Family Flashcards
What are the cancers for which screening does not exist?
Endometrial, ovarian, skin, lymphoma
What is a normal PSA?
Less than 4
What test can be used to assess the stability of the calcaneofibular ligament?
inversion stress test
What factors are taken into consideration in grading an ankle sprain?
loss of function, ecchymoses, severity of pain, severity of swelling
What should be used for compression of ankle injuries/
semirigid support
What is in the differential for lateral ankle tenderness?
lateral ankle sprain (A), peroneal tendon tear (due to inversion injury) (D), fibular fracture (E), talar dome fracture (often related to ankle sprain) (G), and subtalar dislocation (H).(often high energy)
Distinguish basal cell carcinomas from squamous cell carcinomas
basal cell carcinomas - plaque like, waxy/transulcent. rarely itchy. usually slow growing and rarely malignat
squamous cell - fleshy, irregular borders, bleed easily, more frequently malignant
What are examples of end organ damage in diabetes?
neuropathy, nephropathy, coronary heart disease, cerebrovascular disease,
What is the mortality rate of HHNK?
often 15-20%
Describe HHNK vs. DKA
few ketones, glucose often >600, no metabolic acidosis
What proportion of the population is affected by diabetes?
8.3%
What should you look for on fundoscopic exam to evaluate for diabetic retinopathy?
Retinal hemorrhages - are dark blots with indistinct borders that indicate partial obstruction and infarction.
Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages.
Microaneurysms
What proportion of diabetic neuropathy is asymptomatic?
up to 50%
What tests should be performed to screen for diabetes?
fasting lipid profile, spot albumin-creatinine ratio, B12 levels (metformin lowers B12), TSH, lipid profile
What can be done to improve cardiovascular outcomes in diabetic patients?
quit smoking, lower BP, add statin, lifestyle modification (diet, exercise), consider aspirin in patients with existing CV risk (hasn’t been shown to improve mortality except in patients with increased CV risk
What are the classifications of blood pressure?
<120 - normotensive
120-139 - prehypertensive
if less than 60, anything greater than 140 is hypertension
If greater than 50, anything greater than 150 is hypertension
What is the cause of most hypertension?
98-99% is essential hypertension with no known identifiable cause
rest are secondary hypertension
How should BP be measured?
should be seated for 5 minutes, arm at heart level, length of bladder at least 80% width of arm circum, width at least 40% arm circumference
What are the BP med recommendations for different populations of patients (consider age and race). What meds are not recommended?
General non-black population <140/90
Calcium channel blocker or thiazide diuretic
-beta blockers, t blockers, non-selective diuretics not recommended
What are potential side effects of thiazide diuretics to consider?
can cause electrolyte abnormalities (e.g. hyponatremia), should be avoided in patients with hx of gout because can precipitate flares, can cause incontinence in older patients, can cause hypotension (so start at low dose like 6.25mg)
What lifestyle change modifies BP the most?
weight reduction
What are some of the best prognostic indicators of death (1 and 2)
age is 1, LVH (in patients both with and without hypertension)
What tests are suggested for patients diagnosed with hypertension?
EKG (look for LVH), UA, hematocrit (look for anemia), serum K, serum Cr, (not serum Na/serum Cl) , lipid panel, serum Ca (look for hyperparatyhroidism that might indicate renal damage from kidney stones)
When should you prescribe aspirin in patients with hypertension?
wait till BP is within normal range to avoid risk of hemorrhagic stroke
Does an increased dose of thiazide diuretics affect CV morbidity or mortality
nope
What are other considerations when adding additional medications for African American populations?
BB, ACE inhibitors, and ARBs still reduce morbidity and mortality from hypertension in African Americans (renal protection, cardio-protection) separately from the BP levels. African Americans, however, are 2 - 4 times more likely to develop angioedema from ACE Inhibitors than other groups.
What is the definition of resistent hypertension?
Resistant hypertension is defined as the failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic (D
What mneumonic can be used to evaluate the causes of back pain?
CT MIND and V
C of CT MIND and V
congenital -
scoliosis, kyphosis, spondylolysis
T of CT MIND and V
trauma -
lumbar strain
compression fracture
M of CT MIND and V
metabolic - osteoporosis hyperparathyroidism Paget's disease osteomalacia
I of CT MII ND and V
infectious - Infectious pyelonephritis osteomyelitis discitis herpes zoster spinal or epidural abscess
Inflammatory causes of back pain
inflammatory -
Inflammatory ankylosing spondylitis
sacroiliitis, rheumatoid arthritis
Neoplastic causes of back pain
multiple myeloma
metastatic disease
lymphoma/leukemia
osteosarcoma
D of CT MIND and V
degenerative: disc herniation osteoarthritis facet arthropathy spinal stenosis
V of CT MIND and V
vascular:
aortic aneurysm
diabetic neuropathy
second V of CT MIND and V
visceral: prostatitis PID ovarian cyst endometriosis kidney stones cholecystitis pancreatitis
Describe back pain due to malignancy
localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough.
Describing ankylosing spondylitis
Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and lumbar spine.
Describe the back pain associated with spondylithisthesis
Anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.
Can occur at any age.
Causes aching back and posterior thigh discomfort that increases with activity or bending.
What physical exam findings are associated with L5 and S1 disc herniations
Difficulty with heel walk is associated with L5 disc herniation
Difficulty with toe walk is associated with S1 disc herniation
What physical exam findings are associated with central spinal stenosis?
squatting/sitting will reduce the pain, radiating pain and numbness to lower extremities (pseudoclaudication)
What findings are associated with L3 nerve impingement?
Decreased patellar tendon reflex, pain in the lateral thigh and medial femoral condyle, trouble with extension of the quadriceps, squat down and rise.
What findings are associated with L4 nerve impingement?
Trouble with dorsiflexing ankles and walking on heels
What findings are associated with L5 nerve impingement?
Decreased medial hamstring reflex; pain in the lateral leg and dorsum of the foot; trouble with dorsiflexion of the great toe and walking on heels.
What findings are associated with S1 nerve impingement?
Decreased Achilles tendon reflex; pain in the posterior calf; sole of the foot and lateral ankle; trouble with standing on toes and walking on toes (plantarflex ankle).
What does the crossed leg raise test indicate?
suggests disc herniation
What does the FABER test indicate?
Flex ion, abduction, external rotation,The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain from sacroiliitis).
What are the symptoms associated with disk herniation?
increased pain with coughing and sneezing pain radiating down the leg and sometimes the foot
paresthesias
muscle weakness, such as foot drop (D)
What are the symptoms that might suggest herniated nucleosus pulposus?
Major muscle weakness (strength 3 of 5 or less)
2. Foot drop
What are the indications for MRI for back pain?
Neurological deficit
Radiculopathy
Progressive major motor weakness
Cauda equina compression (sudden bowel/bladder disturbance)
Suspected systemic disorder (metastatic or infectious disease)
Failed six weeks of conservative care
What treatments are recommended for patients with disc herniation?
muscle relaxant/aspirin and NSAIDs, moist heat, good posture PT,
What is the prognosis for acute back pain?
90% resolving within one month and only 5% remain disabled longer than three months. Patients who are older (>45) (D) and patients who have psychosocial stress take longer to recover. Recurrence rate for back pain is high at 35 to 75% (D)
What are the options for persistent pain from back disc herniation?
surgery referrel, cortisone injection, continue conservative treatment
According to the new guidelines, what individuals are eligible for statin therapy?
Pts with cardiovascular risk, LDL>200, diabetes patients (moderate unless ASCVD risk greater than 7.5%), and people with risk >7.5% ages 40-75
What are the new guidelines for blood pressure?
If under 60, maintain BP 140/90
If over 60, maintain BP 150/90
What are some alternate causes of hypertension that should be considered?
sleep apnea, drug induced, chronic kidney disease, primary aldosteronism, renovascular disease, pheo, cushings, coarctation of aorta, thyroid/parathyroid disease
What statins are considered high intensity?
atorvostatin, rasuvostatin
How is diabetes diagnosed?
fasting blood glucose above 126, HgA1C above 6.5, random blood glucose over 200, 2 hour post prandial above 200 - if at least 2 of these criteria are met, diabetes
Why have thiazolidenediones been phased out?
increases risk of heart failure, MI, and bladder cancer
What are the findings on X ray of osteoarthritis?
weight bearing, subchondral sclerosis, peaking of tibial spines, osteophytes, joint narrowing,
Describe the function of the rotator cuff muscles
supraspinatus - abduction
infraspinatus and teres minor - external rotation
subscapularis - internal rotation
Where does most referred shoulder pain originate from?
neck
What is the scarf test?
tests for AC joint pathology - drape arm adducted across chest
Describe the impingement test and what impingement is
passive forward motion while in internal rotation
impingement syndrome is a process of degeneration leading to RTC tears involving edema, fibrosis, and finally rotator cuff tears
What is spondylolysis?
stress fracture of pars interarticularis - most common cause of back pain in adolescents
What is the side effect profile of tricyclic antidepressants?
anti-cholinergic side effects (dry mouth, constipation, urinary retention)
What screening is recommended for patients aged 73 years old?
colorectal cancer (50-75), depression, HBP, biennial mammography (50-74)
What vaccinations are recommended for a patient 73 years old.
Td boost every 10 years, pneumococcal if over 65, flu every year, zoster if over 60
What causes of shoulder pain would merit urgent diagnosis and management?
septic glenohumeral arthritis, septic subacromial bursits
How do you distinguish patients that have active and passive ROM vs. patients with just active ROM issues?
patients with active and passive ROM have joint disease vs. patients with active ROM issues have muscle disease
What are the major stabilizers of the shoulder?
labrum, rotator muscle group, glenohumeral ligaments
What tests can be used to consider Impingement syndrome with bursitis
Apley’s Scratch test causes pain and/or limited range of motion with these conditions.
Neer and Hawkins-Kennedy tests used to rule out these conditions
What tests are used to consider labral tears?
Clunk and O’Brien’s tests
What are the management options for rotator cuff tendinopathy?
. Physical therapy: Re-establish a more normal range of motion.
2. Followed by progressive strengthening of the rotator cuff and scapular stabilizers.
What conditions require sling immobilization?
shoulder dislocation, fracture
What spirometry results are diagnostic of COPD?
FEV1/FVC less than 70%
FEV1 are 80, 50, and 30% of predicted.”
What are common features of COPD?
worsening winter cough, dyspnea on exertion, lack of orthopnea or PND
What is the key distinguishing factor between COPD and asthma?
COPD is not reversible via bronchodilator therapy and asthma is. Mast cells, T helper cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma, and
Macrophages, T killer cells, and neutrophils play a role in an inflammatory and destructive process in COPD
How does quitting smoking affect the progression of COPD?
The subsequent rate of decline in FEV1 among sustained quitters was half the rate among continuing smokers; most improvement occurs n first year. still helpful to quit even if you restart
When should diabetics have fundoscopic exams?
Type 1 - 5 years after diagnosis
type 2 - when diagnosed
What vaccination are recommended fo diabetics?
Pneumococcal, annual flu
What studies should be conducted inpatients with HTN?
EKG, UA, cr, K, lipid, urinary albumin, serum Ca,
What is the utility of self breast exams?
BSE has no beneficial effect and actually increases the number of biopsies performed (C).
What are the risk factors for cervical cancer?
Early onset of intercourse , A greater number of lifetime sexual partners, Cigarette smoking, immunocompromised
What are some of the pathologic causes of nipple discharge?
Prolactinoma Breast cancer -Intraductal papilloma -Mammary duct ectasia -Paget's disease of the breast -Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications use (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)
What is the sensitivity of mammograms?
sensitivity of mammography is between 60% and 90%
When is breast MRI recommended?
women with more than a 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin’s disease).
What are some of the factors that increase risk of breast cancer?
Family history of breast cancer in a first-degree relative (i.e., mother or sister) (A)
Prolonged exposure to estrogen (B), including menarche before age 12 or menopause after age 45
Genetic predisposition (C) (BRCA 1 or 2 mutation)
Advanced age (D) (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
obesity
increased alcohol consumption
What are some of the symptoms of menopause?
hot flashes, vaginal dryness, mood swings
What are the calcium recommendations for perimenopausal and post menopausal women?
premenopausal women need approximately 1000 mg of calcium daily while postmenopausal women need 1500 mg of calcium daily
What are the risk factors associated with osteoporosis?
early menopause, Lack of physical activity, Family history of osteoporotic fracture
Personal history of previous fracture as an adult (E)
Dementia, and Cigarette smoking, white race
According to the Bethesda system, what is considered an adequate sample for pap smear?
5,000 squamous cells and have sufficient endocervical cells.
What does the guardasil vaccine protect against? When should it be given?
6,11 (cause genital warts) 16 and 18 (cause most cervical cancers) 6,11 (cause genital warts) 16 and 18 (cause most cervical cancers) for ages 9-26, take slightly before sexual debut
What are the risk factors for CVD?
SMOKING (major) sedentary lifestyle (A) stress (C) premature family history (E) excess alcohol use (H) Leg pain with activity Chest pain with activity
What are the Cs of addiction?
- Compulsion to use
- lack of Control
- Continued use despite adverse consequences
What are the 5 As for counseling behavior change?
Ask or Address the behavior needing change.
Assess for interest in behavior change.
Advise on methods to change behavior.
Assist with motivation to change behavior.
Arrange for follow-up.
How effective are oral medications in helping people quit smoking?
Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 - 3 times the placebo quit rate
If you do drink alcohol, how much and what kind should you drink?
up to 1 drink per day for women, up to 2 drinks per day for men.
no consensus on the kind
What are some methods for obtaining a more accurage diet hx?
24-hour Dietary Recalls
- Daily Dietary Intake Records (or Food Diaries)
- Food Frequency Questionnaire
- Usual Diet History
- Observed Intakes
- Weighed Intakes
What is the formula for BMI?
Formula: weight (kg) / [height (m)]2
What are the cutoffs for BMI classifications?
Underweight below 18.5
Normal 18.5 - 24.9
Overweight 25.0 - 29.9
Obese 30.0 and above
What screenings have earned A and B recommendations by the USPTF?
Colorectal cancer Obesity Diabetes mellitus Lipid disorders Tobacco use
Hypertension (B) Alcohol misuse (E) Hepatitis C (F)
What are the EKG findings that might indicate CAD?
Horizontal ST segment depression or downsloping ST segment (A) Suggests cardiac ischemia Convex ST segment elevation (D) Suggests acute myocardial injury Q waves (B) that are greater than 25% of succeeding R wave and greater than 0.04 seconds Indicate infarction
What aspects of diet may help reduce CAD?
eating fish twice a week. Eating more fatty fish like mackerel, lake trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk.
Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower heart disease risk.
How do you calculate the estimated due date?
first day of the last normal menstrual period, then:
add 1 year
subtract 3 months
add 1 week
How long is abortion legal?
up to 22 weeks of gestation
What blood tests should be ordered for a patient who is just found to be pregnant?
CBC, Hepatitis B surface antigen, rubella, Blood type (E) to detect rhesus antibody presence, RPR tests for syphilis , HIV status
When is RhoGam indicated?
always! prevents fetal death, hydrops
What is Ectropion?
When the central part of the cervix appears red from the mucous-producing endocervical epithelium protruding through the cervical os, onto the face of the cervix. It has no clinical significance and is common in women who are taking oral contraceptive pills.
What does bleeding during the first trimester mean? How does it affect risk of miscarriage?
One in four pregnant patients experience vaginal bleeding during the first trimester.
When women have significant bleeding in the first trimester, there is a 25-50% chance of miscarriage.
What tests should be done during first trimester bleeding?
CBC, Wet mount preparation for gonorrhea, chlamydia, and trichomonas, Progesterone (E): Laboratory testing for progesterone is most useful in extreme situations. If the result is >25, it is highly associated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage or ectopic pregnancy
How does beta HCG levels change during pregnancy?
in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first 6-7 weeks of gestation.
What are the most common causes of vaginal bleeding during first trimester?
spontaneous abortion (A), ectopic pregnancy (B), and idiopathic bleeding in a viable pregnancy
What is used by ultrasound to estimate due date in first, second and third trimester?
first trimester - crown-rump length second trimester- biparietal diameter 2.head circumference 3.abdominal circumference 4.femur length
What are the different ways of subdividing spontaneous abortions?
A) Threatened abortion - bleeding before 20 weeks gestation.
Threatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is - in some ways - a “catch-all” descriptive diagnosis. Savannah has had a threatened abortion during most of this case.
(B) Inevitable abortion - dilated cervical os.
(C) Incomplete abortion - some but not all of the intrauterine contents (or products of conception) have been expelled.
(D) Missed abortion - fetal demise without cervical dilitation and/or uterine activity (often found incidentally on ultrasound without a presentation of bleeding).
(E) Septic abortion - with intrauterine infection (abdominal tenderness and fever usually present).
(F) Complete abortion - the products of conception have been completely expelled from the uterus
What are the options for treatment with an inevitable abortion?
Expectant management (A) means watchful waiting
Surgical (C) options include dilitation and curettage
Medical management - vaginal administration of 800 mcg of misoprostol (Cytotec
What is the cause of most miscarriages and how common are they?
About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities. You are not alone in this, it is very common: about one-third of all pregnancies end in miscarriage
What are some causes of palpitations?
Cardiovascular: Arrhythmia, cardiomyopathy, hypovolemia
Psychiatric: Anxiety, panic attacks
Medications: Caffeine, stimulants, theophylline, and albuterol use
Substances: Tobacco, caffeine, alcohol intoxication or withdrawal, cocaine
Endocrinologic: Hyperthyroidism, pheochromocytoma, hypoglycemia
Hematologic: Anemia
Infectious: Febrile illness
What are the causes of enlarged thyroid?
Lack of iodine, Hypothyroidism, Hyperthyroidism, Nodules, Thyroid cancer, Pregnancy, Thyroiditis
What is the most common cause of hyperthyroidism?
Toxic diffuse goiter (Graves’ disease) (B) accounts for the majority (60-80%) of hyperthyroidism
What is the leading cause of death in the country? break down those deaths - what pathophysiologically causes them? ?
smoking - 160,848 (41%) of deaths were attributed to cancer, 128,497 (32.7%) to cardiovascular diseases, and 103,338 (26.3%) to respiratory diseases.
How much does uncontrolled hypertension affect life expectancy?
uncontrolled hypertension decreases life expectancy by 20 years
How much does diabetes affect mortality?
doubles mortality
How much does obesity affect mortality?
BMI of 30-35 reduces life expectancy by two to four years while severe obesity BMI > 40 reduces life expectancy by 20 years for men and 5 years for women
In a patient with acute left lower leg swelling and pain, what are the most likely diagnoses?
venous insufficiency (gradual, should see hyperpigmentation), lymphadema (chronic, grdually moves up leg), DVT, PAD (but he’s got pulses), cellulitis
What test can be done to consider DVT vs cellulitis?
venous duplex scan
What tool can be used to evaluate if a patient is at risk for DVT (and should get a D-dimer)
Well’s criteria
What is the Wagner grading system for wounds?
Grade 1: Diabetic ulcer (superficial)
• Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
• Grade 3: Deep ulcer with abscess or osteomyelitis
• Grade 4: Gangrene forefoot (partial)
• Grade 5: Extensive gangrene of foot
What are the conditions required to be able to treat DVTs on an outpatient basis?
Hemodynamically stable (A) With good kidney function (B) At low risk for bleeding (D)
Stable and supportive (F)
Capable of providing the patient with daily access to INR monitoring (G)
What are the advantages of LMWH over unfractionated heparin?
Longer biologic half-life so it can be administered subcutaneously once or twice daily (A)
Laboratory monitoring is not required (B)
Thrombocytopenia is less likely although periodic monitoring of platelets may be needed (C)
Dosing is fixed (D)
Hence, LMWH may be used in the outpatient setting (F
How long should a patient with idiopathic thromboembolic disease be anticoagulated?
he has a first episode of idiopathic thromboembolic disease, so he should be anticoagulated for at least six months (
How long should a patient who as a DVT as a result of trauma/surgery be anticoagulated?
three months (B) for patients who have a first time event as a result of trauma or surgery
How long should patients with thrombophlebitis be anticoagulated?
Six to twelve weeks (A) in patients who have symptomatic isolated calf thrombophelbitis
What patients should be screened for inheritied thrombophilia?
thrombosis occurring prior to age 50 without an immediately identified risk factor, family history of venous thromboembolis, recurrent DVTs,
What are the health risks associated with obesity?
hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis,, sleep apnea, respiratory problems, endometrial cancer, breast cancer , colon cancer
What is the half life of warfarin (how long does it take for levels to stabilize)
40 hours, that means it will take five to seven days for the steady state to be stable.
IF a patient comes in with an INR of 11, how do you treat?
Warfarin should be held, and an oral dose of Vitamin K
How long should LMW heparin be continued while transitioning to warfarin?
at least 5 days and until INR > 2 for at least 24 hours
Distinguish GERD pain from PUD from gastritis
GERD - substernal, worse with food
PUD - epigastric, gnawing feeling, improves with food
gastritis- epigastric pain that improves immediately following a meal. - associated with alcohol and NSAIDs
How much GERD is nonerosive?
About 60% of cases of GERD can be classified as non-erosive reflux disease (NERD)
How much does GERD affect QOL?
In many patients, reported health-related quality of life is lower than age-matched patients who have untreated angina pectoris, diabetes mellitus or chronic heart failure
How long do the symptoms associated with gastric and duodenal ulcers last?
Both gastric and duodenal ulcers may be associated with nausea and vomiting occurring anytime shortly after eating to several hours later
What are possible complications of GERD?
Esophagitis, Peptic strictures, Barrett’s esophagus
What are possible complictions of PUD?
Hemorrhage or perforation, Ulcer scar healing - gastric outlet obstruction
What should you look for on physical exam for a patient with dyspepsia
Hemodynamic status, Signs of anemia, malignancy signs (Weight loss, palpable mass, presence of signal lymph nodes (Virchow’s nodes) and acanthosis nigricans ) , Signs of gall bladder disease, Signs of hypo or hyperthyroidism
How does H pylori spread?
H. pylori is spread through human saliva and feces and via food and water sources
How is H pylori epidemiology changing?
Ninety percent of patients worldwide with duodenal ulcers are infected with H. pylori - The incidence of H. pylori is declining worldwide.
What tests can be done to check for active H. pylori?
fecal antigen, urease
If a patient does not respond to H . pylori treatment, what should be done next?
endoscopy
What findings on physical exam indicate consolidation?
whispered petriloquey, increased tactile fremitus, egophany (hear A when patient says E)
When does bronchiolitis typically occur?
Caused by viruses such as respiratory syncytial virus (RSV).
Seen in young children with the incidence peaking at 6 months of age
What are possible complications of flu?
- otitis media
- streptococcal PNA
- lower respiratory tract infections including bronchitis and pneumonia, neurological
What are the risk factors for dysmenorrhea?
smoking, depression
What is an abnormal pelvic exam?
large uterus (more than a fist) and immobile
What is premenstrual syndrome?
bloating, fatigue, behavioral symptoms
What are the risk factors for osteoporosis?
Low estrogen, lack of physical activity, fam Hx of osteoporosis, dementia, cigarrete smoking
Dark discolored fluid with fat globules on aspiration
osteochondral fracture
Dark discolored fluid with fat globules on aspiration
osteochondral fracture
How should you counsel women with diabetes who are pregnant?
optimize control, stay off ACE inhibitors
How should you counsel women who are pregnant with a hx of depression?
avoid benzos
When might a HIDA scan be indicated?
typical symptoms of biliary colic but no visible stones on the gallbladder ultrasound (look for biliary dysfunction)
When might an ERCP be justified?
there was jaundice and/or gallstone pancreatitis suggestive of a common duct stone
What are possible treatment options for risky and hazardous drinking behavior?
Brief intervention by the family physician (A) consisting of a 10-15 minute session with advice and goal-setting. Usually this is followed by return visit or phone call. This is the most likely option to choose for a patient in a rural area.
Referral for MET (B) consisting of 4 sessions over 12 weeks utilizing techniques of motivational interviewing. This intervention requires more of a commitment from the patient to attend sessions. This modality may not be available in a rural area
Referral for CBT (C), a structured form of psychotherapy that works to improve the patient’s awareness of his behavior and to develop new, more adaptive behaviors. Also requires patient commitment and may not be readily accessible in a rural area.
Describe the quality and type of pain that occurs in migraines
Moderate to severe, Often occur with nausea and vomiting, Pulsating and can be unilateral, Worsened with physical activity, Last from 4-72 hours
How many episodes of migraines are necessary for diagnosis?
5
How many episodes of tension headaches are necessary for diagnosis?
10
Describe pain of cluster headaches
severe, associated with rhinorrhea, Last 15-180 minutes
What are the 3 serious secondary causes of headaches?
Meningitis, intracerebral hemorrhage, brain tumor
What are common causes of secondary headaches?
analgesic abuse, depression
What are the guidelines for MRI imaging patients with headaches?
The patient has migraine with atypical headache patterns or neurologic signs
The patient is at higher risk of a significant abnormality
The results of the study would alter the management of the headache
What medications can act as triggers for migraine headaches?
estrogen, aspartame, tobacco, caffeine, alcohol
What are the contraindications to triptans?
cerebrovascular, or peripheral vascular disease, severe hypertension, pregnancy
What are the contraindications to ergot alkaloids?
heart disease or angina, hypertension, peripheral vascular disease, pregnancy, renal insufficiency, breastfeeding
What tricks can be used to prevent opiate abuse?
Set clear goals, Use non-pharmacologic treatments, first select specifically targeted non-opiate therapies , Use long-acting agents, Use a pain medication agreement
What are the criteria for controlled headache symptoms?
Fewer than two headaches per week or eight per month and they are relieved with lifestyle modification and acute treatment medicine
What are key PE findings for the scrotal exam?
cremasteric reflex - sensitivie (non specific) for testicular torsion
Blue dot sign - pathognomonic for appendiceal torsion
Prehn sign - physical lifting of the testicles relieves the pain caused by epididymitis
What are the viability rates in testicular torsion based on time?
6 hours 90%
more than 12 hours 50%
more than 24 hours 10%
What are common causes of insomnia in the elderly?
Sleep apnea, restless leg syndrome, cardiorespiratory disorders, GERD, hyperthryoidism
What therapies have been shown to be effective for primary insomnia?
Cognitive Behavioral Therapy for Insomnia, zolpidem (E) [Ambien)
What medical conditions in old age are frequently associated with depression?
hypothyroidism, Parkinsons disease, dementia
What can increase a patient’s liklihood of completed suicide?
male, increasing age, previously attempting suicide
If hospitalization not warranted, what steps should be taken?
no-harm contract - go to doctor if feel like you want to harm yourself
What are the side effects of zoloft?
gastrointestinal side effects
How does diagnosis of depression in ethnic minorities compare to that of white individuals?
Hispanics have their depression identified less frequently than non-Hispanic white
Hispanic patients will more frequently present to a doctor for somatic complaints
How do you assess patients in the timed up and go test?
< 20 Mostly independent
20-29 Variable mobility
> 30 Impaired mobility
What test can be performed to assess for upper extremity weakness?
pronator drift
What test is used by ambulance paramedics to rapidly assess stroke risk in patients?
Face Arm Speech (FAST) test
What is Hypokalemic periodic paralysis?
rare syndrome characterized by episodes of general or focal weakness.
Episodes usually begin in childhood or adolescence.
How can hemiplegic migraine be distinguished from stroke?
cessation of symptoms by mid-adult
What are the major mechanisms of stroke?
Embolic, Thrombotic (native clot in the artery), Cardiogenic (caused by decreased cardiac output) Hemorrhagic
What are the treatment options for atrial fibrillation with rapid ventricular response?
Rate control: Controlling the heart rate with intravenous diltiazem, beta-blockers, or verapamil
Rhythm control: Cardioversion either via electric shock to the heart with the patient under sedation or via medications given orally or intravenously (has a risk of stroke)
What are functions impacted by a right parietal infarct?
left hemiplegia, difficulties with their spatial and perceptual abilities, left spatial neglect, denial of stroke disability
What therapies can be used in treating thrombotic stroke?
Aspirin alone, aspirin with dipyridamole, and clopidogrel
What are common complications of stroke?
aspiration pneumonia, malnutrition/dehydration, and pressure sores.
What secondary prevention measures can be taken to prevent future stroke?
Hyperlipidemia, Hypertension, Smoking, Diet, Physical activity, Stroke education
What proportion of stroke victims are affected by post stroke depresssion?
One third of stroke survivors experience post-stroke depression
How do you distinguish between fatigue and sleepiness?
fatigue - A feeling of exhaustion or tiredness that is pervasive, not relieved by rest, and often worsened by exertion.
sleepiness - A feeling of tiredness that gives a patient the tendency to fall asleep, and is often relieved by either rest or exertion.
For which cancers does the USPTF have A or B ratings?
Breast cancer, Colorectal cancer, cervical cancer
Has glycemic control been tied to improved outcomes with CAD mortality?
NO!
What measures have been shown to be effective in slowing the progression of CAD?
BP control, aspirin, cholesterol control, weight control (non rapid), beta blockers
What are the findings on chest X ray that might indicate CHF?
Cardiomegaly, Central vascular congestion and hilar fullness, Pleural effusions, Cephalization of pulmonary vasculature, Kerley B lines (indicate interstitial fluid in lung tisuse)
What is the most comon cause of diastolic heart failure?
uncontrolled hypertension
What drugs have been shown to play a role in management of Grade C systolic heart failure?
ACE inhibitors, ARBs, Digoxin, Loop diuretics , Certain Beta-blockers such as metoprolol succinate, Eplerenone
What tests are appropriate for a patient with intermediate risk of CAD?
Exercise treadmill testing (ETT), Stress echocardiography
Nuclear stress testing
What has been shown to be helpufl in the management of oesteoarthritis?
exercise, SAM-e, injections, tramadol (maybe), hyaluronic acid (maybe), glucosamine (maybe)
Why is tramadol useful?
stimulates release of serotonin and inhibits reuptake of norepi, alleviates pain, less abuse potential than opiods
What beta HCG level is a pregnancy detected by transvaginal ultrasound? How about transabdominal?
1500 - transvaginal
5000 transabdominal
What number of drinks is considered a positive screen according to the Association for Addiction Medicine?
14 drinks/week as a man
more than 7 drinks per week as a woman
What physical exam skills can be used to rule out appendicits?
psoas sign, obturator sign
Squamous cell cancers of what size are at increased risk of metastasis?
2cm
If endometrium is greater than __ on US, you need follow up
5mm
What are the concerns of hormone replacement therapy?
increases risk of breast cancer, endometrial cancer, coronary artery disease, stroke
What are the different types of estrogen therapy available?
systemic - use with progesterone to protect against endometrial cancer
Topical - good for urinary symptoms and atrophic vaginitis
What are the different types of estrogen therapy available?
systemic - use with progesterone to protect against endometrial cancer
Topical - good for urinary symptoms and atrophic vaginitis
What medications can be used as headache prophylaxis?
beta blockers, topiramate (neurostabilizers) amitryptyline (tricyclics)
When is it appropriate to evaluate eradication of H. Pylori?
H. pylori ulcers, H. pylori cancer, dyspepsia despite test and treat
Describe the RISE approach for prevention
Risk factors
Immunizations
Screening
Education
How do you calculate Targeted Heart RAte?
(220-age)x 0.7
What is the liklihood of a pt. who has a TIA developing stroke?
8-12% chance within 1 week
What are the predictive factors for COPD?
smoking more than 40 pack years, self reported, max laryngeal height >4, age over 45
Is X ray suggested for COPDers?
can help eval for other causes of dyspnea, like cancer
What is the definition of dysmenorrhea?
painful menses
What therapuetic life style choices can lower LDL?
TLC diet Saturated fat <200 mg/day Consider increased viscous (soluble) fiber (add 5-10 g/day) and plant stanol/sterols (add 2 g/day) to enhance LDL lowering Weight management Increased physical activity
What can raise HDL levels?
Exercise (A), weight loss (B), and smoking cessation (D), moderate alcohol
How does one calculate BMR?
Basal metabolic rate (BMR) can be approximated by multiplying body weight in pounds by 10
How many calories make a lb?
3500
How many calors/day does a baby need?
Adequate growth for a term infant requires approximately 100 to 120 cal/kg/day
How quickly do babies grow?
double birth weight by 4-5 mo, triple by 12
