Fam Med Flashcards
1
Q
What are the major risk factors for Breast CA - 7
A
- 1st degree relative with breast CA
- Prolonged estrogen exposure (menstruating outside of 12-45 y/o range vs utero DES vs HRT)
- Genetics (BRCA 1/2 mutation)
- Alcoholic
- Obesity
- Radiation
- Age 40-70 yo
Average Menopause onset = 51
2
Q
Formula for BMI
A
(kg weight) / (height in m2)
3
Q
Guidelines for PAP Smear Cervical CA Screening - 3
A
- [Age 21 - 65 every 3 years (cytology only)] ≥ 3x consecutively
- [Age 30-65 can alternatively get Co-HPV Testing every 5 years] ≥ 2x consecutively
- Risk Groups (immunocompro/CIN2, 3 or CA hx) need more frequent screening and voids out #1 and 2 if present
Immune system in under 21 yof clears HPV on its own within 1-2 years, thus < 21 yo don’t need testing
4
Q
Guidelines for Lung CA screening - 3
A
low dose annual CT if fits all 3 criteria:
- [55-80 yo]
- smoked for 30 pack years
- still smoking or quit within last 15 years
- Pack Year = [# of packs/day x # of years smoking]*
- ex: [4 packs/ day x 30 years smoking = 120 pack years]*
5
Q
Guidelines for ovarian CA screening
A
NO routine screening in asx women!
6
Q
Guidelines for Breast CA screening - 3
A
- 45-54 get mammograms annually
- > 55 cont mammograms every year OR switch to every 2 years
- 40-44 have the option
No mamm in pt < 40 unless known BRCA mutation
7
Q
What are characteristics of a breast lump that suggest malignancy - 5
A
- single
- solid (consider US to differentiate from cystic lesion)
- immobile
- >2 cm
- irregular borders
8
Q
Pregnancy and Breast stimulation are normal causes of nipple discharge
What are pathologic causes? - 5
A
- CA (Intraductal/Paget’s/DCIS/Mammary duct ectasia)
- Hormone imbalance
- Trauma
- Abscess
- Meds (Antidepressant/Antipsychotics/AntiHTN)
9
Q
What are the 6 characteristics of a Good Screening Test?
A
- HIGH Specificity and Sensitivity
- Detects disease in asx phase
- Minimum risk
- Affordable
- Acceptable to pt
- Tx available for disease
10
Q
Risk factors for Cervical SQC - 5
A
- Early Sexual Intercourse
- High # of lifetime sex partners
- utero DES exposure
- Smoking
- Immunocompro
11
Q
For Adults, list immunization recommendations for Influenza
A
Purple = Pt has Risk Factors
12
Q
For Adults, list immunization recommendations for TDaP
A
Purple = Pt has Risk Factors
13
Q
For Adults, list immunization recommendations for Pneumococcal vaccine
A
Purple = Pt has Risk Factors
14
Q
For Adults, list immunization recommendations for Zoster
A
Purple = Pt has Risk Factors
15
Q
For Adults, list immunization recommendations for HPV
A
Purple = Pt has Risk Factors
APPROVED FOR FEMALES AGE 9-26 yo
16
Q
Dx for Menopause
A
No menstruation for 1 year straight!
Average Menopause onset = 51
17
Q
What are the 5 A’s to counseling someone?
A
SD drinks GIN
aSk
aDvise
aGree
assIst
arraNge
18
Q
Which interviewing technique should be used for teens?
A
HEE-AD-SS (HEEADS)
Home
Employment/Education
Eating
Activities
Drugs
Sex
Suicide Depression
Safety/Violence
Teens can be interviewed WITHOUT PARENTS
19
Q
What are the guidelines for ANNUAL GC/Chlamydia Screening (Women vs Men)
A
Women
- ALL sexually active women < 25
- Sexually active women > 25 IF HIGH RISK
Men: Insufficient evidence :-(
ANNUAL GC/Chlamydia screening done via NAAT - vaginal or cervical swab
20
Q
What are 3 ideal times to incorporate Preconception Counseling? ; Name the 6 important features of this type of counseling
A
[Urgent care visits/Walk-ins], Teen well check, Sports physicals
- Folic Acid px (400-800 mcg/day in any sexually active woman)
- Genetics screening
- STI screening
- Environmental (Smoking/EtOH)
- Lifestyle (Exercise/Diet)
- Medical hx (DM & Epilepsy = ⬆︎Folic Acid)
21
Q
What are the major s/s of Pregnancy - 7
A
- Amenorrhea (this may be normal in teens)
- NV
- Breast TTP
- Urinary frequency
- [Hegar’s Uteral / Goodell’s Cervical Softening]
- [Chadwick’s Bluish vaginal & cervical hue]
- Uteral Enlargement
Remember to screen sex active women < 25 for Chlamydia
22
Q
What are the options for unplanned pregnancy? - 4
A
- Cont pregnancy and raise the child
- Cont pregnancy and create adoption plan
- Terminate pregnancy medically
- Terminate pregnancy surgically
Abortion is legal up to 22 weeks gestation
23
Q
Abortion is legal up to ____ weeks gestation ; How do you calculate Estimated Gestational age (EGA) - 2 options?
A
22 WG ; [Current Date - date of LNMP] = EGA
OR
serial testing of SERUM βhCG
( LNMP = last normal mentrual period)
24
Q
Which labs do you order initially for newly discovered Prenatal? - 6
A
- CBC (detect anemias & platelet dysfxn)
- Blood Type & Screen (RH-D = RH neg, and these women need anti-D Ig)
- Rubella IgG
- Hep B surface antigen
- RPR
- HIV
25
What's the best way to diagnose ectopic pregnancy or miscarriage? - 2
1. *SERUM* βhCG level trend
2. Progesterone ( ectopic/miscarriage \< 5 - 25 \< healthy pregnancy) - not reliable tho
26
How much and When is [RhoGam Anti-RhD] administered to pregnant women? - 4
1. 50mcg during 1st trimester
2. **300mcg at 28 WG**
3. **300 mcg within 3 days after delivery**
4. with any episodes of vaginal bleeding (if indicated)
27
Lab w/u for [1st trimester vaginal bleeding]
## Footnote
*Remember: this is 25-50% chance of miscarriage*
1. **Serum βhCG trend WITH Pelvic US**
2. CBC
3. Saline Wet Mount for trichomonas
4. GC/Chlamydia PCR
5. Progesterone ( ectopic/miscarriage \< 5 - 25 \< healthy pregnancy) - not reliable tho
28
βhCG levels have to be ____ for pregnancy to be detected via trans*vaginal* US, and usually _____ when trans*abdominal* US can finally detect it
What are βhCG levels during:
A: Ectopic Preg/Miscarriage
B: Molar Pregnancy
βhCG levels have to be **1500-2000** for conclusive pregnancy detection via transvaginal US and usually **\>5000** for transABDominal US to finally detect it
A: Ectopic Preg/Miscarriage = low βhCG
B: Molar Pregnancy = \> 100,000 βhCG!!!
*βhCG should double every 2 days in normal pregnancy for first 7 weeks*
29
Why are serial βhCG more important than point value βhCG?
[βhCG should **double** every 2 days x first 7 weeks] in normal pregnancy so tracking the velocity trend is important
30
What are the options for Mngmt of Miscarriage - 4
1. **Expectant**: Watchful Waiting for products of conception to expel naturally in 2-6 weeks
2. **Surgical**: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration]
3. **Medical**: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel
## Footnote
*ALL REQUIRE 1 WEEK FOLLOW UP*
31
Why is the TDaP given to ____ week gestation pregnant patients?
27-36 week ; Protects **BABY** from Pertussis
32
1st trimester is ___ weeks gestation
What are the 3 biggest questions to ask during history taking for these patients? Why?
\< 14 weeks
1. NV? - asking because this is treatable
2. Vaginal Bleeding?
3. Cramping/contractions?
33
2nd trimester is ___ weeks gestation
What are the 4 biggest questions to ask during history taking for these patients? Why?
14 - 27 weeks
1. Leakage of Fluid? -OOP
2. Vaginal Bleeding? -OOP
3. Cramping/contractions? -OOP
4. Fetal Movement? -OOP
**It is a medical emergency when Fetal Movement is not felt by 24 wks!**
34
2nd trimester is ___ weeks gestation
Fetal Movement should be felt when? ; **It is a medical emergency when Fetal Movement is not felt by \_\_\_\_**
14 - 27 weeks
## Footnote
**It is a medical emergency when Fetal Movement is not felt by 24 wks!**
35
3rd trimester is ___ weeks gestation
What are the 5 biggest questions to ask during history?
28 - 42 weeks
1. Leakage of Fluid?
2. Vaginal Bleeding?
3. Cramping/Contractions?
4. Fetal mvmnt?
5. S/S Preeclampsia (HTN/edema/Proteinuria/spotty vision)
36
What does APGAR stand for? ; How is it done? ; How is it used?
**A**ppearance, **P**ulse, **G**rimace(reflex irritability), **A**ctivity(tone), **R**espiration
Performed at **1** and **5** min postpartum, All scaled from 0 to 2 and then added together
[≤ 3 = Critical] / [4-6 = fair] / [7-10 = normal]
37
Why shouldn't you be alarmed if newborn loses weight within first 2 days after birth?
Newborns lose up to 10% of birth weight in first several days, **but by 2 weeks should return to original birth weight**
## Footnote
*Expect wt gain of ounce/day with maternal milk*
38
DDx for infant fussiness? - 6 ; Give description of each
1. Colic (bouts of fussing \> 3 wks)
2. Infection (do sepsis w/u, especially if fever in \< 2 mo old)
3. GI Reflux (occurs before 1 yo and manifest as "dribbling" regurgitation)
4. Failure To Thrive (fail to gain wt)
5. Milk Allergy (RARE and usually confused w/early feeding problems)
6. Pyloric Stenosis (Non-bilious vomiting)
7. Intussuception (usually males neonate - 2 yo)
39
What are the leading Etx of Infant Colic - 5
## Footnote
*One of the main causes of Fussiness in Infants*
paroxysmal FUSSINESS that's...
[\> **3** **hrs** for \> **3 days**/week for \> **3 wks**!]
1. **Baby's Digestive system adapting to actual food**
2. GI imbalance of gut microflora between lactobacillus and coliforms
3. Atopic Allergy
4. ⬆︎ Motilin --\> ⬆︎Peristalsis (RF: Smoking & Prematurity)
5. Neurodevelopment problem
40
What are Risk factors for Infant Colic - 2 ; Best tx?
## Footnote
*One of the main causes of Fussiness in Infants*
paroxysmal FUSSINESS that's...
[\> **3** **hrs** for \> **3 days**/week for \> **3 wks**!]
Smoking during pregnancy vs prematurity --\> ⬆︎Motilin
Best tx = STICK WITH BREAST MILK!
41
What is a healthy crying pattern for infants 2 wks, 6 wks and 3 mo in age?
42
Postpartum **depression** affects women during what time periods? What 2 methods are used to screen for this?
within 1st year \> first 3 mo ;
1. [PHQ2 --(if both +)--\> PHQ9]
2. Edinburgh Postnatal Depression Scale
*Screen prenatal, postnatal and well child*
43
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
* Blues = onsets after birth, peaking at postpartum day 5 and subsiding PPD14, worst w/lactation
* Depression = onset right after birth - 12 months later. **Traditional s/s**. Previous Depression hx is RF
* Psychosis = RARE but onsets IMMEDIATELY after birth
44
What are important components for newborn/infant HPI - 12
1. [G1P1001 + 1st,2nd,3rd child?
2. Planned vs Unplanned?
3. Complicated pregnancy?
4. Weeks of Gestation before delivery?
5. GBS status
6. Hep B vaccination status
7. Hearing screening results
8. Feeding hx (breast vs formula? frequency?)
9. Describe 1st and 2nd stages of Labor
10. Wt of Baby
11. APGAR Score
12. When Mom was d/c
45
What is the Rooting Reflex? ; When is it observed?
When stroking a newborn's cheek--\>they turn head toward stimulus (used for breastfeeding) ; birth-4 mo
46
When is Group B Strep screening done for pregnant women?
35-37 WG via rectovaginal swab
47
What are the advantages of Group Prenatal care? - 4 ; What's the most important for black women?
1. Educate/support each other
2. More efficient for provider to give **more education** (prenatal, labor preparedness, adequacy of prenatal care)
3. **⬇︎ Preterm delivery (especially in Blacks)**
4. ⬇︎lethal low birth wts in infants that are Preterm --\> ⬇︎Racial disparities between black and white infant deaths
48
What is the normal Fetal Heart Rate and variability on a NST?
110 - 160/min (w/variability of 6-25)
## Footnote
*Normal Fetus' should have a _reactive_ NST*
49
*For Antepartum patients, their NST (Non Stress Test) should be reactive*
What does this mean?-4 Does this happen in pts in labor?
neurologically intact fetus should have
1. two HR acclerations within a
2. **20 min period that are**
3. **15 bpm over baseline**
4. **for at least 15 seconds**
THIS IS NOT REQUIRED FOR PTS IN LABOR
50
What are the 2 clinical features for diagnosing ACTIVE labor?
*Labor = LAPD*
1. **Strong** Contractions **every 3-5 min**
2. Cervix Dilation \> 6 cm, growing at 1-2 cm/hr and effaced
*Fetal Heart Tracing is IRRELEVANT to diagnosing active labor*
51
*Pregnant pt is a Jehovah's Witness and doesn't want blood during L & D*
What are steps to ⬇︎ Maternal Blood Loss? - 3
1. Clamp umbilical cord **EARLY** **(2 min after delivery**)
2. Give Pitocin after birth to help placenta detach faster & ⬆︎Uterine tone to stop bleeding
3. Uterine massage after placenta detaches to stop blood vessels from pumping
52
What are the Stages of Labor - 4
*Labor = LAPD*
**1st: L**atent phase = Strong Contractions q3-5 min
**2nd:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**3rd**: **P**ushing Time! since Cervix is now 10 cm FULLY DILATED
**4th: D**eliver Baby and then Deliver Placenta
https://www.youtube.com/watch?annotation\_id=annotation\_563008&feature=iv&src\_vid=Xath6kOf0NE&v=ZDP\_ewMDxCo
53
*Criteria for PreEclampsia is **Gestational HTN** + **Proteinuria***
How do you clinically diagnose Gestational HTN? - 6
1. NO previous HTN
2. \> 20 WG (2nd trimester)
3. **Systolic \> 140**
4. **Diastolic \> 90**
5. At least 2 readings taken \> 6 hrs apart
6. BP taken in seated or semi-reclined position
54
*Criteria for PreEclampsia is **Gestational HTN** + **Proteinuria***
How do you clinically diagnose Proteinuria for pregnant women - 3
1. ≥300 mg protein on 24 hr urine
OR
2. ≥ 30 mg/dL on dipstick
OR
3. At least 1+ on dipstick
* Must occur at least 2 times at least 6 hours apart*
55
*Criteria for PreEclampsia is **Gestational HTN** + **Proteinuria***
Which demographic are at greater risk for this?
Af American Women
## Footnote
*greater risk of having PreEclampsia, it being severe and suffering placental abruptio and Eclampsia*
56
*Criteria for PreEclampsia is **Gestational HTN** + **Proteinuria***
What is the pathologic evolution of PreEclampsia? How do you evaluate for this?-3
**PreEclampsia** --\> [**SEVERE PreEclampsia** (HA + vision changes)] --\> **HELLP** and at anytime, **Eclampsia** is possible
1. LFTs
2. Renal Function (spot Urine protein/Creatinine ratio)
3. CBC (look for thrombocytopenia & hemoconcentration)
57
*Criteria for PreEclampsia is **Gestational HTN** + **Proteinuria***
How do you clinically diagnose _SEVERE_ PreEclampsia? - 6
**PreEclampsia** --\> [**SEVERE PreEclampsia** (HA + vision changes)] --\> **HELLP** and at anytime, **Eclampsia** is possible
ANY **ONE** OF THE FOLLOWING:
1. Systolic \> 160
2. Diastolic \> 110
3. RUQ pain
4. Doubling of LFTs
5. Platelets \< 100K
6. Pulmonary Edema
58
What are Late Decelerations in Fetal Heart Rate?-2 ; What does this possibly indicate?
Decelerations in FHR that
1. Begin AFTER Contraction starts
2. [Nadir lowest point] is AFTER peak of contraction
= Hypoxemia during contractions 2/2 Utero-Placental insufficiency
59
What does *Early* Decelerations indicate? Is this normal or abnormal?
Head compression when fetus is lower in pelvis; **NORMAL**
## Footnote
*Late Decelerations occur AFTER peak of contraction while early decelerations "mirror" contraction wave*
60
How do you manage FHR Late Decelerations? - 4
1. Continuous Fetal Heart Monitoring
2. Turn pt on side to ⬆︎ IVC venous return
3. O2 face mask
4. IV fluid bolus
61
What are alternatives to Epidural for L&D pain mngmt? - 4
1. Water Immersion
2. Intradermal sterile water injections
3. Self Hypnosis
4. Acupuncture
62
What are the 4 major causes of Postpartum Hemorrhage? - 4
The 4 T's!
**T**one (Uterine aTony)
**T**rauma (Perineal vs Cervix lacerations vs Uterine inversion)
**T**issue (retinaed/invasive placental tissue)
**T**hrombin (rare bleeding DO)
63
How long should women breastfeed their newborns? - 2
AT LEAST 6 months, followed by [BF + complementary foods up until 12 mo.] (Remember: breast milk may take 3 days postpartum to release)
## Footnote
*avoid pacifiers/educate women & partners/feed only on demand/immediate skin2skin contact postdelivery = good breastfeeding techniques*
64
What are the 4 biggest things to assess during Postpartum checkup?
1. Help at home?
2. Rx (Prenatal viamins, other meds)
3. Diet
4. Mood
65
How should you test for TORCH infections in newborns?
T((**O**ther))RCH = HepB/HIV/HPV/Syphillis
66
What is a normal Blood Glucose for newborn infants
\> 45
67
Which meds are routinely given to all newborns? - 3
*Give **HEK** to protect!*
1. **H**ep B Vaccine ( give to infants \> 2000 grams)
2. **E**rythromycin Ophthalmic IF INDICATED (GC-Chlamydia px)
3. **K** Vitamin (prevents Hemorrhagic Disease of Newborn)
68
What are the salient physical findings of Congenital CMV? - 6
1. **Progressive** BL Hearing Loss --\> complete loss in 1 year
2. Microcephaly--\> developmental delay
3. Intracranial CT calcifications --\> developmental delay & seizures
4. Hepatosplenomegaly w/Anemia (resolves within weeks)
5. Rash w/Jaundice (resolves within weeks)
6. Chorioretinitis
## Footnote
*Tx = Parenteral Ganciclovir vs PO ValGanciclovir x 6 mo*
69
What are the major benefits of Breastfeeding - 5
1. ⬆︎GI maturity and motility--\> ⬇︎Diarrhea
2. ⬆︎newborn cognitive development
3. ⬇︎Acute infections/illness(DM/obesity/CA/CAD/IBD)
4. ⬇︎Maternal Breast & Ovarian CA
5. ⬇︎Maternal Osteoporosis
70
When does s/s of inborn metabolic errors present?
Within 1-3 days after birth
## Footnote
*Anorexia/Vomiting/Lethargy/Seizures/MetAcidosis*
71
What is the purpose of Anticipatory Guidance in Infant Well Child exams?
helps parents anticipate child's developmental, safety/immunization & nutritional needs
72
What are the main components of a **Well Child Visit** - 8
1. Interval Hx (any problems since last visit/birth)
2. Development (Use *PEDS @ 2/6/9 mo.*)
3. Growth Curves
4. Diet hx (breast or bottle?/foods?)
5. Social hx (who lives with/environmental [lead tox for 5 y/o]/behavior)
6. Physical Exam (dont forget Red Reflex)
7. Anticipatory Guidance
8. Immunizations
## Footnote
*PEDS = Parents Evaluation of Developmental Status*
73
What are the Caloric Requirements of 1-2 Month old infants who are Full Term? PreTerm? Very Low Birth Wt?
* Term infant = **100** cal/kg/day
* PreTerm infant = **115-135** cal/kg/day
* VLBW (Very Low Birth Wt) = **Up to 150** cal/kg/day
## Footnote
*~25 grams/day wt gain is expected in Full Term infant*
74
How much wt per day do you expect a Term infant to gain with the recommended _____ cal/kg/day?
~100 cal/kg/day ; ~25 grams/day wt gain
75
Which growth parameters are measured during well Child exams? - 3
Weight / Height (length) / Head Circumference
76
What is the Difference between Developmental **Surveillance** and **Screening**?
Dvpmental **Surveillance (image)** = Checks milestones by comparing child to *expected* behaviors *by age*. NOT AS SPECIFIC/SENSITIVE
vs
Dvpmental **Screening** (*PEDS*) = Evidence based, for kids 0-8 yo, elicits parents to answer 10 questions on their perspectives of their child
*PEDS = Parents' Evaluation of Dvpmental Status*
77
T or F: Breast Milk has more than sufficient Vitamin D for infants
**FALSE**
## Footnote
(Supplement Breastmilk with liquid vitamin drops in newborns vs chewable multivitamins in toddlers)
78
By what ages should an infant double and triple their birth weight? What about Doubling length?
Double by 5 months, triple by 12 months ; Double length by 4 yo
## Footnote
*Remember these are approximations*
79
Why is their caution to using APAP around infant vaccinations?
Using APAP ⬇︎ Antibody response to the vaccine - **ONLY USE IF ABSOLUTELY NECESSARY**
80
Caloric requirements for 9 month infant?
100 cal/kg/day
## Footnote
*Meats can be started at this age!*
81
Which foods should never be given to infants less than 1 year old because of choking? - 4
1. Popcorn
2. Grapes
3. Hot Dogs
4. Hard Candy
82
DDx for RUQ abd mass in infant - 6
1. **Neuroblastoma (could be chest/neck/abd and age \> 1 yo)**
2. Hepatic CA (will be asx)
3. Hepatic Abscess
4. Hydronephrosis w/UTI 2/2 obstruction @ uretopelvic junction
5. Teratoma rare
6. Wilms' nephroblastoma (usually ~3 yo)
83
What is the most common cause of Left abd mass in infants?
Constipation (L**L**Q sigmoid colon)
84
DDx for RUQ abd mass in infants include **Neuroblastoma**
What would differentiate this from other dx?-3
1. **Urine elevated HVA/VMA**
2. CT: [heterogenous retroperitoneal **non**renal mass w/cystic areas] +/- calcifications
3. Histo: small round blue cells forming rosettes
## Footnote
*Most Neuroblastoma are 2/2 somatic NonFamilial mutations*
85
DDx for RUQ abd mass in infants include **Wilms' Nephroblastoma**
What would differentiate this from other dx?-3
1. Renal US
2. CT: Pseudocapsule from demarcation between tumor and renal parenchyma + Lung metz
3. CXR: Lung metz
## Footnote
*Usually around ~3 yo*
86
DDx for RUQ abd mass in infants include **Hepatic CA**
What would differentiate this from other dx?-3
1. **⬆︎AFP & bilirubin**
2. Abd XRay: Hepatic enlargement
3. CT: Lung Metz
87
DDx for RUQ abd mass in infants include **Teratoma**
What would differentiate this from other dx?-2
1. CT: well defined masses with **solid and cystic components**
2. Xray: possible calcification of teeth or bony fragments
## Footnote
*THIS IS RARE*
88
What type of effects does Smoking have on neonates when taken during pregnancy?-2 What about Cocaine?
* Tobacco--\> low birth wt & colic
* Cocaine --\> low birth wt 2/2 vasoconstrictive placental insufficiency
89
Name Intrauterine **Maternal factors** that can --\> IUGR (IntraUterine Growth Restriction)? - 5
*Includes Alcohol use*
## Footnote
*Always consider Gestational Dating may be inaccurate*
90
Name Intrauterine **Placental abnormalities** that can --\> IUGR (IntraUterine Growth Restriction)? - 3
*Always consider Gestational Dating may be inaccurate*
91
Name Intrauterine **Fetal abnormalities** that can --\> IUGR (IntraUterine Growth Restriction)? - 4
*Always consider Gestational Dating may be inaccurate*
95
What office tool (other than LMP) is used to estiamate gestational age?
Fundal height (+/- 3 cm margin of error)
(*measured from superior aspect of enlarged uterus to pubic symphisis*)
96
Name Factors that ⬆︎ Risk for Vertical transmission of HIV -6
1. Unprotected Sex during pregnancy (*chorioamnionitis and other STI ⬆︎HIV transmission*)
2. Maternal HIV load \> 1000 copies
3. Fetal Membrane rupture \> 4 hrs prior to delivery in Mother not on HAART
4. Vaginal Delivery
5. Breastfeeding
6. Premature Delivery \< 37 WG
97
*You've just discovered a positive rapid HIV test on pregnant pt in labor*
Name Factors that will ⬇︎ Risk for Vertical transmission of HIV -3
1. Giving HAART if viral load \> 1000 copies
2. C-section **prior to onset of labor** **and rupture of fetal membranes**
3. NO Breastfeeding
98
What is the Ballard Tool?
Uses **Physical** and **Neuromuscular** signs to estimate gestational age
99
What constitutes a FULL term infant?
≥ **37** wks gestation
100
What clinical problems are associated with SGA (Small for Gestational Age)?-3 ...and why?
1. hypOglycemia BG \< 45 (⬇︎ glycogen stores and gluconeogenesis)
2. hypOthermia (⬆︎Surface area and ⬇︎SubQ insulation)
3. Polycythemia presenting w/Respiratory distress (Chronic hypoxia)
101
Toddlers should **stay in booster seats** until they reach height of \_\_\_\_\_
4'9
102
Identify disease? AKA ____ ; What's a possible etx? ; DDx?-2
Eczema Atopic Dermatitis (**The itch that rashes**) ; Allergies +/-Asthma ; Psoriasis vs Seborrhea
103
Identify disease? AKA ____ ; Tx - 4?
Eczema Atopic Dermatitis (The itch that rashes)
1. Lubricate skin
2. Anti-Inflammatories in short burst (Steroids \> Calcineurin inhibitors)
3. Antihistamines
4. Tx associated skin infections
104
What's the biggest risk factor for Early childhood caries? How can we prevent this?
Constant Teeth Bathing with milk/juice **via bottle** ; d/c bottle use by 12-15 month old
105
What are key things to remember regarding Iron in Toddler diets? Juice?
1. **Iron** is crucial to CNS development (sources:iron fortified cereals/eggs/tuna) - REMEMBER PICKY EATING TODDLERS ARE AT⬆︎RISK FOR ANEMIA
2. **Juice** LIMITED to 4-6 oz/day
106
Important Physical exam tips for Toddler well child checks - 2
1. Listen w/stethoscope **first** in case pt cries later
2. If exam is shortened, focus on Neurodvpment, Monitoring previous findings, New findings, Physical problems common in preschoolers
## Footnote
*Neurodvpment = Language/FineMotor/GrossMotor/Cognition*
107
What are the **SocioEmotional** Developmental Milestones for a
[3 year old-2] ; [4 year old-3] ; [5 year old-3]
108
What are the **Language** Developmental Milestones for a
[3 year old-2] ; [4 year old-3] ; [5 year old-5]
109
What are the **Cognitive** Developmental Milestones for a
[3 year old] ; [4 year old-5] ; [5 year old-3]
110
What are the **Motor** Developmental Milestones for a
[3 year old-4] ; [4 year old-4] ; [5 year old-5]
111
*PICKY EATING TODDLERS ARE AT⬆︎RISK FOR ANEMIA*
What test assess for this? When should it be ordered?-3
Hgb/Hct Fingerstick ;
1. 1 y/o old
2. Preschool/Kindergarten entry
3. PRN at any age if Risk Factors are present
*RF = special health/nonmeat diets/poverty*
112
Which demographic of kids are at greatest risk for lead poisoning and why? What is a risk factor for lead *Absorption*?
6 mo-3 yo ; mouthing behavior and ⬆︎mobility ; Iron deficiency--\> ⬆︎Lead *Absorption*!
113
What are the most common causes of anemia in kids? - 5
1. **⬇︎ Iron (PICKY EATER/food allergies/gluten enteropathy/chronic GI blood loss)**
2. Sickle Cell
3. alpha thalassemia
4. G6PD deficiency
5. Vitamin Deficiencies (folate B9 and Pyridoxine B6)
114
First line tx for Iron deficiency anemia in kids?
PO elemental iron supplement (2-4 mg/kg/day)
115
Name common food sources of Iron - 7
1. Eggs
2. Salmon
3. Beef
4. Tuna
5. Whole Grain
6. Dried Fruits
7. Iron fortified cereals
116
What are the 3 core sx of ADHD?
1. **A**ttention deficit
2. **H**yperactive
3. Impulsivity
117
What is the diagnostic criteria for ADHD? - 5
1. Sx present for **at least 6 mo.** AND inappropriate for dvpmental age
2. Sx **start** **between 6-12 yo** and not after 12 yo
3. Evident in **2 or more settings** (school/work/home)
4. Sx interfere with ability to function
5. Sx are not attritable to another DO
118
Name common conditions that contribute to a child's school failure - 5
1. Sensory impairment (hearing/vision problems)
2. Sleep issues
3. Mood DO
4. Learning Disability (often accompanies ADHD)
5. Conduct DO (defiance/aggression/truancy)
119
What are the major side effects of ADHD stimulant meds? - 4
1. ⬇︎ **APPETITE**
2. Insomnia
3. ⬇︎Growth velocity in kids
4. Tic DO in kids - rare (resolves with d/c)
120
What are the major Risk Factors for childhood obesity? - 5
1. High Birth Wt
2. Maternal DM during pregnancy
3. Having Obese Parent
4. Lower Socioeconomic status
5. Genetics (*PraderWilli/Cohen Syndrome*)
121
What are the health complications of childhood obesity? - 6
1. **HTN**
2. HLD
3. DMT2
4. Sleep Apnea
5. Steatohepatitis
6. Slipped Capital Femoral Epiphysis (SCFE)
122
What are the screening guidelines for Type 2 DM in kids/teens? - 3
1. Check Fasting BG at 10 yo or puberty (whichever comes first) every 3 years
2. Check every 2 years if [BMI\>85 %tile + DM RF]
3. Check every 2 years if [\>95 %tile alone]
## Footnote
*%tile = Percentile*
123
*[Children BP percentile] is based on systolic BP in relation to weight and height percentile*
What are the 4 BP percentile classifications for HTN in children
*Only use meds for Stage 2/secondary HTN/end-organ damage* *and give 6 mo f/u to everyone*
124
What are some causes of Secondary HTN in kids? - 6
1. DM
2. UTIs
3. Catecholamine Excess (Neuroblastoma/Pheochromocytoma)
4. Umbilical Artery vs Umbilical Vein placement --\> Renal Dz
5. Fam hx of Renal disease
6. Coarctation of Aorta
125
In kids, how do you distinguish between Nutritional Weight gain and Underlying Endocrine disorder?
Endocrine DO --\> **Short Stature** **from ⬇︎ Growth**
## Footnote
*Only 1% of Overweight peds have Endocrine issues*
126
What are the complications of GASP (Group A Strep Pharyngitis) - 6
1. Rheumatic Fever
2. PSGN
3. PeriTonsillar abscess
4. Mastoiditis
5. Meningitis
6. Bacteremia
127
Contraindications to Vaccine administration - 3
1. allergy/sensitivity to specific vaccine
2. Immunodeficiency of pt or household relative (sometimes)
3. Moderate-Severe illness (wait until recovery)
128
What are the Vaccinations required prior to school entrance - 5
1. MMR x 2
2. Varicella x 2
3. Hep B x 3
4. TDaP x 5
5. Polio x 5
129
For a 5 y/o, parents are usually concerned about their child's _____ while the school is usually concerned about ____ & \_\_\_\_\_
knowledge base ; Language skills & Social Readiness
## Footnote
*Be sure Health maintenance visits for 5 yo are guided by context child is entering elementary school for first time*
130
*BMI categorization is different for children than Adults*
What is the BMI categories for a child/adolescent?
*Age/Sex Percentile (used in kids) is found using BMI wheel*
131
*During **5 y/o** well child checks, selective screening for Lead toxicity may be necessary*
What questions are used to determine if selective screening for lead tox is needed? - 3
1. Does your child live or regularly visits buildings built before 1950?
2. Does your child live or regularly visits buildings built before 1978 **that is being/has recently been renovated**?
3. Does your child have a sibling/playmate who has/did have lead poisoning?
132
What is Scarlet Fever? - 2
GASP Pharyngitis + [Diffuse/Erythematous/Papular *Sandpaper* Rash in Neck, Axilla, Groin]
133
What are classic s/s of GASP (Group A Strep Pharyngitis) - 5
**Old CAFE**
1. **Old** = Ages 5-15 yo (*Subtract 1 point if \> 45 yo)*
2. **C**ervical Anterior LAD
3. **A**bsence of Cough/Rhinitis-Rhinorrhea/Conjunctivits
4. **F**ever \> 100.9 F
5. **E**xudates Tonsillar (36% sensitivity)-image
*Each gets 1 point for Centor criteria*
134
What is the DDx for sore throat? - 8
1. Viral Pharyngitis (Rhino/Adeno/Coronavirus)
2. GASP
3. Mononucleosis
4. Epiglottitis
5. Pertussis
6. Retropharyngeal Abscess
7. Viral Croup
8. Allergic Pharyngitis/Rhinitis
135
What is the classic triad for infectious mononucleosis? Dx?
1. Pharyngitis
2. LAD - Posterior Cervical
3. Fever
Dx = Monospot test (**but this can only be done \> 7 days after sx onset**)
136
What is the problem with misdiagnosing Mononucleosis pts with GASP?
Pts with Mono who receive [Amoxicillin vs Ampicillin] for GASP --\> 90% will develop iatrogenic **prolonged pruritic maculopapular rash**
137
When can you treat a child for GASP?
**AFTER** microbiological confirmation with RADT (RADT first and then --\> reflex throat culture if RADT is negative just to double check)
138
The Centor Criteria is used to determine likelihood of GASP
Recite the criteria ; What is the McIsaac interpretation?
**O****ld****CAFE = Old**:Age /**C**ervical LAD anteriorly / [**A**bsence of Cough/congestion/conjunctivits] /**F**ever\>100./9 /**E**xudates Tonsillar
*Remember: 1 point is subtracted if \> 45 yo*
139
*Pt has GASP and is indicated for tx*
What are the abx choices? - 6
1. **PCN V\*\*\***
2. PCN G IM
3. Amoxicillin
4. Cephalexin (1st gen Cephalosporin)
5. CefaDroxil (1st gen Cephalosporin)
6. Erythromycin (for PCN allergy pts)
140
List a **V**ascular cause of Lower back pain
*VITAMIN C*
AAA
141
List the **I**nfectious causes of Lower back pain - 9
*VITAMIN C*
1. Pyelonephritis
2. Osteomyelitis
3. Herpes Zoster
4. Epidural Staph A. Abscess
5. Prostatitis
6. PID
7. Kidney Stones
8. Endometriosis
142
List the **T**rauma causes of Lower back pain - 4
*VITAMIN C*
1. Compression Fracture
2. Disc Herniation
3. Lumbar Strain
4. Spinal Stenosis
143
List the **M**etabolic causes of Lower back pain - 5
*VITAMIN C*
1. Osteoporosis which can--\>Vertebral fx
2. Osteomalacia
3. HyperParathyroidism
4. Paget's Osteitis Deformans
5. Diabetic Neuropathy
144
List the **I**nflammatory causes of Lower back pain - 6
*VITAMIN C*
1. Ankylosing Spondylitis (morning stiffness over SI joint & lumbar spine)
2. SacroiLitis
3. Discitis
4. Rheumatoid Arthritis
5. Osteoarthritis
6. Facet Arthropathy
145
List the **N**eoplastic causes of Lower back pain - 4
*VITAMIN C*
1. Multiple Myeloma
2. Metastasis
3. lymphoma/leukemia
4. osteosarcoma
146
List the **C**ongenital causes of Lower back pain - 3
*VITAMIN C*
1. Scoliosis
2. Kyphosis
3. Spondylolysis
147
What are the 4 most common causes of back pain?
**Lumbar Strain (evidenced by paraspinal m. spasms)** \> OsteoArthritis \> Herniated Disc \> Spinal Stenosis
## Footnote
*Most Back Pain is Mechanical*
148
What are the classic positional changes for disc herniation? - 4 ; What are other classic s/s?-4
[Back Pain with sitting & bending]
[Back Relief with lying & standing]
1. ⬆︎Pain w/coughing/sneezing
2. Radiation down leg
3. Paresthesia
4. Muscle weakness (foot drop)
149
Which patients with lower back pain should receive imaging and/or referral? - 2
1. Refractory to 1 month conservative tx
2. Red Flags
150
How should the physical exam for lower back pain be performed?
Evaluate Standing, Sitting and Supine
151
\_\_\_\_ (Thoracic/Lumbar/Sacral) mobility is the best measure of spine mobility
What does it suggest if ___ **Flexion** is restricted? - 3
**LUMBAR** flexion restriction =
1. Disc Hernation
2. Osteoarthritits
3. Muscle Spasm
152
\_\_\_\_ (Thoracic/Lumbar/Sacral) mobility is the best measure of spine mobility
What does it suggest if ___ **Extension** is restricted? - 2
**LUMBAR** extension restriction =
1. Degenerative arthritis
2. Spinal Stenosis
153
\_\_\_\_ (Thoracic/Lumbar/Sacral) mobility is the best measure of spine mobility
What does it suggest if ___ **Lateral motion** is restricted? - 3
**LUMBAR** lateral motion restriction =
1. (if on same side as bending) = Nerve compression or Osteoarthritis
2. (if on CTL side as bending) = Muscle spasm
154
How can you use assessment of Gait to determine disc herniation location? - 2
Difficulty with...
Heel Walk = L5 Disc herniation
Toe Walk = S1 Disc herniation
155
⬇︎Patellar Reflex implies nerve impingement at the ____ level
L3-4
156
⬇︎Achilles Reflex implies nerve impingement at the ____ level
L5-S1
157
Pts, while supine, who can not straight leg raise \> 80° either have ___ or ____ ; How do you differentiate between these two?
Sciatica or Tight Hamstrings ; Straight Raise leg to point of pain, lower slightly and then **dorsiflex foot.** Pain with this = Sciatica
## Footnote
*NOTE: PAIN EARLIER THAN 30° = MALINGERING*
158
Ipsilateral and Contralateral Straight leg test, based on sensitivities/specificities can be trusted when?
* Ipsilateral straight leg test can be trusted if it's **negative**
* CTL straight leg test (asx leg is raised) can be trusted if it's **POSITIVE**
## Footnote
*These suggest large central disc hernation*
159
When is the **FABER** test result positive?-3 ; What does this indicate?
## Footnote
*FABER: **F**lexion, **AB**duction, **E**xternal **R**otation*
* Pain at Hip
* Pain at Sacral Joint
* Tested Leg can not lower to point of being parallel to opposite leg
This indicates [Hip joint SacroiLiac pain from **SacroiLitis**]
160
[Cauda Equina Syndrome] etx ; Clinical Presentation - 5
(Compression of S2 - S4 n. roots) --\>
1. Saddle Anesthesia (*image*)
2. ⬇︎ **Ano**cutaneous Reflex (perianal pinpoint does NOT cause anal sphincter contraction)
3. Incontinence (urinary AND fecal)
4. uL (uniLateral) Radiculopathy
5. **hypOreflexia** (*Conus Medullaris syndrome has HYPEReflexia*)
*Decompression required within 72 hours!!!*
161
Demographic for Ankylosing Spondylitis ; Classic Presentation
15-40 yo ; morning stiffness over the sacroiLiac joint & lumbar spine
162
What is Spondylolisthesis?
ANT displacement of vertebra at any age that --\> aching back & posterior thigh with activity & bending
163
What are the indications for getting Lumbar Spine films in Lower Back pain pts - 10
1. \> 50 yo
2. Trauma recently
3. Wrosening Neuro ∆
4. Ankylosing Spondylitis hx (SI joint morning stiffness)
5. Substance abuse (Drug vs EtOH)
6. Malignancy hx (≥10 lb wt loss, nocturnal pain)
7. \> 100F Fever
8. Prolonged Steroids (vertebral fx?)
9. Osteoporosis (vertebral fx?)
10. Refractory to 1 month conservative tx
164
What are the indications for getting MRI in Lower Back pain pts - 6
1. Neuro deficits
2. Radiculpathy
3. Progressive motor weakness
4. Cauda Equina compression
5. Systemic DO (metastatic or infectious)
6. **Failed 4-6 weeks of conservative tx**
165
**Conservative** Tx for Lower Back Pain - 9
1. **EXERCISE!!!!!**
2. NSAIDs
3. ASA
4. APAP
5. Local therapy (heat/cold packets)
6. Diazepam
7. Cyclobenzaprine
8. TENS (Transcutaneous Electrical Nerve Stimulation)-*image*
9. Steroids *if Sciatica is suspected*
166
Abortion is legal up to ____ weeks gestation ; How do you calculate Estimated Due Date (EDD) - 3?
**22** weeks ; [date of LNMP] + 1 year - 3 months + 1 week = EDD
## Footnote
* THIS IS KNOWN AS NAEGELE'S RULE and is [+/- 2 wk accuracy]*
* Use US to confirm BUT ONLY IN WOMEN \< 20 WKS GESTATION*
167
*Naegle's Rule is the most accurate for determining gestation*
When can you use Ultrasound to determine gestation? - 4
1. Only in Women **\< 20 wks gestation** OR...
2. For discrepancy \> 1 wk between US and another method during 1st trimester
3. For discrepancy \> 2 wk between US and another method during 2nd trimester
4. For discrepancy \> 3 wk between US and another method during 3rd trimester
(the earlier the better!)
168
When is Fundal height used for gestational dating? What are the rules? - 2
[28-42 wks: **3rd** trimester] ;
1. At 20 wks gestation, Fundus should be at Umbilicus. It goes ⬆︎ by 1 cm every week after
2. After 20 wks, fundal ht in cm correlates with wks gestation
169
What is the relationship between Pregnant Women and Hot tubs?
They need to **avoid them**! Maternal heat exposure --\> Miscarriage & Neural tube defects
170
Which foods should Pregnant women avoid? - 5
1. Raw Eggs (Salmonella)
2. Unpasteurized Milk (toxo and listeria)
3. Soft Cheeses (listeria)
4. Raw Fish/Shellfish
5. Unwashed fruits/vegetables (toxo and listeria)
171
What supplements should normal Pregnant Women take? - 2 ;
How does this change for preggos with DM, epilepsy and previous children with neuro tube defects?
1. [Folic Acid 0.4 - 0.8 mg/day]
2. [Iron 30 mg/day]
**Dietary or Epilepsy** preggos =[Folic Acid **1** mg/day]
**Previous child with NTD** preggos =[Folic Acid **4** mg/day]
172
During Fetal development, what happens at...
4 weeks?
7 weeks?
27 weeks?
4 weeks = Neuro tube closes
7 weeks = Heart starts to beat and fetus moves!
27 weeks = Fetus opens eyes & detects light
173
What are the minimum things to check during Prenatal f/u? - 3
1. Maternal wt
2. Maternal BP
3. Fetal HR (heard at 10-12 wks gestation)
174
Which Prenatal Vaccinations should be given? - 3
1. **FLU** [Dead IM]
2. [RhoGam Anti-RhD Ig] @ [\<14 WG:1st trimester] + [28 WG] + [within 72 hrs after delivery] + [with any episodes of vaginal bleeding] (if indicated)
3. Rubella **after delivery**
## Footnote
*WG = Weeks Gestation*
175
What is Hyperemesis Gravidarum?
**Persistent** NV during pregnancy
## Footnote
*Normal NV Starts 4WG until 20WG*
176
What are Dietary measures women with Hyperemesis Gravidarum can take? - 4
1. Frequent but small meals
2. **Bland** solid foods high in carbs, low in fat
3. Salty morning foods
4. Sour liquids \> Water
177
When can a fetus have its sex determined via US?
[**18WG**: 2nd trimester]
178
Name the major risk factors for Placental previa? - 4
1. \> 35 yo
2. Smoking
3. Prior Pregnancy (especially if with twins!)
4. Previous Uterine surgery like C-section
179
What are the 4 types of HTN in pregnancy?
1. Chronic HTN (present **before** 20 WG and persist beyond 12 weeks postpartum)
2. Gestational HTN (≥140 systolic or 90 diastolic BP without proteinuria in women after 20 WG)
3. PreEclampsia
4. Eclampsia
180
What complications do pregnant women with [**SEVERE** Gestational HTN] and/or PreEclampsia have? - 3
1. PreTerm Delivery ( \< 37 WG)
2. SGA infants (Small for Gestational Age)
3. Placental Abruptio
## Footnote
*Women with mild Gestational HTN do NOT have these complications*
181
What complications do pregnant women with Gestational DM have? - 6
1. PreEclmapsia
2. Fetal Macrosomia
3. Birth Trauma
4. C-sections requirement
5. Neonatal mortality
6. neonatal hypOglycemia, hyperbilirubinemia
182
Gestational DM is determined via _______ test. According to the the Carpenter Coustan criteria, how is this interpreted?
[**3-hour glucose tolerance test**] (measure pt BP after fasting and then 1,2,3 hrs after 100 gram glucose oral load);
**at least 2** of:
1. Fasting BG ≥ 95
2. 1 hour BG ≥ 180
3. 2 hour BG ≥ 155
4. 3 hour BG ≥ 140
183
What are the common pregnancy rashes?-3 ; How do you treat them? -2
Topical Emollients and Steroids
## Footnote
*Do not confuse with Cholestasis which --\> whole body itching*
184
When is Group B Strep screening done for pregnant women?
35-37 WG via rectovaginal swab
185
Postpartum contraception can be started when? What are the postpartum contraception options? - 5
Start **after 6 weeks** postpartum for expulsion & breastfeeding purposes..
1. Progestin pills
2. [DepoProvera Injectable Progestin]
3. Progestin implant
4. [Mirena Levonorgestrel IUD]
5. Copper IUD *(can be inserted immediately postpartum if needed)*
186
At Postpartum visits, what 3 things should be talked about? What is the postpartum f/u for vaginal delivery? C-section?
Mood/Contraception/Breastfeeding
Vaginal delivery f/u = 6 wks postpartum
C-section = 2 wks postpartum
187
What is the DDx for Vaginal Bleeding and/or discharge in pregnant women? - 5
1. **Placenta Previa** (Spontaneous bleeding after 20 WG)
2. Placental Abruptio
3. UTI (GC/Chlamydia/BV/Candidiasis)
4. Cervical Trauma
5. PROM (premature rupture of membranes) = fetal membrane rupture prior to labor. Preterm PROM --\> premature birth
188
Home pregnancy test can detect Urine βHCG at levels of ____ while serum blood βHCG can be detected at levels of \_\_\_\_.
What is the pattern of βHCG? - 4
≥25 ; 5 mIU/mL
## Footnote
1st: βhCG doubles every 2 days for first 7 weeks
2nd: peaks at 12 weeks
3rd: rapidly declines until 22 weeks
4th: gradually rises again until delivery
189
*You have a pt who's **newly became pregnant***
What are the initial studies to be ordered? - 9
1. Blood Type/Rh status
2. Hgb/Hct (detects anemia)
3. GC Chlamydia
4. HIV
5. Hep B and C
6. Varicella hx
7. Herpes hx (active labia lesions during pregnancy is ctd)
8. PAP smear
9. UA (detects proteinuria)
190
What is the Prenatal Maternal Quad Serum screening? When is this obtained?
Measures 4 chemical markers for fetal anomalies and down syndrome- 81% accuracy (QUAD = **BUAD**):
1. **β**HCG⬆︎
2. **U**nconjugated EsTriol⬇︎
3. **A**FP⬇︎
4. **D**imeric inhibin A⬆︎ - *only in QUAD screen*
Performed 16 -18WG
*Be sure to f/u abnml results with cell free fetal DNA test and US*
191
When is routine ultrasound for fetal anomalies performed?
[18-21 WG: 2nd trimester]
192
What are 3 physical exam findings specific to Testicular Torsion? - 3
1. **Blue dot sign to upper pole w/TTP** = Appendage torsion-*image*
2. Loss of Cremasteric Reflex
3. Prehn sign (Lifting testicles relieves pain which means NOT torsion but possibly epididymitis)
193
What are major causes of Testicular Torsion? - 6
1. Congenital mesentery between epididymis and testis
2. Congenital contraction of muscles which shorten spermatic cord --\> initiates testicular torsion
3. Congenital Bell Clapper deformity
4. Undescended testes
5. Recent genital trauma/exercise
6. Idiopathic
## Footnote
*Untreated Scrotal Pain \> 12 hours --\> less than 50% testicular viability*
194
Epidemiology of Testicular CA ; Which demographic typically has it?
[Most common CA in males 15-35 yo] but only 1% of CA in ALL men ; Af Americans
195
What are the variable presentations for Testicular CA?-3 ; What are the guidelines for screening?
1. Heavy sensation in lower abd, perianal, scrotum
2. Testicular Nodule
3. Testicular **Painless** swelling
NO SCEENING! No evidence to support routine screening in asx teens/young adults
196
What are the 3 types of Testicular Tumors
1. Germ Cell (Seminomatous vs NonSeminomatous)
2. Non-Germ Cell (Leydig vs Sertoli)
3. Extragonadal (lymphoma vs leukemia vs melanoma)
197
What are 5 ways to build rapport with Teens during interview?
1. Introduce yourself to teen first, look them in their eye, shake hand and sit down during interview
2. Direct questions primarily to the teen (not parents)
3. Use conversation icebreakers so they're comfortable
4. Allow teen to remain dressed and sit in chair during interview
5. Ensure confidentiality
198
Describe the 3 major components to a proficient testicular exam
1. **Inspect** for erythema, swelling and position (L sits Lower than R normally)
2. **Palpate** for edema, size and TTP (start on unafected side)
3. **Transilluminate** if necessary
199
DDx for scrotal pain in Teen male -9
1. **Epididymitis (Fever, Pyuria, CORD TTP)**
2. Trauma
3. Inguinal Hernia
4. Hydrocele (usually causes painless scrotal swelling)
5. Henoch Schonlein Purpura
6. Testicular Tumor
7. varicocele
8. Testicular Torsion
9. Testicular **Appendage** Torsion
200
Dx for testicular torsion - 2
1. [Radionuclide Scintigraphy (100% Sensitive)] = Confirms Testicular Torsion by revealing ⬇︎ intratesticular blood flow via radiotracer
2. [Color Doppler US (88% sensitive BUT FASTER)] = Confirms Testicular Torsion by revealing ⬇︎ intratesticular blood flow via echogenicity + enlarged testicle
201
Tx of Testicular Torsion - 2
1. Manual DeTorsion...STILL followed by [option 2 vs 3]
2. Orchiopexy of affected testicle WITHIN 6 HOURS --\> Px Orchiopexy of UnAffected testicle
## Footnote
*Orchiopexy = (surgical repair of testes)*
202
6 major causes of Syncope
1. ⬇︎ Cardiac Output *(Valvular Dz/HOCM/Pulm HTN/PE/Tamponade/myxoma/aFib)*
2. Bradyarrhythmia *(SA Node dysfunction/AV Block)*
3. **VAN** - **V**asovagal **A**utonomic **N**eurocardiogenic
4. Dehydration
5. CVA/TIA
6. Metabolic *(⬇︎Glucose vs ⬇︎Na+)*
## Footnote
*OBTAIN ECHOS ON ANY PT WITH SUSPICIOUS SYNCOPE!*
203
Nausea & Sweating are preceding sx for what **type** of syncope?
Neurocardiogenic only
204
What are triggers of **VAN** (Vasovagal Autonomic Neurocardiogenic) Syncope? -6
1. Pain
2. Emotional distress
3. Prolonged Standing
4. Defecation
5. Micturition
6. Coughing
## Footnote
*VAN Syncope is preceded by nausea & sweating*
205
What are the 3 types of Dizziness?
1. Presyncope (lightheaded)
2. Disequilibrium (feeling off balance)
3. Vertigo (sensation of room spinning)
206
5 most common causes of Vertigo?
BPPV \> [Vestibular neuritis (assc w/URI)] \> [Vestibular Migraine] \> [Acute Labyrinthitis (will also have tinnitus and deafness)] \> Otitis Media
## Footnote
*Be sure to differentiate between Peripheral and Central Vertigo with Head Thrust test*
207
Indication of Head Thrust Test ; Describe how to do the test
differentiates in nystagmus pts between peripheral & central vertigo;
pt looks at fixed target and their head is rapidly turned from the target. Normally, eyes remained fix on target, but in [**Peripheral** vestibular dysfunction pts] eyes move w/head and then horizontal saccade back to target after
208
BPPV (Benign Paroxysmal Positional Vertigo) etx and CP-3
Ca+ otoliths accumulated within semicircular canals --\> Dizzines, Nystagmus and Nausea only
209
What are 4 physical exam findings for differentiating a Peripheal vertigo from Central vertigo using Nystagmus
Peripheral is...
1. Unidirectional
2. Does not change direction
3. Stops when fixing on point
4. Worsened with Frenzel glasses (since these prevent fixation)
210
What is MRI indicated for pts with Dizziness?
When there are findings to suggest **CENTRAL** lesion
211
Between abx and observation, what's given for **uncomplicated** otitis media in kids ...
\< 6 months old
between 6 mo - 2 years old
\> 2 yo
\< 6 mo old = abx
between 6 mo - 2 yo = *Cautious* observation depending on certainty, social support, clinical picture
\> 2 yo = observation only
212
What is a major Risk Factor for Maxillary Sinusitis? ; Is abx indicated in Uncomplicated Maxillary Sinusitis?
**Recent hx of URI**
NO! (only when pain/purulent discharge is present)
***S**inusitis **N**ever **F**eels **M**erry*
213
Why are abx NOT indicated in _healthy_ pts with acute bronchitis?
most recover w/out abx so use observation instead
214
Tx for Peripheral Vertigo - 4
1. [Diuretics + low salt diet] = ⬇︎endolymphatic pressure (especially in Meniere's disease)
2. Epley canalith repositioning maneuver
3. Vestibular Rehabilitation
4. Anticholinergics (meclizine,dimenhydrinate)
215
What major **lifestyle** changes should pt with Hyperlipidemia take to ⬇︎ASCVD risk - 5
## Footnote
*ASCVD = AtheroSclerotic CardioVascular Disease*
1. \< 7% of calories is Saturated Fat
2. Cholesterol \< 200 mg/day
3. ⬆︎Soluble Fiber intake
4. Exercise
5. Wt loss (⬇︎Fat stores & improves HTN)
## Footnote
*These are examples of SECONDARY ASCVD prevention*
216
\_\_\_ is the initial preferred imaging for suspected Angina. When is CT indicated?-2
CXR; s/s of PE or Aortic Dissection
217
Major SE of Atorvastatin - 3
1. Myalgia
2. Rhabdomyolysis--\>Myoclobinuria--\>Acute Kidney Injury
3. Liver Dysfunction (Get LFTs before starting statin!)
218
Major SE of Metoprolol - 3
1. Bradycardia
2. hypotension
3. heart block
219
Major SE of HCTZ - 5
1. Dehydration
2. hyponatremia
3. hypokalemia
4. renal dysfunction
5. gout attack 2/2 ⬆︎serum uric acid
220
Major SE of [Lisinopril ACE inhibitors] - 4
1. Angioedema
2. Cough
3. HyperKalemia
4. Renal dysfunction
221
What are the 3 MAIN characteristics of Angina
1. Substernal \>20 min. **PRESSURE**
2. Exertional
3. relieved with NTG or rest
* [Atypical = GOE 2 out of 3] /// [NonAngina = \<2 out of 3]*
222
Name the 4 Medications that **Prevent LV Remodeling** in HF pts
"**BANA** helps HF pts live Loonger"
## Footnote
**B**eta Blockers (Metoprolol / Carvedilol)
[**A**CEk2 inhibitors AND ARBs]
[**N**itrates + Hydralazine]
[**A**ldosterone Blockers (Spironolactone / Eplerenone)]
223
What therapies are used to treat Unstable Angina?-7
Pts with Unstable Angina **N**eed **OBAMAA** too!
1. **N**TG = VasoDilates Veins and Coronary Arteries
2. **O**xygen = Minimizes ischemia
3. **B**eta Blockers = DEC HR --\> DEC Arrhythmia risk and DEC O2 demand
4. [**A**SA and Heparin] = limits thrombosis
5. **M**orphine = Pain
6. **A**CEk2 inhibitors within 24 hrs= DEC [L Ventricle Dilation/Remodeling]
7. **A**torvaSTATIN - comes later
*ASA and Beta blockers can --\> asthma exacerbation*
224
The **CHA2DS2 VASc** score is used to determine _______ risk in pts with \_\_\_\_\_\_. Decsribe the Criteria
determines Thromboemobolism risk in pts with AFib
226
When should Men take QD ASA for cardiovascular px? When should Women? What is it helping in each?
Men = **45** - 79 to ⬇︎ MI
Women = **55** - 79 to ⬇︎ Stroke
227
What all labs should be ordered when concerned for Angina; and why?-6
1. CBC: Anemia contributes to ischemia
2. BMP: Electrolyte derangement
3. BUN/Creatinine: Kidney Dz --\> Heart Dz
4. TSH: Hyperthyroidism --\> ⬆︎O2 demand of heart
5. Lipid Panel: Cardiac Risk
6. ALT/AST: Obtain baseline before starting Statin
228
Criteria for Metabolic Syndrome X -4
**DIVe** --\> ASCVD
## Footnote
*≥ 3 of the following:*
**D**yslipidemia (TAG\>150 vs HDL\<50)
**I**nsulin resistance (Fasting Glucose \>110)
**V**isceral Waist Obesity (Men\>40 inch / Women\>35 inch)
Hyp**e**rtension (BP\> 130/85)
229
*Common Causes of Chest Pain are usually **C**RGMP*
Describe the **C**ardiac Causes -6
**C**RGMP
## Footnote
1. ACS (Unstable,Stable,Prinzmetal Variant, MI)
2. Cocaine
3. Pericarditis
4. Aortic Dissection
5. Valvular
6. [Non-ischemic Cardiomyopathy]
*CRGMP = Cardiac/Respiratory/GI/Msk/Psych*
230
*Common Causes of Chest Pain are usually C**R**GMP*
Describe the **R**espiratory Causes -5
C**R**GMP
1. PE
2. PNA
3. Pleurisy
4. PTX
5. Pulm HTN/Cor Pulmonale
*CRGMP = Cardiac/Respiratory/GI/Msk/Psych*
231
*Common Causes of Chest Pain are usually CR**G**MP*
Describe the **G**astrointestinal Causes -5
CR**G**MP
1. GERD
2. PUD
3. Esophageal (dysmotility, inflammation)
4. Pancreatitis
5. Biliary (cholecystitis, cholangiits)
*CRGMP = Cardiac/Respiratory/GI/Msk/Psych*
232
*Common Causes of Chest Pain are usually CRG**M**P*
Describe the **M**usculoskeletal Causes -5
CRG**M**P
1. Costochondritis
2. Rib Fracture
3. Muscular strain
4. Herpes Zoster
5. Myofascial syndrome
*CRGMP = Cardiac/Respiratory/GI/Msk/Psych*
233
*Common Causes of Chest Pain are usually CRGM**P***
Describe the **P**sychogenic Causes -3
CRGM**P**
1. Panic DO
2. Hyperventilation
3. Somatoform DO
*CRGMP = Cardiac/Respiratory/GI/Msk/Psych*
234
When is Angina classified as **Unstable** -3
when chest pain is...
1. \> 20 min or ⬆︎in frequency
2. New
3. occurs at rest
235
What is Cardiac Syndrome X ; Lab findings?-3
Exertional angina-like cp usually in Women ;
1. **Normal coronary angiogram**
2. Normal EKG
3. Abnormal Exercise Stress test
236
Based on the 3 characteristics of Angina, when is Angina:
**Atypical**?
**NonAngina**?
1. Substernal \>20 min. **PRESSURE**
2. Exertional
3. relieved with NTG or rest
* [Atypical = ≥ 2 out of 3 +/- atypical sx] /// [NonAngina = \<2 out of 3]*
237
Which demographics typically have **Atypical** Angina? -3
1. Diabetics
2. Women
3. Elderly
238
In addition to smoking, being male, obesity and many others...age \> ___ years old is a risk factor for CAD in males and ___ in females
\> 45 yo = Male
\>55 yo = Female
*Family hx is only risk factor is **1st degree relative** has CAD **at younger ages than these***
239
Tx for Stable Angina -3
**Beta Blockers** \> Calcium Channel Blockers
## Footnote
+
ACE inhibitors
+
ASA
240
Some pts present with **SOB as the only sx** of cardiac ischemia
What is this called?!
Anginal Equivalent
## Footnote
*Example of Atypical Angina*
241
**Compartment Syndrome/Peripheral arterial occlusion is one of the serious s/s of limb threatening injury!**
What are its features? - 6
The 6 **P**'s!
1. **P**OOP (*Pain Out Of Proportion*)
2. [**P**aresthesia - EARLY finding]
3. [**P**ulselessness - LATE finding]
4. **P**allor
5. **P**oikilothermia *(inability to regulate body temp)*
6. **P**aralysis
242
How do you determine if a pt is "weight bearing" or not? ; Why does this matter in Ankle injuries?
Weight bearing = Pt can take 4 steps independently ; **SERIOUS** Ankle injuries are NOT weight bearing
243
Which ankle ligaments are most often damaged in ankle sprain? - 3
1. **ANTERIOR talofibular = MOST EASILY INJURED** (ANT Drawer test dx)
2. POSTERIOR talofibular
3. Calcaneofibular (Inversion Stress test dx)
## Footnote
*These are the Lateral Stabilizing ligaments which --\>_Lateral_ Ankle sprains are most common*
244
Name 2 classic physical exam maneuvers for diagnosing ankle injuries
1. Negative Inversion test (pts ankle is inverted and if too lax = calcaneofibular ligament damage)
2. Crossed Leg test (pt injured leg rest midcalf on knee to detect high ankle sprains)
245
DDx for Ankle Pain - 8
1. **LATERAL ANKLE SPRAIN**
2. Medial Ankle Sprain
3. Peroneal tendon tear
4. Fibular Fracture
5. Talar dome fracture (*may interrupt perfusion--\>avascular necrosis*)
6. SubTalar dislocation (*high energy injury involving talocalcaneal & talonavicular joints*)
7. Ankle Arthritis of Tibiotalar joint
8. Syndesmotic Sprain (*has positive ankle squeeze test*)
246
*Ankle Sprains are most common in the ED but \< 15% are clinically significant*
When is radiographic imaging actually _indicated_ for **ankle** sprains?
Ankle Radiographs are indicated if there is ...
[Malleolar Pain]
+
[(Bony TTP along distal 6 cm of posterior edge for EITHER malleolus) OR (NONWeight bearing immediately after injury and in ED)]
*This is the Ottawa Ankle Rule*
247
*Ankle Sprains are most common in the ED but \< 15% are clinically significant*
When is radiographic imaging actually _indicated_ for **foot** sprains?
Foot Radiographs are indicated if there is ...
[Midfoot Pain]
+
[(Bony TTP at either the navicular bone or the 5th metatarsal base) OR (NONWeight bearing immediately after injury and in ED)]
*This is the Ottawa Ankle Rule*
248
Tx mngmt for Ankle Sprains - 3
1. **RICE** (use for most msk injuries)
## Footnote
(**R**est for first 3 days after injury + intermittent stretching
**I**ce 10 min at at time all throughout day
**C**ompression
**E**levation)
2. Semi-Rigid Ankle support
3. Ibuprofen
249
What are key ways to prevent Ankle **Re-Injury**? - 3
1. Daily Ankle & Proprioceptive Exercises
2. Protective Semi-rigid ankle support when returning to sports
3. No flip flops/sandals until ankle is fully healed
250
Common s/s of HYPERthyroidism -9
**TT** **F**eels **ARCHED**
1. [**T**remor & **T**achycardia]
2. **F**atigue
3. **A**ppetite ⬆︎ but Wt ⬇︎
4. **R**eflexes ⬆︎
5. **C**ardio (Tachycardia, Palpitations,Exertional SOB)
6. **H**eat intolerance --\> **SWEATING**
7. **E**xopthalmous with lid lag
8. **D**iarrhea w/ possible dyspepsia
*Older pts may only have Fatigue and Cardio sx!*
251
Major causes of Goiter -7
1. Iodine deficiency = MOST COMMON
2. hypOthyroidism
3. HYPERthyroidism
4. Nodules
5. Thyroid CA
6. Pregnancy
7. Thyroiditis (usually tender)
252
What does it mean if TSH is ⬆︎ while T4 is ⬇︎
253
What does it mean if TSH is *mildly* elevated (5-10) while T4 is Normal
254
What does it mean if TSH is Normal while T4 is ⬆︎
Thyroid gland fails to receive negative feedback
255
What does it mean if TSH is ⬇︎ while T4 is ⬇︎
TSH vs TRH deficiency
256
What does it mean if TSH is ⬇︎ while T4 is Normal and T3 is ⬆︎
T3 Toxicosis!!!
257
How soon will you see Exopthalmous with lid lag improve in hyperthyroid pts after tx?
YOU WON'T!! **HYPERTHYROIDISM TX DOES NOT HELP EYE MANIFESTATIONS!!**
258
*Graves' disease usually affects 40-60 yo women with fam hx of thyroid disease*
What are triggers of Graves' disease? -3
1. Stress
2. high iodine intake
3. Pregnancy
259
*S/S of hypothyroidism is mostly opposite of Hyperthyroidism*
What are 6 _distincitve_ s/s of hypothyroidism?
*Mosty opposite of **TT** **F**eels **ARCHED*** but may also have...
1. **C**ardio: Diastolic HF
2. Depression
3. Menorrhagia
4. Pedal Edema
5. HTN
6. BOTH HAVE FATIGUE
260
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **S**ubstances causes for Palpitations? -5
1. tobacco
2. caffeine
3. EtOH intoxication
4. EtOH withdrawal
5. Cocaine
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
261
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **P**scyhological causes for Palpitations? - 2
1. Anxiety / Panic Attacks
2. Hyperawareness of own heart beat
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
262
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **I**nfectious causes for Palpitations?
Any Febrile illness
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
263
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **C**ardiovascular causes for Palpitations? -6
1. **Arrhythmia (aFib/aFlutter)**
2. **Cardiomyopathy (HOCM/CHF)**
3. Anemia
4. Valvular (MS/MVP/AS)
5. CAD
6. hypOvolemia
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
264
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **E**ndocrine causes for Palpitations? -4
1. HYPERthyroidism
2. Pheochromocytoma
3. menopause
4. ⬇︎Glucose
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
265
DDx for Palpitations fall into 6 categories known as **SPICED**
What are the **D**rug Medication causes for Palpitations? -3
1. Albuterol
2. Stimulants
3. Theophylline
## Footnote
***SPICED**: **S**ubstances/**P**scyh/**I**D/**C**ardio/**E**ndocrine/**D**rugs*
266
Most common causes of HYPERthyroidism -5
1. **Toxic Diffuse Goiter=MOST COMMON (Graves' disease)**
2. Toxic Nodular Goiter (multi in older pts/solitary in younger)
3. Thyroiditis (virus & pregnancy --\> T4 leakage)
4. Excess iodine intake
5. Drug (Amiodarone) induced
267
*Pt with low TSH and HIGH T4 wants to be evaluated for HYPERthyroidism*
What's initial evaluation for **HYPERthyroidism**? - 3
1. RAIU scan (RadioActive Iodine Uptake)
2. Thyroid PerOxidase Ab (Common in Graves' patients)
3. Obtain Thyroid US **FIRST** if nodule is present
268
Tx for HYPERthyroidism - 2
1. Methimazole (Sx ⬇︎ by 1 month)
2. RAI (RadioActive Iodine) oral (destroys overactive thyroid cells but eventually --\> need for hormone replacement)
269
What are the precautions of giving RAI (RadioActive Iodine PO) tx to patients? - 3
1. CTD in pregnancy
2. pt with RAI tx should NOT be near pregnant women or kids x 7 days after tx 2/2 urine/stool excretion
3. Transient worsening of sx (including eye sx) may occur
270
What are the main points to remember regarding f/u after RAI (RadioActive Iodine PO) tx in HYPERthyroid pts? - 3
1. f/u **every** 3 months after tx to follow TSH UNTIL STABILIZED & d/c propranolol (if prescribed) when euthryroid
2. Once TSH is STABILIZED, f/u can be every 6 months
3. Inform patient of s/s of hypothyroidism since inevitably this will occur. Start HRT then
271
*RAI (RadioActive Iodine) destroys overactive thyroid cells but eventually --\> need for hormone replacement*
Once hypothyroidism occurs in s/p RAI HYPERthyroid pts, what is the tx course for treating the hypOthyroidism? - 4
1st: Thyroxine 1.5-1.8 mcg/kg
2nd: ⬆︎dose slowly (especially in elderly) and **check TSH in 6 weeks**
3rd: ONCE TSH IS STABLE, f/u can be 1-2x / year
4th: Monitor for relapse/need for second RAI
272
*Smoking is the single greatest contributor to death in USA*
What 3 things do Smokers actually die of though?
Lung CA \> Ischemic Heart disease \> COPD
273
What's the most effective way to prevent death from pulmonary embolism? Why?
**Prevent DVT from ever happening in first place** ; \>95% of PE deaths happen within 1-2 hours of onset, BEFORE pt can even obtain therapy
274
How much does Obesity ⬇︎ Life Expectancy by?-4
1. BMI \> 32 in general --\> DOUBLED mortality rate in Females
2. [BMI 30-35 = ⬇︎life by 2-4 years]
3. [BMI\>40 = ⬇︎life by 20 years in Male]
4. [BMI \> 40 = ⬇︎ life by 5 year in Female]
*Obesity is also strong RF for Venous AND Arterial Insufficiency*
275
DDx for unilateral leg swelling - 6 ; Give descriptions to differentiate them
## Footnote
*Evaluate with Venous Doppler*
1. **DVT** (*Rubor,Calor,Dolor,Tumor +/- Homan's dorsiflexion pain*)
2. **Venous Insuffiency** (*SOFT, hyperpigmentation of distal leg, malleoli ulceration*)
3. **Cellulitis** (*Rubor,Calor,Dolor,Tumor*)
4. **Peripheral Arterial Disease** (*Claudication hx, ABI\<0.9*)
5. **lymphedema** (*painless, starts @ foot--\>entire limb*)
6. **Ruptured popliteal cyst**
276
How is smoking related to vascular disease? -2
1. Peripheral Arterial Disease (usually sub-patellar) is 4x more prevalent in DM pts
2. PAD progression is majorly driven by smoking
277
What can be used for DVT Px -6
1. Heparin, unfractionated
2. Lovenox
3. Warfarin
4. SCD (sequential compression devices)
5. Compression Stockings
6. Ambulation
278
Describe the system used to diagnose and assess for DVT
Wells Criteria!
279
2 greatest risk factors for DVT development
1. Smoking
2. Obesity
280
What are the requirements for treating DVT **OUT**patient? -5
Pt must be...
1. Low risk for bleeding
2. Good Kidney Function
3. Hemodynamically stable
4. Daily access to INR monitoring at home
5. Stable and supportive at home
281
DVT tx - 2
1st: [(Therapeutic Heparin vs Lovenox) x 5 days]
2nd: [(Warfarin px vs NOAC) x at least 3 months]
282
Advantages of Lovenox over Unfractionated Heparin - 4
Lovenox...
1. Longer half life = administered SubQ only 1-2/day (but note: this also means it takes longer to reverse if surgery is needed)
2. No Lab monitoring
3. FIXED Dosing
4. ⬇︎probability of HIT Thrombocytopenia
283
How should you manage a pt on Warfarin whose INR is now \> 3? -3
## Footnote
*Therapeutic INR = 2-3*
1. **Hold Warfarin**
2. Vitamin K PO dose (or 5 mg IV dose if INR 5-9)
3. Repeat INR in 1 day
284
How much does HTN ⬇︎ Life Expectancy by?
20 years!!
285
Guidelines for **Colon** CA screening - 6
starting at 50-75 yo
1. \*\*\*[Colonoscopy every **10 years**]\*\*\* and if unavailable...
2. [FOBT every **year**] OR
3. [FIT every **year**]OR
4. [Barium Enema every **5 years**]OR
5. [CT Virtural Colography every **5 years**]OR
6. [Flexible Sigmoidoscopy every **5 years**]OR
*FIT (Fecal Immunochemical Test) looks for intact hgb in stool*
286
S/S of Menopause - 5
1. Menstrual irregularity in older female (heavy/last\>1 week) = *peri*menopause
2. Hot Flashes (last 30 sec - 10 min)
3. Atrophic vaginitis --\> Vaginal Dryness, dyspareunia, urinary sx, smooth vaginal mucosa
4. Palpitations
5. Mood Swings
287
What are risk factors for Osteoporosis? - 9
## Footnote
*Bone Mineral Density (T-score) ≥ 2.5 SD BELOW mean*
1. **PERSONAL OR FAMILY HX OF OSTEOPOROTIC FX**
2. ⬇︎Estrogen (postmenopause)
3. LOW BMI (malnutrition/malabsorption)
4. Sedentary lifestyle
5. Poor Ca+ intake (body needs 1000mg/day premenopausal and 1200mg post)
6. Smoking
7. EtOH abuse
8. White race
9. CTS
288
Preventitive measures for Osteoporosis? - 4
## Footnote
*Bone Mineral Density ≥ 2.5 SD below mean*
1. **Dietary** Ca+ intake 1200-2500 mg/day
2. **Dietary** VitD intake 600 IU/day
3. Sun \> 10 min/day
4. Weight bearing exercises (walking,jogging,dancing)
## Footnote
*Only use supplements WHEN ABSOLUTELY NEEDED*
290
Guidelines for Osteoporosis screening - 3
## Footnote
*Bone Mineral Density (T-score) ≥ 2.5 SD BELOW mean*
1. Women ≥65 = DEXA
2. Women \< 65 get DEXA if fracture risk is ≥ a 65 yo WHITE woman (*9.3% 10 year risk for osteoporotic fx*) per FRAX score
3. Grade i for Men
## Footnote
*Bone Mineral Density (T-score) ≥ 2.5 SD BELOW mean*
291
Desribe the 3 components of a physical exam for abnormal uterine bleeding
1. **Pelvic**: Look for vulvar/vaginal lesions, assess size & mobility of uterus since fixed uterus=uterine CA
2. **Neck**: Assess Thyroid since thyroid dz--\>uterine bleeding
3. **Skin**: Look for abnormal bruises (bleeding DO) and jaundice (liver dz--\>bleeding DO)
292
Osteoporosis etx
⬇︎ Trabeculae bone density despite NORMAL mineralization
293
Risk factors for Endometrial CA -3
1. EEE - Excess Estrogen Exposure (HRT, neoplasm, [menstruation **outside** of 12-52], Nulliparity, Anovulation/PCOS)
2. Tamoxifen
3. Obesity
## Footnote
*Smoking and Progestin OCP ⬇︎Endometrial CA Risk*
295
Name the most common locations for osteoporotic fractures? - 4
1. Hip
2. Vertebrae
3. Distal Radius
4. Proximal Humerus
296
Based on DEXA, when is a pt classified as having Osteoporosis? What about Osteopenia?
**OSTEOPOROSIS = Bone Mineral Density (T-score) ≥ 2.5 SD BELOW mean** of Bone Mineral Density in Young health person
osteopenia = BMD Tscore between 1 - 2.5 BELOW mean
*Normal = 0-1 below mean*
297
DDx for Abnormal uterine bleeding - 7
1. **CERVICAL POLYPS** **= MOST COMMON** **IN postpartum/PERImenopausal**
2. Endometrial Hyperplasia/Proliferation
3. Endometrial CA
4. Hormone-producing Ovarian tumors
5. hypOthyroidism --\> menorrhagia
6. Steroids
7. SSRIs
298
Osteoporosis rx treatments - 4
1. Bisphosphonates (Bone resorption inhibitors)
2. Calcitonin
3. Estrogen HRT
4. PTH synthetic - **cant use for \> 2 years**
299
What tools are used for diagnosing AUB (Abnormal Uterine bleeding) in women, and why? - 5
1. Transvaginal US = evaluates endometrial thickness (\<5mm = ok), leiomyoma fibroids, ovaries
2. Endometrial biopsy = gold standard for AUB in women w/high risk for endometrial CA
3. CBC = looks for anemia/thrombocytopenia
4. TSH = hypOthyroidism --\> AUB
5. FSH & LH = In menopause, FSH/LH⬆︎ due to lack of inhibin
300
What are the Benefits-3 and Risk-4 of Hormone Replacement Therapy?
## Footnote
*There is no right answer for whether women should use HRT*
**Pros**
1. Prevents Osteoporosis
2. ⬇︎Menopausal sx (Atrophic vaginitis, Hot flashes)
3. ⬆︎Cognitive/mental status
**Cons**:
1. ⬆︎Breast CA risk if combined Estrogen/Proges is used \>3 years
2. ⬆︎Endometrial CA risk with Excess Estrogen
3. STARTING HRT \> 60 yo--\> CAD
4. HRT ⬆︎Stroke risk within first 2 years of use
302
What are *alternative* tx for postmenopausal sx? - 4
1. Yoga
2. Acupuncture
3. Tai Chi
4. Qi Gong
303
*Primary skin lesions are initial uncomplicated lesions while Secondary skin lesions are **consequences** of disease progression/scratiching/infection of the primary lesions*. Describe:
Macule?
Patch?
Papule?
Plaque?
1. Macule: Flat, change in skin color \< 1 cm
2. Patch: Macule \> 1 cm
3. Papule: raised lesion with distinct borders \< 1 cm
4. Plaque "plaque": Papule \> 1 cm
304
*Primary skin lesions are initial uncomplicated lesions while Secondary skin lesions are **consequences** of disease progression/scratiching/infection of the primary lesions*. Describe:
Nodule?
Tumor?
Vesicle?
Bullae?
1. Nodule: Raised lesion **w/out distinct borders** within epidermis, dermis or SubQ
2. Tumor: Solid Mass of SQ tissue that's larger than nodule
3. Vesicle: Raised lesion **filled with clear fluid** \< 1 cm
4. Bulla: Raised lesion **filled with clear fluid** \> 1 cm
305
*Primary skin lesions are initial uncomplicated lesions while Secondary skin lesions are **consequences** of disease progression/scratiching/infection of the primary lesions*. Describe:
Pustule?
Wheal?
1. Pustule: Papule **that contains pus**, variable size
2. Wheal: Area of elevated edema in upper epidermis
306
What are the 2 best methods for preventing Skin CA?
1. Avoid Excess Sunlight (clouds and water won't work!)
2. [SPF ≥ 15 Sunscreen] applied every 2 hours **and** after swimming/sweating
307
Describe the ABCDE criteria for evaluating Melanoma
**A**symmetry in ≥ 2 axes
**B**order is irregular
**C**olors of 2 or more
**D**iameter ≥ 6mm
**E**nlarging evolution of the lesion's surface
308
CP of Prostatits - 3
1. Lower abd pain
2. Perineal pain
3. Penis and Testicle Pain +/- w/ejactulation
309
The following skin conditions typically occur where:
Psoriasis?
Atopic Eczema? - 2
P**S**oriasis = Exten**S**or surfaces
eczema atopic dermatitis = flexor surfaces & palms/soles *(the itch that rashes!**)*
310
A: Describe Annular lesions
B: What is **AIBE** lesion stand for? Describe it
A: **Circular** erythematous macule or papule w/normal skin in center ;
B: [**AIBE** (**A**nnular **I**ris **B**ulls **E**ye) lesion] Target lesion in which erythematous annular macule/papule has second ring or purplish papule or vesicle in center - *image*
311
How does arrangement of skin lesions help with diagnosis? - 2
**Linear** arrangement = Contact rxn (tx=topical CTS) vs Herpes Zoster
312
How does size make a difference in SQC? What about Nevus?
SQC \> 2 cm = ⬆︎Risk for Metastasis & Recurrence
Nevus \> 6 cm = Malignant
*Image: Congenital nevus*
313
DDx for Oval shaped Erythematous Patch - 9 (Give brief descriptions to help differentiate)
1. Eczema
2. SQC (***Raised w/fleshy borders**,**scaly,erythematous*)
3. Actinic Keratoses (*Flat borders, scaly*)
4. Basal Cell Carcinoma (*waxy +/-telangiectasia, common on face, usually benign*)
5. Melanoma
6. Fungal infection
7. Psoriasis (*Extensor surfaces*)
8. Lichen Planus (*polygonal **purple** papules commonly @ wrist & above ankles*)-image
9. Seborrheic Keratoses (*stuck-on brown appearance*)
314
When evaluating for BPH, what 3 things most be consider?
1. **LUTS** (Lower Urinary Tract Sx): Urinary freq/urgency
2. **Similar conditions**: UTI/Prostatitis/Prostate CA/OAB
3. **Complications if untreated**: UTI/Obstructive nephropathy/Urinary Retention
315
What all test are included in the evluation for BPH - 6
1. Digital Rectal Exam (don't forget to check rectal tone)
2. UA (look for UTI, blood)
3. Prostate specific antigen
4. BUN/Cr
5. [Max urinary flow rates \> 15 mL/sec of at least 150 mL] **rules out bladder outlet obstruction**
6. PVR volume
316
Topical Corticosteroids (CTS) are best at treating what type of lesions?
**burning** or **pruritc** lesions 2/2 hyperproliferation, inflammation and immune involvement
## Footnote
*Topical CTS work mostly by vasoconstricting in upper dermis*
317
What is the vehicle base of a topical Corticosteroids? ; Describe the 4 types of topical agents and what their best used for
substance in which active ingredient is dispersed and determines rate of skin absorption
1. Creams = exudative inflammation since it dries out skin (can also use Gel for exudative inflammation)
2. Gels = exudative inflammation (poison ivy)
3. **Ointments** =Best on dry skin and has **better absorption**
4. Lotions = Lotions contain EtOH which dries oozing lesions. Use Lotion on scalp since it leaves lil residue
318
Common SE for Topical CTS (CorTicoSteroids) - 2
1. Skin Atrophy
2. hypOpigmentation (skin lightening)
319
Tinea Capitis tx - 2
1. **Griseofulvin PO**
2. Terbinafine PO
320
Tinea Unguium Onychomycosis tx - 3
1. Terbinafine PO
2. iTraconazole PO
3. Griseofulvin PO (if absolutely necessary due to low keratin affinity)
321
Which dermatologic fungal infections are treated with **topical** antifungal agents?-3 ; Good or bad pgn?
Tinea Magnum (image), Tinea Corporis, Tinea Cruris;
GOOD! Resolves within 2-4 wks post tx
322
BPH mngmt - 7
1. **Alpha R Blockers** for mod-severe sx (relaxes internal urethra)
2. **5-alpha reductase inhibitors** in men with prostates \> 40 g or add if monotx with #1 doesn't work
3. Surgery
4. Avoid Evening Drinking (includes EtOH, caffeine)
5. Avoid Decongestants
6. Avoid Antihistamines
7. Avoid rushing the urination process
323
Difference between Incisional biopsy and Punch biopsy? ; What are the advantages of these type of biopsies?-3
324
Describe Excisional biopsy? ; This type of biopsy is most useful in diagnosing what type of skin CA?
**E**xcisional = Removes **E**ntire skin lesion with 2-3 mm margins ; Malignant Melanoma
325
When would you use a Shave biopsy? ; How is this helpful cosmetically?
When lesion is elevated above surface ; Some MDs elevate lesion intentionally with lidocaine to shave --\> avoids stiches
326
What type of Skin CA is Surgical Excision used to treat?
Cutaneous SCC \< 2 cm **without high risk features**
## Footnote
*Will require 4 mm margin around tumor*
327
What type of Skin CA is Mohs Microscopic Surgery used to treat? - 4
1. NONMelanoma \> 2 cm
2. CA that has lesions with indistinct margins
3. Recurrent lesions
4. Lesions close to sensitive structures (eyes,nose,mouth)
328
What type of Skin CA is 5-FU used to treat? - 3
1. **Actinic Keratosis**
2. Bowens SCC in-situ - ALT TX
3. Superficial SCC - ALT TX
329
What type of Skin CA is Cryotherapy used to treat? - 2
1. Bowens SCC in-situ
2. Superficial SCC
330
What type of Skin CA is Radiation used to treat?-2 ; Where on the body is it contraindicated for use and why?-2
**lowrisk SCC** in nonsurgical and elderly ; Trunk & Extremities due to atrophy and ulceration
331
what are the 2 major complications of influenza in kids?
1. Bacterial PNA (Strep Outpt vs Staph inpatient)
2. Otitis Media
## Footnote
*The younger the child, the greater the risk for complication*
332
What are the major RF for developing complications from influenza? - 7
1. children \< 5 yo
2. children on long-term ASA (Kawasaki's)
3. Chronic Heart disease
4. Chronic pulmonary disease
5. Chronic Renal disease
6. Immunosuppression
7. DM
333
Tx for Strep PNA? ; Tx for **WAP**(**W**alking **A**typical **P**NA)?
[**Amoxicillin** 90mg/kg/day x 7] ; [**Azithromycin** 10mg/kg on day 1 followed by 5 mg/kg days 2-5]
334
**FLU** = **F**ever, **L**ethargy/myalgia/headache, **U**RI sx (cough,congestion)
What are major signs of a pt developing complications from influenza? - 4
**FLU** = **F**ever, **L**ethargy/myalgia/headache, **U**RI sx (cough,congestion/clear rhinorrhea)
1. Abrupt Sx onset \> 7 days
2. SOB
3. Worsening Cough
4. Difficulty maintaining hydration
335
Guidelines for Obesity screening
Kids \> 6 yo (Screen with BMI)
336
***Stages of treating childhood Obesity =** Prevention --\> Structured Wt Mngmt --\> Comprehensive Multidisciplinary Intervention --\> Tertiary Care*
Describe the Prevention Stage
337
***Stages of treating childhood Obesity =** Prevention --\> Structured Wt Mngmt --\> Comprehensive Multidisciplinary Intervention --\> Tertiary Care*
Describe the Structured Wt Mngmt Stage
338
***Stages of treating childhood Obesity =** Prevention --\> Structured Wt Mngmt --\> Comprehensive Multidisciplinary Intervention --\> Tertiary Care*
Describe the Comprehensive Multidisciplinary Intervention Stage
339
***Stages of treating childhood Obesity =** Prevention --\> Structured Wt Mngmt --\> Comprehensive Multidisciplinary Intervention --\> Tertiary Care*
Describe the Tertiary Care Stage
340
What are physical exam pulm findings that do NOT indicate consolidation? - 2
1. Wheezing
2. Rhonchi (snoring sounds) = bronchial secretions usually
341
How can lung crackles be used to determine stage of PNA - 2
**Mid-**inspiratory **fine** crackles = Acute PNA
vs
**Late**-inspiratory **coarse** crackles = Resolving PNA
*Random Note: everything is LOUDER when heard over consolidation lung areas*
342
Major s/s of Bacterial PNA - 5
1. **CRACKLES**
2. Fever \> 100.4 F / Chills
3. SOB
4. Cough
5. Pleuritic CP
## Footnote
*Strep PNA = MOST COMMON CAUSE*
343
Major s/s of Acute Bronchitis - 3
1. **Cough lasting 1-3 wks *usually* w/purulent sputum**
2. +/- Rhonchi (coarse low pitched rattling)
3. +/- Wheezing (give B2 agonist)
## Footnote
*etx = **VIRAL** self-limited large airway inflammation*
344
Influenza dx - 2
NasoPharyngeal Swab + Clinical
345
*Flu tx can ⬇︎ sx by 1 day if given within 2 days of sx onset*
When is it indicated to give Flu tx AFTER 2 days of sx onset? - 2
1. Concomitant Moderate-Severe community acquired PNA
2. pt is clinically worsening at time of initial visit
346
Mngmt elements for Pediatric PNA - 5
1. Obtain [CXR (PA and lateral) in kids hypoxic, not responding to tx or inpatient]
2. Uncomplicated Outpatient PNA in kids 5 yo-teens = Azithromycin *(since there is ⬆︎chance of it being atypical PNA)*
3. Uncomplicated Outpatient PNA in kids 3 **mo**. - 5 yo = a**mo**xicillin
4. Inpatient PNA in kids 3 weeks - 5 yo = Ampicillin vs PCN G vs CefTriaxone
5. Inpatient PNA in newborns - 3 weeks= Ampicillin vs Gentamicin
347
What is a normal total cholesterol
\< 170 mg/dL
348
What is a normal LDL? ; At what LDL should you start treating with Statins?
\< 130 mg/dL ;
[**\> 190** in pts over 21 yo = Use HIGH-dose Statins]
349
Demogaphic for Dysmenorrhea ; Risk factors-5
## Footnote
*Dysmenorrhea = painful menses starting hours-days before menstruation and lasting 3 days*
Teens/Young Adults, starting 1-2 years after menarche
1. Mood DO (Depression/Anxiety)
2. Smoking
3. Nulliparity (not having a lot of kids)
4. Poor health
5. Early Menarche
350
What are normal physical exam findings for a Pelvic Exam? - 6
1. Uterus Size of clenched fist (not \> 8 wks)
2. Uterus Midly tender on or immediately prior to menses
3. Uterus can be Anteflexed or Retroflexed
4. Cervical/Vaginal clear/white discharge (physiologic leukorrhea)
5. Nabothian cervical cyst (intermittent inclusion cyst formed during metaplasia)
6. Ovaries the size of an oyster and mild TTP
## Footnote
*Knobby knubs on uterus may = mucosal leiomyoma fibroids*
351
Clinical criteria for diagnosing Menorrhagia - 2
[Menstrual Blood loss \> 80 mL] + [menses \> 7 days]
352
What is Metorrhagia
**Irregular** frequent bleeding
353
Clinical criteria for diagnosing PMS (PreMenstrual Syndrome)
At least 5 sx (from Group A and B) began 1 week before menses, **improve during menses** and resolve during week after menses
## Footnote
*If sx occur irregularly or throughout menses = mood or personality DO*
354
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on sx from Group A and Group B*
Describe sx for Group A - 6
At least 5 sx (from Group A and B) began 1 week before menses, improve during menses and resolve during week after menses
A: (at least one)
1. Mood lability
2. irritability
3. depression
4. hopelessness
5. anxiety
6. ⬇︎libido
355
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
## Footnote
What is the Clinical Criteria for PMS? ; Name some of the PMS sx
PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase)
## Footnote
Sx:
- Bloating
- Fatigue
- HA
- Hot Flashes
- Breast Tenderness
- **Irritability/Mood Swings**
- ⬇︎Concentration
356
DDx for *Secondary* Dysmenorrhea - 3
1. Endometriosis (Also causes **dyspareunia**,pelvic pain, abn vaginal bleeding)
2. Leiomyoma Fibroids (knobby knub uterus)
3. Chronic PID (usually also has lower abd pain)
357
DDx for Menorrhagia - 6
1. Adenomyosis (symmetrical boggy uterus)
2. Polyps cervical/uterine (also has intermenstrual vs postcoital bleeding)
3. Molar Pregnancy
4. Leiomyoma Fibroids (knobby knub uterus)
5. Chronic PID (usually also has lower abd pain)
6. hypOthyroidism
358
What are the common s/s of Endometriosis - 6
1. **Dyspareunia** (not found in Leiomyoma fibroids)
2. Dysmenorrhea
3. Cul-De-Sac Pain
4. Immobile Retroflexed Uterus
5. Nodules on Uterosacral ligaments
6. Uterine motion tenderness
359
RF for Endometriosis - 4
1. 25-35 yo
2. Nulliparity
3. Mensturation [outside of 12-52 yo]
4. excessively short or long menstural cycles
360
What test would you order to initially w/u dysmenorrhea? - 5
1. CBC
2. Pregnancy test
3. [US - Abd AND Intravaginal]
4. TSH (thyroid sx may overlap w/menstrual DO sx)
5. Von Willebrand's testing **only in** **TEENS with menorrhagia**
361
*Primary Dysmenorrhea involves painful menses within first 2 days **without** pelvic pathology*
What demographic typically displasy this? tx-2?
Women \< 20 yo ;
## Footnote
**1st: Ibuprofen 2 days prior to menses x 4 days**
2nd: Combo OCP w/medium dose estrogen
362
Tx for PMS (PrMenstrualSyndrome) - 6
1. **SSRIs - if severe**
2. Menstrual Diary
3. Exercise
4. [OCP - ethinyl estradiol + drospirenone] - if severe and also needs BCP
5. Danazol (Androgen that ⬇︎ estrogen and inhibits ovulation but also --\> wt gain & hirsutism)
6. Leuprolide (GnRH R agonist that inhibits ovulation but also --\> hot flashes)
363
Indications for POIUD (Progesterone only IUD) - 3
## Footnote
*Brand Name: Mirena*
1. **Birth Control** (some still have periods but w/⬇︎ bleeding)
2. **Leiomyoma Fibroids** (MOA: ⬇︎Menstrual flow by ⬇︎Uterine volume and endometrial atrophy)
3. **Dysmenorrhea**
*This stays in place for 5 years!*
364
Side Effects / Complications of POIUD (Progesterone only IUD)- 8
1. **Irregular bleeding (possibly up to 6 mo.)**
2. Lower abd pain (do w/u if fever present)
3. Breast TTP
4. Bleeding & cramping x 3 days post insertion (ibuprofen tx)
5. Uterine perforation during insertion
6. Infectious risk within first 20 days of insertion
7. Uterine expulsion
8. dyspareunia
365
Contraindications for Progesterone only IUD - 4
1. Infection
2. CA
3. HA hx = relative ctd
4. Vascular disease = relative ctd
366
Describe ParaGard ; What demographic uses this? ; Side Effects?-2
**Copper** IUD that stays in uterus for up to 10 years ; Women who don't want kids EVERR
1. Dysmenorrhea
2. Menorrhagia
367
*APGAR is used to assess newborn status immediately postpartum*
Describe the grading system for **R**espiration?
APGA**R**
## Footnote
0 = not breathing
1 = breathing slow/irregular
2 = crying
368
*APGAR is used to assess newborn status immediately postpartum*
Describe the grading system for **P**ulse?
A**P**GAR
## Footnote
0 = No HR
1 = \< 100 bpm
2 = \> 100 bpm
369
*APGAR is used to assess newborn status immediately postpartum*
Describe the grading system for **A**ctivity & tone?
APG**A**R
## Footnote
0 = no motion
1 = arms & legs **flexed** but not active
2 = Active Motion of extremities
370
*APGAR is used to assess newborn status immediately postpartum*
Describe the grading system for **G**rimace & reflex irritability?
AP**G**AR
## Footnote
*Test response to stimulation (i.e. pinch)*
0 = no rxn
1 = grimace
2 = grimace **AND** cough/cry/sneeze
371
*APGAR is used to assess newborn status immediately postpartum*
Describe the grading system for **A**ppearance?
**A**PGAR
## Footnote
0 = entirely blue
1 = pink with blue extremities
2 = entriely pink
372
Causes of insomnia in elderly -8
1. **DEPRESSION/ANXIETY**
2. **OSA**
3. Environment (noisy, uncomfortable bed)
4. Drugs (rx, caffeine, EtOH) -avoid caffeine/EtOH 5 hrs prior to bedtime
5. Restless Leg Syndrome
6. Cardiorespiratory DO--\> SOB--\> insomnia
7. GERD
8. Hyperthyroidism
## Footnote
*Don't confuse with Advanced Sleep Phase syndrome in which elderly get sleepy earlier and wake up at 3 AM*
373
What is the diagnositic criteria for Major Depression DO? - 3
1. At least 5 out of 9 of **SIG E CAPSS** for
2. ≥2 weeks
3. At least 1 must be **S**adness or **I**nterest loss anhedonia
## Footnote
**SIG E CAPSS**
374
*The diagnositic criteria for Major Depression DO assess for 9 major sx*
What are they?
**SIG E CAPSS**
## Footnote
**S**adness most of day/everyday
**I**nterest loss anhedonia most of day/everyday
**G**uilt & worthlessness
**E**nergy deprived & fatigued
**C**oncentration loss
**A**ppetite ⬇︎
**P**sychomotor agitation/retardation observable by others
**S**leep ∆ (insomnia vs Hypersomnia)
**S**uicidal ideation (thinking about it but haven't acted yet)
375
*A pt has just experienced death in family and is bereaving*
How long before MDs consider MDD as the dx instead? ; What are s/s of diagnosis being MDD?-6
2 months after loss ;
1. Guilt about things irrelevant to the loss
2. Thoughts of death not related to the loss
3. Morbid preocupation with worthlessness
4. Marked pscyhomotor retardation
5. Prolonged functional impairment
6. Hallcuinating about things that are not related to the loss
376
Describe the clinical tool used to assess whether a pt is seriously contemplating suicide
**SAD PERSONS**
## Footnote
*Each is worth 1 point and* *[normal \<-- **4**--(outpt tx)--**7** --\> Hospitalize now!]*
**S**ex Male
**A**ge external to 19-45
**D**epression diagnosis hx
**P**revious attempt hx
**E**tOH/substance abuse
**R**ational thinking impaired (psychosis, delusions, hallucinations)
**S**ocial support lacking
**O**rganized plan
**N**o significant Other
**S**ickness physically
377
Common side effects of SSRIs/SNRIs - 4
1. HA
2. Sleep ∆
3. GI distress
4. ⬆︎Fall risk in elderly
378
Risk factors for Elderly abuse - 5
1. Dementia
2. Shared living w/abuser (except in financial abuse)
3. Caregiver is substance abuser or mentally ill
4. Heavy dependence of **caregiver** on elder
5. Social isolation of elder from everyone except abuser
379
*hypothyroidism, Parkinson's disease and Dementia all can mimic or present with depression*
What type of lab w/u is warranted to evaluate for Fatigue or Depression and why for each? - 3
1. TSH (detect hypothyroidism)
2. CBC (detect anemia and vitamin deficiencies)
3. CMP (detect electrolyte, renal, hepatic problems)
380
What are the 2 major tx modalities for insomnia?
1. **CBTi** (Cognitive Behavioral Therapy for insomnia) - sleep hygiene instruction/sleep restriction/sleep compression
2. **Rx** (Non-Benzos (Zolpidem) and Melatonin R Agonist)
381
Main tx options for Major Depression Disorder - 5
1. **SSRI/SNRIs** \> TCAs
2. **CBT Psychotherapy**
3. Exercise
4. Avoidance of recreational substances (includes EtOH!)
5. ElectroConvulsive Therapy
382
All SSRIs have a unique Side Effect profile. Give a brief description of the following:
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
1. Fluoxetine = **LONG** **3 DAY HALF LIFE** but SE c/w general SSRI SE
2. Sertraline = Used in pregnancy/breastfeeding, worse SE are mostly GI distress
3. Paroxetine = **CATEGORY D**, best studied SSRI in kids, and high risk of antidepressant d/c syndrome
4. FluVoxamine = Very useful for OCD but causes Vomiting
383
All SSRIs have a unique Side Effect profile. Give a brief description of the following:
Citalopram
EsCitalopram
1. Citalopram = QT prolongation in pts \> 60 yo
2. Escitalopram = specifically for GAD
384
Guidelines for HTN screening
Age \> 18 yo
385
What is a Normal BP? PreHTN? What is BP for HTN?
* Normal = 120 / 80
* PreHTN = Between [Normal and 140 / 90]
* **HTN = \> 140** **(or 150 in age older than 60)** **/ 90**
## Footnote
*Must be HTN for [2 measurements], [5 min apart], [one on each arm] in [at least 2 visits]*
386
What are the serious / end-organ complications of chronic HTN (BP \> 140/90) ? - 5
1. Stroke
2. Retinopathy
3. Heart (aFib,failure,angina,LVH,CAD)
4. Renal Failure
5. PAD
387
What are the recommended allotments for EtOH in Men-2? What about Women- 2?
Men = [≤ 2 drinks/ day] and [≤ 4 drinks/ social occasion]
Women = [≤ 1 drink / day] and [≤ 3 drinks/ social occasion]
*1 drink = (12ozBeer / 10ozWine / 3ozWhiskey)*
388
Main causes of *Secondary* HTN - 12
1. Renal Parenchymal Disease (*⬆︎creatinine*)
2. Renal artery stenosis (*Systolic \> 180, Abd bruit, \>55 yo*)
3. Primary Aldosteronism
4. Pheochromocytoma (*HA, diaphoresis, palpitations*)
5. Cushing Syndrome
6. OSA
7. hypOthyroidism
8. Primary HyperParathyroidism
9. Coarctation of Aorta
10. Excess EtOH \> 2 drinks/day
11. Stress (via release of NorEpi & Angiotensin 2)
12. Meds (OCP/Decongestants/NSAIDs/steroids)
389
What are s/s of lower extremitiy Peripheral Artery Disease? - 5
1. Diminished pulses
2. Cold Skin
3. Red Skin
4. Hairless
5. Thick toenails
390
What are important elements for properly taking BP? - 4
1. Pt seated quietly **in chair** with back supported for ≥5 min
2. Arm supported at heart level
3. Length of cuff ≥80% of arm
4. width of cuff ≥40% of arm
391
Lab w/u for *NEW* HTN pt during **initial** evaluation - 6
1. EKG
2. CBC (anemia ⬆︎risk for stroke/MI in HTN pts)
3. CMP
4. UA (check microalbuminemia)
5. Blood Glucose
6. Creatinine (serum and urine albumin/creatinine ratio)
## Footnote
*Don't order TSH unless thyroid disease is actually suspected*
392
What is the recommended HTN agents for:
NonBlack \< 60 yo - 4
**DACB**
## Footnote
1st: **D**iuretic thiazides
2nd: **A**CE/ARBs
3rd: **C**a+ channel blockers
4th: **B**eta blockers [Not JNC recommended]
393
What is the recommended HTN agents for:
ALL Black people (except those with CKD) - 2
**DC**
1st: **D**iuretic thiazides
2nd: **C**a+ channel blockers
* Blacks should always be started with* ***DC*** *first since they have **D**arker **C**olor :-)*
394
What is the recommended HTN agents for:
NonBlack ≥ 60 yo - 4
*BP Goal is 150 / 90 unless there is CKD or DM*
**DACB**
## Footnote
1st: **D**iuretic thiazides
2nd: **A**CE/ARBs
3rd: **C**a+ channel blockers
4th: **B**eta blockers [Not JNC recommended]
395
What is the recommended HTN agents for:
ANYONE with CKD (+/- proteinuria) - 3
*BP Goal is 140 / 90*
**A**CE/ARBs \> Diuretic thiazides \> CCB
396
Why is it futile to ⬆︎ a pt's [25 mg qd HCTZ regimen]
Doses of HCTZ \> 25 mg **DO NOT** ⬇︎BP further
## Footnote
*Be sure to start elderly at 6.25 mg qd since they are sensitive!*
397
List the main lifestyle modifications that contribute to BP control - 6
"this **WEEENS** you off HTN, HLD and DM!"
## Footnote
**W**tLoss / **E**ating / **E**tOH / **E**xercise / **N**a+ / **S**mokingCessation
*DASH = diet rich in fruits/vegetables/lowfat dairy/low fat/fatty fish Omega3fattyAcids*
398
List the Blood Pressure Goals - 2
1. Majority (includes CKD & DM pts) = \<140/90
2. Pts ≥ 60 yo WITH NO CKD OR DM = \<**150**/90
399
DDx for persistent cough & wheezing -10
1. **ASTHMA**
2. UACS-PND (Upper Airway Cough Syndrome Post Nasal Drip)
3. GERD (dx: esophageal pH studies)
4. Smoking
5. Post-infectious cough
6. COPD
7. Vocal Cord dysfunction
8. CHF (2/2 to infectious myocarditis in kids)
9. NAEB (NonAsthmatic Eosinophilic Bronchitis)
10. foreign body
400
What are the comorbid conditions of asthma that requrie tx in order to help treat asthma itself? - 5
1. GERD
2. Obesity
3. OSA
4. Rhinitis/Sinusitis
5. Depression
401
Diagnostic clinical criteria for diagnosing Acute Sinusitis-2 in adults ; What about Chronic Sinusitis?
Must have **2** out of 4 clinical sx + Radiological evidence :
## Footnote
***S**inusitis **N**ever **F**eels **M**erry*
1. **S**mell loss
2. **N**asal congestion
3. **F**acial fullness/pressure/pain
4. **M**ucopurulent drainage
CHRONIC Sinusitis = same sx but last \> 3 months
*Biggest difference between bacterial and viral sinusitis is that viral gradually improves*
402
Why is it important to inquire about Aspirin in pts with Asthma?
21% of Adults with asthma have **ASA-induced asthma** and thus, should avoid ASA and NSAIDs
403
What are the 5 factors that determine how **severe** asthma is?
*Adult step-wise tx = **BILIO***
1. sx frequency
2. nighttime awakenings frequency
3. Use of Albuterol for sx control frequnecy
4. level of interference with normal activity
5. Lung Function [FEV1 value & FEV1/FVC ratio]
404
What is the biggest long term effect of uncontrolled asthma
inability to **REVERSE** airway obstruction 2/2 airway remodeling
405
*Viral Rhinosinusitis and Bacterial Sinusitis are difficult to distinguish*
What is the main distinguishing factor? - 2
Viral Rhinosinusitis last \< 10 days and is not worsening
406
Dx for Asthma - 3
1. **⬆︎FEV1 by \> 12% with bronchodilator** OR
2. ⬆︎[FEV1 % Predicted] by \> 10% with bronchodilator
3. [Accurate H & P + #1] for kids
## Footnote
*Be sure to obtain CXR to ensure nothing else causes cough*
407
**Asthma** Etx
Excess TH2 cells *(recruited by hypersensitive APC to inhaled allergens)* secrete **IL4** --\>activates [B-lymphocyte class switching for IgE Ab]--\> IgE binds to Mast cells which will then secrete **IL5** --\> Recruits Eosinophils--\>which release mediators like Leukotrienes --\> **REVERSIBLE AIRWAY OBSTRUCTION**
408
Tx for Allergic Rhinitis and/or Chronic Sinusitis - 3
Antihistamine
+
Nasal CorTicoidSteroid
+/- [nasal saline irrigation]
409
List the 5 Step action plan for treating Asthma **in Adults**
**BILIO**
## Footnote
1st: **B**2 agonist ( use ≤ 2x/week)
2nd: **I**nhaled CTS
3rd: **L**ABA vs LAA vs Leukotriene R blocker
4th: **I**ncrease Inhaled CTS
5th: **O**ral CTS +/- Anti-IgE
410
Which Adults should receive the Pneumococcal **23 valent** vaccine (*Pneumovax)* specifically? - 6
ALL 19-64 yo with **Chronic**....
1. Heart Disease (CHF,CAD,cardiomyopathy)
2. Lung Disease (COPD, emphysema, asthma)
3. Liver Disease **[also give Hep B vaccine]**
4. Alcoholism
5. DM **[also give Hep B vaccine]**
6. ≥ 65 yo
411
What is CAGE and how is it interpreted?
CAGE = Determines EtOH abuse; ≥ 2 positive answer = EtOH abuse/dependence
1. ever tried to **C**ut back on drinking?
2. **A**ngry when someone criticizes ur drinking?
3. **G**uilty about how much you drink?
4. **E**ye opener needed in morning to prevent withdrawal/calm nerves?
412
PE findings for Appendicitis (5)
**PMR PD**
1. Peritoneal signs (Rebound, Guarding)
2. McBurney's point TTP
3. [Rovsing's LLQ TTP]
4. [Psoas & Obturator sign]
5. DEC bowel sounds
413
DDx for RUQ abd pain - 5
1. Biliary Colic 2/2 CholeDocholethiasis
2. Cholecystitis
3. Duodenal ulcer (also causes epigastric pain, relieved by antacids)
4. Atypical acute pancreatitis
5. Atypical Hepatitis (usually is chronic)
414
classic w/u for RUQ abd pain - 6
1. CBC (look for leukocytosis and anemia)
2. CMP (look at electrolytes)
3. LFTs (liver and biliary involvement)
4. Lipase/Amylase (pancreas)
5. UA (renal involvement)
6. abd UltraSound \> KUB(use for perforation/obstruction)
415
Mngmt for [Gallstones with biliary colic] (2)
1. [Elective Lap Chole]
2. [Ursodiol (ursoDeoxycholic acid) in poor surgical candidates]
416
Mngmt for **Complicated** Gallstones (Acute cholecystitis vs. CholeDocholithiasis vs. Gallstone pancreatitis)
Cholecystectomy within 72 hours!
## Footnote
*Acute Cholecystitis = inflammation & distension of gallbladder from [cystic duct obstruction]*
417
**After RUQ UltraSound**, when is the following imaging indicated for Gallbladder stone pt:
HIDA
ERCP-2
* HIDA = assess for gallbladder dysfunction **when RUQ US shows no GB stones**
* ERCP = [use if Jaundice or gallstone pancreatitis is present suggesting CholeDocholelithiasis] or for [repeat episodes of biliary colic]
## Footnote
*MRCP is similar to ERCP but is only diagnostic*
418
What is the % chance a pt who's had TIA will have a stroke in 1 week? what about 1 month?
12% ; 15%
419
What is the purpose of the NIHSS (National Institute of Health Stroke Scale)
Assess stroke-related neuro deficits, determines appropriate tx and predicts pgn
420
*You suspect a pt had a Stroke*
After FIRST, ruling out Hemorrhagic stroke with \_\_\_\_\_, when should thrombolytic therapy be given? What should be given?
NonContrast Head CT; **WITHIN 3 HOURS OF SX ONSET!** ; IV Alteplase
421
*You suspect a pt had a Stroke*
After FIRST, ruling out Hemorrhagic stroke with \_\_\_\_\_, when *can* Intra-Arterial therapy be given?
NonContrast Head CT; **WITHIN 6 HOURS OF SX ONSET!**
422
What are some causes of aFib **with RVR** - 6
1. Fever
2. cardiac infection (myocarditis/pericarditis)
3. volume depeletion
4. Thyrotoxicosis
5. Catecholamines
6. AV node dysfunction
423
What portion of stroke pts develop post-stroke depression? What's the tx?
1/3 ; SSRIs
424
Purpose of TUG (Timed Up & Go test)
Measures mobility and fall risk
## Footnote
*pt may wear usual footwear and any assistive device they normally use*
425
Describe Todds Paralysis
Self-limited focal (ipsilateral UE and LE) paralysis after seizure that **resolves naturally within 36 hours**
426
What w/u should be ordered for pt suspected of having stroke?
1. Head CT/MRI
2. EKG
3. Renal function/CMP
4. troponin
5. O2 saturation
6. CBC
427
*Pt just had a stroke recently and now wants px*
What are the therapy regimens for prevention of stroke? - 3
1. Give ASA vs [ASA + Clopidegrel] vs Warfarin **after** **first stroke**
2. START WARFARIN FOR SURE **after second stroke** (if warfarin contraindicated, use only ASA)
3. Give WARFARIN vs NOAC if pt has **aFib** after ANY stroke
## Footnote
*Also make sure pt is on a Statin*
428
When should Rehab begin for stroke pts?
Within 1-2 days after stroke
429
What's the recommended sodium limit for pts with hx of stroke?
\< 24 grams / day with a Mediterranean diet
430
What is the recommended amount of physical activity adults should do?
**≥40 min** moderate intensity/session **x 4/week** (or every day if trying to lose weight!)
## Footnote
*Moderate intensity = Target heart Rate = ([220-age) x 0.7]*
431
Name 4 **NON**-musculoskeletal causes of Shoulder Pain
1. MI
2. Lung CA
3. Cholecystitis
4. Rupturued Ectopic pregnancy
432
*Pt may possibly have Septic Glenohumeral Arthritis or Septic Subacromial Bursitis*
How should you manage this pt? - 4
1. **Urgent** US/MRI
2. **Urgent** Orthopedic consult
3. Aspiration w/culture
4. Hospitalization if dx is confirmed
433
CP of somone with Shoulder Impingement Syndrome
434
CP of somone with Fracture of Clavicle or Sprain of AC joint
435
CP of somone with Torn rotator cuff
436
What does it mean to have loss of Active AND Passive ROM, vs just Active ROM?
1. loss of **Active AND passive ROM** = Joint Disease
2. loss of only Active ROM = muscle tissue disease
437
What are the **joint diseases** (produce Active AND passive ROM restriction)?
1. Adhesive Capsulitis (*contracture of joint capsule*)
2. GlenoHumeral Arthritis
438
What are the **muscle tissue issues** that only restrict Active ROM
Rotator Cuff Tear and impingement
439
What are the major Stabilizers of the shoulder joint? - 3
1. Labrum
2. Rotator muscle group
3. Glenohumeral Capsular Ligament
440
Describe the "Empty-Can" test and which muscle it test for?
[90° ABduction of arm] + [30°flexion of arm forward] + [thumbs pointed toward floor] + [must resist downward pressure] --\> Pain = [**Supraspinatus** Rotator cuff injury]
441
Name the Rotator Cuff Muscles ; What are each of their functions?
*Supraspinatus **initiates** shoulder ABduction*
442
What are the two test used to test for Shoulder Impingement?
1. Neer
2. Hawkins Kennedy (more specific)
443
*Rotator Cuff Tendinopathy is 1 of the 4 main causes of Shoulder Pain worst w/mvmnt*
Describe CP-3 ; Name the other 3 major causes
1. Positive Apleys Scratch test
2. Weakness and pain with empty can test
3. Limited ACTIVE ROM
Torn Rotator Cuff
Impingement Syndrome w/bursitis
Labral Tear
444
*Torn Rotator Cuff is 1 of the 4 main causes of Shoulder Pain worst w/mvmnt*
Describe CP-2 ; Name the other 3 major causes
1. Limited ACTIVE ROM w/major pain
2. MAJOR weakness with strength testing
Rotator Cuff Tendinopathy
Impingement syndrome w/bursitis
Labral Tear
445
*Labral Tear is 1 of the 4 main causes of Shoulder Pain worst w/mvmnt*
CP ; Name the other 3 major causes
Clunk and O'Brien's test positive
## Footnote
Rotator Cuff Tendinopathy
Impingement syndrome w/bursitis
Torn Rotator Cuff
446
Tx for Rotator Cuff injury/impingement - 3
1. Rest
2. Physical Therapy
3. NSAIDs prn
447
What is the leading cause of death in the U.S.
CAD
448
What is the test of choice for diagnosing LVH? What does LVH look like on EKG?-2
Echo ;
EKG:
1. **LARGE S wave in V3**
2. ST depressions w/T wave inversion in V5-6
449
*All pts with Systolic HF ALSO has Diastolic HF, but not necessarily the other way around*
Between Systolic and Diastolic HF pts, which have better pgn?
Diatolic HF w/preserved EF (HFpEF)
450
What value of BNP indicates CHF dx
≥ 100 pg/mL
## Footnote
*Note: BNP is excreted by Kidneys = Naturally Elevated in Renal Failure pts!*
451
Most common cause of CHF
**Ischemic Cardiomyopathy** (scarring of myocardium from ischemia --\> ⬇︎systolic function)
## Footnote
*Other causes include: MI vs Arrhythmia vs HTN*
452
For pts presenting with chest pain, how are their CAD pre-test probabilities categorized?
what about pts not presenting with chest pain?
*Use the nomogram to calculate*
low risk= \< 10%
Intermediate risk= Everyone Else
HIGH risk = \> 80%
**Pts not presenting with chest pain, use ASCVD 10 year risk**
453
List the diagnostic test for CAD pts with **Intermediate** pre-test probability? - 3
1. **Exercise EKG Treadmill Testing =*usually* initial test** (note: this test has low negative predictive value & not great for women)
2. Stress Echo
3. Nuclear Stress testing
454
How do you slow the progression of CAD - 7
1. Glucose control
2. BP control
3. Cholesterol control
4. Weight control
5. ASA
6. Immunizations (Flu, Pneumo23)
7. Beta Blockers
455
Recommended target BP for diabetics
\< 140 / 90
456
What is the recommended guidelines for cholesterol management in Type 1 or 2 DM pts? - 2
DM1 or 2 pts ➕ LDL \> 70 ➕ age 40-75 yo should be on
1. moderate-intensity statin **PERIOD**
2. OR HIGH-intensity if 10 year ASCVD risk ≥7.5%
*Remember that ANY pt \> 21 yo with LDL \> 190 = Use HIGH-dose STATIN!*
457
Which tx is the mainstay of managing NYHA **systolic** HF? ; What are the other tx?
ACE inhibitors ;
1. ARBs (alternative to ACE)
2. Digoxin
3. Lasix
4. Beta Blockers (Metoprolol *Succinate* / Bisoprolol / Carvidolol)
5. Eplerenone
458
Main tx for **Diastolic** HF - 2
1. Beta Blocker
2. Diltiazem
## Footnote
*This is because excessive Diuresis and preload reduction may exacerbate **Dilated** HF*
459
List the 9 main causes of Dyspnea
**I C**ough**CCAAPPP**
## Footnote
**I**nterstitial Lung Disease
**C**HF
**C**ancer Lung
**C**OPD (*wheezing + Prolonged expiration*)
**A**sthma (*wheezing + Prolonged expiration*)
**A**cute Coronary Syndrome (*Angina/Cardiac MI)*
**P**E
**P**NA
**P**TX
*Don't forget psychogenic, neuro related and Anemia*
460
Which 4 features, GREATLY predict the chances a pt has COPD
1. \> 40 pack year smoking
2. ≥45 yo
3. Max laryngeal height of 4 cm or less
4. Self-reported hx of COPD
461
List the major *symptomatology* differences between COPD and Asthma
COPD = macrophages/TKiller cells/neutrophils
Asthma = Mast cells/ Helper T cells/eosinophils
462
*Clinical* diagnosis of COPD should be made when?-4 ; How is this confirmed?
All 4:
1. **Adult ≥ 45 yo (if younger, consider alpha1AntiTrypsin deficiency)**
2. Productive Cough
3. SOB
4. \> 40 pack year smoking hx
Confirm with **Spirometry of FEV1/FVC \< 70% (or 5th %tile) & irreversible**, DON'T USE CXR to diagnose COPD
463
What are 3 great statements to say to smokers to help them quit
1. Your lungs will work better within first year of quitting!
2. When u quit, ur lungs won't age as quickly
3. Even if you quit and start again, there may be beneift for you
## Footnote
*Get them in Group tx!*
464
Based on GOLD Criteria, how should COPD pts be treated?
466
Tx for COPD Exacerbation-4
Which improves survival? Which ⬇︎future events?
"I'm having COPD Exacerbation! Give me **DOPA**! (but not really)"
1. **D**uoneb (albuterol + ipratropium)
2. **O**2 PRN via BiPAP (goal: 90-94% O2 Sat) -only when desat
3. [**P**rednisone 40 mg qd x 5]
4. **A**bx (**A**zithro-⬇︎future events vs Levoflox vs Doxy)-only in situations in image
467
Progressive Dyspnea on exertion is a cardianl sx for what conditions? - 2
1. Mitral Stenosis
2. COPD
468
*Orthopnea differs from Paroxysmal Nocturnal Dyspnea in that it occurs **while pt is awake** EVERY time they lie down*
Which conditions are associated with Orthopnea? - 6
1. CHF which can --\> Pulmonary Edema
2. Pulmonary edema
3. Asthma
4. Chronic Bronchitis
5. OSA
6. Panic Disorder
469
Most common sx of Pulmonary Embolism-5
1. **Pleuritic Chest Pain**
2. SOB
3. Cough
4. Tachypnea
5. Tachycardia
## Footnote
*Physical Exam: Rales, low Fever, Hemoptysis*
470
Clinical Presentation of Albuterol (SABA) overuse - 3
1. Tachycardia palpitations
2. Tremor
3. hypOkalemia (especially if Diuretic Thiazide on board)
471
What are the major causes of COPD exacerbation?
1. Air pollution
2. TracheoBronchial tree infection
3. Idiopathic
472
Recommended guidlines for screening for AtheroSclerotic CardioVascular Disease - 4
1. in adults \> 21 yo
2. **Draw Lipid Panel** and assess major ASCVD risk factors
3. at least 8 hours after last food intake
4. every 4-6 years
473
List beneficial effects of **moderate** EtOH intake - 2
1. ⬆︎HDL
2. ⬇︎clotting
474
Describe the USPSTF grading system - 5
Grade...
* (A): Service is **Recommended** and has net benefit that is **substantial**
* (B): Service is **Recommended** and has net benefit that is **moderate to substantial**
* (C): Service should **not be routine** and should be based on individual pt since net beneift is small
* (D): **Recommended AGAINST**
* (I): Insufficient Evidence
475
Guidelines for Hepatitis **C** screening - 3
1. **One time** screen in
2. adults born between 1945-65
3. who are high risk
476
Guidelines for Prostate CA screening
**NO** routine screening in asx Men!
## Footnote
*USPSTF Grade D*
477
Indications for *Routine* Exercise Stress Testing in asx pts - 2
1. Males \> 45 yo ➕
2. ≥ 1 Risk factor for ASCVD (HLD,HTN,Smoking)
## Footnote
*Do NOT get Exercise Stress Testing if ACS dx is already pretty certain*
478
What are the 3 C's of addiction?
1. **C**ompulsion to use
2. **C**ontrol is lost
3. **C**ontinues despite consequences
479
When someone is attempting to change behavior, describe the stages they go through? - 4
**PCAR**
1. PreContemplative = Not aware or don't care about changing behavior
2. Contemplative = Interested in changing behavior
3. Active = ACTIVE in making behavior change
4. Relapse = attempted change but is not longer doing it
480
What food assessment tool is used to determine nutritional deficiencies and excesses over a month?
the **REAP** tool
## Footnote
(**R**apid **E**ating and **A**ctivity assessment for **P**atients)
481
[Atrial Fibrillation] is the most common tachyarrhythmia. It is often precipitated by what 4 things?
"Smh, **SAME** Afib as before!"
1. **S**ympathetic tone ⬆︎
2. **A**cute Systemic Illness (*Hyperthyroid / HF / HTN*)
3. **M**itral or Aortic Stenosis
4. **E**tOH - excess
482
*You ask a pt with chest pain to characterize the chest pain*
What characterization of chest pain typically **excludes** Acute Coronary Syndrome as the dx
describing it as **STABBING** = NOT ACS/CAD
## Footnote
*Pleuritic, pulsating, positional* *also ⬇︎ ACS likelihood*
483
*Many Women with MI don't report having cp before the MI*
Why is this?
Angina reported by women is most likely **atypical** and may not include actual chest pain! which --\> Women are more likely to DIE from ACS even tho they're diagnosed less
## Footnote
*may include neck-jaw pain/NV/indigestion/SOB*
484
What are HPI items that suggest palpitations is **cardiac**-related? - 4
1. palpitations \> 5 min
2. irregular beat
3. previous heart disease hx
4. Male
485
*EKG and physical exam aren't enough to rule in or out ddx for palpitations*
What is? - 2
1. Exercise Stress Test
2. +/- 2 week loop monitoring
## Footnote
*Be sure there's a HIGH Pre-test probability*
486
DDx for constant Knee pain in **Adults** - 10
1. Pes Anserine Bursitis (2/2 overuse)
2. Ligamental Sprain 2/2 acute trauma
3. Inflammatory chronic arthropathies (RA, septic arthritis, Reiter's)
4. iLiotibial Band tendonitis (lateral knee pain)
5. Septic arthritis
6. Osteoarthritis
7. Psoriatic arthritis
8. Gout
9. Popliteal Baker's Cyst
10. PatelloFemoral Anterior Knee syndrome (dx of exclusion)
## Footnote
*Be sure to determine if pain is acute or gradual*
487
Give Descriptions that differentiate
Gout vs Rheumatoid Arthritis vs Osteoarthritis
Gout = great toe or knee
RA = ≥3 joints, **bilateral** (including hands & feet + subQ nodules)
Osteoarthritis = **Asymmetrical involvement** of Back, Hips, Knees worst w/activity (joint space narrowing on xray)
488
*You perform an Arthrocentesis on a pt with knee pain*
Which labs do you order for the drawn fluid? - 6
1. Cell count w/differential
2. Glucose
3. Protein
4. Bacterial cx and sensitivity
5. Polarized light microscopy for crystals
6. Gross analysis for blood (simple joint effusion vs hemarthrosis)
489
*You perform a Knee joint Arthrocentesis*
What do these colors of effusion represent?
Straw
Yellow/Green
Cloudy
Red/Pink
**Straw** = normal synovial fluid (in setting of effusion = OA, Meniscal degenerative injuries)
**Yellow/Green *S*not** = ***S***eptic arthritis and Inflammatory arthritis
**Cloudy** = **C**rystals or ⬆︎WBCs
**Red/Pink** = Trauma (ACL damage/Acute Meniscal tear/Osteochondral fx-also has fat globules)
490
Major side effects of NSAIDs - 5
1. GI damage
2. Secondary HTN
3. Bleeding (DO NOT USE WITH WARFARIN)
4. ⬇︎Efficacy of BP meds
5. ⬆︎ Efficacy of Sulfonylureas --\> possible hypoglycemia
491
Which components of the knee does the Valgus and Varus stress test analyze? - 2
1. Medial Collateral ligament
2. Lateral Collateral ligament
492
Which components of the knee does the McMurray test analyze? - 2
1. **M**eniscus Medial
2. **M**eniscus Lateral
493
Carpal Tunnel Syndrome Clinical Presentation - 4
1. Paresthesia vs Pain with **Median n. Distribution** worst at night
2. [Thenar ABductor pollicis brevis] atrophy (⬇︎flexion/ABduction/Opposition)
3. Tinel Sign (tapping over flexor surface ⬆︎ sx)
4. Phalen Sign (flexing Wrist ⬆︎ sx)
## Footnote
*CARPEL TUNNEL STARTS uL and --\> BL*
494
Indications for obtaining **Xray** imaging for pt with knee pain - 3
1. Uncertain diagnosis
2. Assessment of Severity/location
3. Refractory to conservative tx
## Footnote
*Only obtain MRI if locking, popping or joint instability are concern*
495
Expected Xray findings for pt with osteoarthritis of knee - 4
1. **JOINT SPACE NARROWING (best predictor of disease progression)**
2. Subchondral sclerosis
3. Subchondral cyst
4. Osteophyte bone spurs (best correlate for degree of pain)
496
*EMG is the preferred dx test for Carpal Tunnel Syndrome but dx is usually made via clinical s/s*
When is it indicated to obtain? - 3
1. [Thenar ABductor pollicis brevis] atrophy present
2. motor dysfunction present
3. refractory to conservative tx
497
Osteoarthritis tx - 7
1. **Exercise (Swimming/tai chi/resistance/wt loss)**
2. **APAP**
3. NSAIDs
4. IntraArticular CorticoSteroid injections (short term, for actively inflammed joints only and can only give ≤ 3 per year)
5. Tramadol
6. Omega3Fatty Acid supplement
7. Acupunture
8. SAM-e (S Adenosylmethionine) - same as NSAIDs
498
Indications for referring Knee pain patient to orthopedics for knee replacement
When conservative tx have failed
499
What are the major classes of drugs used to treat *Chronic* Pain - 2
1. Opioids
2. TCAs
500
3 main causes of Dementia
**Alzheimers** \> Vascular \> DLB (Dementia with Lewy Bodies)
501
Dementia with Lewy Bodies (DLB) CP - 3
DLB at the **DMV**
1. **D**ementia confusion periodically
2. **M**ichaelJFox Parkinsonism (PARK + hamp) tht **does NOT respond to dopaminergic tx**
3. **V**isual Hallucinations
*Lewy Body= [**LABS** (**L**ewy **α**-synuclein **B**odie**S**)] that are Eosinophilic intracytoplasmic accumulations*
502
What is Respite Care and who does it help?
Replaces caregiver of disabled/elderly pt with fam member or paid professional for a block of time to allow stress decompression of caregiver ; Caregivers
## Footnote
*Best example of Respite Care = Adult Day program*
503
What is the CAM score and describe its criteria
CAM score = **Diagnosis Delirium** and differentiates it from Dementia/Depression.
***AIDA:** Requires A and I, but only either D vs. A*
**A**cute onset and fluctuating
**I**nattention (spell "world" backwards & forward)
**D**isorganized thinking (rambling/illogical)
**A**ltered level of consciousness (intermittently not alert)
505
How do Older Adults typically present with Depression?
With c/o **somatic** complaints (i.e. sleeping problems) instead of mood changes
506
Broad DDx for Altered Mental Status (specifically Delirium)
## Footnote
*Use VI**NN**D**II**C**AA**TE*
**V**: [CVA/TIA] /HTN Encephalopathy/Arrhythmia/MI
**I**: Withdrawal / ilicits / Wernickes/Benzo/[Anticholinergics]/Antihistamines/opioids/TCA
**N**: Tumor
**N**: Seizures post-ictal / NPH / Pain
**D**: Na+ ∆/Glucose∆/⬆︎calcemia/ ⬇︎K+ /O2, CO2/B12 deficiency/Uremia/Dehydration
**I**: Encephalitis/Meningitis/UrosepsisUTI/PNA/Endocarditis
**I**: Fecal impaction/PostOp/⬇︎Sleep/Urine retention
**C**:
**A**:
**A:**
**T:** ICH/ SDH / Restraints
**E:** thyroid
*Tx: Haloperidol, Risperidone, Quetiapine*
507
What does the MMSE (MiniMental State Exam) assess for?
Cognitive Function (NOT DELIRIUM)
## Footnote
*New Alternative is now the MoCA (Montreal Cognitive Assessment)*
508
What is the score interpretation for the MMSE
\< 19 = impaired
509
Tx for Delirium
PO haloperidol - short course
## Footnote
*alternatives: Aripiprazole/Olanzapine/Risperidone are better for Elderly*
510
List ways to minimize Delirium in hospital setting - 4
1. Frequently Reorient and stimulate pt w/**familiar** staff
2. Avoid delirium-causing meds (opioids/TCA/benzo/anticholinergics/antihistamine)
3. Get the up and moving! (also ⬇︎decubitus ulcers)
4. ⬇︎length of time for catheters!
511
Alzheimer's tx - 7 ; Which medication should be used last?
CLAV --\> HANDU
1. Donepezil - *AChnesterase inhibitor*
2. Tacrine - *AChnesterase inhibitor*
3. Rivastigmine - *AChnesterase inhibitor*
4. Galantamine - *AChnesterase inhibitor*
5. Memantine - *NMDA R Blocker: **USE LAST***
6. Respite Care for Caregivers (ex: Adult day program)
7. Atypical antipsychotics - Olanzapine vs Risperidone (for acute psycosis)
512
Colorectal CA risk factors - 8
1. Age \> 50 yo
2. Black Male
3. DM
4. IBD
5. Hereditary conditions (FAP)
6. Colorectal/Endometrial/Ovarin/Breast/adenoma CA hx
7. 1st degree relative with adenomas before 60 yo
8. 1st degree relative with CRC
## Footnote
*Fat intake ⬆︎risk for adenomas which --\> ⬆︎risk for CRC*
513
Why is obtaining CT pelvis/abd and CXR appropriate for Colorectal CA w/u?
Clinical staging of CRC is based on **depth of invasion** and because of metz to Lung, Liver and Pelvic lymph nodes, imaging of these areas is warranted
514
Is CEA used for Colorectal CA diagnosis or prognosis? explain
**PROGNOSIS** only! ; CEA \> 5 = Worst Pgn
## Footnote
*CEA can't be used for dx because it's found in benign conditions*
515
Describe a compassionate approach to delivering bad news - 7
**SPIKESS**
1. **S**et up interview in private room, face2face
2. **P**erception of what pt understands should be assesed
3. **I**nformation should be delivered according to pt preference
4. **K**nowledge given in non-tech and emotional way
5. **E**mpathetic responses given for Emotional response
6. **S**trategy laid out
7. **S**ummarize everything!
516
DDx for Fatigue -9
1. **DEPRESSION**
2. Anemia (CRC, menorrhagia, dietary)
3. OSA
4. CA
5. CAD
6. DM
7. Sleep Restriction
8. Thyroid DO
9. Chronic Fatigue Syndrome (fatigue ≥ 6 mo. + 4 physical sx)
517
Tx for Iron Deficiency Anemia - 2
1. Ferrous Sulfate 325mg TID
2. Docusate 100mg BID prn
518
A child who has SOB with cough suggest what etx for the cough?
inflammatory cause for the cough (asthma)
519
s/s of TB in kids - 4
1. **USUALLY NO s/s**
2. Failure to thrive
3. nonproductive cough
4. but.. productive cough w/systemic complaints = pulmonary dissemination
520
Dx for TB **for kids** - 4
TST (Tuberculin Skin Test)
1. \> 5 mm in asx high risk kids
2. \> 10 mm in asx moderate risk kids
3. \> 15 mm in asx low risk kids
4. Positive M.TB cx from sputum sample or morning gastric aspirate in **sx** **kids**
521
Diagnostic clinical criteria for diagnosing sinusitis **in Kids** - 3
One of below...
1. persistent b/l nasal discharge and/or daytime cough \> 10 days w/no improvement
2. #1 that Worsens after initial improvement
3. High Fever + Purulent nasal discharge \> 3 days
522
End-expiratory wheeze is classic finding for what disease?
Asthma
523
classic physical exam findings for Allergies - 3
1. Boggy Edematous Turbinates
2. **Clear** nasal discharge
3. Allergic Shiners - image
524
What is Atopy - 3
Genetic predisposition to develop IgE mediated
1. Asthma ➕
2. Allergic Rhinitis ➕
3. Eczema atopic dermatitis
525
Kids with asthma who use inhaled Corticosteroids (although rare!) are at risk of what side effects? - 4
1. ⬆︎BP
2. ⬆︎BG
3. Growth delay
4. Cataracts
## Footnote
*This occurs with HIGH DOSES and is rare*
526
Describe pathophysiology of an asthamtic exacerbation
527
*Crackles are typically heard on \_\_\_\_\_*
Which conditions are Crackles associated with? - 4
*Crackles are typically heard on* ***Inspiration***
1. Pulmonary Edema
2. Bronchitis
3. PNA
4. Intersttial disease
528
Stridor **in Kids** is typically caused by what? - 3
1. **CROUP**
2. foreign body partial obstruction of larynx or trachea
3. Laryngomalacia
529
Some dx can be made by analyzing a pt's *Cough*
What is DDx for Cough that is...
Dry-3
Wet
Barking-3
* Dry= Asthma / Environmental / Fungal
* Wet = Lower Respiratory infection
* Barking = Croup / SubGlottic disease / Foreign body
530
Some dx can be made by analyzing a pt's *Cough*
What is DDx for Cough that is...
Brassy or honking-2
Paroxysmal-4
Worst at night-2
Associated with gagging/choking
* Brassy/Honking= Tracheitis / Habitual
* Paroxysmal= Pertussis / Chlamydia / Mycoplasma / Foreign body
* Worst at night= Asthma / Sinusitis
* Gagging/Choking = GERD
531
*PEF (Peak Expiratory Flow) in asthma is used for ___ (diagnosing vs monitoring) asthma*
How do you calculate a pt's **personal best** PEF?
**MONITORING** asthma progress
Average the PEF values for 14 consecutive "good" days together
532
List the 5 step action plan for managing Asthma **in kids**
**biiLO**
1. **b**2 agonist (use ≤ 2x/week)
2. **i**nhaled CTS
3. **i**ncrease inhaled CTS (if sx are daily!)
4. **L**ABA vs LAA vs Leukotriene R blocker (if sx thrughout day, everyday!)
5. **O**ral CTS adjunct- short course considered #1-4
*CTS = CorTicoSteroid*
533
Postconcussive syndrome can occur \_\_*(length of time)*\_\_ after any TBI (Traumatic Brain Injury).
Describe CP for Postconcussive Syndrome - 4
hours-days;
1. Continued Confusion/Amnesia
2. HA
3. Mood changes
4. Vertigo
*This is Self-Resolving*
534
How are pain medications associated with Headache?
Chronic Analgesic use can --\> Analgesic Rebound HA
## Footnote
*MUST BE \> 15 BL HA/month, worst with waking and exertion*
535
Brudzinski's sign is used to diagnose \_\_\_\_. Describe it
Meningitis; Involuntary hip flexion when neck is passively flexed
536
Kernig sign is used to diagnose \_\_\_\_. Describe it
Meningitis; With hip flexed 90º, Knee extension --\> ⬆︎neck pain & resistance
537
Name the common triggers of Tension & Migraine Headaches - 5
**EEATS**
1. **E**tOH
2. **E**strogen (BC/HRT)
3. [**A**spartame & phenylalanine from diet soda]
4. **T**obacco
5. **S**tressss (depression/anxiety/exercise)
*Also Onions, Chocolate and Banans!*
538
What are the indications for obtaining neuroimaging in Headache pt? - 3
1. unexplained abnormalities and HA patterns (HA awakening from sleep, abnormal reflexes)
2. Pt is at higher risk for significant abnormality (age \> 50)
3. Results of study would alter mngmt of HA
539
What are at-home, conventional ways to manage chronic HA -4
1. HA diary
2. Avoid Caffeine (especially in Diet Soda)
3. 8 hours of sleep/night
4. ⬆︎ Exercise
540
Px for Migraine HA - 4
**VTAP** the migraine BEFORE it gets BAD, and **SEND** it away when it comes!
1. **V**erapamil
2. **Topiramate**
3. **A**mitryptyline
4. **P**ropranolol
541
Tx for Acute Migraine HA - 4
**VTAP** the migraine BEFORE it gets BAD, and **SEND** it away when it comes!
1. **S**umatriptan
2. **E**rgots
3. **N**SAIDs
4. **D**2 Blockers (Metaclopramide/Prochlorperazine)
542
Describe Dyspepsia (indigestion)
Upper abd pain w/belching, bloating, NV from ***bad digestion***
## Footnote
*This does NOT include heartburn/regurgitation from GERD*
543
DDx for Dyspepsia - 8
## Footnote
*g**reatest to least*
1. Idiopathic Functional Non-ulcer dyspepsia
2. PUD-*image*
3. GERD
4. Gastritis
5. Med side effects
6. Pancreatitis
7. CA -rare
8. Cardiac/Angina-rare
544
CP of Gastritis
Epigastric pain that improves **immediately** after meal
## Footnote
*Pts with s/s of Gastritis, GERD or PUD should first try trial of PPI for dx*
545
CP of Acute Pancreatitis - 4
1. SEVERE Epigastric pain that **radiates to back**
2. worst with eating
3. associated w/NV
4. dehydrated (tachycardia)
546
When GERD can not be easily diagnosed (i.e. PPI trial did not ⬇︎ heartburn/regurgitation), what other dx tool can be used?
24-hour pH probe
547
What is the order of diagnostic workup for a dyspepsia pt with possible PUD 2/2 H.Pylori - 4
**SURF** to the hp & then PAC it away for 2 weeks!
**S**--(if + and sx= treat) --\> confirm eradication with **U** & **R**. Use **F** if alarming sx or sx persist even after confirmation of eradication
1. **S**erum H.pylori IgG test (great 1st-time test / do BEFORE treatment / will not tell u if HP is eradicated since it remains high for years)
2. **U**rea breath test (**detects active infection** / be sure pt is not on PPI, abx or bismuth during test)
3. **R**ectal fecal antigen detection
4. **F**ind tissue to test for urease via endoscopy if alarming sx present or **U**rea breat test ctd
548
***After H.Pylori has been ruled out***, *you've diagnosed pt with Idiopathic Functional Non-Ulcer dyspepsia*
Tx?
TCAs
549
Tx for H.Pylori
SURF to the hp & then **PAC** it away for 2 weeks!
**P**PI BID x 2 weeks
**A**moxicillin 1 gram BID x 2 weeks
**C**larithromycin 500mg BID x 2 weeks
(metronidazole if PCN allergy)
550
Guidelines for Intimate Partner Violence screening
Annual screen (or whenever red flags present) of **ALL women of childbearing age**
## Footnote
*"Do you feel safe at home, and in your current environment?"*
551
Recommended screening guidelines for DM - 3
1. Screen **at any age** if BMI \> 25 AND risk factors (image)
2. Start at 45 yo routine screening every 3 years if test are normal
3. Screen asx adults \< 45 yo if [BP \> 135/80]
552
pathophysiology of retinopathy in DM ; what things should you look for on fundoscopic exam?-3
Retinal vessel occlusion --\> hypoxia --\> ⬆︎VEGF --\> Neovascularization --\> Proliferative Retinopathy
1. Microaneurysms (punctate dark lesions)
2. Cotton Wool spots
3. Retinal Hemorrhages
553
What is Normal fasting blood glucose? ; What is normal postprandial blood glucose (1-2 hrs after meal)?
Fasting BG = 80-120
Postprandial BG should be \< 180
554
What is a way you can ensure bilateral dialogue with patients about a disease - 5
**LEARN** them!
## Footnote
**L**isten with empathy regarding pt perception of illness
**E**xplain your perceptions and strategy for tx
**A**cknowledge differences/similarities between the 2 perceptions
**R**ecommend tx while considering cultural parameters
**N**egotiate agreement!
555
* Foot exams in Diabetics should be performed annually*
* This exam includes testing Sensation, Pedal Pulses and Inspection*
What does the *Sensation* component of the exam consist of?-2
10 gram monofilament
➕ (one of following)
* vibration w/128 Hz tuning fork
* pinprick sensation
* Achilles ankle reflexes
556
How often should HbA1C be obtained in DM pts - 3
1. Once at diagnosis and then...
2. 2x / year if HbA1c remains \< 7
3. 4x / year during med changes
557
*In DM pts, it's important to annually check for diabetic Nephropathy*
How is this done?
**spot Urine Albumin-to-Creatinine ratio** to check for microalbuminuria
558
*Everyone knows Metformin causes Lactic Acidosis (in setting of renal failure) and GI distress but...*
what is a less reported but serious side effect of Metformin??
Vit**B12** deficiency
## Footnote
*Be sure to order this lab in DM pts on Metformin*
559
What tx modality is used to **prevent** vision loss in DM pts
photocoagulation surgery
## Footnote
*does NOT TREAT retinopathy*
560
How do you calculate Daily Caloric needs - 3
[Body wt in lbs] x 10 x [**activity**(image)]
## Footnote
* Eating \< ~Daily Calorie needs --\> WtLoss*
* [Body wt in lbs] x 10 = BMR*
561
In terms of Weight loss, how many calories = 1 pound of weight loss? ; What's the safe # of wt to lose?
3500 calorie decrease = 1 pound WtLoss ; Pts should only lose 1 lb/week
562
Name the primary weight loss drugs-4 ; When are they indicated for use?-2
1. Phentermine (noradrenergic appetite suppressant)
2. Orlistat (GI lipase inhibtor)
3. Lorcaserin (serotonergic R agonist appetite suppressant)
4. Qsymia (appetite suppressant)
Indication: BMI \> 40 or [BMI \> 35 + comorbidity]
563
Main causes of Dyspareunia - 4
1. **ENDOMETRIOSIS**
2. **P**ID
3. Menopause (atrophic vaginitis)
4. POIUD (Progesterone Only IUD)
564
Elderly pts who commit suicide mostly do it thru what means?
Drug OD
565
What are the classical historical features of a Ruptured Achilles Tendon - 3
Mid aged male falls to ground and has *the 3 P's*...
1. **Popping sound** followed by
2. **Posterior ankle pain** immediately after and
3. **P**lantarflex disabled now
566
What % of thyroid nodules are cancerous?
4-5%
## Footnote
*and only 5% of thyroid nodules --\> HYPERthyroidism*
567
\_\_\_% of people with **severe DM** requiring insulin have retinopathy how many years after diagnosis?
**40**% of people with **severe DM** requiring insulin have retinopathy **5** years after dx
568
What is the recommended HTN agents for:
NonBlacks with DM (+/- proteinuria) - 3
*BP Goal is 140 / 90*
**A**CE/ARBs \> Diuretic thiazides \> CCB
## Footnote
*Blacks (as long as they dont have CKD) = DC still*
569
What feature of a physical exam suggest Lumbosacral sprain/strain?
Paraspinal muscle spasm
570
*Pt with Disc herniation comes to see you...*
⬇︎Hip flexor strength suggest lesion at what level?
L2 - 4
*"L2, 3 can't flex (hips) to be a whore"*
571
What is the relationship between NSAIDs and Warfarin?
Their use together **is CONTRAINDICATED!**
## Footnote
*Note: It's ok to use NSAIDs in previous H.Pylori pts*
572
*A pt with Gout can NOT use NSAIDS or Colchicine*
How do you determine what the best tx is now?
**Assess # of joints involved since**....
≥2 joints = Arthrocentesis with intraArticular Corticosteroid injection
Polyarticular = Oral Corticosteroids
573
Differentiate the following abortions:
Inevitable abortion
Threatened abortion
Missed abortion
Complete abortion
1. Inevitable = early vaginal bleeding \< 20 WG **with cervical os open or dilated** --\>abortion will *inevitably* happen soon
2. Threatened = early vaginal bleeding \< 20 WG **with cervical os closed** is clearly a threat
3. Missed = Fetal demise **without cervical dilation**...which is why we *Missed* it
4. Complete = ALL PRODUCTS OF CONCEPTION COMPLETELY EXPELLED
574
Gestational DM is determined via _______ test. When is this test even indicated?
[**3-hour glucose tolerance test**];
Obtain this test if :
[1 hour glucose \> 130 after 50 gm load] --(obtain)---\> [3-hour glucose tolerance test]
*but remember, Fasting BG ≥ 126 OR 1 hour BG \> 130 is positive result. Only 1 hour BG \> 130 requires 3 hour GTT f/u*
575
classic s/s of Hepatitis - 4
1. Jaundice
2. icterus
3. anorexia
4. malaise
576
Demographic for Acral lentiginous melanoma ; where is this found-2
dark-skinned people ; palms & soles ;
577
How often should pts receive whole body **skin** exams?
every 6 months
## Footnote
*in addition to SPF 15 suncreen, avoiding indoor tanning, wear sunhats to prevent skin CA*
578
what are alternative tx for hot flashes - 3
1. Black Cohosh
2. Flaxseed
3. St. John's Wart
579
*Diagnositc w/u for H.Pylori involves **S**erologic testing, if positive then treat, and then ONLYtesting for eradicatoin if indicated*
When is it indicated to perform **U**rea breath test and **R**ectal fecal antigen detection? - 5
**SURF** to the hp & then PAC it away for 2 weeks!
1. Pt with H.Pylori-associated ulcer
2. Persistent sx despite tx
3. H.Pylori associated MALT
4. hx of resection for early gastric CA
5. **pt planning to resume chronic NSAID therapy**
580
When is having a family hx of CAD significant for a pt?
ONLY when that family member is a **1st degree relative with premature CAD** (Male \< 55 yo and Female \< 65 yo)!!
581
**Neonatal Abstinence Syndrome**
Classic Signs - 5
**TYT D**oes **H**eroin
1. **T**remors
2. **Y**awning
3. **T**achypnea
4. **D**iarrhea
5. **H**igh Pitched Cry
*Caused by maternal opioid (**H**eroin) use during pregnancy*
