Fam Med - Uworld

Question 1

What to give in patient who is on chronic opioid therapy for pain (ie cancer)?

Answer 1

Naloxone - to prevent overdose - should be offered in every patient with chronic opioid therapy

Question 2

Naltrexone - mechanism and when to use

Answer 2

An opioid antagonist => Treat opioid use disorder => start after patient has stopped opioid for 1-2wks

Question 3

What intervention improves/prolonged survival rate of patient with COPD?

Answer 3

Stop smoking

Long-term supplemental O2 therapy (LTOT)

Question 4

Treatment of choice for HTN due to ADPKD?

Answer 4

ACE inhibitors (lisinopril) due to their ability to inhibit the RAAS system

Question 5

Management for lumbosacral radiculopathy (hernia after lifting heavy objects)

Answer 5

Activity modification (not bed rest)
First 1-2 weeks: NSAIDs
After 2 weeks: consider physical therapy, oral glucocorticoids
After 4-6 weeks: obtain MRI & assess for surgical indication

Question 6

Test for suspected strabismus (ocular misalignment)?

Answer 6

Presents with eye deviation, asymmetric corneal light and red reflexes, and an abnormal cover test

First step in evaluation is a dilated funduscopic examination to assess for secondary causes, particularly retinoblastoma, an intraocular malignancy that can often be visualized on funduscopy as a nodular, cream-colored retinal mass

Question 7

Eye exam for different eye conditions

Answer 7

Fluorescein stains epithelial defects of the eye, and drops are applied to the eye to evaluate for a corneal abrasion

Intraocular pressure is measured if funduscopic examination reveals optic nerve cupping indicative of glaucoma.

Visual evoked potential testing may be performed for optic neuritis

Question 8

Additional meds for type 2 DM with obesity and cardiovascular disease comorbid? - 1st line is always metformin

Answer 8

Glucagon-like peptide-1 receptor agonists (GLP-1) and/or certain sodium-glucose co-transporter-2 inhibitors (SGLT2) can be added to decrease cardiovascular mortality, induce weight loss, and minimize the risk for hypoglycemia.

Question 9

When imaging is indicated for nipple discharge?

Answer 9

When there is sign of pathologic discharge: unilateral, bloody, abnormal breast exam, lymphadenopathy, etc.

Physiology (bilateral, nonbloody, normal breast exam, etc.) => pregnancy test, TSH level, prolactin, etc. => but no imaging indicated

Question 10

When is XRay indicated for ankle injury?

Answer 10

Indicated for patients with pain in the malleolar region in association with either
1) bony tenderness at the posterior margin or tip of the lateral or medial malleolus

or 2) inability to bear weight (4 steps)

Question 11

Management for hand OA?

Answer 11

• stretching and strengthening exercises
• Topical nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac)
• oral NSAIDs are also effective but carry a greater risk for toxicity (eg, peptic ulcer).

Question 12

Tinea corporis - Appearance and and Rx

Answer 12

Superficial dermatophyte infection = slowly expanding, pruritic rash with a raised border and central clearing.

Transmitted by skin-to-skin contact, contact with animals, or via fomites.

The diagnosis = inspection - confirmed with potassium hydroxide of skin scrapings.

First-line treatment is a topical antifungal (eg, terbinafine, miconazole)

Question 13

Diagnosis of diabetes neuropathy

Answer 13

DN can lead to renal complications

The diagnosis of DN is made in the setting of persistently (ie, >3 months) elevated levels of albuminuria (>30 mg/g).

The random urine albumin-to-creatinine ratio (UACR) is MOST SENSITIVE for detecting early elevations in albumin excretion

Should be screened at least annually, starting either at diagnosis (for type 2) or 5 years after diagnosis (for type 1).

Question 14

How ovarian endometrioma showed on US?

Answer 14

Bimanual examination reveals left adnexal tenderness.

A unilocular mass with homogeneous, low-level echoes on US

Question 15

CKD in children- MC, Symptoms, Next step,

Answer 15

MC: congenital urinary track abnormality (ie. Posterior Urethral Valve)

Symptoms: Fatigue, poor growth, HTN, bedwetting, urinary incontinence day and night, recurrent UTIs due to vesicoureteral reflux.

Next step: serum creatinine level – or renal US or cystourethrogram

Question 16

Rx for psoriasis plaques

Answer 16

Topical vitamin D analogues

Question 17

Squamous cell carcinoma (SCC) - symptoms, management

Answer 17

Symptoms: asymptomatic, not pruritic, present where solar damage

• SCC in situ => confined to the epidermis, well-demarcated, scaly, red macules or plaques
• Invasive SCC => nodules and ulcerations are typically seen

Management => biopsy => confirm Dx => imiquimod therapy (topical immune response modifier)

Question 18

Blood glucose and meds (thiazide diuretics, ACEi, statin)

Answer 18

Thiazide and statin => raise blood glucose

ACEi => can increase insulin sensitivity => sometimes induce hypoglycemia

Question 19

Asymptomatic bacteriuria (ASB)

Answer 19

General population = not treated

Pregnant =
- All are screened and treated at the initial prenatal visit due to the risk of acute pyelonephritis and complications (eg, preterm delivery, low birth weight)

• The most common pathogen is Escherichia coli.
• First-line antibiotics include cephalexin, amoxicillin-clavulanate, or nitrofurantoin.

Question 20

Frozen shoulder - Adhesive capsulitis (AC)

Answer 20

Stiffness and pain in shoulder joint - gradual onset, 1-3 years

• caused by glenohumeral capsule contracture - risk increased with medical condition/procedure (stroke, mastectomy)

Management = Range of motion exercise - Adjunctive: NSAIDs or corticosteroid - Surgery

Usually self-limited

Question 21

Iliotibial (IT) band syndrome

Answer 21

Poorly localized lateral knee pain

Usually happens in inexperienced runners => overused

Medial knee pain could be Pes anserinus pain syndrome, often termed pes anserine bursitis

Question 22

Presbycusis (age-related hearing loss)

Answer 22

a bilateral, progressive, sensorineural hearing loss (SNHL).
=> related to cochlear hair cell loss and cochlear neuron degeneration

High frequency => affected first => difficulty understand higher speech voice (women, children)

Other associated symptoms: tinnitus (ringing buzzing), problem with speech discrimination in elderly (from background noise)

Meds can cause SNHL => aminoglycosides, loop diuretics

Question 23

Earliest sign of nephropathy?

Answer 23

Albuminuria (urine albumin/creatinine ratio ≥30 mg/g)

Hypertension

Rx => ACE inhibitors (eg, lisinopril) or ARBs are indicated if either presents.

Sodium-glucose cotransporter-2 inhibitors (eg, dapagliflozin) => can slow nephropathy => use when cardiac comorbidity presents

Question 24

Diabetic patients and when to give lipid-lowering meds

Answer 24

All diabetic patients ≥ 40y/o, regardless of baseline lipid level or < 40y/o with established ASCVD

=> start statin + modified lifestyle

Question 25

Tarsal tunnel syndrome

Answer 25

Due to compression of the posterior tibial nerve

Characterized by pain, numbness, and tingling along the sole of the foot and may extend up to the ankle

Question 26

Congenital hypothyroidism

Answer 26

Asymptomatic at birth, can be a rare cause of delayed (>48 hr of life) passage of meconium.

Supportive findings include constipation, a large fontanelle, hypotonia, and poor feeding and growth.

Diagnosis is confirmed with elevated TSH and low T4.

Question 27

Acute epididymitis

Answer 27

Unilateral testicular pain and epididymal swelling (scrotal swelling and pain)

> 35 => bacteruria from bladder outlet obstruction=> Most likely E. coli

<35 => due to sexually transmitted infections with Chlamydia trachomatis or Neisseria gonorrhoeae.

***Mumps => prodrome of fever, malaise, myalgia, PMH of parotitis

Question 28

Postherpetic neuralgia and management

Answer 28

Burning pain and hyperesthesia lasting >4 months following acute zoster.

The risk is greatest in those with advanced age, severe initial pain, or severe rash.

First-line treatment includes anticonvulsants (eg, gabapentin) and tricyclic antidepressants (eg, amitriptyline).

Question 29

Lactational mastitis

Answer 29

Presents with flulike symptoms, focal unilateral breast pain with surrounding erythema and induration, and axillary lymphadenopathy.

Associated: inadequate milk drainage (pumping instead of direct breastfeed)

Treatment

• Antibiotics against methicillin-sensitive Staphylococcus aureus (eg, dicloxacillin, cephalexin)
• Analgesics
• Continued breastfeeding => help completely drain the milk duct

Question 30

HIV ART and prophylaxis for Toxo and CMV

Answer 30

ART to all patients regardless of CD4 counts

Toxo => only when CD4 counts ≤ 100/mm

CMV => Not indicated

Question 31

Lumbar spinal stenosis

Answer 31

Common cause of back pain in patients age >60.

Back pain radiating to both thighs => worse with lumbar extension and persists while standing still => better with leaning forward (shopping cart, bike, walk uphill)

“Neurologic claudication” ≠ Vascular claudication (exertion-dependent and resolves with standing still)

Question 32

Proctalgia fugax (PF)

Answer 32

Functional anorectal disorder => diagnosis of exclusion => physical examination (eg, digital rectal, prostate, pelvic) and laboratory analysis are normal

Signs:
- recurrent episodes of rectal pain unrelated to defecation.

• Attacks may be precipitated by stress, sexual intercourse, and/or sitting but often occur without an obvious stimulus.

Management: reassurance => nitroglycerin or biofeedback if refractory

Question 33

The 3 main categories of diabetic retinopathy

Answer 33

Background or simple = microaneurysms, hemorrhages, exudates, retinal edema

Pre-proliferative = cotton wool spots

Proliferative or malignant = neovascularization

Visual impairment occurs with the development of macular edema. Argon laser photocoagulation is performed for the prevention of complications.

Question 34

Contraindication for receiving future DTaP

Answer 34

Anaphylaxis, unstable neurologic disorders, and encephalopathy (eg, coma, decreased consciousness, prolonged seizures) within a week of vaccine administration

However, uncomplicated seizures are not.

Question 35

Management for patients with carotid atherosclerotic disease

Answer 35

All should receive intensive medical management (ie, aspirin, statin, blood pressure control) and counseling on lifestyle changes to reduce future stroke risk.

Carotid endarterectomy (revascularization) is also generally recommended for patients with symptomatic stenosis of 70%-99%.

Question 36

Trachoma - Clinical appearance and Rx

Answer 36

caused by Chlamydia trachomatis serotype A,B,C (genital infection is D-K)
- spread via crowded and unsanitary conditions

Presents with follicular conjunctivitis and inflammation of the tarsal conjunctivae. Repeated or chronic infection causes inversion of the eyelashes and scarring of the cornea.

Rx: azithromycin

Question 37

Copper-containing intrauterine device (IUD) benefits

Answer 37

No effects on HTN (≠ estrogen-containing method)

Efficacy 99%

Reversible (≠ bilateral tubal ligation)

Question 38

Venlafaxine

Answer 38

antidepressant drug (serotonin-norepi reuptake inhibitor) => can cause hypertension