Fam Med Dump List Flashcards
RF for breast cancer 11
Things that decrease breast ca 4
Family history of breast cancer in a first degree relative (mother or sister)
Menarche before age 12 or menopause after age 45 (prolonged exposure to estrogen)
Genetic predisposition (BRCA 1 or 2 mutations)
Advanced age – the incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor
Female sex
Increased breast density
Advanced age at first pregnancy
Exposure to diethylstilbestrol - Diethylstilbestrol (DES) is a synthetic form of the female hormone estrogen. It was prescribed to pregnant women between 1940 and 1971 to prevent miscarriage, premature labor, and related complications of pregnancy (1).
Hormone therapy
Therapeutic radiation
Obesity
Factors assoc. w/ decreased breast ca rates
Pregnancy at an early age
Late menarche, early menopause
High parity
Medications such as SERMs (short, block the effects of estrogen in the breast tissue) and possibly NSAIDs and aspirin
Disc herniation (nucleus pulposus pinch nerve) sxs 5 2 tests to do case 10
CLASSICALLY exacerbated when sitting or bending (traction on nerve) and relief while lying or standing
Increased pain w/ coughing and sneezing
Pain radiating down the leg and sometimes the foot
Parasthesias
Muscle weakness such as foot drop
Tests CLR*, ( passive SLR)
CROSSED LEG RAISE
ASYMPTOMATIC LEG is raised; test positive if pain increased in contralateral leg; correlates with degree of disc HERNIATION
Very specific, less sensitive HENCE neg doesn’t help BUT if POSITIVE VIRTUALLY DIAGNOSTIC OF DISC HERNIATION
PASSIVE STRAIGHT LEG REASE
Normal leg raise 80 degrees; if LESS TIGHT HAMSTRING OR SCIATIC NERVE PROBLEM
To differentiate raise leg to point of pain, lower slightly, then dorsiflex foot—if no pain hamstrings tight; positive test if pain radiates down posterior/lat thigh.
Pain indicates stretching of nerve root (S1 or L5) over a herniated disc between 40-70 degrees; pain will not occur if not lifted at least 30 degrees. Pain earlier than 30 suggestive of malingering
PAIN ON OPPOSITE LEG ROOT COMPRESSION due to DISC HERNIATION
Sensitive, less specific
Gait
Difficulty w/ HEEL WALK L5 DISC HERNIATION
Difficulty w/ TOE WALK S1 DISC HERNIATION
Causes of back pain and their sxs “CT MIIND VV”
- Congenital—scoliosis, kyphosis, spondylolysis (vs. spondlolisthesis)
SPONDYLOLISTHESIS:
Occurs at ANY AGE
ANTERIOR DISPLACEMENT of vertebra or vertebral column in relation of vertebrae below
Causes achy back and posterior thigh that increases with activity and bending
SPONDYLOLYSIS:
Congenital weakening of pars interarticularis (part of vertebra located between the inferior and superior articular processes of the facet joint) seen in teenagers (ex: gymnast acute onset of LBP; tx: rest 6-8 weeks, heal by fibrosis)
Aka scotty dog fracture
Positive STORK test - The assessment of the Stork test involves palpation of the posterior superior iliac spine (PSIS). The therapist places one thumb directly on the PSIS and the other thumb is placed medial to the PSIS, on the sacral base. Ask the patient to raise one knee up, that the hip and knee are flexed to 90°. The examiner should feel the PSIS move inferiorly and laterally relative to the sacrum. A positive test is when this motion is absent. The examiner should then compare this to the opposite side. - Traumatic—lumbar strain, compression fracture
LUMBAR STRAIN (note disc herniation has same s/sx; difference is radiation/numbness with disc):
Pain worse with movement and sitting that improves while lying down suggestive of mechanical back pain such as strain
VERTEBRAL Fractures:
Pain aggravated w/ movement
RED FLAGS
Prolonged use of steroids
Mild trauma >50 or age >70
h/o osteoporosis
recent trauma at any age
previous vertebral fracture - Metabolic—osteoporosis, hyperPTH, paget’s - excessive resorption and formation of bone/thick bones, osteomalacia -severe vit d deficiency
- Infectious—pyelo, osteomyelitis, discitis, herpes zoster, spinal or epidural abscess
RED FLAGS (infection)
Persistent fever, chills
Recent bacterial infection , esp bacteremia (UTI, cellulitis,pneumonia)
IVDU
Immune suppression (steroids, transplant, HIV)
DISCITIS– Refusal to walk, fever, signs of sepsis; disk space narrowing, sclerosis per radiograph. Young age (s. aureus) - Inflammatory—ankylosing spondylitis, sacroilitis, RA
ANKYLOSING SPONDYLITIS
Chronic, painful, inflammatory arthritis primarily affecting spine and SI jts, causing eventual FUSION OF SPINE
15-40yo; HLA-B27
Assoc MORNING STIFFNESS and ACHINESS OVER SI joint and lumbar spine (bamboo spine), improves with activity - Neoplastic—multiple myeloma, metastatic disease, lymphoma, leukemia, osteosarcoma
MALIGNANCY
>50 yo; dull throbbing back pain localized to affected bones
Progresses slowly, increases w/ recumbency or cough
RED FLAGS
h/o CA, unexplained weight loss >10kg within 6 mo
<17 or >50; failure to improve w/ therapy
Pain persists >4-6 weeks
Night pain or pain at rest - Degenerative—disc herniation, OA, facet arthropathy, spinal stenosis
DISC HERNIATION:
CLASSICALLY exacerbated when sitting or bending and relief while lying or standing
Increased pain w/ coughing and sneezing
Pain radiating down the leg and sometimes the foot
Parasthesias
Muscle weakness such as foot drop
Tests CLR*, ( passive SLR),
CAUDA EQUINA SYNDROME: after spinal cord ends, LMN issues
Results from spinal compression of cauda equine, resulting from large mass effect (herniation or tumor) causing pain radiating down the leg and numbness of the leg
True emergency; decompression should be performed within 72 hrs to avoid permanent neuro deficits
RED FLAGS
UI or retention
Saddle anesthesia
Anal sphincter tone decreased or fecal incontinence
BL lower extremity weakness or numbness
Progressive neuro deficits - Vascular—AA, diabetic neuropathy
- Visceral—prostatitis, PID, ovarian cyst, endometriosis, kidney stones, cholecystitis, pancreatitis
Look for abdominal sx
PROSTATIS/PID
Referred back pain suggested by evidence of infection in the hx and PE
Asthma severity stages 4 and treatment 6 case 13
Intermittent
SX: ≤ 2 days/week
Nighttime: ≤2x/month
Short acting beta-agonist use for control: ≤2 days/week
NO interference w/ normal activity
Normal FEV1 between exacerbations, FEV1> 80% predicted, ratio normal
Persistent MILD
SX: >2 days/week BUT NOT DAILY
Nighttime: 3-4x/month
Short acting beta-agonist use for control: >2 days/week but NOT daily and NOT more than 1x on any day
Minor limitation
FEV1> 80% predicted, ratio normal
Persistent MODERATE
SX: DAILY
Nighttime: >1x/week but NOT nightly
Short acting beta-agonist use for control: DAILY
Some limitation
FEV1 60-80% predicted, ratio reduced by <5%
Persistent SEVERE
SX: THROUGHOUT DAY
Nighttime: often 7x/week
Short acting beta-agonist use for control: several times per day
EXTREMELY LIMITED
FEV1<60% predicted, ration reduced by > 5%
Stepwise approach
Intermittent STEP 1:SABA PRN (needed for asthma pts in all stages)
Persistent: daily meds/maintenance medication
STEP 2: low dose ICS
STEP 3: low dose ICS + LABA or medium dose ICS
STEP 4: medium dose ICS + LABA
STEP 5: high dose ICS + LABA and consider omalizumab for pts w/ allergies (reserved for severe asthma)
STEP 6: high dose ICS + LABA + steroid and omalizumab
EXACERBATION management
Oral Steroids
Suppress, control, and reverse airway inflammation
SE—osteoporosis, adrenal suppression, growth suppression, dermal thinning, HTN, cushing’s, cataracts, emotional lability, etc
Minimize systemic steroid use
SHORT DURATION ONLY
Multiple courses PROMT RE-EVALUATION
Milestones for infants/toddlers 2 months to 5 yrs
2 months - lift head when prone, coo (vowels -oooh, ahhh), social smile
4 - 5 months- rolls, laugh and sqeal, follow person around a room
6 months- sits unassisted, transfer objects hand to hand, babbling, demonstrate stranger recognition
9 -10 months- crawling/ pull to stand, 3 finger (immature)pincer grasp, pat a cake and peek a boo
12 months- walk alone, 2 finger pincer grasp, 1-3 words, 1 step command, separation anxiety
2 yrs old- walk up and down stairs, 2 word phrases and 2 step command
3 yrs old- ride tricycle, copies a circle, 3 word sentence
4 yrs old - hop, copy square and cross, 100% intelligible
5 yrs old- skip, walk backwards, copy triangle, 5 word sentences
Women screening mammogram, cervical cancer, osteoporosis, DM, lipid d/o, sti
Routine mammogram NOT rec <40 unless high risk (BRCA)
40-50 individualized
50-79 bienniel
The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
DEXA in ALL women > 65 yo, awa in women 60-64 who have increased fracture risk.
The United States Preventive Services Task Force concluded that there was insufficient evidence to recommend for or against screening for diabetes in asymptomatic adults.
However, the task force found that there was moderate evidence for and recommended screening in adults with hypertension (blood pressure >135/80 mmHg) as part of an integrated approach to reduce cardiovascular risk.
Lipid d/o : women >45yo if RF
Nucleic acid amplification test; urine or vaginal swabs
ALL sexually active non-pregnant women 24 or younger (Chl and GC)
Non-pregnant 25yo and older at increased risk (Chl, GC, HBV, HIV, syphilis)
Recommends (B)
ALL pregnant women 24 or less (Chl, GC, HBV, HIV, syphilis)
Pregnant women 25+ at increased risk
Advises AGAINST screening 25+ if NOT at increased risk, regardless of pregnancy status
Insufficient evidence for screening men
Immunizations: zoster >60yo; tetanus q10yrs; pneumovax 65yo; annual flu
Men screening lung, colon, prostate, lipid, ab us
Lung
Poor evidence that screening for lung cancer decreases mortality
Evidence insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose CT, CXR, sputum cytology, or a combo of these tests.
Colon women too Colonscopy (preferred) q10yrs Annual—stool cards (FOBT at home) q5 w/ flex sig Double contrast enemas q5 yrs
Prostate
USPSTF rec AGAINST PSA screening; ACS and AUA rec testing be offered to men starting at 50yo but that the doc should first discuss potential benefits and harms.
Lipid d/o:M> 35
Depression: all adults
HTN: 18yo
Ab US: AAA for men 65-75 who have h/o smoking; not recommended for women
Against screening for testicular cancer
Immunizations: zoster >60yo; tetanus q10yrs; pneumovax 65yo; annual flu
Metabolic syndrome case 2 5
3 or more of following: ab obesity, high TG, low HDL, high BP, high fasting glucose
Criteria for diabetes dx 3
A diagnosis of diabetes is made if HBA1C is greater than or equal to 6.5%, or two fasting plasma glucose values over 125 mg/dl, two-hour plasma glucose values over 200 mg/dL during an oral glucose tolerance test, or a random glucose greater than or equal to 200 mg/dL with symptoms of diabetes.
Screenings during pregnancy /ga case 14
1t 3
2t 3
3t 2
1TM (1-12 weeks)
N/V usually self-limited beginning 4-7 week resolving by 20th week
Eat small frequent meals; try high carb, low fat foods
1 in 200—hyperemesis gravidarum dehydration/ketosis/electrolyte disturbances/weight loss
Monitor BP and weight gain
FHT—first heard at 10-12 weeks
Fundal height measurements—
10 weeks fundus may be palpable just above pelvic brim
20 weeks top of uterine fundus at level of umbilicus
> 20 weeks top of fundus elevates ~1cm each week
SCREENING
10-14 week—NTDs (high maternal alpha fetoprotein can suggest it)
1TM—CVS (chorionic villus sampling - gives definitive karyotypic diagnosis)
12-16 weeks—screen for asymptomatic bacteriuria
2TM (13-27 weeks)
GDM—risks associated w/ GDM rises as level of glucose impairment rises, includes:
Preeclampsia
Fetal macrosomia
Birth trauma
Need for operative delivery
Neonatal mortality
Newborn complications
LABS
Triple or QUAD screen
Measures 3-4 chemical markers present in mom’s blood
AFP
hCG
unconjugated estriol
Quad only—inhibin A (high could mean DS)
Abnormal levels indicate increased risk for NTD, trisomy 18, trisomy 21
Not performed until 15-21 weeks (discuss @ 10 weeks)
If screen POSITIVE—IDs individuals at higher risk but does not r/i/o
Triple—69% DOWN’s; quad 81%
DOWN’s diagnosis
4-6 of following signs:
Flat facial profile, excessive skin at nape of neck, slanted palpebral fissures, hypotonia, hyperreflexibility of joints, dysplasia of pelvis, anomalous ears, transverse palmar crease, poor moro reflex
US—routine @ 18-20 weeks for structural abnormalities
Amniocentesis
SCREENING—GDM
24-28 weeks
Measure serum glucose 1 hr after 50g load
Normal fasting <126; 1 hr <140
Abnormal result 3hr gtt
Measure fasting, 1, 2, and 3 hr after 100g load
Need 2 or more abnormal values for dx
3TM (28 - birth)
SCREENING
GBS at 35-37 weeks w/ vag or rectal swab
Most common life-threatening infection in newborns sepsis, meningitis, pneumonia
½ cases occur during 1st week of life; preventable w/ intrapartum PCN
Labor precautions—vag bleeding, discharge, gush, regular ctx
IF PATIENT RH-
Give RHOGRAM @ 28 weeks, within 72 hrs of delivery, and w/ any episodes of vaginal or intrauterine bleeding
Calorie intake/BMI calculation for losing weight
Calculate daily caloric requirement to maintain weight and daily caloric requirement for weight loss
BMR (basal metabolic rate) = body weight *10 {needed to function}
Additional caloric needs x 1.3-1.9 depending on sedentary to high intense activity
Maintain current weight= BMR + additional calories for activity level
Lose weight= caloric intake < est. total caloric needs
3500 cal deficit to lose 1 pound
Exercise—30 mins most days or 20 min vigorously 3 days/wk
BMI/Obesity
BMI used as an index for defining obesity; exceptions: extremes of height and muscle mass
BMI = weight in kilograms / (height in meters)2
18.5 to 24.9 = normal (kids 5-85th percentile)
25.0 to 29.9 = overweight (85-95)
> 30 or greater as obese (>95)
In adults with a BMI of 25 to 34.9 kg/m2, a waist circumference greater than 102 cm (40in) for men and 88cm (35 in) for women, is associated with a greater risk of hypertension, type 2 diabetes, and dyslipidemia and CHD
Case 4 Ligament tear with ankle sprain
Tests
Grading
Sprain Most common ankle injury is a lateral ankle inversion sprain caused by a combo of plantarflexion and inversion. Medial rare; MOI forced dorsiflexion and eversion Acute injury (after trauma) w/ pain, warmth, and swelling; sx usually improve over time, may become stiff if not exercised within a few days. Test anterior drawer, talar tilt
Tests
Anterior drawer—assess integrity of anterior talofibular ligament (most easily injured); indication lateral ankle sprain, most sensitive least painful
Inversion test (or talar tilt)—forced inversion w/o laxity (inversion= injury); assess calcaneofibular ligament; indicated for lateral ankle sprain
Posterior talofibular ligament—strongest
Cross leg test—test high ankle sprain pain in syndesmosis area
Grading ankle sprains I-III (stretching and/or small tear—incomplete tear—complete tear)
CHF: diastolic path, sxs,
Diastolic dysfunction
Pathophysiology—occurs when s/sx of HF are present, BUT left ventricular fx is preserved. LV dev an abnormality of filling and becomes stiffer and noncompliant as disease progresses increased pulm vessel increased filling pressures increased LAP/atrial size/congestion—at this pt see exercise intolerance and clinical signs of failure including DOE, pulm/hepatic congestion, and peripheral edema (more so seen with systolic dysfunction)
Rales in lung bases, dullness to percussion, JVD, PMI laterally displaced in systolic CHF d/t hypertrophy, S3 gallop in systolic, s4 gallop diastolic, hepato-jugular reflux, abdominal distension or shifting dullness, lower extremity edema and pulse.
