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diabetes/cases Flashcards

1
Q

Genetics and DM

A
  • Type 1: 50% btw identical twins

- Type 2: 90% btw identical twins!

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2
Q

HLA association and DM

A
  • Type 1: HLA-DQ/DR

- Type 2: none

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3
Q

Lipids in poorly controlled diabetes/insulin resistance

A

-HyperTGs with HDL depletion

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4
Q

Obesity and T2DM

A
  • greatest RF
  • increased plasma FFAs –> make muscle more insulin resistant
  • FFAs increase liver production of glucose
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5
Q

Dx DM

A

any of the following:

  1. Two fasting glucoses > 125
  2. Single glucose >200 with Sx
  3. Increased glucose lvl on OGT
  4. HbA1c > 6.5%
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6
Q

Dawn phenomenon

A

-morning hyperglycemia due to nocturnal HG secretion

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7
Q

Somogyi effect

A

morning hyperglycemia due to rebound from nocturnal hypoglycemia

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8
Q

Workup morning hyperglycemia in DM

A
  • check 3AM glucose
  • if elevated, pt has dawn phenomenon and evening insulin should be increased
  • if decreased, pt has Somogyi and evening insulin should be decreased
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9
Q

General Management Diabetes

A
  • Goal HbA1c < 7
  • ACEi or ARB if urine + for microalbuminuria (spot >3.5 female, >2.5 male)
  • Refer to podiatry if high risk
  • Statin if LDL >100
  • ACEi or ARB if bp > 130/80
  • Aspirin if >30yo
  • Pneumococcal vaccine!
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10
Q

Screening in Diabetics

A
  • HbA1c q3mos. Goal 100

- BP every visit. ACE or ARB if >130/80

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11
Q

microalbuminuria

A
  • 30-300mg per 24 hrs

- spot urine Albumin/Cr >3.5 (female), >2.5 (male)

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12
Q

Sx of DM and pathogenesis

A
  • Polyuria: glucose in renal tube is osmotically active
  • Polydipsia: reaction to polyuria
  • Fatigue: unknown
  • Weight loss: anabolic effects of insulin
  • Blurred vision: swelling of lens due to osmosis (glucose)
  • Fungal infections: Candida likes sugar
  • Distal Numbness/tingling. Mononeuropathy: microscopic vasculitis leading to axonal ischemia. Polyneuropathy: multifactorial
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13
Q

Glyburide, Glipizide, Glimepiride (class, MoA, Advantages, SEs)

A
  • Sulfonylureas
  • Bind to Katp on pancreas beta-cells, stimulating release of insulin.
  • Effective and inexpensive.
  • SEs: Hypoglycemia, weight gain
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14
Q

Metformin (MoA, Advantages, SEs)

A
  • enhances glucose uptake (GLUT4) and insulin sensitivity (AMPK)–suppressing beta-ox and liver gluconeogenesis.
  • May cause weight loss, does not cause hypoglycemia, reduces cardiac risk (lowers LDL)
  • SEs: GI upset, lactic acidosis, metallic taste
  • Contraindicated if serum creatinine >1.5!! (risk of lactic acidosis
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15
Q

Acarbose (MoA, Advantages, SEs)

A
  • inhibits brush border alpha-glucosidase and pancreas alpha-amylase, reducing glucose absorption from gut
  • Low risk, no significant toxicity
  • SEs: GI: cramping, flatulence, diarrhea
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16
Q

Rosiglitazone, pioglitazone (class, MoA, Advantages, SEs)

A
  • Thiazolinediones
  • Activate PPARgamma: wide array of actions; decrease insulin resistance, inhibit VEGF, modify adipocyte differentiation, decrease some interleukins, decrease LDL synthesis
  • Advantages: reduced insulin level
  • SEs: hepatotoxicity (monitor LFTs!)
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17
Q

Exanatide, liraglutide (class, MoA, Advantages, SEs)

A
  • Incretins (GLP-1) mimetics
  • Act on pancreas to release insulin in response to meals, prevent glucagon release, promote satiety, reduce liver fat production
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18
Q

Pramlintide

A
  • Amylin mimetic

- aids glucose absorption, slows gastric emptying, promotes satiety, limits glucagon

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19
Q

lispro

A

Fast onset human insulin – 15 mins onset 4 hr duration

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20
Q

Regular insulin

A

-30-60 min onset, 4-6hrs duration (only insulin that can be given IV)

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21
Q

NPH insulin/lente

A
  • 2-4 hr onset
  • 10-18 hr duration
  • most widely used
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22
Q

Ultralente insulin

A
  • long-lasting
  • 6-10 hrs onset
  • 18-24 hr duration
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23
Q

70/30 insulin

A
  • 70% NPH/30% regular
  • onset: 30 min
  • duration: 10-16 hr
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24
Q

Glargine (lantus)

A
  • 3-4 hr onset
  • 24 hr duration
  • given at bedtime
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25
Q

70/30 insulin regimens

A
  • Basic: one pre-breakfast injection (Often 2/3 of total dose), one pre-dinner injection (1/3 total dose)
  • supplement with a pre-lunch short-acting if necessary
  • adjust doses by fasting/4pm sticks
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26
Q

Intensive insulin regimen

A
  • Ultralente at bedtime
  • Regular insulin before each meal adjusted by finger sticks
  • shown to decrease incidence of complications
  • Serious risk for hypoglycemia
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27
Q

Three-injection insulin regimen

A
  • 70/30 morning
  • pre-dinner regular
  • pre-bed NPH
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28
Q

T1DM insulin calcuation

A
  • most require .5-1.0 unit/kg per day

- for two-injection regimen, 2/3 in morning, 1/3 in evening

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29
Q

Treatment T2DM

A
  • start w lifestyle
  • if fail, start metformin
  • if fail, add another agent
  • if fail, start insulin
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30
Q

macrovascular complications DM

A
  • mainly, atherosclerosis –> stroke, MI, CHF. Mechanism unknown but proably glycation of lipoproteins, increased PLT adhesion, decreased fibrinolysis
  • Silent MIs common
  • PVD
  • macrovascular complications are what kill ppl. Unclear whether tight control prevents them (as in microvascular)
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31
Q

Diabetic nephropathy

A
  • microvascular complication
  • Path: Kimmelstiel-Wilson–hyaline deposition (Xmas balls) pathagnomonic. Can also have diffuse flomerular sclerosis (also in HTN) and isolated GBM thickening
  • Microabluminuria/proteinuria. If occurs, must have tight glycemic control and BP control or can progress to ESRD.
  • If you catch microalbuminuria early (dipstick is not sensitive enough!), can slow progression w ACEis
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32
Q

Diabetic retinopathy

A
  • microvascular complication
  • 75% prevalence after 20 yrs of diabetes. leading cause of blindness inUS
  • nonproliferative: hemorrhages, exudates, microaneurysms, venous dilations on funduscopic exam. Usually asymptomatic until macular edema.
  • Proliferative: neovascularization and scarring. Vitreal hemorrhage and retinal detachment can occur! Can lead to blindness! Tx w lazer photocoagluation
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33
Q

Diabetic neuropathy

A
  • Peripheral: usually distal/symmetric (“stocking/glove”). Loss of sensation leads to ulcer formation and Charcot joints. Can have painful neuropathy (hypersensitivity to light touch) Tx with gabapentin, TCAs, pregabalin
  • CN complications: 2/2 nerve infarctions. Often CNIII, IV, VI.
  • Mononeuropathies: 2/2 infaction (media, ulnar, common peroneal) Lumbar plexopathy
  • Autonomic neuropathy: impotence, neurogenic bladder, gastroparesis, constipation/diarrhea, postural hypotension
  • Tx is complex. NSAIDs, TCAs,, gabapentin may be helpful. Metoclopramide and other promotility agents for gastroparesis
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34
Q

Diabetic third nerve palsy

A

eye pain, diplopia, ptosis, inability to adduct

-pupils are spared!

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35
Q

Diabetic foot

A
  • Combination of ischemia and neuropathy
  • neuropathy can mask PVD (claudication, rest pain)
  • increased susceptibility to infection (cellulitis, candidiasis, pneumonia, osteomyelitis, polymicrobial ulcers)
  • infected ulcers can –> osteomyelitis –> amputaiton
  • Tx: regular foot care!
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36
Q

Screening tests in Diabetes

A
  • A1C
  • Spot A-C ratio
  • Creatinine/GFR
  • B12 if on metformin, esp if neuropathy
  • TSH in T1DM, new dyslipidemia, women >50
  • fasting lipid profile (q3months if dyslipidemia, q1yr if controlled)
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37
Q

whom to screen for HTN

A

all adults >18

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38
Q

Dx HTN

A

-2 elevated measurements >5mins apart. One in each arm. On 2 separate visits

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39
Q

Causes/Frequency of HTN

A 
95-98% = Essential
2-5 = 2ndry
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40
Q

BP cuff reqs

A 
length = 80% arm circumference
Width = 40% arm circumference
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41
Q

BMI thresholds

A

under - 18.5
over - 25
obese: 30-40
Extreme obesity >40

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42
Q

Thiazides +/-s and doses

A
  • Cost effective (HCTZ)
  • May cause hyponatremia
  • May precipitate gout flares
  • May cause urine incontinence in elderly
  • Low dose HCTZ (25mg) > 50mg HCTZ or beta blockers
  • Start elderly at 6.25 or 12.5 g
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43
Q

Lifestyle mods ranks for HTN

A

Weight reduction > DASH > dietary Na reduction > physical activity > moderation of EtOH

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44
Q

Labs for someone with new Dx of ET

A
  • EKG (look for LVH, arrhythmias contraindicating BBs/CCBs)
  • Urinalysis (proteinuria – HTNive nephropathy, glucosuria)
  • Random blood glucose
  • Hct (anemia incr strokes, MIs)
  • Serum K
  • Serum Cr/eGFR
  • Serum Ca (May increase BP, nephrolethiasis)
  • Fasting lipid profile
  • spot ACR is optional
  • NOT recommended: Serum NA, TSH, LFTs
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45
Q

Aspirin prophylaxis in HTN

A

-wait until BP is normal and stable, since aspirin in pt with uncontrolled BP can inc risk of hemorrhage

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46
Q

Tx algorithm HTN

A
  • Lifestyle
  • if fail, HCTZ. Titrate to 25 mg (unless compelling reason for another agent)
  • if fail, add ACEi, ARB, or CCB
  • most ppl require 2+ drugs
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47
Q

BP control worst in

A

MExican Americans, Native Americans

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48
Q

HTN and African Americans

A

Severity, impact, prevalence increased

Somewhat reduced response to monotherapy with BBs, ACEis, ARBs compared to diuretics or CCBs

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49
Q

CHD risk EQs

A
  • symptomatic carotid disease
  • Peripheral artery disease
  • AAA
  • Diabetes
  • (confers 10 year risk of >20%)
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50
Q

Major CHD RFs

A
  • cigarette smoking
  • HTN
  • Low HDL (60 is negative risk factor
  • FHx premature CHD (male 45, women >55

Almost everyone with 0-1 RF has a <10% 10 year risk

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51
Q

Statin Rx algorythm

A
  • CHD or CHD Risk Eq (10 yr risk >20%) –> TLC at 100, Statin at 130
  • 2+ RFs (10 yr risk TLC at 130, Statin at 130 if 10yr risk is 10-20%
  • 0-1 RFs (10 yr risk TLC at 160, Statin at 190 (optional 160-190)
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52
Q

Resistant HTN

A
  • Fails to improve on appropriate doses of 3 drugs, including a diuretic
  • Causes: Excess Na, Inadequate diuresis, NSAIDs, OTCs, etc, excess EtOH, 2ndry HTN
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53
Q

Kleinman’s Questions

A
  • What do you think caused your problem? What do you call it?
  • Why do you think it started when it did
  • How does it affect your life?
  • How severe is it? What worries you the most?
  • What kind of treatment do you think will work?
  • How can the doctor be most helpful to you?
  • What is most important to you?
  • Have you seen anyone else about this problem?
  • Have you used non-medical remedies?
  • Who advises you about your health?
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54
Q

PE findings COPD

A
  • Increased AP diameter
  • Decreased diaphragmatic excursion
  • Wheezing (often end-expiratory)
  • Prolonged expiratory phase
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55
Q

PE findings CHF

A
  • inspiratory crackles/dullness to percussion (edema)
  • S3
  • PMI displaced laterally
  • Peripheral edema
  • Increased JVD
  • Hepatojugular reflux
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56
Q

CXR in pts with dyspnea

A

not helpful to rule in/out COPD, but to look for other causes (14% of CXRs)

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57
Q

COPD on spirometry

A

FEV1/FVC 80% = mild
50-79% = moderate
30-49% = Severe
<30% = Very Severe

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58
Q

Adverse effects of Beta-agonist overuse

A

tachycardia
somatic tremor
hypokalemia (especially with thiazide)

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59
Q

Tx Moderate COPD

A
  • (FEV1 50-80% predicted)

- inhaled anticholinergics alone or in combination with SABA

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60
Q

Tx Severe COPD

A

(FEV1 <50% predicted)

-add inhaled glucocorticoids to anticholinergics (best with LABA)

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61
Q

Tetanus vaccine schedule

A

-Td (can be TdaP) q10 after initial TdaP

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62
Q

COPD exacerbation

A

-acute change in baseline dyspnea, cough, and/or sputum.
-most commonly infection/air pollution
-Tx: inhaled bronchodilators.
Abx if: inc dyspnea, sputum, and sputum purulence, or req’s MV

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63
Q

COPD and CHF

A
  • major complication
  • chronic hypoxia –> pulm vascoconstriction –> pulm HTN –> muscularization, intimal hyperplasia, fibrosis, obliteration –> Cor Pulmonale –> edema/death
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64
Q

PMH for obesity

A

Screen for:
-Cushing’s (easy bruising, hyperpigmentation, muscle weakness)
-Hypothyroid (fatigue, cold intolerance, constipation)
-Hypogonadism (decreased libido)
-Sleep Apnea
CVD (chest pain/pressure, dyspnea
Cerebro (changes in vision or focal neuro Sx)
-PVD: claudication

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65
Q

Obesity and cancer

A

-BMI >40 –> increased death from NHL, MM, GI cancers, kidney, prostate, breast, uterus, cervix, ovary

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66
Q

Metabolic Syndrome

A

3/5 of:

-fasting glucose > 100
-BP > 130/85
TGs >150
HDL <50 (women)
-Abdominal obesity

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67
Q

5 As of behavioral counseling

A
  • Assess practices/risk factors
  • Advise change
  • Agree on goals
  • Assist in change/motivational barriers
  • Arrange follow-up/support/referral
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68
Q

Estimated Daily Caloric Requirement

A

Basal metabolic rate + activity-dependent needs
BMR = weight in lbs * 10
Activity-dependent needs = weight in lbs * F

F = 1.3 if sedentary

  1. 5 for moderate activity
  2. 7 for heavy activity
  3. 9 for intense activity
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69
Q

Reasonable weight loss goals (long and short term)

A

Reasonable long-term goal: A modest 5% to 10% reduction in body weight can produce significant benefits in health outcomes.
Reasonable short-term goal: Losing half a pound to a pound a week.

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70
Q

Pharm Tx obesity

A
  • Orlistat: GI lipase inhibitor which decreases fat absorption, Side effects include gastrointestinal discomfort, fecal incontinence, and malabsorption of fat-soluble vitamins. Orlistat has been shown to result in modest (3-5 kg) weight loss when used in conjunction with calorie restriction and physical activity.
  • Phenetermine: stimulant/appetite suppressant. Side effects include tachycardia, hypertension, restlessness, insomnia, and tremor. Because of the potential for addiction and withdrawal, phentermine is indicated only for short-term use.
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71
Q

indications for bariatric surgery

A
  • BMI >40 or

- BMI >35 with severe health complications

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72
Q

Differentiating HF vs non-cardiac causes of dyspnea

A

Normal BNP effectively rules out CHF

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73
Q

Diastolic HF

A
  • Sx of HF w/ preserved EF
  • impaired LV filling
  • more common in older women
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74
Q

Tx class II CHF

A
  • ACEi – reduce mortality in systolic HF
  • ARBs – improve mortality in systolic HF
  • Digoxin – improves Sx and hospitalizations. Be careful in renal insufficiency pts
  • Loop diuretics – central role. Caution in diastolic failure (worsen filling)
  • BBs – central role in reducing mortality but can worsen HF initially. Don’t use in decompensated HF. titrate slowly.
  • Eplerenone – improves mortality/hospitalization in Class II HF
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75
Q

Typical/Atypical agina chest pain

A
  1. Substernal
  2. Precipitated by exertion
  3. Relief w/i 10mins rest or with nitroglycerin

Typical angina : all 3 present
Atypical angina: 2 present
Nonanginal: 0-1

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76
Q

evaluation of suspected CHF

A
  • ETT: can be good for intermediate risk pts, but negative test doesn’t r/o CHF. Can’t use in people with baseline complicated EKGs
  • Stress echo/Nuclear stress testing: more sensitive. Can jump to these in new-onset CHF
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77
Q

management of diastolic HF

A
  • less well studied than systolic HF
  • minimize fluid overload w diuretics (careful not to over-do…low preload can worsen ventricular filling.
  • slow down HR (esp in Afib)
  • Manage comorbid CHD
  • Often start on BB and non-DHP CCB (minimize cardiac O2 demand with less reflex tachycardia than DHPs)
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78
Q

FHx Breast Cancer risk

A

-increased risk if first-degree relative had it

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79
Q

Breast Cancer screening

A
  • Self exams: no evidence of reduced mortality
  • Clinical exams: q3 for women in 20s-30s, q1 with mammogram 40+ (ACS) …
  • USPSTF: q2 for 50-74
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80
Q

Cervical Cancer screening

A
  • 21-29: q3
  • 30-65: q3, or q5 if HPV testing also
  • 65+: may stop if 3 consecutive normal paps or 2 consecutive normal with HPV-
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81
Q

Cervical cancer RFs

A
  • early onset sex
  • multiple lifetime partners
  • Cigarettes
  • Immunosuppression
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82
Q

screening for endometrial/ovarian cancer

A

none if asymptomatic

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83
Q

evaluation breast lump

A
  • precise Hx, nipple d/c? change (esp w cycle)
  • Exam. U/S can help determine if cystic
  • If solid –> mammography
  • If cystic –> FNA
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84
Q

RFs breast cancer

A
  • FHx
  • Prolonged exposure to estrogen (early menarche, late menopause, low parity)
  • Genetic (BRCA1/2)
  • Sex/Age
  • increased breast density
  • high alcohol intake
  • Obesity
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85
Q

menopause definition age, normal Sx, and worrisome Sx

A
  • No menstruations for 12 months
  • average age = 51. Smoking hastens onset
  • normal Sx: hotflashes/vasomotor Sx, atrophic vaginitis (dyness and dyspareunia)
  • worrisome Sx: heavy bleeding, very tightly spaced menses, bleeding >7days
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86
Q

Calcium supplementation in women

A
  • premenopausal: 1000mg/day
  • postmenopausal: 1500 mg/day
  • USPSTF currently recommends against supplementation. Try to increase through dairy and do weight bearing exercise
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87
Q

Osteoporosis screening

A
  • women >65: DEXA scan

- women 9% risk over 10 years

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88
Q

RFs osteoporosis

A
  • early menopause,
  • sedentary
  • white
  • Hx of fracture
  • cigarette
  • Obesity is NEGATIVE RF
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89
Q

Gardasil

A
  • 6, 11 (warts)
  • 16/18 (most cervical cancers)
  • females 9-26
  • 3 doses
  • before, shortly after sexual debut
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90
Q

Cervarix

A

-16/18 (most cervical cancers)
-31/45
-females 10-25
-3 doses
before sexual debut or shortly after

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91
Q

“Three C’s of addiction”

A

Compulsion to use
lack of Control
Continued use despite consequences

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92
Q

Stages of Behavior change

A

PRe-contemplative
Contemplative
Active
Relapse

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93
Q

Oral medications to aid in smoking cessation

A
  • Buproprion (often first line), Varenicline
  • somewhat effective: 1.5-3x at 12 months
  • most effective in group setting and with series of counseling sessions
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94
Q

PE signs dyslipidemia

A

corneal arcus, xanthelesma, acanthosis nigricans

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95
Q

PE signs atherosclerosis

A

Decreased peripheral pulses, carotid bruits

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96
Q

Colon cancer screening options

A
  • Screening colonoscopy q10
  • three stools for blood q1 and flex sig q5
  • FOBT q1
  • CT colography is experimental
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97
Q

Exercise stress test in asymptomatic pts

A

-may be useful in men >45 with 1+ RF

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98
Q

EKG changes suggesting CAD

A
  • Horizontal ST depression/downsloping ST segment –>cardiac ischemia
  • Convex ST elevation –> acute MI
  • Q waves >25% of R wave and >.04s –> infarction
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99
Q

chlamydia screening

A
  • Grade A: all sexually active non-regnant women 25 at increased risk
  • Grade B: All pregnant women 25 at increased risk
  • Grade I: men
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100
Q

Folic acid supplementation

A
  • All women planning or capable of pregnancy: 400-800mcg daily
  • 1 mg in diabetes/epilepsy. 4 mg in pts w h/o pregnancy w NT defect
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101
Q

HTN and pregnancy

A
  • avoid ACEis, ARBs, thiazides
  • optimize control.
  • 1mg folate daily
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102
Q

Warfarin and pregnancy

A

switch to heparin

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103
Q

Vitamins and pregnancy

A

avoid overuse of A or D

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104
Q

Goodell’s sign

A

softening of cervix in pregnancy

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105
Q

Hegar’s sign

A

softening of uterus in pregnancy

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106
Q

Chadwick’s sign

A

bluish-purple hue in cervix/vaginal walls caused by hyperemia

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107
Q

Estimated gestational Age vs Actual Embryonic Age

A
  • EGA = LNMP

- actual embryonic age : EGA - 2 weeks

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108
Q

Calculating expected due date

A

-LMNP
+ 1 year
-3 months
+1 week

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109
Q

Lx in pregnancy

A
  • CBC
  • Rubella (if non-immune, need to be vaccinated postpartum (live vaccine))
  • HBsAg (major risk
  • Type (RH(D)-negative women should receive anti(D)IG (RhoGAM) to prevent hemolytic disease of newborn)
  • RPR
  • HIV
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110
Q

serum hCG vs urine

A
  • urine specific but not sensitive in early pregnancy

- if high index of suspicion, do serum when urine is negative

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111
Q

bleeding and miscarriage

A
  • 1/4 pregnant patients experience vaginal bleeding in the first trimester
  • when there is significant bleeding in the first trimester, there is 25-50% chance of miscarriage
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112
Q

Ectropion

A
  • Central part of cervix appears red from mucous-producing endocervical epithelium protruding thorugh the os.
  • no significance, more common in women taking OCPs
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113
Q

Lx in suspected miscarriage

A
  • Progesterone: if >25, strongly suggests viable intrauterine pregnancy. If <5, strongly suggests evolving miscarriage or ectopic. If 5-25, inconclusive
  • quant bHCG: definitive when combined with U/S
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114
Q

U/S and EGA/EDD

A

in first and second trimester, if >7 days from EGA/EDD, should change
-in third trimester, shouldn’t change EDD

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115
Q

distinguishing missed abortion from inevitable abortion

A

-dilated os

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116
Q

Threatened abortion

A
  • bleeding before 20 wks gestation.

- catch all

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117
Q

management inevitable abortion (fetal demise with os dilation)

A
  • expectant
  • D&C (heavy bleeding, pt preference)
  • misoprostol (3-4 days, as opposed to 2-6 wks with expectant)
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118
Q

primary dysmenorrhea

A
  • depression/anxiety
  • tobacco use
  • increase parity is negative RF
  • most common in women in teens and twenties. associated with ovulatory cysts
  • non-sexually active woman <20 w suprapubic pain in first two days of menses, can use NSAIDs w/o a pelvic exam
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119
Q

nabothen cysts on cervix

A
  • inclusion cysts from metaplasia

- normal

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120
Q

Adenomyosis

A
  • Abnormal glandular tissue w/i muscle
  • often presents with menorrhagia. Uterus typically enlarged and diffusely boggy. Urinary/GI Sx
  • Dx: U/S
  • Tx: conservative, NSAIDs
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121
Q

Chronic PPID

A

-Lower abd pain, usually unrelated ot menses. Menorrhagia in 1/3 of women

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122
Q

Endometriosis Sx

A

Dyspareunia, bowel bladder symptoms that cycle with menses, fatigue, abnormal vaginal bleeding, effects on fertility. Chronic pelvic pain or dysmenorrhea.

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123
Q

Leiomyomas

A
  • fibroids: benign tumors of the uterus. more common in Afr Am. Decreased risk with OCPs, parity, smoking. INcreased risk with early menarche, FHx fibroids, inc alcohol use.
  • Sx: dysmenorrhea, urine/GI Sx, menorrhagia, anemia.
  • Tx: NSAIDs, Mirena, OCPs, Depo-Provera, hysterectomy
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124
Q

Tx PMS/PMDD

A
  • Danazol: androgen with progesterone effects. lowers estrogen and inhibits ovulation. androgenic SEs are undesirable.
  • OCPs
  • SSRIs. daily or luteal phase
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125
Q

primary vs secondary skin lesions

A

-secondary are changes that occur 2/2 progression of disease, scratching, or infection of primary lesions

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126
Q

macule vs patch

A

patch is > 1 cm

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127
Q

papule vs plaque

A

plaque is >1 cm

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128
Q

nodule

A

raise solid lesion

-epi, dermis, or subQ

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129
Q

tumor (derm)

A

solid mass of skin or subQ. larger than a nodule

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130
Q

vesicle vs bulla

A

bulla is > 1 cm

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131
Q

pustule

A

circumscrived elevated lesions containing pus

132
Q

wheal

A

area of elevated edema in the upper epidermis

133
Q

USPSTF grade for skin exam

A

Grade I

Discuss with patients

134
Q

RF non-melanoma skin cancer (sun)

A

-lifetime sun exposure

135
Q

RF melanoma (sun)

A

-intense, intermittent blistering sunburns in childhood/adolescence

136
Q

actinic keratoses

A
  • scaly keratotic patches often more easily felt than seen

- Hx of significant sun exposure

137
Q

psoriasis

A
  • usually bilateral
  • extensor surface of knees and elbows
  • usually plaque-like, scaly, elevated lesions
138
Q

Eczema

A
  • erythematous, often pruritic
  • behind the ears and on flexural areas
  • Tx: steroids
139
Q

steroids vehicles (derm)

A
  • creams: can be used in any area. drying effect w continuous use
  • ointments: better for dry skin and greater potency than cream
  • lotions/gels: contain alcohol. good for scalp/exudative lesions
140
Q

steroid potency groups:

A

Group I - strongest

Group VII -weakest

141
Q

application steroid creams

A

once or twice daily. more frequent does not provide better results

142
Q

side effect steroid creams

A

skin atrophy
hypopigmentation
high potency can cause systemic side effects (HPA suppression, glaucoma, septic necrosis, hyperglycemia, HTN)

143
Q

fungal infections requiring oral therapy

A
  • tinea capitis

- tinea unguium (onchomycosis)

144
Q

procedure consent forms

A
  • name of procedure
  • nature/diagnosis of lesion
  • risks
  • benefits
  • alternative to procedure
145
Q

non-melanoma indications for Mohs

A
  • > 2 cms
  • indistinct margins
  • recurrent
  • close to important structures
146
Q

Tx actinic keratoses

A

topical 5-FU

147
Q

Cryotherapy

A

-useful for small, well defined low risk SCCs and Bowen’s

148
Q

DDx prostate Sx

A
  • BPH
  • acute/chronic prostatitis
  • prostate cancer
149
Q

Lower Urinary tract Sx

A
  • inc frequency
  • nocturia
  • hesitancy
  • urgency
  • weak stream
150
Q

complications of untreated BPH

A
  • UTIs
  • acute urinary retention
  • obstructive nephropathy
151
Q

workup BPH

A
  • Sx assessment
  • DRE
  • urinalysis
  • PSA
  • BUN/creatinine (assess for obstructive nephropathy
  • optional: urine flow rate, post-void residual volume
152
Q

Tx BPH

A
  • behavior modification (give time to urinate, don’t drink too much, avoid diuretics, especially in evening, avoid decongestant, avoid antihistamines)
  • Alpha-adrenergic antagonists (tamsulosin, doxazosin)
  • severe Sx, large prostates, or non-responders –> 5-alpha-reductase inhibitors to prevent outlet obstruction
153
Q

Tx primary insomnia

A
  • CBT-I: sleep restriction (time in bed = time spend sleeping. gradually increase). and sleep compression (gradually decrease amount of time in bed until = time slept)
  • Non-benzo hypnotics (Ambien, melatonin)
154
Q

MDD vs bereavement

A
  • MDD not usually given unless Sx present 2 mos after death.
  • Warning Sx not characteristic of “normal” grief:

-Guilt about things other than actions taken or not taken by the survivor at the time of the death;
-Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person;
-Morbid preoccupation with worthlessness;
-Marked psychomotor retardation;
Prolonged and marked functional impairment; and
-Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

155
Q

SI severity assessment

A 
Sex (male);
Age (< 19 or > 45);
Depression, diagnosis of;
Previous attempt(s)
Ethanol or other substance abuse
Rational thinking impaired (psychosis, delusions, hallucinations)
Social supports lacking
Organized plan for suicide
No significant other 
Sickness (physical illness).

One point is scored for each factor present.

A score of 4 to 6 suggests outpatient treatment is an appropriate clinical action
A score of 7 to 10 suggests hospitalization is warranted

156
Q

USPSTF screening recs for depression

A

all adults, but especially those w chronic disease

157
Q

SSRIs in elderly

A

-increased risk of falls

158
Q

rare SEs SSRIs

A
  • SIADH

- Serotonin syndrome

159
Q

fluoxetine

A 
-prozac
Unusually long half life (two to four days), so effects can last for weeks after discontinuation.
Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.
160
Q

Sertraline

A

-Zoloft
In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders.
More gastrointestinal side effects than the other SSRIs.

161
Q

Paroxetine

A

Paxil
Strong antianxiety effects.
Best studied SSRI in children.
Side effects can include significant weight gain, impotence, sedation, and constipation.
Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

162
Q

Fluvoxamine

A

Luvox
Particularly useful in obsessive-compulsive disorder.
Greater frequency of emesis compared to other SSRIs.

163
Q

Citalopram

A

-Celexa

Most common side effects include nausea, dry mouth, and somnolence.

164
Q

Escitalopram

A

Lexapro
Approved specifically for Generalized Anxiety Disorder.
Overall, fewer side effects than citalopram.

165
Q

depression in hispanics

A
  • Less likely than whites to have depression identified
  • more likely to have somatic complaints
  • less likely to receive adequate therapy (true for all minorities
166
Q

RFs for elder abuse

A

Dementia.
Shared living situation of elder and abuser (except in financial abuse).
Caregiver substance abuse or mental illness.
Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder’s dependency and the resulting stress has not been found to predict abuse.
Social isolation of the elder from people other than the abuser.

167
Q

Orthostasis

A
  • reduction of systolic (>20) or diastolic (>10) measured three minutes after pt who has accommodated to supine position stands or sits.
  • some clinicians consider positive if HR has increased by 20
168
Q

TIA and stroke risk

A

Individuals experiencing TIA symptoms have been shown to have an 8 - 12% chance of having a stroke within one week and an 11 - 15% chance of having a stroke within one month.

169
Q

AF with RVR

A

Afib with Rapid Ventricular Response

  • physiologic or electrical VTach in pts with Afib
  • etiology: fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, catecholamines, AV node dysfunction
  • complications: hemodynamic instability, functional impairment, HF, iscehmia
  • Tx: Rate control (diltiazem, BBs, verapamil). Rhythm control (cardioversion–risk of stroke)
170
Q

common stroke complications

A

aspiration pneumonia
malnutrition/dehydration
pressures sores`

171
Q

BRBPR

A

-suggests lower GI bleed (colorectal carcinoma, colon polyps)

172
Q

Site of iron absorption

A
  • jejunum.

- malabsorption can be caused by jejunal disease or celiac sprue

173
Q

Anoscopy

A

detects some sources of bleeding, such as anal fissures and internal hemorrhoids.

174
Q

RFs CRC

A

-age
-FHx
-Personal Hx of other cancers or diabetes
-Diet: Obesity, fat intake (adenoma, not necessarily CRC), red meat??
No benefit of increasing fiber

175
Q

Tx Iron deficiency

A
  • Fe sulfate 325 TID

- Docusate 100 BID PRN

176
Q

bad news mneumonic

A 
SPIKES
Set up
Perception (ask)
Invitation (may not want to know)
Knowledge
Emotions/Empathy
Strategy/Summarize
177
Q

Staging of CRC

A
  • endorectal U/S for depth of invasion
  • CT P/A for mets to LNs, liver
  • CXR for mets to lung
  • CEA (Carcinoembryonic antigen). >5ng/mL suggests worse prognosis
178
Q

Developmental screening in kids

A
  • mandated at 9, 18, 30 month checkups

- autism screening at 18, 24 months

179
Q

when to transition a kid to cow’s milk

A

never before 12 months (can develop colitis)

180
Q

Caloric Req’s for 1-2 month olds

A
  • 100-120 cal/kg/day (average daily weight gain 20-30g) for a term infant
  • preterm: 115-130 cal/kg/day
  • VLBW: up to 150 cal/kg/day
181
Q

Moro reflex

A

-present up to 4 months
-abrupt change in infants head position–>
Symmetric abduction
Extension of the arms followed by adduction of the arms, sometimes with a cry.
The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.

182
Q

Dev Milestones at 2 months

A

50-90% of kids (90% of kids)

  • Motor: head up 45 (Lift head)
  • fine Motor: Follow past midline (follow to midline)
  • Cognitive: Laugh (Vocalize)
  • Social: Smile spontaneously (Smile responsively)
183
Q

Dev Milestones at 4 months

A

50-90% of kids (90% of kids)

  • Motor: Roll over (Sit-head steady)
  • fine Motor: Follow to 180 (Grasp rattle)
  • Cognitive: Turn to rattling sound (laugh)
  • Social: (regard own hand)
184
Q

Dev Milestones at 6 months

A

50-90% of kids (90% of kids)

  • Motor: Sit–no support (Roll over)
  • fine Motor: Look for dropped yarn (reach)
  • Cognitive: Turn to voice (Turn to rattling sound)
  • Social: Feed self (Work for toy out of reach)
185
Q

Dev Milestones at 9 months

A

50-90% of kids (90% of kids)

  • Motor: Pull to stand (Stand holding on)
  • fine Motor: Take 2 cubes (transfer cuve)
  • Cognitive: Dada/Mama (single syllables
  • Social: Wave bye-bye (feed self)
186
Q

Obesity/overweight in kids def

A
  • overweight: 85-95th percentile for age

- obese:BMI > 95th percentile for age

187
Q

Weight/Height age

A

-Age at which the pt’s weight or height would put them in the 50th percentile

188
Q

Objective hearing/vision screens

A

Vision: beginning at 3 years
Hearing: newborn, resumed at 4 years

189
Q

Adverse effects of ADHD meds (stimulants)

A
  • appetite suppression (usually minimal weight loss)
  • rare tic disorder
  • insomnia
  • decrease in growth velocity
  • NO: higher risk of substance abuse, addictiveness. CV risks seem limited to children with known heart disease.
190
Q

RFs childhood obesity

A
  • high birth weight
  • obese parent(s)
  • lower SES
  • Genetic syndromes (Prader-willi)
191
Q

SCFE

A
  • displacement of femoral head from femoral neck
  • commonly onset of puberty in obese pts w delayed maturation
  • antalgic gait due to pain referred to hip/thigh/knee w decrease ROM (esp internal rotation)
  • Dx w plain film
192
Q

steatohepatitis

A

complication of adolescent obesity.

mild increase in liver transaminases, hyperechoic liver on U/S, evidence of fatty infiltration and fibrosis on biopsy

193
Q

pediatric DM screening

A
  • at risk kids, starting at 10 yo, q3.

- Risk = overweigh, FHx, not white, signs of insulin resistance, maternal Hx gestational diabetes

194
Q

HTN classes in kids

A

90th-95th Prehypertension
95th-99th plus 5 mm Hg Stage 1 hypertension
> 99th plus 5 mm Hg Stage 2 hypertension

195
Q

Management preHTN in kids

A

Therapeutic lifestyle changes should be implemented
BP should be followed up in 6 months
No further diagnostic evaluation is needed at this point to look for a secondary cause of hypertension:

196
Q

Presentation epiglotitis

A
  • high fever
  • inspiratory stridor, hot potato voice
  • seated in “tripod” position
  • rapid onset in pts 1-6yo
  • incidence decreasing due to Hib vaccine
197
Q

pertussis presentation

A
  • “common cold” initially

- cough worsened/present >14 days

198
Q

presentation mono

A
  • fever, pharygitis, LNadenopathy
  • classically, posterior cervical LNs (contrast strep)
  • palatal petechiae (can also have with strep)
  • Hepatosplenomegaly
  • “Monospot” not positive until day 7
  • may present with generalized faint rash early (disappears)–can be prolonged and pruritic if pts improperly Tx’d with Abx
199
Q

Retropharyngeal abscess

A
  • fever, dysphagia, hot potato voice. Asymmetric tonsillar enlargement and/or deviation of uvula.
  • May be life threatening!
200
Q

Viral croup presentation

A
  • prodrome of mild fever
  • may have sore throat
  • barking cough, inspiratory stridor, hoarse voice
  • Steeple sign on XR only 50% sensitive
201
Q

GABHS throat presentation and Tx

A
  • mixed sensitivities:
  • fever
  • absence of cough
  • tonsillar exudates
  • ant cervical LNopathy
  • diffuse red papular rash with “sandpaper” texture
  • Tx: Penicillin G or V. Amoxacillin (broader spectrum –> resistance). Cephalexin if PCN allergy
202
Q

viral pharyngitis

A
  • most common cause of sore throat
  • URI Sx
  • can have rash
  • can have low-grade fever
203
Q

Complications of strep throat

A
  • Scarlet fever: punctate red blanching rash, banged out pharynx, strawberry tongue
  • Rheumatic fever
  • post-strep glomerularnephritis
  • peritonsillar abscess, mastoiditis, meningitis, bacteremia
204
Q

witholding vaccines for disease

A

only if moderate-severe (high fever, otitis, diarrhea, vomiting)

205
Q

vaccine schedule

206
Q

lead screening in kids

A

starting at 5 years old:
Does your child live in or regularly visit a house or child care facility built before 1950?
Does your child live in or regularly visit a house or child care facility built before 1978 that is being or has recently been renovated or remodeled (within the last six months)?
Does your child have a sibling or playmate who has or did have lead poisoning?

207
Q

anemia screening in kids

A

starting at 5 years old:
At risk of iron deficiency because of special health needs
Low-iron diet (i.e. nonmeat diet)
Environmental factors (i.e. poverty, limited access to food)

208
Q

Tb screening in kids

A

Children infected with HIV
Incarcerated adolescents
Has a family member or contact had tuberculosis disease?
Has a family member had a positive tuberculin skin test?
Was your child born in a high-risk country (countries other than the United States, Canada, Australia, New Zealand, or Western European countries)?
Has your child traveled (had contact with resident populations) to a high-risk country for more than one week?

209
Q

req’s for Dx ADHD

A
  • behaviors present in >2 settings

- >6 years old

210
Q

DDx palpitations

A

Cardiovascular: Arrhythmia, cardiomyopathy, hypovolemia
Psychiatric: Anxiety, panic attacks
Medications: Caffeine, theophylline, and albuterol use
Substances: Tobacco, caffeine, alcohol intoxication or withdrawal, cocaine
Endocrinologic: Hyperthyroidism, pheochromocytoma, hypoglycemia
Hematologic: Anemia
Infectious: Febrile illness

211
Q

Toxic Nodular goiter (Grave’s)

A
  • most common cause of hyperthyroid
  • auto-Abs stimulate TSH R
  • hypervascularization may cause a bruit/thrill
  • exophthalmos and eyelid retraction –> corneal edema (rarely unilateral). Eye Sx NOT affected by treating thyroid!
  • pretypial myxedema–rare
  • thyroid peroxidase/TSH R Abs usually positive
  • Tx: methimazole to suppress T4 production (agranulocytosis). Oral radioactive iodine (few side effects)–need to replace hormone, get hCG
212
Q

toxic nodular goiter

A

rare cause of hyperthyroidism
5% cancerous
-older: multiple nodules
-younger: single nodule

213
Q

thyroiditis

A

hyperthyroid from inflamed gland

-happens after viral illness or pregnancy

214
Q

sx hypothyroid

A 
-weight gain
cold intolerance
pedal edema
heavy periods
fatigue
215
Q

thyroxine therapy

A
  • starting dose: 1.5-1.8 mcg/kg
  • increase slowly. Check TSH q6weeks
  • when stable, can check TSH 1-2/year
216
Q

RF with most attributable US deaths

A

smoking: lung cancer, heart disease, COPD

217
Q

PAD

A

atherosclerosis of peripheral arteries

  • Hx of claudication
  • late in disease, night pain, nonhealing ulcers, skin color changes
  • ABI <0.9
  • RFs: smoking, DM, HLD, obesity
218
Q

Wells criteria DVT

A

All worth 1 pt:

  • active cancer
  • paralysis, paresis, or immobilization
  • Recently bedridden >3 days or major surgery w/i 4 weeks
  • localized tenderness along deep venous distribution
  • entire leg swollen
  • Calf swelling by more than 3 compared to other leg (measured 10cm below tibial tuberosity)
  • Pitting edema
  • Collateral superficial veins (non-varicose)
  • Alternative diagnosis as likely as DVT (-2 points)

0 or less: low probability
1-2: moderate
3+: high

219
Q

Wagner grading system for ulcer

A
  • Grade 1: Diabetic ulcer (superficial)
  • Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
  • Grade 3: Deep ulcer with abscess or osteomyelitis
  • Grade 4: Gangrene forefoot (partial)
  • Grade 5: Extensive gangrene of foot
220
Q

Req’s for treating DVT as outpt

A
  • hemodynamically stable
  • good kidney function
  • low risk for bleeding
  • stable environment w access to daily INR monitoring
  • Tx: LMWH. Longer halflife, no lab monitoring, thrombocytopenia less likely, dosing is fixed
221
Q

length of anticoagulation for different pts

A
  • symptomatic isolated calf thrombophlebitis : 6-12 wks
  • First time event post surgery/trauma: 3 months
  • idiopathic disease: 6 months
  • Recurrent or inherited thrombophilia: 12 months - indefinitely
222
Q

when to measure INR in warfarin Tx

A
  • half-life ~40hrs

- takes 5-7 days for steady state

223
Q

transitioning to warfarin

A

-LMWH, UFH, or fondaparinux should be ct’d for at least 5 days after beginning and until INR is >2 for 24+hrs

224
Q

Diverticulitis

A
  • Sx: acute LLQ pain, change in BMs, fever

- pts >50

225
Q

Acute pancreatitis

A
  • Severe abdominal pain, nausea, vomiting, ill appearance, and signs of volume depletion.
  • epigastric pain radiating to the back, worse with eating
226
Q

GERD pain

A
  • mild epigastric pain worse after means
  • “burning” may be substernal
  • hematemesis is unusual and concerning for upper GI bleed
  • hematochezia/melena unusual
227
Q

PUD

A
  • epigastric pain that improves with meals (some cases worse)
  • associated with NSAIDs
  • hematemesis concering
  • Melena –> upper GI bleed 2/2 PUD or NSAID-gastritis
  • etiologic factors: SAS/NSAIDs, cigarettes, physiologic stress (ICU), H Pylori. Not caffeine/psychosocial stress
228
Q

Gastritis

A
  • inflammation of the stomach lining —> epigastric pain improves immediately following meal
  • commonly 2/2 NSAIDs/alcohol
229
Q

dyspepsia

A

-Upper abdominal pain/discomfort that is episodic/persistent.
Up to 1/4 of adults affected
-50% functional, 20% PUD, 20% GERD, 15% gastritis. Commonly medication side effects. Gastric/pancreatic/esophageal cancer rare but important, as are angina, aortic aneurysm

230
Q

complications of GERD

A

Dysphagia
Difficulty in swallowing. Dysphagia to solids suggests possible development of peptic stricture. Rapidly progressive dysphagia potentially indicates adenocarcinoma. Dysphagia to liquids suggests development of a motility disorder.
Initial onset of upper GI symptoms after age 50
Increased chance of cancer.
Early satiety
May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer).
Hematemesis
Vomiting blood, which suggests bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices.
Hematochezia
Passing red blood with stool, which may indicate a rapidly bleeding ulcer or mucosal erosions.
Iron deficiency anemia
The presence of hematemesis, hematochezia, and/or iron deficiency anemia may indicate possible bleeding from a peptic ulcer, mucosal erosions, or cancer.
Odynophagia
Painful swallowing, which is associated with infections (e.g. candida), erosions, or cancer.
Recurrent vomiting
Suggestive of gastric outlet obstruction.
Weight loss
Associated with malignancy.

231
Q

Workup suspected GERD

A
  • PPI trial
  • reduces endoscopy/24 hr pH monitoring
  • sensitive and specific for GERD
232
Q

workup of PPI-resistant GERD

A
  • Test for H Pylori (serum. if positive, urea breath test/stool)
  • R/O bleeding FOBT
  • Trial H2 blockers
  • TCAs
233
Q

Tx H Pylori

A

Triple therapy: PPI BID, Amoxicillin BID, Clarithromycin BID

Quadruple therapy: PPI BID, metronidazole QID, tetracycline QID, bismuth QID (higher eradication rate

234
Q

complications of influenza

A
  • bacterial pneumonia
  • otitis media
  • less common: aseptic meningitis, GBS, febrile SZ
  • rare: myositis, myocarditis
235
Q

communication with parents

A
  • direct to kid/parent
  • specific details
  • written material
  • signs of complications
236
Q

Tx pneumonia in kids

A

3mos - 5yrs: amoxicillin
>5yrs: azithromycin

If fail, amox-clav

237
Q

Screening for pediatric T2DM

A
  • all kids at age 10 with BMI >85% and RFs or >95% regardless.
  • Check q2 after that
238
Q

Screening for HLD in kids

A
  • fasting lipid on all children with BMI >85%

- Goal is total cholesterol 170, LDL 130

239
Q

prevalence adolescent obesity

240
Q

Tx kids overweight/obese

A 
Prevention Plus: 5-2-1-0 counseling
5 servings F/V
2 hrs screen time
1 hr physical activity
0 sugary drinks
241
Q

Tx kids BMI 85-94%

A

5-2-1-0 and structured weight management:

  • Reduce energy-dense foods
  • Structure meals
  • 1hr screen time
  • Diet and activity monitoring
  • monthly office visits
  • support by dietitian, counselor, exercise therapist as needed
242
Q

Tx kids BMI >95%

A

Comprehensive multidisciplinary intervention

Structured Weight Management + multidisciplinary obesity team and behavioral modifaction

243
Q

Tx kids failing Comprehensive Multidisciplinary Intervention

A

Referral to Tertiary weight management center

244
Q

Guidelines for whether kids should maintain/lose weight

A
  • Under 7yo, BMI >95% w/o complications should maintain weight. With complications should lose until 85%
  • > 7yo, weight loss recommended to achieve 85%
245
Q

Abx in AOM

A

> 2yo: don’t need
<6months: treat
6-24mos:may be observed first, depending on circumstances

246
Q

Vestibular neuritis

A
  • commonly associated with recent URI

- nystagmus does not change direction with gaze

247
Q

Vestibular migraine

A

cause of central vertigo

248
Q

Central vs peripheral nystagmus

A
  • peripheral: unidirectional (horizontal and rotational) and does not change direction. inhibited by fixating and intensifies when fixation withdrawn. exacerbated by Frenzel glasses (prevent fixation)
  • Central: purely horizontal, vertical, or rotational. Does not improve with fixation. Persists for longer
249
Q

Meniere’s disease hallmark and Tx

A
  • episodes of unilateral hearing loss, tinnitus, vertigo

- Tx: diuretics and low-salt diets, but inconclusive evidence

250
Q

Vestibular neuronitis vs labyrinthitis

A

labyrinthitis: both branches of nerve, causing tinnitus and/or hearing loss as well as vertigo.

251
Q

Test for BPPV

A

Dix-Hallpike maneuver

252
Q

Test for central vs peripheral

A

head thrust test. If normal in the presence of vertigo, lesion is central.

253
Q

vestibular suppressants

A

antiAch: meclizine, dimenhydrinate (also anti-emetics)

  • metoclopramide and promethazine (non-selective anti-emetics) can be used as adjuvants)
  • Caution in elderly! cause sedation
254
Q

risks/benefits HRT in menopause

A
  • reduces vasomotor Sx, atrophic vaginits, helps prevent OA ?cognitive decline
  • Risks: increased risk of breast cancer, endometrial Ca, CAD (if begun after 60), stroke (first 1-2 years of use)
  • should use lowest possible effective dose
255
Q

cervical polyp

A

most common in postpartum and perimenopausal women.

-can cause vaginal bleeding

256
Q

endometrial hyperplasia

A
  • can cause vaginal bleeding
  • simple –> cancer 5%
  • atypical –> cancer 25%
257
Q

ovarian cancer Sx

A
  • abdominal/pelvic pain
  • increase in abdominal size/bloating
  • difficulty eating/feeling full
  • rarely can cause bleeding, but concerning cause of postmenopausal bleeding
258
Q

proliferative endometrium

A
  • normal response to estrogen stimulation
  • occasionally happens in postmenopausal women, esp in higher estrogen states
  • difficult to distinguish from simple hyperplasia on biopsy
259
Q

endometrial cancer RFs

A

Estrogen exposure!!

  • unopposed estrogen Tx
  • tamoxifen
  • obesity
  • anovulatory cycles
  • early menarche
  • late menopause
  • menstrual cycle irregularities
  • nulliparity
  • HRT
260
Q

lab tests for confirming menopause

A

FSH/LH

ovarian follicles become resistant, produce less inhibin –> increased FSH/LH

261
Q

osteoporosis prevetion

A
  • smoking cessation
  • Ca intake 1200 mg/day
  • Vitamin D 600 IU/day
  • bisphosphanate Tx (Alendronate/risedronate).
  • PTH can prevent fracture (costly) as can HRT and calcitonin
262
Q

Tx Hot flashes

A
  • mind/body techniques
  • SSRIs/SNRIs
  • HRT
  • clonidine, gabapentin
263
Q

core skills family interviewing

A 
Greet and build rapport
Identify each person's agenda
Check each person's perspective
Allow each person to speak
Recognize and acknowledge feelings
Avoid taking sides
Respect privacy and maintain confidentiality
Interview the patient separately, if needed
Evaluate agreement with the plan
264
Q

advanced skills family interviewing

A

Guide communication
Manage conflict
Reach common ground
Consider referral for family therapy

265
Q

Examination for testicular torsion

A
  • Cremasteric reflex absent sensitive but not specific
  • Negative Prehn sign: pain relieved by lifting of testis (indicates epididymitis when positive.)
  • Blue dot sign: with tenderness limited to upper pole of testis is suggestive of appendiceal torsion.
266
Q

Hydrocele

A

cystic painless scrotal fluid collection

  • most common cause of painless scrotal swelling
  • positive transillumination
  • generally asymptomatic and slow growing
267
Q

varicocele

A

collection of dilated/tortuous veins in pampiniform plexus surround spermatic cord

  • more common on left side (because left spermatic vein enters renal vein at 90 degrees)
  • more common in adult men but can be seen in adolescents
  • associated with infertility, but mechanisms unknown
  • asymptomatic/dull ache/fullness
268
Q

Testicular torsion

A
  • testicle twists around vascular supply
  • dangerous. Surgical window 4-12 hrs
  • Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion.
  • Physical findings: swollen, tender scrotum and the cremasteric reflex is typically absent. Testicular torsion causes the orientation of the testis to change, causing a “transverse lie” although this may be difficult to appreciate in a very swollen and tender patient.
269
Q

appendix testis torsion

A
  • less dangerous than testicular torsion
  • may be comfortable until examined (like epidydimitis)
  • blue dot sign!
270
Q

epididymitis

A

most frequent cause of sudden scrotal pain
-typically slowly progressive Sx over days
-It is caused by bacterial infection of the epididymis, typically from a urinary tract or sexually-transmitted infection.
-The patient may appear comfortable except when examined.
Severe swelling and exquisite pain are present on the involved side, often accompanied by high fever, rigors, and irritative voiding symptoms.
Patients may have had preceding symptoms suggestive of a urinary tract infection or sexually transmitted disease.
On exam, the scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex is usually present, and the testis is in its normal location and position. Positive Prehn sign (pain relieved by lifting)

271
Q

Causes of testicular torsion

A
  • idiopathic
  • congenital anomaly (bell clapper deformity)
  • undescended testes (torsion often caused by development of a tumor)
  • recent trauma/physical exercise
272
Q

Dx Testicular torsion

A
  • color doppler (faster and more available)

- Radionuclide scintography

273
Q

Tx Testicular torsion

A
  • manual detorsion. often impossible because of pain. If successful, must still do orchiopexy
  • Surgical approach: testis unwound and inspected for viability. if not viable, should be removed and contralateral orchiopexy
274
Q

Patient centered medical home

A

personal physician
physician-directed medical practice
whole person orientation
Coordinated/integrated care

275
Q

GAPS

A

Guidelines for Adolescent Preventative Services

Preventing hypertension (B)
Promoting parents’ ability to respond to the healthcare needs of their adolescents
Preventing hyperlipidemia (C)
Preventing the use of tobacco products
Preventing the use and abuse of alcohol and other drugs
Preventing severe or recurrent depression and suicide
Preventing physical, sexual, and emotional abuse
Preventing learning problems
Preventing infectious diseases
Promoting adjustment to puberty and adolescence
Promoting safety and injury prevention (D)
Promoting physical fitness (E)
Promoting healthy dietary habits and preventing eating disorders and obesity
Promoting healthy psychosexual adjustment and preventing the negative health consequences of sexual behaviors

276
Q

RFs testicular cancer

A
  • Genetics (i.e. Klinefelter’s)
  • FHx
  • Cryptorchidism
  • Environmental hazards (industrial occupations, drug exposure)
  • Hx of testicular cancer
277
Q

Main types of testicular tumor

A
  1. Germ cell tumors: seminonmatous and nonseminomatous
  2. non-GC tumors (leydig cell and Sertoli cell). Rare and malignant only 10%
  3. Extragonadal: lymphoma, leukemia, melanoma mets
278
Q

acute visit history components

A
  • all of them!

- even immunizations—may not get another chance

279
Q

Significant Hx features of ankle injury

A

A patient who seeks help immediately, and is non-weight bearing is more likely to have a severe injury than one who presents a few days after an incident and is fully weight bearing.
A history of previous ankle sprain is a common risk factor for ankle injury.
While hearing a snap or tear is diagnostically significant in an acute knee injury, it is not in an acute ankle injury.

280
Q

Compartment syndrome

A
  • life/limb threatening complication of trauma
  • etiologies: fractures, crush injuries, burns, arterial injuries
  • high index of suspition
  • 6 P’s: Pain (esp disproportionate), Pallor, Pulselessness, Paresthesia (most reliable), Poikilothermia, paralysis
  • Tx: fasciotomy decompression
281
Q

DDx lateral ankle injury

A
  • Lateral ankle sprain (most commonly anterior talofibular ligament)
  • Peroneal tendon tear (esp repeat trauma)
  • Fibular fracture – severe pain, deformity
  • Talar dome fracture – may occur in conjunction w sprain and initial XRs may miss
  • Subtalar dislocation – high energy injury involving talocalcaneal and taloavinicular joints. Pain, swelling deformity
282
Q

Ankle XR per Ottowa rules

A

-Only indicated if Pain in the malleolar zone and either bony tenderness along the distal 6 cm of the posterior edge of either malleolus or inability to bear weight 4 steps immediately after the injury and in the emergency department.

283
Q

PE ankle injury

A
  • inversion test: laxity indicates injury of calcaneofibular ligament
  • crossed leg test: Have the patient cross their legs with the injured leg resting at midcalf on the knee to detect high ankle sprains (syndesmotic injury between the tibia and fibula).
  • anterior drawer test: laxity indicates anterior talofibular ligament tear
284
Q

Tx ankle sprain

A

RICE + NSAIDs

  • use semirigid support for compression
  • stretching after first few days to improve ROM
285
Q

Three most common causes of lower back pain

A

97% is mechanical

  1. lumbar strain/sprain
  2. DJD (disks and facets)
  3. herniated disc
286
Q

RFs for low back pain

A

-prolonged sitting
-deconditioning
-sub-optimal lifting
-repetitive bending
-spondylolysis, disc-space narrowing, spinal instability, spina bifida occulta
?obesity

287
Q

Red flags for low back pain

A

-fever
-unexplained weight loss
-night pain
bowel/bladder incontinence
-neuro Sx

288
Q

Lumbar disk herniation pain

A
  • worse w movement and sitting.
  • worse with coughing/sneezing
  • radiating down leg
  • improves with supine position
289
Q

lumbar spinal stenosis pain

A

-improves when supine

290
Q

spondylolisthesis

A
  • anterior displacement of vertebra or vertebral column in relation to vertebra below
  • can occur at any age
  • aching back and posterior thigh discomfort that increases with bending
291
Q

Physical Exam Back Pain

A
  • Standing: inspect curvature (bending). palpate for rope-like tension or bony tenderness. ROM: flex, extend, lateral. Gait (heel difficult –> L5 herniation. Toe difficult –> S1 herniation). Squat test (reduces stenosis pain)
  • Seated: CVA tenderness, modified SLR test, Neuro exam
  • Supine: Abdominal exam, Rectal exam (when alarm Sx), passive SLR, crossed leg raise, FABER test, pelvic compression, muscle atrophy
292
Q

L3 herniation

A

decreased patellar tendon reflex, pain in lateral thigh and medial femoral condyle. trouble with extension of quads

293
Q

L4 herniation

A

trouble dorsiflexing ankles and walking on heels

294
Q

L5 herniation

A

decreased medial hamstring reflex, pain in lateral leg and dorum of foot, trouble with dorsiflextion of great toe and heel walk

295
Q

S1 herniation

A

Decreased Achilles tendon reflex; pain in the posterior calf; sole of the foot and lateral ankle; trouble with standing on toes and walking on toes (plantarflex ankle).

296
Q

indications for imaging of low back pain

A
  • progressive neuro deficit
  • radiculopathy
  • cuada equina syndrome
  • suspected systemic d/o
  • failure of 6 weeks of conservative care
297
Q

conservative care for low back pain

A
  • NSAID/muscle relaxant
  • local heat/cold
  • PT
298
Q

prognosis low back pain

A

90% resolve in 1 month

  • pts who are older and have psychosocial stress take longer to recover
  • recurrence rate 35-75%
299
Q

patellofemoral pain syndrome

A
  • chondromalacia patellae
  • anterior leg pain 2/2 overuse injury
  • typically presents in women, worse after prolonged sitting
300
Q

IT band tendonitis

A
  • lateral knee pain 2/2 overuse (repetitive knee flexion

- pain aggravated with activity

301
Q

Meniscal tear

A
  • pain on medial or lateral joint line 2/2 sudden twisting injury
  • can occur with DJD
  • mild effusion
  • can have atrophy of quadriceps
  • catching/locking of knee
  • positive mcmurray test
302
Q

popliteal cyst

A
  • pain in posterior popliteal area
  • no h/o trauma
  • insidious onset mild-moderate pain
303
Q

gout vs pseudogout

A

gout = negative birefringence
psuedogout = positive birefringence
psuedogout is deposition of calcium pyrophosphate dihydrate crystals. most common in knee

304
Q

Lachman’s test

A

analogous to ant drawer test. assesses stability of ACL

305
Q

psoriatic arthritis

A

usually oligoarthritis or polyarthritis
-associated with psoriatic plaques. Must have psoriasis to make the diagnosis, but the arthritis can appear before lesions

306
Q

First line choice for mild- to moderate- OA pain

A
  • acetaminophen

- 2nd line: NSAIDs

307
Q

steroid injections for OA

A

should be considered if there is knee inflammation

  • no more than 3 per year
  • long acting triamcinolone is preferred
308
Q

most common SE of opiods

A

constipation

309
Q

pain referred to shoulder

A

MI
lung cancer
cholecystitits
ruptured ectopic

310
Q

Restricted active and passive movement on exam

A

more likely to be joint problem.

311
Q

Adhesive capsulitis

A

common in pts with metabolic disease (diabetes, hypothyroid). contraction of joint capsule

312
Q

rotator cuff tendinopathy exam

A

Positive Apley’s Scratch test leads one towards this diagnosis, but is not definitive.
Weakness and pain with empty can testing strongly suggests supraspinatus (i.e., rotator cuff) pathology. Whether this pathology is tendonitis or a tear is often a matter of degree.
Limited active ROM due to pain supports this diagnosis.

313
Q

rotator cuff tear exam

A

Limited ROM with significant pain is a hallmark of the physical exam in the patient with a partial or complete rotator cuff tear. In a complete tear, the patient will likely not be able to raise his arm above his head.
significant weakness with strength testing on examination that would be present with any significant tear.
Young athletes tend to present with traumatic torn rotator cuff, whereas older people present with insidious onset because of the degenerative process that occurs.

314
Q

biliary colic vs cholecystitis

A

Pathophysiology similar, but in cholecystitis, obstructing stone does not dislodge from cystic duct outlet. Pain is more severe and unremitting.
Fever and white count in cholecystitis.

315
Q

Rare signs for acute pancreatitis

A

Grey-Turner’s sign: ecchymotic discoloration in the flank

• Cullen’s sign: ecchymotic discoloration in the periumbilical region

316
Q

Lx pancreatitis

A

amylase/lipase. If nml, makes it unlikely

317
Q

cholecystitis on U/S

A

GB wall thickening

318
Q

Tx biliary colic with lots of stones in GB

A
  • consult for cholecystectomy

- 70% complication rate in the future

319
Q

Classification of drinking

A
  • Risky/hazardous: exceeding threshold (4 drinks per occasion for men)
  • Problem: significant physical, social, psychological harm
  • Abuse: failure to fulfill obligations, recurrent use in hazardous situations, continued use despite problems
  • dependence: Tolerance, withdrawal, desire to cut down, time spent, tasks sacrificed, use despite problems
320
Q

interventions for risky/hazardous drinking

A
  • Brief intervention by physicial
  • Referral for motivational therapy
  • Referral for CBT
  • AA
321
Q

number of episodes needed to Dx different headaches

A

5 for migraine
10 for tension
5 for cluster

322
Q

criteria for imaging someone with a HA

A

The patient has migraine with atypical headache patterns or neurologic signs
The patient is at higher risk of a significant abnormality
The results of the study would alter the management of the headache

Symptoms that increase the odds of positive neuroimaging results include:
Rapidly increasing frequency of headache
Abrupt onset of severe headache
Marked change in headache pattern
A history of poor coordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep.
A headache that is worsened with use of Valsalva’s maneuver
Persistent headache following head trauma
New onset of headache in a person age 35 or over
History of cancer or HIV

323
Q

Migraine prophylaxis

A
  • Betablockers (cheap/good. contraindicated in Asthma, depression, IDDM)
  • Depakote, Topiramate, Gabapentin (expensive/good. contraindicated in pregnancy!! Topiramate causes renal stones)
  • TCAs (not FDA approved. Also work for fibromyalgia and tension HAs. contraindicated in conduction defects, MAOI)
  • CCB (Verapamil) – not FDA approved. Contraindicated in AV Block)
324
Q

Approach to chronic pain Tx

A

Set clear goals with patients. Rarely possible to completely relieve pain, so aim to achieve a level of pain the patient feels he/she can live with. Measure with functional goals and numeric assessment of pain level.
Use non-pharmacologic treatments such as biofeedback for chronic pelvic pain, physical therapy and cognitive behavioral therapy for chronic back pain.
When using medications, first select specifically targeted non-opiate therapies such as anti-epileptic drugs for neuropathic pain or anti-inflammatories for musculoskeletal pain.
When using opiates:
Use long-acting agents along with the other agents and use the lowest possible dose that improves patients’ function.
Use a pain medication agreement.

325
Q

Criteria for controlled HAs

A
  • fewer than two per week or eight per month

- relieved with lifestyle modification and acute Tx medicine

Family Med (8 decks)

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