodenal atresia
- Hirschsprung disease
- meconium ileus

Question 17

CT for malrotation (not-preffered)

Answer 17

“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

Question 18

what is the greatest risk factor for periductal mastitis?

Answer 18

smoking cigarettes - smoking damages mammary ductal tissue causing inflammation of the subareolar ducts which can then become infected.

Question 19

periductal mastitis

Answer 19

inflammatory condition of the breast most commonly seen in cigarette smokers.

“young female smoker with unilateral breast tenderness and purulent nipple discharge”

Question 20

first-line and second-line tx for periductal mastitis

Answer 20

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)

Question 21

primary risk factor for mammary duct ectasia

Answer 21

age

Question 22

BRCA 1 and 2 increase the risk for

Answer 22

breast and ovarian cancer

Question 23

recent trauma of the breast is a risk factor for

Answer 23

Mondor disease or thrombophlebitis of the superficial veins of the breast. Responds to NSAIDs but is self-limited.

Question 24

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.

Answer 24

epididimytis

Question 25

epididymitis results from…?

Answer 25

retrograde passage of urine from the prostatic urethra into the spermatic duct.

may be caused by: infection, trauma, exercise

Question 26

epididimytis physical exam signs

Answer 26

-tender/ swollen right posterior scrotum
- positive prehn sign
-positive cremasteric reflex
- tender spermatic cord
- leukocytes on UA w/ pyuria
-inc inflammatory markers

Question 27

younger male with sudden/acute onset unilateral painful testis/lower abdomen and nausea and vomiting

Answer 27

testicular torsion

Question 28

testicular torsion physical exam

Answer 28

• swollen, erythematous and tender testis
• abnormal position of testis (transverse lie, scrotal elevation)
  negative prehn sign
  -absent cremasteric reflex
  -non-tender spermatic cord

Question 29

male with slowly progressing (weeks to months), usually painless mass +/- dull ache; “heavy” testis, possible increase in serum markers (alpha-fetoprotein)

Answer 29

testicular tumor

Question 30

testicular tumor physical exam

Answer 30

-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)

Question 31

insidious onset of unilateral scrotal pain in boys 3-5 yo

Answer 31

torsion of testicular appendage (hydatid of morgagni)

Question 32

torsion of testicular appendage (hydatid of morgagni) - physical examination

Answer 32

-tender testis
-blue dot sign on scrotal skin (infarcted appendage)

Question 33

ortolani maneuver

Answer 33

grip the infant’s femur, flex leg at hip to 90 deg and ABD while lifting or pushing the trochanter anteriorly

Question 34

barlow maneuver

Answer 34

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

Question 35

positive barlow negative ortolani

Answer 35

observation and repeat examination

Question 36

positive ortolani maneuver + positive barlow

Answer 36

pts have a reducible dislocated hip.

• refer to orthopedist to determine course of treatment/dx

Question 37

when are infants with developmental hip dysplasia warranted an immediate ultrasound (dx of choice for less than six months of age)

Answer 37

• 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)

Question 38

when is plain x-rays used for developmental hip dysplasia dx?

Answer 38

imaging modality of choice after 6 months of age. Prior to this the femoral head and acetabulum are cartilaginous

Question 39

mechanism of action of ezetimibe

Answer 39

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

Question 40

what medications are used in pediatric patients with hyperlipidemia?

Answer 40

-Statins (first-line)
- bile acid sequestrants (cholestyramine and colesevelam)- lack of toxicity

• SE: flatulence and loose bowel movements

Question 41

What is the only time on a Family Medicine exam when bile acid sequestrants should be considered as an answer choice?

Answer 41

-treatment of pruritis due to hyperbilirubinemia in liver failure patients.
-treat diarrhea in pts who have Crohn’s disease status post-ileum resection

Question 42

Bile acid sequestrants and resins MOA

Answer 42

bind to bile acids in the gut and prevent reabsorption of bile acids that would otherwise be placed back into the cholesterol synthesis pathway

Question 43

Fibrates (fenofibrate, gemfibrozil) MOA

Answer 43

-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

Question 44

when are fibrates used as first line?

Answer 44

severe hypertriglyceridemia (>1000mg/dL) –> high risk of developing pancreatitis

Question 45

MOA of statins

Answer 45

inhibit HMG-CoA reductase (rate limiting step of cholesterol synthesis) –> inc cholesterol metabolism

Question 46

the most common reason for statin noncompliance?

Answer 46

muscle cramping

Question 47

Statin toxicity profile

Answer 47

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

Question 48

niacin (nicotinic acid) MOA

Answer 48

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)

Question 49

Generalized anxiety disorder

Answer 49

excessive worry about multiple areas of their lives on most days for at least 6 months; +/- physical symptoms (restlessness, muscle tension, fatigue, insomnia)

Question 50

GAD first-line

Answer 50

SSRI

• not considered major teratogens, may have mild inc risk of post-partum hemorrhage and mildly dec birth weight

Question 51

buspirone indications

Answer 51

-serotonergic agent, often used as an augmentation to SSRI in GAD

Question 52

clonazepam indications

Answer 52

• panic disorder (sudden, unexpected onset of severe anxiety, tachycardia, SOB, palpitations)

Question 53

dialectical behavioral therapy indications

Answer 53

• form of CBT for borderline personality disorder (unstable relationships, emotional dysregulation, recurrent suicidal thoughts)

Question 54

when is CBT a first line for GAD?

Answer 54

• when GAD pts opt out of meds