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Med > Family > Flashcards

Family Flashcards

1
Q

Purpose of periodic health examination

A

Primary prevention (identify RFs, counsel pt to promote healthy behavior)

Secondary prevention (presymptomatic detection of disease to allow early treatment/prevent progression)

Update clinical data

Enhance pt-physician relationship

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2
Q

Folic acid suppl in low risk women

A

Dose: 0.4-1 mg/d
Since:2-3 mo before conception
Until: end of postpartum period

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3
Q

High risk women for NTD

A 
Epilepsy
Insulin dependent DM
BMI>35
FHx of NTD
High risk ethnicity
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4
Q

Folic acid suppl in high risk

A

Start: 3 mo prior
Until: postpartum or end of lactation
Dose: 5Mg/d until end of T1, then 0.4-1mg/d

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5
Q

If poor compliance, no birth control, taking teratogenic substance

A

5mg/d

Counselling about birth defects prevention

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6
Q

Strength of recommendation for

Community fluoridation

A

A

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7
Q

Dental brushing

A

A

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8
Q

Flossing

A

A

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9
Q

Noise control

Hearing prorection

A

A

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10
Q

Nicotine replacement therapy

A

A

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11
Q

Referral to smoking cessation program

A

B

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12
Q

Dietary advice on leafy green vegetables

A

B

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13
Q

Seat belt use

A

B

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14
Q

Injury prevention (bicycle helmet, smoke detectors)

A

B

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15
Q

Moderate physical activity

A

B

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16
Q

Unexposure, protective clothing

A

B

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17
Q

Problem drinking screen/counselling

A

B

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18
Q

Counselling to protect against STI

A

B

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19
Q

Nutritional counselling/dietary advice on fat/cholestrol

A

B

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20
Q

Dietary advice on Ca/vit D requirements

A

B

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21
Q

Blood pressure measurement

A

A

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22
Q

BMI in obese adults

A

B

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23
Q

Folic acid supplementation for women of child-bearing age

A

A

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24
Q

Pharmacologic Tx of HTN

A

A

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25
Q

Varicella vaccine for age 1-12
And
Susceptible adolescents/adults

A

A

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26
Q

Rebella vaccine for all non-pregnant women of child-bearing age, unless proof of immunity

A

B

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27
Q

Tetanus vaccine, routine booster q 10 y after 1° series

A

A

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28
Q

Pertussis vaccine, one booster for adults<65 as Tdap

A

A

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29
Q

Home visit of children for high risk families

A

A

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30
Q

Inquiry into developmental milestone

A

B

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31
Q

Counsel on sexual activity and contraceptive methods

A

B

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32
Q

Counsel to prevent smoking cessation

A

B

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33
Q

Assess for RFs of osteoporosis/Fx in perimenopausal (>50) women

A

A

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34
Q

Counsel on osteoporosis,

Counsel on risk/benefit of HRT

A

B

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35
Q

Follow-up on caregiver concern of cognitive impairment in adults>65

A

A

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36
Q

Multidisciplinary post-fall assessment

A

A

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37
Q

Repeated examination of eye, hearing, hip in pediatric, esp in 1st year

A

A

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38
Q

Serial height, weight, head circumference

A

B

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39
Q

Visual acuity testing after age 2

A

B

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40
Q

Visual acuity (snellen sight chart) after 65

A

B

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41
Q

Hearing assessment (inquiry, whispered voice test, audioscope)

A

B

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42
Q

Full body exam if 1st degree relative with melanoma

A

B

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43
Q

Routine Hb for high risk infants

A

B

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44
Q

Blood lead screening for high risk infants

A

B

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45
Q

Mantoux skin tesf for high risk groups

A

A

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46
Q

Voluntary HIV Ab screening for high risk group

A

A

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47
Q

Gonorrhea screening in STI high risk

A

A

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48
Q

Chlamydia screeninv in STI high risk group/women

A

B

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49
Q

Syphilis screen in STI high risk group

A

A

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50
Q

VDRL in syphilis risk group

A

A

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51
Q

Routine immunization in pediatrics

A

A

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52
Q

Outreach strategies for influenza vaccination in high risk group

A

A

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53
Q

Annual immunization with influenza vaccine

A

B

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54
Q

INH prophylaxis for TB household contacts/skin test converters

A

B

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55
Q

INH prophylaxis for high risk subgroups

A

B

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56
Q

Pneumococcal vaccine for high risk group

A

A

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57
Q

High risk group for pneumococcal vaccine

A 
Immunocompromised
Age 65 or more
COPD
Asthma
CHF
Asplenia
Liver disease
Renal failure
DM
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58
Q

Average risk woman for breast cancer

A

Age: 40-74
With non of:
• personal Hx of breast cancer
• Hx of breast cancer in 1st degree relatives
• known mutation in BRCA1/BRCA2
• previous exposure of chest wall to radiation

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59
Q

Routine screen for breast cancer

A

Age 50-74 yo, mammography q 2-3 y
Age 75+, take overall health into acount. Screen if benefit outweighs harm
Recommend not advise women to routinely practice self-examination

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60
Q

Lung cancer screening guideline

A

Age: 55-74
Smoking Hx: at least 30 pack-year
Current condition: smoking/ quit less than 15 years ago
Frequency: yearly up to 3 consecutive times
Method: low-dose CT

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61
Q

Average risk individuals for CRC

A 
Asymptomatic
No FHx (of UC, CRC, Polyps)
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62
Q

CRC screening for average risk

A

Age: 50-75

FOBT/FIT q2 y
Or
Flexible sigmoidoscopy q 10y

Screening after 75yo: on an individual basis for 76-85

Colonoscopy as screen? No

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63
Q

Asymptomatic with FHx of HNPCC

A

Genetic counselling

Begin: age 20/ 10 y younger than the earliest case in the family
Colonoscopy q 1-2 y

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64
Q

Asymptomatic with FHx of FAP

A

Age 10-12
Anually
Sigmoidoscopy

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65
Q

Asymptomatic with AAPC

A

Age 16-18
Anually
Colonoscopy

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66
Q

Asymptomatic with
One 1st degree with CRC/Adenomatous polyp at age <60
Or
Two or more 1st degree relatives with polyp/CRC at any age

A

Colonoscopy every 5 y

Begin at: age 40/10y younger than the earliest case

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67
Q

Asymptomatic with
One 1st degree with CRC/A-polyp at age >60
Or
Two or more 2nd degree with polyp/CRC

A

Average risk screening, but starting at 40

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68
Q

Asymptomatic with
One second degree relative
Or
Third degree relative

A

Average risk screening

Beginning at 50

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69
Q

If polyp found at colonoscopy

1-2 tubular adenomas <1cm

A

Colonoscopy in 5 y

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70
Q

> 2 adenomas

A

Colonoscopy in 3 yr

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71
Q

Incomplete examination at colonoscopy

A

Colonoscopy after a short interval

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72
Q

Numerous polyps at colonoscopy

A

Colonoscopy after a short interval

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73
Q

Advanced adenoma at colonoscopy

A

Colonoscopy at short interval

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74
Q

Malignant adenoma at colonoscopy

A

Colonoscopy after a short interval

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75
Q

Large sessile adenoma at colonoscopy

A

Colonoscopy after a short interval

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76
Q

Cervical cancer screening target population

A

All women age 25 or older (ontario: 21yo or olded if ssxual activity has started)
Interval: q 3y
Strongest recommendation:30-69

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77
Q

Discontinuation of cervical cancer screening:

A

Women >70 with:

3 normal tests in a row, and no abn tests in last 10 years

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78
Q

Cervical cancer screening for pregnant women

A

Follow the routine

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79
Q

Cervical cancer screen for women who have sdx with women

A

Follow the routine

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80
Q

Cervical cancer screening after total hysterectomy

A

Discontinue if: hysterectomy for benign reasons, no Hx of cervical dysplasia/ no Hx of HPV infection

If Hx of uterine malignancy/dysplasia: continue to swab vaginal vault

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81
Q

Cedvical cancer screening for subtotal hysterectomy

A

Continue according to guidlines

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82
Q

If adequate sample on Pap, no TZ

A

Routine screen q 3y

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83
Q

The most effective preventive strategy

A

Health promotion

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84
Q

Effective way to promote healthy behavior changes:

A

Discussion appropriate to a pt’s present stage of change

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85
Q

1st step in behavioral change

A

Consider pt’s current stage of change

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86
Q

If stage: pre-contemplation

A

Encourage to consider the possibility of change

Assess readiness for change

Increase the pt’s awareness of the problem and it’s risks

**Offer (not impose) a neutral exchange of information

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87
Q

If stage: contemplation

A

Understand the pt’s ambivalence

Encourage change

Build confidence

Gain commitment to change

**Offer opportunity to discuss pros and cons of change using reflective listening

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88
Q

Preparation stage of change

A 
Explore options
Choose the course most appropriate to pt
Identify high-risk situations
Develop strategies to prevent relapse
Continue to strengthen commitment and confidence

** offer realistic options for change and opportunity to discuss inevitable difficulties

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89
Q

Pt in action stage

A

Help pt design rewards for success
Develop strategies to prevent relapse
Support/reinforce convictions towards long-term change

  • *offer reinforcement
  • *explore ways of coping with obstacles
  • *encoirage sdlf-rewards
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90
Q

Pt in maintenance

A

Help pt maintain motivation
Review identified high risk situations and strategies for preventing relapse

**discuss progress, discuss signs of impending relapse

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91
Q

Pt in relapse stage

A

Help pt view relapse as a learning experience
Support appropriate to present level of readiness

  • *offer non-judgmental discussion about cicumstance surrounding relapse and how to avoid relapse in the future
  • *reassess pt’s readiness to change
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92
Q

Serving size for: meat, fish, poultry

A

Palm of hand

3 oz

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93
Q

Serving size for: milk/ yogurt

A

1 cup

Size of fist

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94
Q

Serving size for: bread/ grains

A

One slice

Palm of hand

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95
Q

Serving size for: rice/ pasta

A

1/2 cup

One hand cupped

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96
Q

Serving size for: fruit/ vegetable

A

1 cup

Two cupped hands

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97
Q

Serving size for cheese

A

1 oz

Full length of thumb

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98
Q

Oil/butter

A

1 tsp

Tip of thumb

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99
Q

Serving size for: nuts/chips/snacks

A

Palm covered

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100
Q

Energy content of food

A

Carb: 4 kcal/g
Protein: 4 kcal/g
Fat: 9 kcal/g
Ethanol: 7 kcal/g

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101
Q

Total daily energy expenditure

A

35 kcal/kg/d
Women:2000-2100
Men:2700–2900

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102
Q

Cancers prevented by vitD

A

CRC
Breast
Prostate

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103
Q

VitD recommended suppl

A

1000 IU/d during fall and winter
1000 IU/d all year round if: older, dark skin, do not go outside often, covering clothing

Exclusively breast-fed babies: 400 IU/d

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104
Q

Daily fat intake

A

26-27% of total energy
Saturated fat: 5-6 %
Trans fat: reduce intake, replace with MUFA, PUFA

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105
Q

Daily protein intake

A

15-18% of total energy

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106
Q

Daily carb

A

55-59%

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107
Q

Effect of controlled fat/carb/pro intake on lab

A

Lower LDL

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108
Q

Omega3 fatty acid rich food

A

2 or more servings of fish/wk esp oily like salmon

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109
Q

Effect of omega 3

A

Lower TG

Decreased sudden death/ CAD death

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110
Q

Daily salt intake

A

2400 mg/d or less

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111
Q

Effect of lowering salt

A

Lower BP

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112
Q

Alcohol intake

A

3 drinks or less for men (max 15/wk)

2 drinks or less for women (max10)

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113
Q

Effect of decreasing alcohol intake

A

Decreased hyper TG
Decreased HTN
decreased osteoporosis
Decreased certain cancers

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114
Q

DASH diet effect

A

Lower BP

Lower LDL

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115
Q

DASH diet:

A

High: vegetables/fruits, low-fat dairy, whole grains, poultry, fish, nuts
Low in: sweets, sugar sweetened beverages, red meats
Low in: saturated/total fat, cholestrol
High in: K, Mg, Ca, Pro, fibre

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116
Q

Daily vit D requirement

A

<50: 800-1000 IU

50 or higher: 800-2000

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117
Q

Daily Ca requirement

A

<50, pregnant, lactating: 1000

>50, 1200/d

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118
Q

Reduction of daily caloric intake for loosing weight:

A

500-1000 kcal/d

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119
Q

Energy expended/Wt lost per each pound of fat burn

A

3500 kcal

1-2 pound (0.5-1kg) weight

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120
Q

At which BMI, waste circumference increases the risk of DM/CVD

A

25-35

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121
Q

Normal BMI range

A

18.5-24.9

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122
Q

Duration of efficacious behavioural interventions in Wt reduction

A

> 12 mo

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123
Q

BMI at which behavioural and lifestyle changes should be offered

A

> 25

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124
Q

Candidate BMI for bariatric surgery (failing behavioural modification)

A

BMI >35 + RFs
Or
BMI >40

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125
Q

Amount of Wt reduction which is clinically significant for reducing cardiovascular risk factors

A

> 5%

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126
Q

Pharmacologic therapy for obesity

A 
Orlistat
No longer tgan: 2y
Contra: IBD, Chronic bowel disease
Adjunct to LSM
Start if pt has not lost 0.5-1 kg/wk by 3-6 mo after LSM
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127
Q

Increased waist circumference:

A

Men: 102 or more
Women: 88 or more

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128
Q

When to measure waist circumference?

A

If BMI>25

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129
Q

If BMI>25 or WC>cutoff point, next step?

A

BP
PR
FBG
Lipids: total Cholestrol, TG, LDL, HDL, total chol/HDL ratio
Assess and screen for: depression/ mood disorders/ eating disorders

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130
Q

Mx of BMI>25 Or WC> cutoff

A

Treat comorbidities, health risks

Assess readiness to change behaviour/ barriers to wt loss

Then: devise goals, LSM program for wt loss, reduction of RFs

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131
Q

Wt loss goal

A

5-10% of body weight
Or
0.5-1 kg (1-2 lb)/wk for 6 mo

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132
Q

LSM program for wt reduction

A 
Nutrition: reduce 500-1000 kcal/d
Physical activity: 
•initially: 30 min, moderate, 3-5 times/wk
•Eventually >60 min, on most days
• add endurance exercise
CBT
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133
Q

If goal achieved with LSM

A

Regular monitoring
Assist with wt maintenance/ prevention of wt regain
Reinforce healthy eating/ physical activity advice
CBT
Address other RFs
Periodic monitoring of weight/BMI/WC q 1-2 y

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134
Q

If goal not achieved with LSM

A

If BMI 40 or higher, Bariatric surgery
If BMI 35 or higher + RFs, Bariatric surgery
If BMI 30 or higher, pharmacotherapy
If BMI 27 or higher + risk factors, pharmacotherapy

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135
Q

Hyperlipidemia screen

A 
q1-3 y
Males> 40yr
Females> 50 or menopausal
At any age if
•first nations/ south asians
•current cigarette smoking
•diabetes
•HTN
•FHx of premature CVD
•FHx of hyperlipidemia
•erectal dysfunction
•CKD
•inflammatory disease
•HIV
•COPD
•clinical atherosclerosis, abdominal aneurism
•clinical manifestation of hyperlipidemia
•BMI>27
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136
Q

Variation of fasting vs non-fastin lipids

A

TC: 2%
Non-HDL: 2%
LDL: 10%
TG: 20%

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137
Q

LDL cannot be calculated ic TG:

A

4.5 or more

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138
Q

Statins and DM

A

Slightly increases DM risk

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139
Q

Mx of detected hyperlipidemia

A

Mx of hyperlipidemia

  1. Search for 2° causes: hypothyroidism, CKD, DM, nephrotic, liver disease
  2. FRS
  3. Search for statin-indicated conditions
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140
Q

Statin-indicated conditions

A 
LDL: 5 or higher
Genetic dyslipidemia
Clinical atherosclerosis
Abdominal aortic aneurism
Chronic kidney disease
DM with:
•Age 40 or more
•Age 30 or more + 15 y duration
•Microvascular disease
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141
Q

Risk classification of hyperlipidemia

A

Low risk: FRS<10%

High risk: FRS>20%

Intermediate risk: FRS 10-19% +
•LDL-C: 3.5 or more
•Non-HDL: 4.3 or more
•ApoB: 1.2 or more
Men 50 or more/ women 60 or more with
▪low HDL-C
▪ IFG
▪high waist circumference
▪smoker
▪HTN
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142
Q

Hyperlipidemia Tx

1st step

A

For all:
Smoking cessation
Diet
Exercise: 150 min/wk, moderate-vigorous aerobics

For all (except low risks)
\+ Statin
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143
Q

Targets of hyperlipidemia Tx

A

LDL <2
LDL >50% reduction
apoB <0.8
non-HDL-C <2.6

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144
Q

If lipid target not achieved on maximally tolerated dose?

A

Discuss risk/cost/benefit of add-on with pt
1st line: Ezetimibe
Alternative: BAS

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145
Q

If target achieved

A

Monitor response and health behaviour

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146
Q

Repeating screen based on FRS

A

FRS <5% , q 5 y

FRS 5% or more, every year

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147
Q

Impact of health behavior on LDL reduction

A

Up to 10%

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148
Q

The most important health behaviour for prevention of CAD

A

Smoking cessation

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149
Q

Time of initiation of drug therapy for hyperlipidemia

A

After 3 mo of LSM

For high risk pt immediately with LSM

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150
Q

Effect of pharmacologic therapy on LDL

A

By 40%

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151
Q

Effect of pharmacologic therapy on LDL

A

By 40%

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152
Q

If severe side effects with statins

A

Ezetimibe (cholestrol absorption inhibitor)

19% reduction in LDL

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153
Q

Hyperlipidemia Tx monitoring

A

ALT, CK, Cr: at baseline and after 6wk

If adequate response, fasting lipids q6-12 mo

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154
Q

Tolerable CK rise

A

Up to 10 times upper limit of normal

Up to 2-3 times if symptomatic

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155
Q

Hyper TG principal Tx

A

LSM: Wt loss, exercise, avoidance of smoking/alcohol, DM control, intake omega3

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156
Q

TG level associated with pancreatitis

A

> 10
Tx: nicotinic acid
Fibrate

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157
Q

Metabolic syndrome definition

A 
Central Obesity (men> or 94, women> or 80)
\+ 2 OF
• TG > 150
• HDL <40 in men, <50 in women
BP 130/85 or mor
FPG 100 or higher
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158
Q

Screen time in infants

A

None

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159
Q

Screen time in toddlers, preschool

A

1 h/d

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160
Q

Screen time 5-17 y

A

Creational: 2h/d

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161
Q

Physical activity for adults

A 
150 min/wk
Mod-vig
Aerobic
Bouts of 10 min or more
Muscle/bone strengthening at least x2/ wk
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162
Q

Daily activity Mx

A

Assess current level of fitness/ motivation
Assess access to exercise
Encourage warm up/ cool down
Caution if: CAD/DM/Exercise induced asthma
Prior cardiac assessment for CAD

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163
Q

The most preventable cause of premature illness/death

164
Q

Mx of cigarette smoking

A

Approach depends on pt’s stage of change
5 As
*Ask if the pt smokes (elicit smoking habits/previous quit attempts), consider current stage of change
*Advise clearly to quit
*Assess willingness to quit
*Assist in quit attempt (STAR): set date, tell family/friend/ anticipate challenges (withdrawal), remove tobacco-related products
*Arrange F/U

165
Q

CAN-ADAPTT 2012

A

Update tobacco use status regularly for every pt
Clearly advise to quit
Monitor mental health status/other addictions while quitting smoking
Monitor/adjust medication dosage

166
Q

Most effective smoking cessation method

A

Consultation + medication

167
Q

If willing to quit smoking

A

Provision of: social support, community sources
Counselling sessions: at least 4 sessions, more than 10 min each, 6-12 mo follow up
Pharmacologic Tx:
• NRT
• Antidepressants: Bupropion
• Varenicline (partial nicotine agonist/antagonist)

168
Q

Effectiveness of different pharmacologic treatments for smoking cessation

A

NRT=bupropion
Varenicline > bupropion
More adverse effects for varenicline

169
Q

Smoking cessation in pregnancy

A

1st line: consultation
If not enough: NRT (better intermittent)
Bupropion if benefits> risks

170
Q

The 2-3 pattern of smoking cessation

A 
Onset of withdrawal in 2-3 h
Peak withdrawal in 2-3 d
Improvement of withdrawal in 2-3 wk
Resolution if withdrawal in 2-3 mo
Highest relapse rate within 2-3 mo
171
Q

If unwilling to quit

A

Motivational interview:

  • Relevance to pt (health concerns, family/social concerns)
  • Risks of smoking
  • Rewards
  • Roadblocks (fear of withdrawal/ wt gain/ failure, lack of support
  • Repetition
172
Q

Assessments for alcohol dependence

A
  • CAGE to screen for dependence
  • screen for other drugs use
  • identify medical/physical complications
  • ask about drinking and driving
  • screen for spouse/child abuse
  • ask about past recovery attempts
  • current readiness for change
173
Q

Alcohol dependence inv

A

CBC
ALT, AST, GGT
(GGT & MCV used for baseline/follow up)

174
Q

Alcohol dependence Mx

A 
Consistent with pt's motivation for change
Counselling
Follow up
Alcoholic anonymous/ 12 step program
In-pt program
Pharmacologic
Family Tx
175
Q

Indication of alcoholic anonymous program

A

Chronic/resistant problem
Out patient
Day program

176
Q

Indications for in-patient program

A

Dangerous/ unstable home environment
Severe medical/psychiatric problem
Addiction to drug requiring in-pt detox
Refractory

177
Q

First choice imaging for renal stone

A

Non-contrast helical CT

178
Q

Abdominal pain red flags

A 
Severe pain
Signs of shock
Peritoneal signs
Distention
Pain out of proportion to clinical findings
Elderly: new onset pain, change in pain, altered bowel habits
Wt loss
Anemia
Supraclavicular nodes
FHx of serious bowel disease
179
Q

When to maintain a high index of suspicion for AAA

180
Q

Associations of allergic rhinitis

A

Asthma
Eczama
Sinositis
Otitis media

181
Q

Mx of allergic rhinitis

A

Minimize exposure
Maintain hygiene
Saline nasal rinses
Oral antihistamines (1st line for mild symptoms)
Intranasal CS (mod-sev, >1mo use to see results)
Intranasal decongestants (<5d)
Allergy skin test (if chronic, not controlled by above measures)
Immunotherapy (if severe, unresponsive, weekly SC injection of solutions)

182
Q

Screening anxiety

A

To you tend to be an anxious or nervous person?
Have you felt unusually worried about things recently?
Has this worrying affected your life? How?

183
Q

Mx of anxiety disorders

A 
Emphasize prevalence, good recovery rate
Decrease caffeine, alcohol 
Exercise
Relaxation techniques, mindfulness strategies
Self-help material, community resources
CBT
Tx underlying medical/comorbid conditions
Support to family and caregivers
Pharmaco
184
Q

Age of PFT

185
Q

Asthma Mx

A

Ongoing education, environmental control, SABA + maintenance meds

Maintenance:

1: low-dose ICS
2: med-high dose ICS or + LABA or + LT modifier or + long-acting theophylline
3: med-high dose ICS + LABA/ LT modifier/ long-acting theophylline
4: 3+ immunotherapy/ oral CS

Pneumococcal vaccine
Influenza vaccine

186
Q

COPD Mx

A 
* Mild: 
1-SABA
2-SABA + LAAC/LABA
* Moderate:
3-SABA+ LAAC + ICS/LABA (consider oral CS)
* Severe:
4-SABA+ LAAC + ICS/LABA + Theophylline

Pneumococcal vaccine
Influenza vaccine

187
Q

Lyte abnormality with salbutamol

A

Hypokalemia

188
Q

BPH investigations

A 
U/A
PSA
BUN, Cr
U/S for PVR volume, renal
Pt voiding diary
189
Q

PSA testing inappropriate if

A

Life expectancy < 10y
Prostatitis
UTI

190
Q

PSA results

A

<4: normal
4-10: measure free and total PSA
>10: high likelihood of pathology

191
Q

Men with whom we discuss PSA testing

A

Positive FHx of prostate cancer
African ancestry
Men who are concerned about development of prostate cancer

192
Q

If deciding to test PSA in an asymptomatic man

A

Discuss the risks and possible benefits

193
Q

Tests not recommended as primary evaluation for BPH

A 
Urodynamic studies
Prostate U/S or Bx
Cystoscopy
Cytology
IVP
194
Q

BPH Mx

A

If mod-sev: refer
If mild, or mod-sev but non-bothersome:
*fluid restriction
*avoid alcohol and caffeine
*avoid/ monitor: antihistamines, decongestants, antidepressants, diuretics
*pelvic floor/ kegel exercise
*bladder retraining (scheduled voiding)
*Pharmaco (for mod/sev):
• a-receptor antagonists
• 5 a-reductase inhibitor (only if enlarged prostate)
• phytotherapy: saw palmetto, pygeum africanum

195
Q

Acute bronchitis inv

A

Clinical Dx
CXR if suspect pneumonia
PFT + methacholine challenge if suspect asthma

196
Q

Mx of acute bronchitis

A

1° prevention: frequent hand washing, smoking cessation, avoid irritant exposure

Symptomatic relief: rest, fluid, humidity, analgesics, antitussives

AB if: elderly, comorbidities, suspected pneumonia, toxic pt

197
Q

Characteristics in favour of bacterial over viral

A

High fever
Excessive amount of purulent sputum
Associated with COPD

198
Q

Chest wall pain Dx

A 
At least 2 of:
Muscle tension present
Absence of cough
Reproducibility by palpitation
Stinging nature
199
Q

Triad of pericarditis

A

Pleuretic chest pain
Friction rub
ECG: diffuse ST elevation, PR depression, No T inversion.

200
Q

Chest pain inv:

A

CXR
ECG
other tests if indicated
Refer to ED if suspect serious etiology

201
Q

Mx of angina/IHD

A

NTG spray q 5 min

No response after 3 doses, refer to ED

202
Q

MI Mx

A 
ASA
Clopidogrel
LMWH
Morphine
O2
NTG
Fibrinolysis (ideally in< 30 min. Up to 12h)
PCI (if <90 min)
203
Q

Common cold Mx

A

Education:
peak at 1-3 d, subside within 1 wk
Cough may persist for days to weeks
2° bacterial infection can present within 3-10 d

Prevention:
Frequent hand washing, avoid hand to mucous membrane contact, surface disinfectants, yearly flu vaccine

Symptomatic relief:
Rest, hydration, gargling warm salt water, steam, nasal irrigation, analgesics, antipyretics, antitussives, decongestants, antihistamines

Increase use of bronchodilators/ ICS if reactive airway diseas

204
Q

Cough medications not for:

A

Children under 6

205
Q

MI in elderly women

A

Dizziness
Back pain
Lightheadedness
Weakness

206
Q

MI in DM

A

Dyspnea
Syncope
Fatigue

207
Q

Flu vs cold

A 
In flu:
Sudden onset
High fever
Severe dry cough
Fine throat
Dry and clear nose
Severe exhaustion
Head ache
Muscle ache
Chills 
Decreased appetite
208
Q

Pregnancy test after EPC

A

Within 21d if no bleeding

209
Q

OTC EPC

210
Q

Chronic cough definition

211
Q

Cough inv

A

Guided by clinical findings

212
Q

Best screening test for dementia

213
Q

Denentia type in which depression is most common

A

Vascular and mixed

214
Q

Most common causes of chronic cough

A

Post-nasal discharge
GERD
Asthma
Non-asthmatic eosinophilic bronchitis

215
Q

Dementia quick screen

A

Mini cog + Animal testing

Further evaluation if:
<15 animals in 1 min
0-1 words recalled
Abnormal clock drawing

216
Q

Screening for depression

A

Are you depressed?
Have you lost interest/pleasure in the things you usually like to do?
Do you have problems sleeping?

217
Q

Depression lab

A

CBC, Lytes, TSH, ferritin, B12, folate, FBG, U/A

218
Q

Phases of depression Tx

A 
Acute phase (8-12 wk)
Maintenance phase (6-12 mo)

Continue treatment for at least: 6 mo

Reassess/referral if: no improvement after 6-8 wk

219
Q

Mild depression in youth (10-21 y)

A

A period of active support and monitoring beford initiating Tx

220
Q

Depression Tx

A

Mild: CBT, IPT

Mod-sev: psychotherapy + medication

221
Q

Youth with mod-sev depression

A

Referral if: psychosis, substance abuse

222
Q

Bupropion chosen for:

A

Lack of sexual side effects

223
Q

Vitamine deficiencies causing depression

224
Q

Screening of DM

A

Start at age 40 q 3y

More frequent Nd/or earlier if RF

225
Q

DM goal

A1c

226
Q

DM goal

BP

227
Q

DM goal

LDL

228
Q

DM SMART goals

A

A1c, BP, LDL, exercise, eating, smoking cessation,

ACE/ARB, statin, ASA

229
Q

DM diet

A

All should see a dietician
Moderate wt loss (5%)
Saturated fat+ trans fatty acids < 10% of calories
Avoid simple sugar
Low glycemic index foods
Regularity in timing and spacing of meals

230
Q

DM physical activity

A

At least 150 min/ wk, aerobic

+ 2 sessions strength exercise /wk

231
Q

Self monitoring of BG

A

Type 1: 3 or more/d
Type 2: vary. If insulin treated, more frequent
If FBG > 14: ketone testing
If bedtime level <7: have bedtime snack

232
Q

Mx of DM2 with symptomatic hyperglycemia with metabolic decompensation

A

LSM
+ Insulin
+/- metformin

233
Q

Mx of DM2 with A1c > 8.5%

A

LSM
+ Metformin
+/- another antihyperglycemic

234
Q

Mx of DM2 with A1c < 8.5

A

LSM +/- Metformin

If not at glycemic target within 2-3 mo, start/increase metformin

235
Q

If any of the previous not at glycemic target

A

Add another agent

236
Q

For DM with cardiovascular disease

A

SGLT2 inh

Ending with -gliflozin

237
Q

Insuline secretagogues

A

Meglitinide ( ending in -glinide)

Sulfonylurea

238
Q

OHA with genital infection

239
Q

DM medications increasing wt

A

Insulit
Insulin secretagogues
Thiazolidinediones

240
Q

DM drug causing CHF

A

Thiazolidi…

Saxagliptin (incretin)

241
Q

DM drug causing UTI

242
Q

Attain target A1c within

243
Q

Sulfonylurea with most hypoglycemic effect

244
Q

Caution in RF with use of

245
Q

Advantage of meglitinide

A

Less hypoglycemia if missed meals

246
Q

Indication of ACE/ARB on DM

A

If:
Clinical macrovascular disease
Age 55 or higher
Age<55 + microvascular

247
Q

Indication of statin in DM

A

Age 40 or higher
Age 30-40 and duration>15 y
Microvascular
Other cardiovascular RFs

248
Q

Indication of ASA

A

If established CVD

249
Q

Vestibular vertigo symptoms

A

Worse with eye closure

Worse with head movement

250
Q

Vertigo (vertiginous) sign/symp

A

External world seems to revolve

Individual revolves in space

251
Q

Ototoxic meds

A

Aminoglycosides
Erythro
ASA
Antimalarials

252
Q

Inv in syncopal vertigo

A 
Cardiac
PVD
Neurologic exam
Blood work
ECG, 24h holter, treadmill stress test, loop ECG, tilt table testing, carotid/vertebral doppler, EEG
253
Q

Vertiginous vertigo test

A 
ENT exam
Neurologic exam
Dix-Hallpike
Audiometry
MRI
254
Q

Non-syncopal, non-vertiginous

A 
Neurologic
Cardiac
3 min hyperventilation trial
ECG, EEG
Romberg test
255
Q

Tx of vertigo

A 
Education
LSM
Physical maneuvers 
Symptomatic Mx
Pharmacotherapy
Surgery
256
Q

When to refer vertigo

A

When significant central disease suspected
When persistent peripheral (>2-4 wk)
Atypical presentation

257
Q

Ask in all psychologic interviews

A 
Suicide/homicide
Abuse/violence
Substance
Anxiety/depression/mania screen
Psychosis
Bereavement
GMC
Pregnancy
258
Q

Domestic violence Mx

A

*Screen ALL pts
Determine the victim’s level of immediate/long-term danger
Ask about weapons in the house
*Ensure pt safety
Most at risk when attempting to leave home, following separation
*provide community resources
Access to exit, safe place to go, having money, clothes, keys, medications, important documents, emergency items, shelter, helpline, involve social worker, domestic violence advocates
*F/U
*reassure pt they’re not to blame, assault is crime
*document all evidence of abuse-related visits
*spousal abuse is not reportable without pt’s concent

259
Q

Screenimg for domestic violence

A
  • In general how would you describe your relationship (tension)
  • How do you work out your arguments? (Difficulty level)
  • Hits:
    How often does your partner physically hurt you? Insult you? Threaten you with harm? Scream or curse at you?
260
Q

Red flags of dyspepsia

A 
Wt loss
Dysphagia
Persistent vomiting
GI bleeding
Onset>50
261
Q

New onset dyspepsia Mx

A

UBT/Serology for H-pylori
Upper endoscopy/ upper GI series (not if alarm signs)
LSM: decrease caffeine, decrease alcohol, avoid citrus, avoid supine after meals, smoking cessation
H2blocker, PPI (PUD, GERD)
Prokinetics ( if functional)
H-pylori eradication
Gasteroscopy for non-responders

262
Q

How long keep pt on PPI

A

At least 1 trial off the medication per year

263
Q

H-pylori eradication

A 
10 d Tx:
PPI bid x 10d
Amoxicillin 1g bid (day 1-5)
Metronidazole 500 bid (day 6-10)
Clarithromycin 500 bid (day 6-10)
264
Q

Dyspnea Mx

A 
CXR
ECG
PFT
ABG (acute)
ABC
ED if severe respiratory distress
265
Q

Dx of UTI

A

2 of: Dysuria, leukocytes, nitrites
Or
Culture

266
Q

Dysuria inv

A

Not needed if Hx/PEx consistent with uncomplicated UTI, treat empirically

U/A when indicated
Dip stick, R&M, C&S

CBC, diff

If discharge, wet mount, KOH test, Gram, vaginal pH, yeast/trichomonas culture, endocervical/urethral swab or urine PCR for gono/chla

Other tests if atypical presentation

267
Q

UTI in pregnancy

A

Treat if bacteriuria

Then monthly culture

268
Q

Indication of prophylactic AB

A

Recurrent (>3/y)

269
Q

Tx of complicated UTI

A

Longer course

Broad spectrum

270
Q

Tx of urethritis

A

All have to return 4-7d after completion of therapy for clinincal evaluation

271
Q

Prevention of UTI

A

Good hydration
Cranberry juice
Wipe urethra from front to back
Avoid feminine hygiene sprays/scented douche
Empty bladder immediately before and after intercourse

272
Q

Duration of erectile problem to Dx erectile dysfunction

273
Q

The most common cause of erectile dysfunction

274
Q

Inv for erectile dysfunction

A 
HPG Axis: LH, Testosterone, PRL
RFs: FPG, HbA1c, lipid profile
TSH, CBC, U/A
\+/-  :
Psychological/psychiatric consultation 
In-depth psychosexual/relationship evaluation
Nocturnal penile tumescence and rigidity
Doppler, angiography
275
Q

When to refer erectile dysfunction

A

Significant penile anatomic disease
Younger with Hx of pelvic/PERINEAL trauma
Requiring vascular/ neurosurgical intervention
Complicated endocrinopathy
Complicated psychiatric/psychosocial problems
Pt/physician desire for more evaluation

276
Q

Erectile dysfunction Mx

A

LSM: reduce alcohol, reduce smoking, exercise, relationship/sexual counselling, vacuum devices

Pharmacologic: PDE5-inh, a-blocker(yuhimbine), trazodone, testosterone (only if deficiency)

277
Q

Fatigue inv

A

Based on Hx, PEx

Beta, CBC, diff, ESR, lytes, Ca, P, FPG, BUN, Cr, AST, ALT, ALP, Bil, Ferritin, B12, TSH, SPEP, Bence-Jones pro, Alb, ANA, U/A, CXR, ECG,

Lyme, HBV, HCV, HIV, PPD

278
Q

Fatigue red flags

A 
Wt loss
Fever
Night sweats
Neurological deficits
Ill apearing
279
Q

Mx of fatigue without etiology found

A 
Reassurance
Quick F/U
Counselling, behavioural therapy, group therapy
Encourage to stay physically active
Review meds
280
Q

Tx of chronic fatigue syndrome

A 
Sleep hygiene
Support/reassurance that most pts improve
Regular physical activity
Optimal diet
CBT, family therapy, support groups
Antidepressants 
Anxiolytics
NSAIDs
Animicrobials
Allergy therapy
Anti hypotensive therapy
281
Q

Unrefreshing sleep

A

Chronic fatigue disorder

282
Q

Physical symptoms in chronic fatigue disorder

A 
Sore throat 
Headache
Joint pain
Muscle pain
Tender cervical/axillary lymph nodes
283
Q

Fever definition

A

Oral
T> 37.2 AM
T>37.7 PM

Rectal (<2 yr)

TM not accurate until >5y

284
Q

Fever inv

A

CBC, diff, B/C, Urine SandC,R&M,
Stool OandP, gram, culture
CXR, Mantoux, sputum culture
LP

285
Q

Caffein withdrawal headache

A 
How much caffeine? 2.5 cup/d
Onset: 12-24 h
Lasts: about a week
Quality: severe, throbbing, 
Associated symptomes: waves of hot/cold sensation, anxiery, muscle stiffness, nausea, drowsiness
286
Q

Tx of caffeine withdrawal headache

A

Acetaminophen/ASA +/- Caffeine

Caffeine

287
Q

Proportion of aura in migrain

288
Q

Headache with photo/phonophobia

289
Q

Headache aggrevated by physical activity

290
Q

Tx of acute migraine

A

1st line: Acetaminophen, NSAIDs, ASA, +/- caffeine

2nd line: NSAIDs

3rd line: 5-HT agonists +/- antiemetics

291
Q

Migraine prophylaxis

A

1st line: BB
2nd line: TCA
3rd line: AED

292
Q

Band-like pain

A

Tension headache

293
Q

Contracted neck/scalp muscles

A

Tension headache

294
Q

Acute tension headache Tx

A

Rest, relaxation
NSAIDs
Acetaminophen

295
Q

Prophylaxis for tension headache

A

Rest, relaxation
Physical activity
Biofeedback

296
Q

Headache which awakens pt

297
Q

Headache with conjunctival injection, tearing

298
Q

Suicide headache

299
Q

Trigger of cluster headache

300
Q

Cluster headache Tx (Acute)

A

Sumatriptan
Dihydroergotamine
High flow O2
Intranasal lidocaine

301
Q

Headache red flags

A 
Fever
Anticoagulation
Pregnancy
Cancer
Impaired mental status
Neck stiffness
Seizures
Focal neurological deficits
Sudden and severe onset
New headache after 50
Following head trauma
Awakens pt
Jaw claudication
Scalp tenderness
Worse with exercise/sexual activity/valsalva
Different pattern
Rapidly progressing in severity/frequency
302
Q

Headache inv

A 
Only if red flags present
CBC
ESR (if suspected temporal arteritis)
CT/MRI
CSF analysis
303
Q

Hearing loss assessment

A 
Universally for newborn babies 
Elderly: 
Whispered voice test (6 words, 2 feet away, non-test ear distraction)
Tuning fork test (not for screening)
Formal audiogram assessment
304
Q

Mx of hearing impairment

A

Counselling: noise control, hearing protection

Referral: for complete audiological exam, ENT if unknown etioligy, ENT if sudden SNHL (with high dose oral CS)

If unexplained hearing loss: FBG, CBC, diff, TSH, syphilis
If progressive, asymmetric: MRI/ CT

Hearing amplification
Assisstive listening devices
Cochlear implants

305
Q

Elderly who indicate they have no hearing problem

A

Screen with whispered voice test

If unable to perceive, audiometry

306
Q

Elderly who acknowledge a hearing impairment

A

Audiometry

307
Q

HTN in 80yo and older

308
Q

Urgent HTN

A

SBP>210, DBP>120

No/minimal target organ damage

309
Q

Accelerated HTN

A

Recent increase
+ evidence of vascular damage on fundoscopy

Emergent

310
Q

Severe HTN

A

DBP > 120
+ Acute target organ damage

Emergent

311
Q

Malignant HTN

A

+ papilledema

+ other manifestations of vascular damage

312
Q

Inv for all pts with HTN

A 
Lytes, Cr, 
FBG/A1c
Lipids
12 lead ECG
U/A
313
Q

If HTN + DM or CKD

A

Urinary protein excretion

314
Q

If suspected renovascular HTN

A

Renal U/S
Captopril renal scan (if GFR > 60)
MRA/CTA (If normal renal function)

315
Q

Renovascular HTN with ACEI/ARB

A

Rise in Cr of 30% or more

316
Q

If profound hypokalemia with diuretics

A

Suspect hyperaldosteronism

317
Q

Hypertensive emergencies

A 
Papilledema
Hypertensive encephalopathy 
Intracerebral hemorrhage
SAH
Stroke
Aortic dissection
LV failure
MI/ischemia 
Acute pulmonary edema
Renal failure
318
Q

If suspected endocrine cause

A

Plasma aldosterone, plasma renin, ARR

319
Q

If suspected pheo in HTN

A

24 h urine metanephrine and creatinine

320
Q

HTN screen

A

BP assessed for all adults at all appropriate clinical visits

321
Q

HTN visit 1

A

Dx if 180/110 or higher

If > 140/90 (office) or > 135/85 (automated), out of office assessment

322
Q

Out of office assessment after visit 1:

A

If daytime ambulatory/home > 135/85
Or
24h ambulatory > 130/80

Dx is HTN in visit 2

If not, repeat ambulatory/home to confirm

323
Q

Alternative to out of office assessment:

A

Visit2: if > 140/90, proceed to visit 3

Visit3: if sBP>160, dBP>100, Dx: HTN
If not, proceed to visits 4-5

Visit4-5: if sBP > 140, dBP > 90, Dx: HTN
if not, No HTN

324
Q

LSM in HTN Mx

A 
May be sufficient for stage1 (<160/100)
DASH diet
Limit daily Na to <5g
Increased dietary K
Moderate intensity exercise: 30-60 min, 4-7 x/wk
Smoking cessation
Low-risk alcohol consumption
BMI 18.5-24.9
WC: m<102, w<88
CBT for stress management
325
Q

Indications of pharmacologic Tx for HTN

A

*dBP 100 and higher
*sBP 160
*dBP 90 and higher if: target organ damage, independent cardiovascular risk factors
sBP 140 or higher with target organ damage

326
Q

Pharmaci for HTN

A 
1st line: 
Thiazide/thiazide-like diuretics
ACEI (for non-African pts) 
ARB
Long-acting CCB
BB (if<60y)
327
Q

If partial response to 1st line monotherapy

A

If std dose, add another 1 st line

328
Q

Choice for isolated diastolic HTN

A 
Thiazide
BB
ACEI
ARB
CCB
\+/- ASA, statin
329
Q

Choice for isolated systolic HTN

A

Thiazide
ARB
CCB

330
Q

Choice for HTN in CAD

A

ACEI
ARB
BB (for stable angina)

331
Q

Choice for HTN in prior MI

A

BB and ACEI (or ARB)

332
Q

LV hypertrophy

A

ACEI
ARB
thiazide
CCB

333
Q

Cerebrovascular disease

A

ACEI + diuretics

334
Q

Choice for HTN in Heart failure

A

ACEI (ARB)
+BB
+Spironolactone (NYHA II-IV)

335
Q

HTN in DM with albuminuria

A

ACEI

diuretic

336
Q

HTN in DM without albuminuria

A

ACEI
ARB
CCB
thiazide

337
Q

Tx of HTN in renovascular disease

A

Same HTM without ither indications

Caution in using ACEI/ARB

338
Q

HTN in asthma

A

K sparing

+thiazide

339
Q

HTN in gout

A

Do not use thiazide

Ok with asymptomatic hyperuricemia

340
Q

HTN Tx in smokers

A

Low dose thiazide
ACEI
BB not recommended

341
Q

HTN in >60

A

BB not recommended

342
Q

Emergency Tx of HTN

A

Labetolol

Nifedipine

343
Q

F/U for HTN

A

LSM q 3-6 mo
Pharma q 1-2 mo until under target for 2 consecutive visits
More often if severe/ symptomatic…
q 3-6 mo once at target

344
Q

Refereal of HTN if

A

Refractory
Suspected secondary cause
Worsening renal failure

345
Q

Hospitalization for HTN if

A

Malignant HTN

346
Q

Inv for joint pain

A

Guided by Hx &PEx

CBC, diff, lytes, Cr, U/A
ESR, CRP, ferritin, fibrinogen, alb, C3, C4
ANA, anti-dsDNA, HLA-B27, anti-Jo-1, anti-sm, anti-La, anti-Ro, RF, anti-CCP
Synovial fluid analysis
Tissue culture
Plain film, CT, MTI, U/S, Bone densitometry, angiography, bone scan

347
Q

Tx of joint pain

A 
Education
LSM
physiotherapy, occupational therapy
Manage pain (acetaminophen, NSAIDS)
Treat specific causes
348
Q

Morning stiffness in inflammatory arthritis

349
Q

Low back pain timing

A

<6wk acute
6-12 wk subacute
>12 wk chronic

350
Q

Inv for low back pain

A

If infection/cancer suspected: CBC, ESR

if worsening neurologic deficit/suspect cancer/infection: CT/MRI

351
Q

Red flags in low back pain

A 
Bowel/bladder dysfunction
Saddle anaesthesia 
Constitutional symptoms 
Chronic disease
Paresthesia
Age >50 and mild trauma
First episode >50
IV drug use, 
Infection
Neuromotor deficits
Severe worsening pain (esp at night/lying down)
352
Q

Indications for lumbar xray

A 
No improvement after 6 wk
Fever>38
Unexplained wt loss
Prolonged CS use
Significant trauma
Progressive neurological deficit
Suspicion of ankylosing spondylitis
Hx of cancer
Alcohol/drug abuse
353
Q

L4 exam

A

Sens: medial malleolus
Motor: squat
Reflex: patellar
Test: femoral stretch test

354
Q

L5 exam

A

Sens: 1st dorsal web space
Motor: heel walking
Reflex: medial hamstring
Test: SLR

355
Q

S1 exam

A

Sense: lateral foot
Motor: toe walking
Reflex: achilles
Test: SLR

356
Q

Yellow flags of low back pain

A 
Belief that pain/activity is harmful
Sickness behaviour
Low/negative mood
Social withdrawal
Treatment expectations that do not fit best practice
Problem with claim and compensation 
Hx of back pain, time-off, other claims
Problem at work, poor job satisfaction 
Heavy work, shift work
Overprotective family, lack of support
357
Q

Mx of low back pain with red flags

358
Q

Mx of acute/subacute low back pain

A

*Educate (that resolves)
*Prescribe self-care strategies: alternating cold/heat, continuation of usual activities as tolerated
*Encourage early return to work
*Recommend physical activity and/or exercise
*Analgesics:
1st line: acetaminophen
2nd line: NSAIDs
Short course muscle relaxants
Short-acting opioids (if severe)

359
Q

Acute/subacute low back pain, not resolving within 6 wk

A

Physical therapist
Chiropractor
Osteopathic physician
Physician specialising in musculoskeletal medicine
If unresolving radicular symptoms: spinal surgeon
If not returning to work: multidisciplinary pain program
Indication lumbar xray

360
Q

Mx of chronic low back pain

A 
Physical or therapeutic exercise
Analgesic 
• Acetaminophen
• NSAIDs
• low dose TCA
• short term cyclobenzaprine fpr flare-up
Referral:
▪community-based rehabilitation program 
▪community-based self management, CBT
Progressive muscle relaxation 
Acupuncture
Massage therapy
TENS
Aqua therapy
Yoga

If mod-sev pain
Opioid
Referral
• chronic pain program
• epidural steroids (short-term relief of radicular pain)
• prolotherapy, facet joint injection, surgery

361
Q

Pattern 1 low back pain

A

Worse with flexion
Arising from intervertebral discs or adjacent ligaments
Neuroexam: normal

Tx: scheduled extension
Lumbar roll
Night lumbar roll
Medication

362
Q

Pattern 2 low back pain

A

Worse with extension
Never worse with flexion
Neuroexam: normal

Arising from posterior joint complex

Tx: scheduled flexion
Limited extension
Night lumbar roll
Medications

363
Q

Pattern 3 low back pain

A

Leg dominant
Pain changes with back movement/position
Constant (currently, previously)
Positive SLR

Pathology: sciatica

Tx: prone extension
Supine Z lie
Lumbar roll
Night lumbar roll
Medication
364
Q

Pattern 4 low back pain

A

Leg dominant
Worse with activity
Improves with rest
Neurologic claudication

Tx: abdominal exercise
Night lumbar roll
Sustained flexion
Pelvic tilt
Medication as required
365
Q

Mx of OA

A 
Education, 
Wt loss
Low impact exercise
Assisstive devices
Pharma:
1st line: Acetaminophen up to 4g/d
2nd line: NSAIDS+ gastreprotection
COX2 inhibitors (if long term Tx)
Combination analgesics 
Intraarticular Hyaluronic acid injection
Intra-articular CS (at most 3-4 x/y) 
Topical NSAIDS 
Capsaicin cream
Oral glucosamine
Surgery
366
Q

Basic bone health for individuals >50 y

A

Ca 1200g/d
Vit D 800-2000/d
Regular weight bearing exercise
Fall prevention

367
Q

Indications of BMD in <50 y

A 
Fragility fx
High-risk medication
Hypogonadism
Malabsorption syndromes
Chronic inflammatory conditions
Primary hyperparathytoidism
Disorders strongly associated with rapid bone loss:
-DM1
-Osteogenesis imperfecta
-Primary hyperpara
-Uncontrolled hyperthyroidism
-hypogonadism
-premature menopause <45y
-Cushing
-Chronic malnutrition/ malabsorption
-Chronic liver disease
-COPD
-Chronic inflammatory conditions
368
Q

Indications of bone scan in 50-64 yr

A

Fragility fx

Prolonged CS/ high-risk meds

Parental hip

Vertebral fx/ osteopenia on radiography

High alcohol intake

current smoking

Low body weight <60

Major wt loss

Diseases strongly associated with osteoporosis

369
Q

BMD indications for >65

370
Q

Next step after BMD testing

A

Assessment of 10 y fracture risk

371
Q

If risk < 10 %

A

No pharmacotherapy

Reassess in 5 yr

372
Q

If moderate risk of 10 y fx

A

Lateral thoracolumbar radiography
Or vertebral fx assessment to aid in decision-making

If:
Additional vertebral fx
Previous wrist fx in age>65/ T-score 2.5 or less
Lumbar spine Tscore &laquo_space;femoral neck Tscore
Rapid bone loss
Men undergoing androgen deprivation Tx
Women undergoing aromatase inhibitor Tx
Long-term/ repeated systemic CS
Recurrent falls (2 or more in the past 12 mo)
Other disorders strongly associated with osteoporosis, rapid bone loss, fx

Then: pharmacotherapy
Repeat BMD in 1-3 y and reassess risk

373
Q

Other indications of pharmacotherapy

A

10 yr risk of fx > 20%
Prior fragility fx of hip/spine
>1 fragility fx

374
Q

PEx for osteoporosis

A

Annual height (prospective loss > 2cm, historical loss>6cm)
Annual wt (>10 loss since age 25)
Rib to pelvic distance 2 fingers or less
Occiput to wall >5 cm
Fall risk: get up from chair without support with arms and walking several steps and return

375
Q

Investigations for osteoporosis

A 
CBC
Cr
Corrected Ca
ALP
TSH
25-OH-VitD (after 3-4 mo of adequate supplementation)
SPSP if vertebral fx
376
Q

STI inv

A

Individuals at risk (even if asymptomatic)
Chlamydia
Gonorrhea
HBV
HIV
syphilis
Pap test (if not performed in the preceding 12 mo)

377
Q

Primary prevention of STI

A

HBV vaccine
Gardasil
Discuss RFs
Always use condoms
Management of partner (contact tracing by public health)
Abstain from sexual activity until 7d after treatment completion for both partners or test of cure
Report all except TV

378
Q

STI detected in a child

A

Must evaluate sexual abuse

379
Q

Gono Dx in men

A

Urethral swab for gram and culture

+ pharyngeal / rectal swab if indicated

380
Q

Gono Dx in women

A

Urine PCR
Or
Endocervical swab for gram/culture

+ vaginal swab for wet mount to R/O TV
+ pharyngeal /rectal swab if indicated

381
Q

Tx of gono

A

Ceftroaxone 250 mg IM single dose

+ Tx of non-Gono

382
Q

F/U of gono:

A

Rescreen 6-12 mo post treatment

If: pregnant, pharyngeal/rectal infection, potentially reduced susceptibility:
Culture 4 d post treatment
Or
Urine PCR 2 wk post treatment

383
Q

Inv for non-gono(chlamydia) urethritis/cervicitis

A

Azithromycin 1g PO single dose
+ Tx of gono

Same F/U as gono

384
Q

Dx of genital HSV

A

Swab of vesicular content for culture

HSV1, HSV2 Serology (to Dx type, primary vs recurrent)

385
Q

Duration of Tx for primary HSV

386
Q

Duration of Tx of recurrent HSV

387
Q

Syphilis Dx

A

Specimen collection from 1° and 2° lesions
VDRL in high risk individuals
Universal screening of pregnant women

388
Q

Syphilis Tx

A

Benzathine penicillin G IM

Notify partner (last 3-12mo)

Continue testing until seronegative

389
Q

Acute sinusitis Mx

A 
Symptom relief: 
-oral analgesics (Acetaminophen, NSAIDs)
-Nasal saline rinse
-Short-term topical/oral decongestants 
NO ANTIHISTAMINES 
If mild-mod bacterial: intranasal CS
If severe bacterial: AB + intranasal CS

AB, 1st line: amoxicillin
2nd line: amoxicillin-clavulanic or quinolone

390
Q

Referral of sinusitis to ENT

A

If:

  • anatomic defect
  • failure of 2nd line
  • 4 episodes or more a year

Urgent referral (red flags) if:

  • orbital extension (swelling, change in visual acuity, EOM)
  • meningitis
  • intra-cranial abscess
  • venous sinus thrombosis
  • altered mental status
  • headache
  • systemic toxicity
  • neurological findings
391
Q

Dx of acute bacterial sinusitis

A
  • if symptoms of viral URTI persist, worsen, change
  • symptoms > 7d without improvement
  • worsening after 5-7 d (biphasic illness)
  • presense of purulence for 3-4 d with high fever

Symptoms:
*Nasal obstruction or nasal purulence/discolored PND
+ at least one of:
P: facial Pain/Pressure/Fullness
O: nasal Obstruction
D: nasal purulence/discolored post Nasal discharge
S: hyposmia/anosmia (smell)

392
Q

Mx of ABRS

A

Mild-mod: INCS
If no improvement after 72 h, add AB

Severe: INCS+ AB
If no response after 72 h, use 2nd line
If no response Fter 72 h, referral
If lasting >4 wk, chronic

393
Q

Indication of radiology in sinositis

A

Multiple recurrent episodes
Standard 3 view sinus xray
Or CT

394
Q

Insomnia inv

A 
Sleep diary for 2 wks
CBC, diff, TSH
refer for:
Sleep study
Nocturnal polysomnogram
Daytime multiple sleep latency test ( if suspicion of sleep apnea/ periodic leg movements of sleep)
395
Q

Tx of insomnia

A

Treat any suspected medical/psychiatric cause
Regular exercise (not within 3 h of bedtime)
1st line: CBT
-avoid alcohol/caffeine/nicotine
-comfortable sleep environment
-regular sleep schedule
-no napping
-relaxation therapy: deep breathing, meditation, biofeedback
-stimulus control therapy: re-association of bed/bedroom with sleep, re-establishment of a consistent sleep-wake schedule, reduce activities that cue staying awake
-sleep restriction therapy: total time in bed should closely match total sleep time
-address inappropriate beliefs and attitude
Pharmaco:(<7d)
Short-acting benzod, at lowest effective dose, <7 consecutive nights
Non benzod

If no improvement, referral to sleep medicine program

396
Q

Snoring inv:

A

Only if severe

Nocturnal polysomnography, CT/MRI

397
Q

Tx of snoring

A

Wt loss
Sleep on side
Nasal dilators

398
Q

OSApnea inv

A

BP
+/- TSH
nocturnal polysomnography

399
Q

Tx of OSA

A 
Wt loss
Avoid sleeping supine
Avoid alcohol, sedatives, opioids
If nasal swelling: inhaled CS
Dental apliances
Primary Tx: CPAP
400
Q

Pharyngitis inv:

A

Gold std in suspected GABHS: throat culture

Rapid test for strep Ag: low Sn

Suspected EBV: PBS, heterophil Ab test (latex agglutination test or monospot)

401
Q

Red flags in sore throat

A

Symptoms> 1wk without improvement
Respiratory difficulty
Difficulty in handling secretions (peritonsilar abcess)
Difficulty swallowing (ludwig)
Severe pain in the absence of erythema (supraglotitis, epiglotitis)
Palpable mass ( neopladm)
Blood in pharynx/ear (trauma)

402
Q

Approach to GABHS

A 
Cough absent +1
Hx of fever>38 +1
Swollen, tender anterior nodes +1
Tonsillar exudate +1
Age 3-14yo +1
Age>45yo -1

Scores:
0-1: no culture, no AB
2-3: culture, AB if culture +
4-5: culture+ AB, D/C AB if negative culture

403
Q

Tx of viral pharyngitis

A

Acetaminophen, NSAIDs, decongestants

EBV: Acetaminophen, NSAIDs, avoid heavy physical activity/contact sport for at least 1 mo, CS and ENT consult for acute airway obstruction

404
Q

Indication of F/U culture for GABHS

A

Hx of rheumatic fever
Family member with Hx if acute rheumatic fever
Suspected streptococcal carrier

405
Q

AB for GABHS pharyngitis

A

1st line in children: penicillin V PO x 10 d or amoxicillin
2nd line: erythromycin estolate x 10d
3rd line: cephalexin x 10d, cefprozil

Adults
1st line: penicillin V 300 PO tid x 10 d
2nd line: erythro
3rd line cephalexin

Med (25 decks)

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