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
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
3
Q
High risk women for NTD
A
Epilepsy Insulin dependent DM BMI>35 FHx of NTD High risk ethnicity
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
5
Q
If poor compliance, no birth control, taking teratogenic substance
A
5mg/d
Counselling about birth defects prevention
6
Q
Strength of recommendation for
Community fluoridation
A
A
7
Q
Dental brushing
A
A
8
Q
Flossing
A
A
9
Q
Noise control
Hearing prorection
A
A
10
Q
Nicotine replacement therapy
A
A
11
Q
Referral to smoking cessation program
A
B
12
Q
Dietary advice on leafy green vegetables
A
B
13
Q
Seat belt use
A
B
14
Q
Injury prevention (bicycle helmet, smoke detectors)
A
B
15
Q
Moderate physical activity
A
B
16
Q
Unexposure, protective clothing
A
B
17
Q
Problem drinking screen/counselling
A
B
18
Q
Counselling to protect against STI
A
B
19
Q
Nutritional counselling/dietary advice on fat/cholestrol
A
B
20
Q
Dietary advice on Ca/vit D requirements
A
B
21
Q
Blood pressure measurement
A
A
22
Q
BMI in obese adults
A
B
23
Q
Folic acid supplementation for women of child-bearing age
A
A
24
Q
Pharmacologic Tx of HTN
A
A
25
Varicella vaccine for age 1-12
And
Susceptible adolescents/adults
A
26
Rebella vaccine for all non-pregnant women of child-bearing age, unless proof of immunity
B
27
Tetanus vaccine, routine booster q 10 y after 1° series
A
28
Pertussis vaccine, one booster for adults<65 as Tdap
A
29
Home visit of children for high risk families
A
30
Inquiry into developmental milestone
B
31
Counsel on sexual activity and contraceptive methods
B
32
Counsel to prevent smoking cessation
B
33
Assess for RFs of osteoporosis/Fx in perimenopausal (>50) women
A
34
Counsel on osteoporosis,
| Counsel on risk/benefit of HRT
B
35
Follow-up on caregiver concern of cognitive impairment in adults>65
A
36
Multidisciplinary post-fall assessment
A
37
Repeated examination of eye, hearing, hip in pediatric, esp in 1st year
A
38
Serial height, weight, head circumference
B
39
Visual acuity testing after age 2
B
40
Visual acuity (snellen sight chart) after 65
B
41
Hearing assessment (inquiry, whispered voice test, audioscope)
B
42
Full body exam if 1st degree relative with melanoma
B
43
Routine Hb for high risk infants
B
44
Blood lead screening for high risk infants
B
45
Mantoux skin tesf for high risk groups
A
46
Voluntary HIV Ab screening for high risk group
A
47
Gonorrhea screening in STI high risk
A
48
Chlamydia screeninv in STI high risk group/women
B
49
Syphilis screen in STI high risk group
A
50
VDRL in syphilis risk group
A
51
Routine immunization in pediatrics
A
52
Outreach strategies for influenza vaccination in high risk group
A
53
Annual immunization with influenza vaccine
B
54
INH prophylaxis for TB household contacts/skin test converters
B
55
INH prophylaxis for high risk subgroups
B
56
Pneumococcal vaccine for high risk group
A
57
High risk group for pneumococcal vaccine
```
Immunocompromised
Age 65 or more
COPD
Asthma
CHF
Asplenia
Liver disease
Renal failure
DM
```
58
Average risk woman for breast cancer
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
59
Routine screen for breast cancer
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
60
Lung cancer screening guideline
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
61
Average risk individuals for CRC
```
Asymptomatic
No FHx (of UC, CRC, Polyps)
```
62
CRC screening for average risk
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
63
Asymptomatic with FHx of HNPCC
Genetic counselling
Begin: age 20/ 10 y younger than the earliest case in the family
Colonoscopy q 1-2 y
64
Asymptomatic with FHx of FAP
Age 10-12
Anually
Sigmoidoscopy
65
Asymptomatic with AAPC
Age 16-18
Anually
Colonoscopy
66
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
Colonoscopy every 5 y
| Begin at: age 40/10y younger than the earliest case
67
Asymptomatic with
One 1st degree with CRC/A-polyp at age >60
Or
Two or more 2nd degree with polyp/CRC
Average risk screening, but starting at 40
68
Asymptomatic with
One second degree relative
Or
Third degree relative
Average risk screening
| Beginning at 50
69
If polyp found at colonoscopy
| 1-2 tubular adenomas <1cm
Colonoscopy in 5 y
70
>2 adenomas
Colonoscopy in 3 yr
71
Incomplete examination at colonoscopy
Colonoscopy after a short interval
72
Numerous polyps at colonoscopy
Colonoscopy after a short interval
73
Advanced adenoma at colonoscopy
Colonoscopy at short interval
74
Malignant adenoma at colonoscopy
Colonoscopy after a short interval
75
Large sessile adenoma at colonoscopy
Colonoscopy after a short interval
76
Cervical cancer screening target population
All women age 25 or older (ontario: 21yo or olded if ssxual activity has started)
Interval: q 3y
Strongest recommendation:30-69
77
Discontinuation of cervical cancer screening:
Women >70 with:
| 3 normal tests in a row, and no abn tests in last 10 years
78
Cervical cancer screening for pregnant women
Follow the routine
79
Cervical cancer screen for women who have sdx with women
Follow the routine
80
Cervical cancer screening after total hysterectomy
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
81
Cedvical cancer screening for subtotal hysterectomy
Continue according to guidlines
82
If adequate sample on Pap, no TZ
Routine screen q 3y
83
The most effective preventive strategy
Health promotion
84
Effective way to promote healthy behavior changes:
Discussion appropriate to a pt's present stage of change
85
1st step in behavioral change
Consider pt's current stage of change
86
If stage: pre-contemplation
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
87
If stage: contemplation
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
88
Preparation stage of change
```
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
89
Pt in action stage
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
90
Pt in maintenance
Help pt maintain motivation
Review identified high risk situations and strategies for preventing relapse
**discuss progress, discuss signs of impending relapse
91
Pt in relapse stage
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
92
Serving size for: meat, fish, poultry
Palm of hand
| 3 oz
93
Serving size for: milk/ yogurt
1 cup
| Size of fist
94
Serving size for: bread/ grains
One slice
| Palm of hand
95
Serving size for: rice/ pasta
1/2 cup
| One hand cupped
96
Serving size for: fruit/ vegetable
1 cup
| Two cupped hands
97
Serving size for cheese
1 oz
| Full length of thumb
98
Oil/butter
1 tsp
| Tip of thumb
99
Serving size for: nuts/chips/snacks
Palm covered
100
Energy content of food
Carb: 4 kcal/g
Protein: 4 kcal/g
Fat: 9 kcal/g
Ethanol: 7 kcal/g
101
Total daily energy expenditure
35 kcal/kg/d
Women:2000-2100
Men:2700--2900
102
Cancers prevented by vitD
CRC
Breast
Prostate
103
VitD recommended suppl
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
104
Daily fat intake
26-27% of total energy
Saturated fat: 5-6 %
Trans fat: reduce intake, replace with MUFA, PUFA
105
Daily protein intake
15-18% of total energy
106
Daily carb
55-59%
107
Effect of controlled fat/carb/pro intake on lab
Lower LDL
108
Omega3 fatty acid rich food
2 or more servings of fish/wk esp oily like salmon
109
Effect of omega 3
Lower TG
| Decreased sudden death/ CAD death
110
Daily salt intake
2400 mg/d or less
111
Effect of lowering salt
Lower BP
112
Alcohol intake
3 drinks or less for men (max 15/wk)
| 2 drinks or less for women (max10)
113
Effect of decreasing alcohol intake
Decreased hyper TG
Decreased HTN
decreased osteoporosis
Decreased certain cancers
114
DASH diet effect
Lower BP
| Lower LDL
115
DASH diet:
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
116
Daily vit D requirement
<50: 800-1000 IU
| 50 or higher: 800-2000
117
Daily Ca requirement
<50, pregnant, lactating: 1000
| >50, 1200/d
118
Reduction of daily caloric intake for loosing weight:
500-1000 kcal/d
119
Energy expended/Wt lost per each pound of fat burn
3500 kcal
| 1-2 pound (0.5-1kg) weight
120
At which BMI, waste circumference increases the risk of DM/CVD
25-35
121
Normal BMI range
18.5-24.9
122
Duration of efficacious behavioural interventions in Wt reduction
>12 mo
123
BMI at which behavioural and lifestyle changes should be offered
>25
124
Candidate BMI for bariatric surgery (failing behavioural modification)
BMI >35 + RFs
Or
BMI >40
125
Amount of Wt reduction which is clinically significant for reducing cardiovascular risk factors
>5%
126
Pharmacologic therapy for obesity
```
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
```
127
Increased waist circumference:
Men: 102 or more
Women: 88 or more
128
When to measure waist circumference?
If BMI>25
129
If BMI>25 or WC>cutoff point, next step?
BP
PR
FBG
Lipids: total Cholestrol, TG, LDL, HDL, total chol/HDL ratio
Assess and screen for: depression/ mood disorders/ eating disorders
130
Mx of BMI>25 Or WC> cutoff
Treat comorbidities, health risks
Assess readiness to change behaviour/ barriers to wt loss
Then: devise goals, LSM program for wt loss, reduction of RFs
131
Wt loss goal
5-10% of body weight
Or
0.5-1 kg (1-2 lb)/wk for 6 mo
132
LSM program for wt reduction
```
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
```
133
If goal achieved with LSM
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
134
If goal not achieved with LSM
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
135
Hyperlipidemia screen
```
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
```
136
Variation of fasting vs non-fastin lipids
TC: 2%
Non-HDL: 2%
LDL: 10%
TG: 20%
137
LDL cannot be calculated ic TG:
4.5 or more
138
Statins and DM
Slightly increases DM risk
139
Mx of detected hyperlipidemia
Mx of hyperlipidemia
1. Search for 2° causes: hypothyroidism, CKD, DM, nephrotic, liver disease
2. FRS
3. Search for statin-indicated conditions
140
Statin-indicated conditions
```
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
```
141
Risk classification of hyperlipidemia
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
```
142
Hyperlipidemia Tx
| 1st step
For all:
Smoking cessation
Diet
Exercise: 150 min/wk, moderate-vigorous aerobics
```
For all (except low risks)
+ Statin
```
143
Targets of hyperlipidemia Tx
LDL <2
LDL >50% reduction
apoB <0.8
non-HDL-C <2.6
144
If lipid target not achieved on maximally tolerated dose?
Discuss risk/cost/benefit of add-on with pt
1st line: Ezetimibe
Alternative: BAS
145
If target achieved
Monitor response and health behaviour
146
Repeating screen based on FRS
FRS <5% , q 5 y
| FRS 5% or more, every year
147
Impact of health behavior on LDL reduction
Up to 10%
148
The most important health behaviour for prevention of CAD
Smoking cessation
149
Time of initiation of drug therapy for hyperlipidemia
After 3 mo of LSM
| For high risk pt immediately with LSM
150
Effect of pharmacologic therapy on LDL
By 40%
151
Effect of pharmacologic therapy on LDL
By 40%
152
If severe side effects with statins
Ezetimibe (cholestrol absorption inhibitor)
| 19% reduction in LDL
153
Hyperlipidemia Tx monitoring
ALT, CK, Cr: at baseline and after 6wk
If adequate response, fasting lipids q6-12 mo
154
Tolerable CK rise
Up to 10 times upper limit of normal
| Up to 2-3 times if symptomatic
155
Hyper TG principal Tx
LSM: Wt loss, exercise, avoidance of smoking/alcohol, DM control, intake omega3
156
TG level associated with pancreatitis
>10
Tx: nicotinic acid
Fibrate
157
Metabolic syndrome definition
```
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
```
158
Screen time in infants
None
159
Screen time in toddlers, preschool
1 h/d
160
Screen time 5-17 y
Creational: 2h/d
161
Physical activity for adults
```
150 min/wk
Mod-vig
Aerobic
Bouts of 10 min or more
Muscle/bone strengthening at least x2/ wk
```
162
Daily activity Mx
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
163
The most preventable cause of premature illness/death
Smoking
164
Mx of cigarette smoking
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
CAN-ADAPTT 2012
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
Most effective smoking cessation method
Consultation + medication
167
If willing to quit smoking
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
Effectiveness of different pharmacologic treatments for smoking cessation
NRT=bupropion
Varenicline > bupropion
More adverse effects for varenicline
169
Smoking cessation in pregnancy
1st line: consultation
If not enough: NRT (better intermittent)
Bupropion if benefits> risks
170
The 2-3 pattern of smoking cessation
```
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
If unwilling to quit
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
Assessments for alcohol dependence
* 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
Alcohol dependence inv
CBC
ALT, AST, GGT
(GGT & MCV used for baseline/follow up)
174
Alcohol dependence Mx
```
Consistent with pt's motivation for change
Counselling
Follow up
Alcoholic anonymous/ 12 step program
In-pt program
Pharmacologic
Family Tx
```
175
Indication of alcoholic anonymous program
Chronic/resistant problem
Out patient
Day program
176
Indications for in-patient program
Dangerous/ unstable home environment
Severe medical/psychiatric problem
Addiction to drug requiring in-pt detox
Refractory
177
First choice imaging for renal stone
Non-contrast helical CT
178
Abdominal pain red flags
```
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
When to maintain a high index of suspicion for AAA
>50
180
Associations of allergic rhinitis
Asthma
Eczama
Sinositis
Otitis media
181
Mx of allergic rhinitis
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
Screening anxiety
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
Mx of anxiety disorders
```
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
Age of PFT
From 6 yo
185
Asthma Mx
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
COPD Mx
```
* 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
Lyte abnormality with salbutamol
Hypokalemia
188
BPH investigations
```
U/A
PSA
BUN, Cr
U/S for PVR volume, renal
Pt voiding diary
```
189
PSA testing inappropriate if
Life expectancy < 10y
Prostatitis
UTI
190
PSA results
<4: normal
4-10: measure free and total PSA
>10: high likelihood of pathology
191
Men with whom we discuss PSA testing
Positive FHx of prostate cancer
African ancestry
Men who are concerned about development of prostate cancer
192
If deciding to test PSA in an asymptomatic man
Discuss the risks and possible benefits
193
Tests not recommended as primary evaluation for BPH
```
Urodynamic studies
Prostate U/S or Bx
Cystoscopy
Cytology
IVP
```
194
BPH Mx
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
Acute bronchitis inv
Clinical Dx
CXR if suspect pneumonia
PFT + methacholine challenge if suspect asthma
196
Mx of acute bronchitis
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
Characteristics in favour of bacterial over viral
High fever
Excessive amount of purulent sputum
Associated with COPD
198
Chest wall pain Dx
```
At least 2 of:
Muscle tension present
Absence of cough
Reproducibility by palpitation
Stinging nature
```
199
Triad of pericarditis
Pleuretic chest pain
Friction rub
ECG: diffuse ST elevation, PR depression, No T inversion.
200
Chest pain inv:
CXR
ECG
other tests if indicated
Refer to ED if suspect serious etiology
201
Mx of angina/IHD
NTG spray q 5 min
| No response after 3 doses, refer to ED
202
MI Mx
```
ASA
Clopidogrel
LMWH
Morphine
O2
NTG
Fibrinolysis (ideally in< 30 min. Up to 12h)
PCI (if <90 min)
```
203
Common cold Mx
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
Cough medications not for:
Children under 6
205
MI in elderly women
Dizziness
Back pain
Lightheadedness
Weakness
206
MI in DM
Dyspnea
Syncope
Fatigue
207
Flu vs cold
```
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
Pregnancy test after EPC
Within 21d if no bleeding
209
OTC EPC
Plan B
210
Chronic cough definition
> 8wk
211
Cough inv
Guided by clinical findings
212
Best screening test for dementia
MOCA
213
Denentia type in which depression is most common
Vascular and mixed
214
Most common causes of chronic cough
Post-nasal discharge
GERD
Asthma
Non-asthmatic eosinophilic bronchitis
215
Dementia quick screen
Mini cog + Animal testing
Further evaluation if:
<15 animals in 1 min
0-1 words recalled
Abnormal clock drawing
216
Screening for depression
Are you depressed?
Have you lost interest/pleasure in the things you usually like to do?
Do you have problems sleeping?
217
Depression lab
CBC, Lytes, TSH, ferritin, B12, folate, FBG, U/A
218
Phases of depression Tx
```
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
Mild depression in youth (10-21 y)
A period of active support and monitoring beford initiating Tx
220
Depression Tx
Mild: CBT, IPT
Mod-sev: psychotherapy + medication
221
Youth with mod-sev depression
Referral if: psychosis, substance abuse
222
Bupropion chosen for:
Lack of sexual side effects
223
Vitamine deficiencies causing depression
B12
| B3
224
Screening of DM
Start at age 40 q 3y
| More frequent Nd/or earlier if RF
225
DM goal
| A1c
<7%
226
DM goal
| BP
130/80
227
DM goal
| LDL
<2
228
DM SMART goals
A1c, BP, LDL, exercise, eating, smoking cessation,
| ACE/ARB, statin, ASA
229
DM diet
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
DM physical activity
At least 150 min/ wk, aerobic
| + 2 sessions strength exercise /wk
231
Self monitoring of BG
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
Mx of DM2 with symptomatic hyperglycemia with metabolic decompensation
LSM
+ Insulin
+/- metformin
233
Mx of DM2 with A1c > 8.5%
LSM
+ Metformin
+/- another antihyperglycemic
234
Mx of DM2 with A1c < 8.5
LSM +/- Metformin
If not at glycemic target within 2-3 mo, start/increase metformin
235
If any of the previous not at glycemic target
Add another agent
236
For DM with cardiovascular disease
SGLT2 inh
Ending with -gliflozin
237
Insuline secretagogues
Meglitinide ( ending in -glinide)
| Sulfonylurea
238
OHA with genital infection
SGLT2
239
DM medications increasing wt
Insulit
Insulin secretagogues
Thiazolidinediones
240
DM drug causing CHF
Thiazolidi...
| Saxagliptin (incretin)
241
DM drug causing UTI
SGLT2
242
Attain target A1c within
3-6 mo
243
Sulfonylurea with most hypoglycemic effect
Glyburide
244
Caution in RF with use of
SGLT2
245
Advantage of meglitinide
Less hypoglycemia if missed meals
246
Indication of ACE/ARB on DM
If:
Clinical macrovascular disease
Age 55 or higher
Age<55 + microvascular
247
Indication of statin in DM
Age 40 or higher
Age 30-40 and duration>15 y
Microvascular
Other cardiovascular RFs
248
Indication of ASA
If established CVD
249
Vestibular vertigo symptoms
Worse with eye closure
| Worse with head movement
250
Vertigo (vertiginous) sign/symp
External world seems to revolve
| Individual revolves in space
251
Ototoxic meds
Aminoglycosides
Erythro
ASA
Antimalarials
252
Inv in syncopal vertigo
```
Cardiac
PVD
Neurologic exam
Blood work
ECG, 24h holter, treadmill stress test, loop ECG, tilt table testing, carotid/vertebral doppler, EEG
```
253
Vertiginous vertigo test
```
ENT exam
Neurologic exam
Dix-Hallpike
Audiometry
MRI
```
254
Non-syncopal, non-vertiginous
```
Neurologic
Cardiac
3 min hyperventilation trial
ECG, EEG
Romberg test
```
255
Tx of vertigo
```
Education
LSM
Physical maneuvers
Symptomatic Mx
Pharmacotherapy
Surgery
```
256
When to refer vertigo
When significant central disease suspected
When persistent peripheral (>2-4 wk)
Atypical presentation
257
Ask in all psychologic interviews
```
Suicide/homicide
Abuse/violence
Substance
Anxiety/depression/mania screen
Psychosis
Bereavement
GMC
Pregnancy
```
258
Domestic violence Mx
*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
Screenimg for domestic violence
* 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
Red flags of dyspepsia
```
Wt loss
Dysphagia
Persistent vomiting
GI bleeding
Onset>50
```
261
New onset dyspepsia Mx
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
How long keep pt on PPI
At least 1 trial off the medication per year
263
H-pylori eradication
```
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
Dyspnea Mx
```
CXR
ECG
PFT
ABG (acute)
ABC
ED if severe respiratory distress
```
265
Dx of UTI
2 of: Dysuria, leukocytes, nitrites
Or
Culture
266
Dysuria inv
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
UTI in pregnancy
Treat if bacteriuria
| Then monthly culture
268
Indication of prophylactic AB
Recurrent (>3/y)
269
Tx of complicated UTI
Longer course
| Broad spectrum
270
Tx of urethritis
All have to return 4-7d after completion of therapy for clinincal evaluation
271
Prevention of UTI
Good hydration
Cranberry juice
Wipe urethra from front to back
Avoid feminine hygiene sprays/scented douche
Empty bladder immediately before and after intercourse
272
Duration of erectile problem to Dx erectile dysfunction
3 mo
273
The most common cause of erectile dysfunction
Vascular
274
Inv for erectile dysfunction
```
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
When to refer erectile dysfunction
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
Erectile dysfunction Mx
LSM: reduce alcohol, reduce smoking, exercise, relationship/sexual counselling, vacuum devices
Pharmacologic: PDE5-inh, a-blocker(yuhimbine), trazodone, testosterone (only if deficiency)
277
Fatigue inv
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
Fatigue red flags
```
Wt loss
Fever
Night sweats
Neurological deficits
Ill apearing
```
279
Mx of fatigue without etiology found
```
Reassurance
Quick F/U
Counselling, behavioural therapy, group therapy
Encourage to stay physically active
Review meds
```
280
Tx of chronic fatigue syndrome
```
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
Unrefreshing sleep
Chronic fatigue disorder
282
Physical symptoms in chronic fatigue disorder
```
Sore throat
Headache
Joint pain
Muscle pain
Tender cervical/axillary lymph nodes
```
283
Fever definition
Oral
T> 37.2 AM
T>37.7 PM
Rectal (<2 yr)
TM not accurate until >5y
284
Fever inv
CBC, diff, B/C, Urine SandC,R&M,
Stool OandP, gram, culture
CXR, Mantoux, sputum culture
LP
285
Caffein withdrawal headache
```
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
Tx of caffeine withdrawal headache
Acetaminophen/ASA +/- Caffeine
| Caffeine
287
Proportion of aura in migrain
20%
288
Headache with photo/phonophobia
Migraine
289
Headache aggrevated by physical activity
Migraine
290
Tx of acute migraine
1st line: Acetaminophen, NSAIDs, ASA, +/- caffeine
2nd line: NSAIDs
3rd line: 5-HT agonists +/- antiemetics
291
Migraine prophylaxis
1st line: BB
2nd line: TCA
3rd line: AED
292
Band-like pain
Tension headache
293
Contracted neck/scalp muscles
Tension headache
294
Acute tension headache Tx
Rest, relaxation
NSAIDs
Acetaminophen
295
Prophylaxis for tension headache
Rest, relaxation
Physical activity
Biofeedback
296
Headache which awakens pt
Cluster
297
Headache with conjunctival injection, tearing
Cluster
298
Suicide headache
Cluster
299
Trigger of cluster headache
Alcohol
300
Cluster headache Tx (Acute)
Sumatriptan
Dihydroergotamine
High flow O2
Intranasal lidocaine
301
Headache red flags
```
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
Headache inv
```
Only if red flags present
CBC
ESR (if suspected temporal arteritis)
CT/MRI
CSF analysis
```
303
Hearing loss assessment
```
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
Mx of hearing impairment
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
Elderly who indicate they have no hearing problem
Screen with whispered voice test
| If unable to perceive, audiometry
306
Elderly who acknowledge a hearing impairment
Audiometry
307
HTN in 80yo and older
150/90
308
Urgent HTN
SBP>210, DBP>120
| No/minimal target organ damage
309
Accelerated HTN
Recent increase
+ evidence of vascular damage on fundoscopy
Emergent
310
Severe HTN
DBP > 120
+ Acute target organ damage
Emergent
311
Malignant HTN
+ papilledema
| + other manifestations of vascular damage
312
Inv for all pts with HTN
```
Lytes, Cr,
FBG/A1c
Lipids
12 lead ECG
U/A
```
313
If HTN + DM or CKD
Urinary protein excretion
314
If suspected renovascular HTN
Renal U/S
Captopril renal scan (if GFR > 60)
MRA/CTA (If normal renal function)
315
Renovascular HTN with ACEI/ARB
Rise in Cr of 30% or more
316
If profound hypokalemia with diuretics
Suspect hyperaldosteronism
317
Hypertensive emergencies
```
Papilledema
Hypertensive encephalopathy
Intracerebral hemorrhage
SAH
Stroke
Aortic dissection
LV failure
MI/ischemia
Acute pulmonary edema
Renal failure
```
318
If suspected endocrine cause
Plasma aldosterone, plasma renin, ARR
319
If suspected pheo in HTN
24 h urine metanephrine and creatinine
320
HTN screen
BP assessed for all adults at all appropriate clinical visits
321
HTN visit 1
Dx if 180/110 or higher
If > 140/90 (office) or > 135/85 (automated), out of office assessment
322
Out of office assessment after visit 1:
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
Alternative to out of office assessment:
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
LSM in HTN Mx
```
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
Indications of pharmacologic Tx for HTN
*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
Pharmaci for HTN
```
1st line:
Thiazide/thiazide-like diuretics
ACEI (for non-African pts)
ARB
Long-acting CCB
BB (if<60y)
```
327
If partial response to 1st line monotherapy
If std dose, add another 1 st line
328
Choice for isolated diastolic HTN
```
Thiazide
BB
ACEI
ARB
CCB
+/- ASA, statin
```
329
Choice for isolated systolic HTN
Thiazide
ARB
CCB
330
Choice for HTN in CAD
ACEI
ARB
BB (for stable angina)
331
Choice for HTN in prior MI
BB and ACEI (or ARB)
332
LV hypertrophy
ACEI
ARB
thiazide
CCB
333
Cerebrovascular disease
ACEI + diuretics
334
Choice for HTN in Heart failure
ACEI (ARB)
+BB
+Spironolactone (NYHA II-IV)
335
HTN in DM with albuminuria
ACEI
| diuretic
336
HTN in DM without albuminuria
ACEI
ARB
CCB
thiazide
337
Tx of HTN in renovascular disease
Same HTM without ither indications
| Caution in using ACEI/ARB
338
HTN in asthma
K sparing
| +thiazide
339
HTN in gout
Do not use thiazide
| Ok with asymptomatic hyperuricemia
340
HTN Tx in smokers
Low dose thiazide
ACEI
BB not recommended
341
HTN in >60
BB not recommended
342
Emergency Tx of HTN
Labetolol
| Nifedipine
343
F/U for HTN
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
Refereal of HTN if
Refractory
Suspected secondary cause
Worsening renal failure
345
Hospitalization for HTN if
Malignant HTN
346
Inv for joint pain
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
Tx of joint pain
```
Education
LSM
physiotherapy, occupational therapy
Manage pain (acetaminophen, NSAIDS)
Treat specific causes
```
348
Morning stiffness in inflammatory arthritis
>30 min
349
Low back pain timing
<6wk acute
6-12 wk subacute
>12 wk chronic
350
Inv for low back pain
If infection/cancer suspected: CBC, ESR
| if worsening neurologic deficit/suspect cancer/infection: CT/MRI
351
Red flags in low back pain
```
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
Indications for lumbar xray
```
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
L4 exam
Sens: medial malleolus
Motor: squat
Reflex: patellar
Test: femoral stretch test
354
L5 exam
Sens: 1st dorsal web space
Motor: heel walking
Reflex: medial hamstring
Test: SLR
355
S1 exam
Sense: lateral foot
Motor: toe walking
Reflex: achilles
Test: SLR
356
Yellow flags of low back pain
```
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
Mx of low back pain with red flags
Referral
358
Mx of acute/subacute low back pain
*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
Acute/subacute low back pain, not resolving within 6 wk
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
Mx of chronic low back pain
```
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
Pattern 1 low back pain
Worse with flexion
Arising from intervertebral discs or adjacent ligaments
Neuroexam: normal
Tx: scheduled extension
Lumbar roll
Night lumbar roll
Medication
362
Pattern 2 low back pain
Worse with extension
Never worse with flexion
Neuroexam: normal
Arising from posterior joint complex
Tx: scheduled flexion
Limited extension
Night lumbar roll
Medications
363
Pattern 3 low back pain
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
Pattern 4 low back pain
Leg dominant
Worse with activity
Improves with rest
Neurologic claudication
```
Tx: abdominal exercise
Night lumbar roll
Sustained flexion
Pelvic tilt
Medication as required
```
365
Mx of OA
```
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
Basic bone health for individuals >50 y
Ca 1200g/d
Vit D 800-2000/d
Regular weight bearing exercise
Fall prevention
367
Indications of BMD in <50 y
```
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
Indications of bone scan in 50-64 yr
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
BMD indications for >65
All
370
Next step after BMD testing
Assessment of 10 y fracture risk
371
If risk < 10 %
No pharmacotherapy
| Reassess in 5 yr
372
If moderate risk of 10 y fx
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 << 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
Other indications of pharmacotherapy
10 yr risk of fx > 20%
Prior fragility fx of hip/spine
>1 fragility fx
374
PEx for osteoporosis
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
Investigations for osteoporosis
```
CBC
Cr
Corrected Ca
ALP
TSH
25-OH-VitD (after 3-4 mo of adequate supplementation)
SPSP if vertebral fx
```
376
STI inv
Individuals at risk (even if asymptomatic)
Chlamydia
Gonorrhea
HBV
HIV
syphilis
Pap test (if not performed in the preceding 12 mo)
377
Primary prevention of STI
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
STI detected in a child
Must evaluate sexual abuse
379
Gono Dx in men
Urethral swab for gram and culture
| + pharyngeal / rectal swab if indicated
380
Gono Dx in women
Urine PCR
Or
Endocervical swab for gram/culture
+ vaginal swab for wet mount to R/O TV
+ pharyngeal /rectal swab if indicated
381
Tx of gono
Ceftroaxone 250 mg IM single dose
| + Tx of non-Gono
382
F/U of gono:
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
Inv for non-gono(chlamydia) urethritis/cervicitis
Azithromycin 1g PO single dose
+ Tx of gono
Same F/U as gono
384
Dx of genital HSV
Swab of vesicular content for culture
| HSV1, HSV2 Serology (to Dx type, primary vs recurrent)
385
Duration of Tx for primary HSV
5-10 d
386
Duration of Tx of recurrent HSV
2-5 d
387
Syphilis Dx
Specimen collection from 1° and 2° lesions
VDRL in high risk individuals
Universal screening of pregnant women
388
Syphilis Tx
Benzathine penicillin G IM
Notify partner (last 3-12mo)
Continue testing until seronegative
389
Acute sinusitis Mx
```
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
Referral of sinusitis to ENT
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
Dx of acute bacterial sinusitis
- 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
Mx of ABRS
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
Indication of radiology in sinositis
Multiple recurrent episodes
Standard 3 view sinus xray
Or CT
394
Insomnia inv
```
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
Tx of insomnia
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
Snoring inv:
Only if severe
| Nocturnal polysomnography, CT/MRI
397
Tx of snoring
Wt loss
Sleep on side
Nasal dilators
398
OSApnea inv
BP
+/- TSH
nocturnal polysomnography
399
Tx of OSA
```
Wt loss
Avoid sleeping supine
Avoid alcohol, sedatives, opioids
If nasal swelling: inhaled CS
Dental apliances
Primary Tx: CPAP
```
400
Pharyngitis inv:
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
Red flags in sore throat
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
Approach to GABHS
```
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
Tx of viral pharyngitis
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
Indication of F/U culture for GABHS
Hx of rheumatic fever
Family member with Hx if acute rheumatic fever
Suspected streptococcal carrier
405
AB for GABHS pharyngitis
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
