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1
Q

Mandatory Reporting

A

Suspected child abuse
Unfit to drive
Reports to workers’ compensation boards
Completion of certificates under vital statistics acts
Diseases (STI, hepatitis, TB, enteric pathogens, foodborne illness, smallpox, anthrax, viral hemorrhagic fevers)

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2
Q

SPIKES Protocol for Breaking Bad News

A

S - SETTING up the interview
P - Assessing patient’s PERCEPTIONS
I - Obtaining the patient’s INVITATION (i.e., to disclose information)
K - Giving KNOWLEDGE and information to the patient
E - Addressing the patient’s EMOTIONS
S - STRATEGY and SUMMARY

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3
Q

Duty to Warn

A
  • There is a clear risk to an identifiable person or group of persons
  • The risk is one of serious bodily harm or death
  • The danger is imminent
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4
Q

Psychosis

A
  • an interruption from reality that may affect thought process, thought content, behaviors, and/or perceptions
  • manifested by delusions, hallucinations, disorganized thoughts and behaviors, or failed reality testing
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5
Q

Delusions

A

Fixed, false beliefs that fall outside of cultural norms

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6
Q

Baseline tests for Schizophrenia

A
  • CBC, electrolytes, renal function tests, toxicology screen, liver function tests, thyroid function tests, fasting plasma glucose, lipid panel, and testing for syphilis and HIV
  • Consider CT/MRI of head, ECG and chromosomal screening for 22q11
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7
Q

Schizophrenia Treatment

A
  • Atypical antipsychotic first line (less change of EPS and TD but more chance of metabolic syndrome)
  • If two fail to control symptoms after 6-8 weeks then switch to clozapine
  • Efficacious but has serious side effects (agranulocytosis, seizures, myocarditis)
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8
Q

Olanzapine

A
  • Atypical antipsychotic
  • Bad in obesity and diabetics because of risk of metabolic syndromes
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9
Q

Risperidone

A
  • Atypical antipsychotic
  • Metabolic complications (weight gain, glucose intolerance, lipid disorders) but less than clozapine/olanzapine
  • Galactorrhea, gynecomastia, menstrual disturbance, infertility
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10
Q

Ziprasidone

A
  • Atypical antipsychotic
  • Increases QT interval
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11
Q

Clozapine

A
  • Atypical antipsychotic
  • Best for refractory (failure to respond to 2 other meds after 6-8 weeks) schizophrenia
  • Can cause agranulocytosis, seizures, myocarditis
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12
Q

Quetiapine

A
  • Atypical antipsychotic
  • Lower incidence of movement disorders
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13
Q

Aripiprazole

A
  • Atypical antipsychotic
  • Increases risk of uncontrolled behavior (gambling)
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14
Q

Amisulpride

A
  • Atypical antipsychotic
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15
Q

Haloperidol

A
  • Typical antipsychotic (high potency)
  • Good in pregnancy
  • More side effects
  • High risk of EPS/TD
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16
Q

Define generalized anxiety disorder? What is the time period?

A

Excess worry and anxiety about a number of topics for most days for at least 6 months and there are three or more of the following: feeling keyed up, fatigue, concentration problems, irritability, muscle tension, sleep disturbance

AND I C REST
Anxious
No control over worrying
Duration of 6 mo
Irritable
Concentration impairment
Restless
Energy down
Sleep impairment
Tension in muscles

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17
Q

Neuroleptic Malignant Syndrome

A
  • Hypertensive crisis, muscle rigidity, fever, changes in consciousness, and elevated creatine kinase, elevated WCB, metabolic acidosis
  • Causes by: antipsychotics, levodopa, lithium, desipramine, phenelzine
  • “Serotonin syndrome, it’s a thrill,
    with hyperreflexia and shivers that chill.
    Neuroleptic malignant syndrome, oh dear,
    has rigidity and fever, watch out for sepsis, don’t you fear.
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18
Q

Treatment of Alcohol Withdrawal

A
  • Diazepam 20 mg po q1-2h or 2-5 mg IV/minute (max 10-20 mg q1h) until symptoms subside
  • If elderly, severe liver impairment, severe asthma, or resp failure then use lorazepam 1-2 mg PO/SL tid-qid
  • Thiamine 100 mg IM initially then 100 mg po qd x 3d
  • Antiepileptics if seizure history
  • Antipsychotic if hallucinations
  • Supportive hydration
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19
Q

Treatment of Opioid Intoxication

A
  • Naloxone 2 mg bolus IV/IM/SL/SC
  • Increase by 2 mg increments until symptoms subside (max 10 mg)
  • Methadone can be used for detoxification
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20
Q

Health Surveillance in Down’s Syndrome

A
  • At each health maintenance visit: review for celiac symptoms, OSA, cervical spine positioning, myopathy symptoms
  • Annually: TSH, hemoglobin, audiological exam, mitral/aortic disease
  • Q3Y: Ophthalmological exam for cataracts, refractive errors, corneal thinning, haze
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21
Q

Generalized Anxiety Disorder

A

Diagnosed when patient finds it difficult to control worry on more days than not for at least 6 months and has 3 or more of the following:
Blank mind
Easily fatigued
Sleep disturbance
Keyed up (restless)
Irritable
Muscle tension

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22
Q

PTSD

A
  • Occurs after life altering/threatening event
  • Spontaneous, recurrent, intrusive dreams/memories/flashbacks/reactions
  • Symptoms for at least one month occurring anytime after event
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23
Q

Obsessions vs Compulsions

A

Intrusive, recurrent, undesired thoughts
VS
Repetitive behaviors or rituals

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24
Q

Anxiety Treatment

A

1st Line: SSRIs (citalopram, paroxetine, sertraline, escitalopram)
SNRIs (venlafaxine, duloxetine)
2nd Line: TCAs, benzo (imipramine or longer acting)
Psychotherapy: CBT

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25
Q

Situational stress vs true anxiety disorder

A
  • Duration and intensity of symptoms
  • Stress is a normal response to a challenging situation that typically improves once the situation is resolved
  • Anxiety disorder is characterized by persistent symptoms that can last for several months or longer, and may not be directly tied to a specific stressor
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26
Q

AAA screening

A

• One time screening ultrasound for:

• Men age 65-80
• Women age 65-80 with smoking history or cardiovascular disease
• First degree relatives after age 55

• Repeat ultrasound 10 yr after initial screening if aortic diameter >2.5 cm and <3 cm

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27
Q

Breast Cancer screening

A

Mammography q2-3y in women 50-74 yo

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28
Q

Cervical Cancer screening

A

Screen women 25-69 yo q3h
Cease at age 70 if 3 successive negative paps in past 10 years OR continue until 3 successive negatives are obtained

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29
Q

Colon Cancer screening

A

Screen adults w/o risk 50-74 yo with FIT or FOBT q2y or flex sig q10y
Do not use colonoscopy for screening

At risk (1st degree relative) should start screening at 50 yo or 10y prior to age of relative diagnosis

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30
Q

Fetal Alcohol Syndrome features

A

Prenatal and postnatal growth deficiency, short palpebral fissures, increased intercanthal distance, a flattened face, hypoplasia of the philtrum and a thin upper lip

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31
Q

Treatment of choice for eating disorders

A

CBT

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32
Q

Surgical treatment modality for atrial fibrillation

A

Cryoablation

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33
Q

MC oral mucosal premalignant lesion

A

Leukoplakia

biopsy it

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34
Q

Most common malignancy in humans

A

Basal cell carcinoma

SCC 2nd MC but MC cutaneous malignancy in immunocompromised

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35
Q

Treatment for moderate allergic reaction

A

Epinephrine IM anterolateral thigh
Antihistamine: cetirizine PO IV (less sedation)
Salbutamol

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36
Q

Treatment for severe allergic reaction

A

ABCs - get definitive airway
Epinephrine IV or ETT
Antihistamine: diphenhydramine IV
Glucocorticoids: methylprednisolone or prednisolone or prednisone
Large volume of crystalloid

Patients on beta blockers may not respond to epiephrine and may benefit from glucagon reversal

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37
Q

Kidney stone composition

A

80% calcium oxalate
10% struvite
10% uric acid

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38
Q

What should be given to any patient with altered LOC?

A

Dextrose
Adults D50W and children D25W

should be given after thiamine to prevent Wernicke’s encephalopathy but do not delay glucose if thiamine is not readily available

If time allows and possible then measure blood glucose first

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39
Q

Who would you not give urgent O2 to in the ED?

A

Paraquat or diquat herbicide inhalation or ingestion
Free radical formation increases to morbidity

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40
Q

Galactorrhea vs breast discharge

A

Galactorrhea has fat droplets present
Breast discharge is usually unilateral and may be bloody or serous

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41
Q

Galactorrhea vs breast discharge

A

Galactorrhea has fat droplets present
Breast discharge is usually unilateral and may be bloody or serous

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42
Q

MCC hypercalcemia in a healthy outpatient

A

Primary hyperparathyroidism

Surgical excision is definitive treatment

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43
Q

MCC hypercalcemia in hospital admitted patients

A

Malignancy associated
Most commonly seen in lung, renal, breast, ovarian, squamous tumors, lymphoma, multiple myeloma

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44
Q

How to approach hypercalcemia

A

Check PTH
If PTH low check phosphate
if phosphate high/normal check vitamin D

If you start to see oliguria or anuria or mental status change it is a medical emergency

45
Q

What allergy do you need to ask about before giving calcitonin?

A

FISH

46
Q

Most common bacterial cause of diarrhea in Canada

A

Campylobactera jejuni

Associated with Guillain Barret

Rx macrolide or fluoroquinolone

47
Q

Most common location of Crohn’s

A

Ileum and right colon

48
Q

History of aortic graft with abdominal pain associated with bleeding should make you think of what condition?

A

Aortoenteric fistula
rare but lethal

Diagnose with emergency endoscopy as may require urgent surgery as window of opportunity is narrow

49
Q

MCC of elevated ALT

A

Fatty liver

50
Q

Clinical features of hemochromatosis

A

Arthralgia
Bronze skin
Cardiomyopathy and cirrhosis
Diabetes
Hypogonadism

MC in Northern European descent

51
Q

What is TIPS procedure for?

A

Decrease portalvenous pressure

Stent placed between portal and hepatic vein via transjugular vein catheterization and percutaneous puncture of portal bein

Can be used to stop acute bleeding or prevent rebleeding or treat ascites

Most commonly used as a “bridge” to liver transplantation

CI with severe liver dysfunction, uncontrolled hepatic encephalopathy and CHF

52
Q

Vast majority of causes of acute pancreatitis are?

A

Gallstones or ethanol

EtOH MCC chronic

53
Q

MCC sudden onset of rigid abdomen postoperatively

A

Perforated viscus

54
Q

MCC pain out of proportion to physical findings postoperatively

A

Ischemic bowel

55
Q

MCC vague pain that subsequently localizes postoperatively

A

Appendicitis

56
Q

MCC colicky pain waves postoperatively

A

Bowel obstruction

57
Q

MCC LGIB

A

Diverticular bleed (40%)

58
Q

MCC severe UGIB

A

Peptic ulcer disease (55%)

59
Q

MCC fever within hours after surgery

A

Inflammatory reaction in response to physiological stress from surgery
Unlikely to be infectious unless necrotizing fasciitis or another infection

Differential: malignant hyperthermia, reaction to blood products recieved at surgery

60
Q

MCC fever POD 1-2

A

Atelectasis, early necrotizing fasciitis, aspiration pneumonitis

Acute adrenal insufficiency, thyroid storm, transfusion reason

61
Q

MCC fever POD 3-7

A

UTI, surgical site infection, IV site infection (Staph), septic thrombophlebitis, leakage at bowel anastomosis

Likely infectious

62
Q

MC sign of paraesophageal hiatus hernia

A

Dysphagia

Least common esophageal hernia

Herniation of all or part of the stomach through the esophageal hiatus into the thorax with an undisplaced GE junction

63
Q

Boerhaave’s vs Mallory Weiss

A

Boerhaave is transmural esophageal perforation
Mallory is non transmural esophageal tear

Both associated with forceful emesis

64
Q

Most common esophageal carcinoma

A

Squamous cell carcinoma (worldwide)
Adenocarcinoma (Western countries)

65
Q

Risk factors for esophageal squamous cell carcinoma

A

Underlying esophageal disease, strictures, diverticula, achalasia
Smoking, alcohol, hot liquids
More common in Black and Asian populations

66
Q

Risk factors for esophageal adenocarcinoma

A

Barrett’s esophagus, smoking, obesity, GERD
More common in Caucasians

67
Q

Most common primary lung tumor type

A

Bronchogenic carcinoma

68
Q

Most common type of lung tumor in a nonsmoker

A

Adenocarcinoma which is a type of non small cell bronchogenic carinoma

69
Q

Screening with low dose CT is recommended for?

A

55-74 yo
>30 pack year smoking hx
Current smoker or has quit within 15 years

Do annually up to 3 years

70
Q

What lung lesion peaks in incidence at 60 yo and appears as ‘popcorn’ pattern of calcification on CXR

A

Hamartoma

Composed of fat, epithelium, fibrous tissue, cartilage

71
Q

MCC solitary pulmonary nodule

A

Benign infectious granuloma: histoplasmosis, coccidiomycosis, TB, atypical mycobacterium

72
Q

Signs of metastatic gastric carcinoma

A

Virchow’s node: left supraclavicular node
Blumer’s shelf: mass in pouch of Douglas
Krukenberg tumor: mets to ovary
Sister Mary Joseph node: umbilical mets
Irish node: left axillary node

73
Q

Location of inguinal hernias

A

MD: Medial to the inferior epigastric artery = Direct inguinal hernia
LI: Lateral to the inferior epigastric artery = Indirect inguinal hernia

74
Q

Kehr’s sign

A

Left shoulder pain due to diaphragmatic irritation from splenic rupture that worsens with inspiration

75
Q

What are the long term complications associated with a splenectomy?

A

Sepsis with encapsulated organisms, splenosis (intra abdominal “seeding” of splenic tissue during removal), increased risk of malignancy, DVT, PE

50% mortality

Should be vaccinated with pneumococcal, H influenza and meningococcus 2 weeks pre or post operatively

76
Q

MC congenital abnormality of the GU tract

A

Cryptorchidism

Palpable testicle within inguinal canal or testicle which can be milked down into the scrotum (called retractile testis)

77
Q

Most common presenting symptom of uterine sarcoma

A

Vaginal bleeding

Rare ~3% of uterine malignancies

78
Q

Most common type of uterine sarcoma

A

Leiomyosarcoma

Age 55 but may present in premenopausal women

Often coexists with leiomyomata (fibroids)

79
Q

Meningitis vs encephalitis

A

Cerebral function is abnormal in encephalitis (altered mental status, motor or sensory defects, altered behavior or speech, movement disorders) but may be normal in patient with meningitis

There is considerable overlap in the two syndromes

80
Q

Positive dipstick for leukocyte esterase and nitrites is highly specific for what?

A

UTI diagnosis

81
Q

Nitrite negative bacteria

A

Enterococci
Staphylococci

82
Q

Nitrite positive bacteria

A

Enterobacteriaceae (E. coli)

83
Q

Calculated osmolality equation

A

(2 x Na) + Glucose + Urea - measures osmolality
mmol/L

Two salts and a sticky BUN
Normal < 10

Causes of increase can be methanol, ethylene glycol, ethanol, polyethylene glycol, manitol, sorbitol

84
Q

Two MCC of acute kidney injury in hospitalized patients

A

Prerenal azotemia
Acute tubular necrosis

85
Q

c-ANCA association

A

Most commonly associated with clinical picture of granulomatosis with polyangitis

86
Q

p-ANCA association

A

Most commonly associated with clinical picture of microscopic polyangitis

87
Q

Cause of hypertensive encephalopathy? What are the symptoms?

A

Acute severe HTN (anything over 130/200 seperately)
Papilledema, hemorrhages, exudates, cotton wool spots on fundoscopic exam
Focal neurological symptoms, nausea, vomiting, visual disturbances, seizures, altered LOC

88
Q

What should be considered in the differential for headache and stroke?

Uncommon but deadly

A

Central venous sinus thrombosis

Diagnosed with magnetic resonance venography or cerebral CT venogram

Treatment is anticoagulation with heparin then warfarin

High morbidity and mortality

89
Q

What affect does systemic hypoperfusion have on the brain?

A

Global cerebral ischemia that primarily affects the watershed areas between the major cerebral arterial territories

90
Q

Most common sites of hemorrhagic stroke

A

Putamen, caudate nucleus, thalamus, cerebellum, pons

91
Q

Steps for treatment of stroke

A
  1. BP, volume, glucose, temperature
  2. Recombinant tissue plasminogen activator within 4.5 h of onset
  3. Intra arterial mechanical thrombectomy
  4. Anti platelet therapy (ASA, clopidogrel)
  5. Anti coagulant
  6. Withhold antihypertensive therapy for 2-3 d in the setting of acute MI, renal failure, aortic dissection, after non thrombolysed ischemic stroke unless the BP is greater then 220/120
92
Q

MC intracranial tumor in adults

A

Metastasis

Lungs < breast < kidney < GI < melanoma

MC PRIMARY intracranial tumor is meningioma that arises from arachnoid c

93
Q

A compressive adenoma in the pituitary will affect which hormones

A

GH
LH
FSH
TSH
ACTH
Prolactin

GO LOOK FOR THE ADENOMA PLEASE

94
Q

Sudden onset of thunderclap headache

A

Subarachnoid hemorrhage
Can be traumatic or spontaneous
Age 55-60 with very few cases under 45 yo

CT shows hyperdense blood in cisterns or fissues
Manage conservatively, may need open or endovascular repair
50% mortality, 30% have moderate to severe disability after

THe only validated neuroprotective agent is nimodipine

95
Q

MCC spinal cord impairment

A

Cervical spondylotic myelopathy

Progressive degenerative process of the cervical spine leading to canal stenosis. Agre related wear and tear affected the neck discs.

96
Q

MCC hemorrhage in third trimester

A

Bloody show (represents cerviacal changes or early stages of dilation) or placental abruption

97
Q

Most common presentation of uterine rupture

A

Prolonged fetal bradycardia

98
Q

MCC episodic vertigo

A

BBPV

Patients often symptomatic when rolling over in bed or moving their head to a position of extreme posterior extension (ie looking up at a tall building)

99
Q

What is the net step if there has been >2 weeks hoarseness in a smoker?

A

Laryngoscopy to rule out malignancy

100
Q

Orphan annie nuclei, psammoma bodies

A

Papillary thyroid carcinoma
Treat with lobectomy if early or total thyroidectomy if late

101
Q

Treatment of croup

A

Racemic epinephrine
Systemic corticosteroids (dexamethasone or prednisone)
Hydrate
Observe closely
May need positive pressure ventilation
Hospitalize if poor response to steroids and persistent stridor
If continued poor response consider different cause ie bacterial tracheitis
Bronchoscopy for definitive diagnosis

102
Q

Cherry shaped swelling with loss of normal air space on the vallecula on lateral neck radiography

A

Thumb sign - Epiglottitis

Medical emergency

Rx airway, IV hydration, AB cefuroxime, cerfotaxime, ceftriazone, moist air, extubate when afebrile

103
Q

Most common congenital heart defect

A

Ventricular septal defect

104
Q

Persistent, painless, firm, rubbery, cervical or supraclavicular lymphadenopathy

A

Hodgkin lymphoma

a/w intussusception, mediastinal mass, head and neck disease

Fever chills night swears weight loss

105
Q

Which drug is associated with formication?

A

Meth

Tactile hallucinations

106
Q

Bilateral hilar adenopathy ddx

A

Think sarcoid or lympoma

107
Q

Unilateral hilar adenopathy ddx

A

Think Neoplasia, TB or sarcoid

108
Q

Behcet’s characteristics

A

Multisystem disorder presenting with uveitis, recurrent oral and genital ulcers, venous thrombosis, skin and join involvement
MC in Meditarranean and Asians ~30 yo

Large vessel disease

109
Q

Vasculitis associated with unequal pulses

A

Takayasu’s
Chronic inflammation most often of the aorta and its branches
Asian descent most commonly and between 10-40 yo

Increased risk of aortic aneurysm

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