Family and Rural Medicine Clerkships Flashcards
USPSTF Abdominal Aortic Aneurysm Screening?
Men Ages 65 to 75 Years who Have Ever Smoked: One-time ultrasound AAA screening
Men Ages 65 to 75 Years who Have Never Smoked: Selectively offer ultrasound AAA screening
Women Ages 65 to 75 Years who Have Ever Smoked: Insufficient evidence
Women who have never smoked: Recommend against AAA screening
USPSTF Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care
Adults aged 18 and older: screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse
Adolescents (under 18 years of age): insufficient evidence
USPSTF Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening
Adults aged 40 to 70 years who are overweight or obese: recommends screening for abnormal blood glucose as part of cardiovascular risk assessment. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
USPSTF Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication
Adults aged 50 to 59 years with a ≥10% 10-year CVD risk: recommends low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) given that the patient is not at increased risk for bleeding, has a life expectancy of at least 10 years, and is willing to take low-dose aspirin daily for at least 10 years.
Adults aged 60 to 69 years with a ≥10% 10-year CVD risk:
The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.
Adults younger than 50 years, Adults aged 70 years or older: insufficient evidence
USPSTF Asymptomatic Bacteriuria in Adults: Screening
Pregnant Women at 12 to 16 Weeks’ Gestation: recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks’ gestation or at their first prenatal visit, if later.
Men and Nonpregnant Women: recommends against screening for asymptomatic bacteriuria
USPSTF Autism Spectrum Disorder in Young Children: Screening
Children aged 18 to 30 months: current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician.
USPSTF Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery: Screening
Asymptomatic Pregnant Women, Low Risk: recommends against screening for bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery.
Asymptomatic Pregnant Women, High Risk: current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in asymptomatic pregnant women at high risk for preterm delivery.
USPSTF Bladder Cancer in Adults: Screening
Asymptomatic Adults: current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults.
USPSTF Blood Pressure in Children and Adolescents (Hypertension): Screening
Children and Adolescents: current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.
USPSTF BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing
Women who have Family Members with Breast, Ovarian, Tubal, or Peritoneal Cancer: recommends that primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
Women Whose Family History is not Associated with an Increased Risk: recommends against routine genetic counseling or BRCA testing for women whose family history is not associated with an increased risk for potentially harmful mutations in the BRCA1 or BRCA2 genes.
USPSTF Breast Cancer: Medications for Risk Reduction
Women, Increased Risk for Breast Cancer: recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.
Women, Not at Increased Risk for Breast Cancer: recommends against the routine use of medications, such as tamoxifen or raloxifene, for risk reduction of primary breast cancer in women who are not at increased risk for breast cancer.
USPSTF Breast Cancer: Screening
Women aged 50 to 74 years: recommends biennial screening mammography for women aged 50 to 74 years.
Women aged 40 to 49 years: decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. (Potential harms = over-diagnosis, over-treatment, biopsies etc). Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.
Women aged 75 years or older: insufficient evidence
All women: USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer.
Women with dense breasts: current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.
USPSTF Breastfeeding: Primary Care Interventions
Pregnant women, new mothers, and their children: recommends providing interventions during pregnancy and after birth to support breastfeeding.
USPSTF Carotid Artery Stenosis: Screening
General Adult Population: recommends against screening for asymptomatic carotid artery stenosis in the general adult population.
USPSTF Celiac Disease: Screening
Asymptomatic adults, adolescents, and children: current evidence is insufficient to assess the balance of benefits and harms of screening for celiac disease in asymptomatic persons.
USPSTF Cervical Cancer: Screening
Women 21 to 65 (Pap Smear) or 30-65 (in combo with HPV testing): recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
Women younger than 30 years, HPV testing: recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
Women younger than 21: recommends against screening for cervical cancer in women younger than age 21 years.
Women Older than 65, who have had adequate prior screening: recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
Women who have had a hysterectomy: recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
USPSTF Child Maltreatment: Primary Care Interventions
Children: current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. This recommendation applies to children who do not have signs or symptoms of maltreatment.
USPSTF Chlamydia and Gonorrhea: Screening
Sexually Active Women: recommends screening for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
Sexually Active Men: current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.
USPSTF Chronic Kidney Disease: Screening
Asymptomatic Adults: evidence is insufficient to assess the balance of benefits and harms of routine screening for chronic kidney disease (CKD) in asymptomatic adults.
USPSTF Chronic Obstructive Pulmonary Disease: Screening
Asymptomatic adults: recommends against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults.
USPSTF Cognitive Impairment in Older Adults: Screening
Older Adults: current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment.
USPSTF Colorectal Cancer: Screening
Adults aged 50 to 75 years: recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years.
Adults aged 76 to 85 years: The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history.
Adults in this age group who have never been screened for colorectal cancer are more likely to benefit.
Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy.
USPSTF Coronary Heart Disease: Screening Using Non-Traditional Risk Factors
Men and Women with No History of CHD: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors studied to screen asymptomatic men and women with no history of CHD to prevent CHD events.
USPSTF Coronary Heart Disease: Screening with Electrocardiography
Adults at Low Risk: SPSTF recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events. (D)
Adults at Intermediate or High Risk: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. (I)
USPSTF Dental Caries in Children from Birth Through Age 5 Years: Screening
Children From Birth Through Age 5 Years: USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B)
Children From Birth Through Age 5 Years: The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B)
Children From Birth Through Age 5 Years: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I)
USPSTF Depression in Adults: Screening
General adult population, including pregnant and postpartum women: USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B)
USPSTF Depression in Children and Adolescents: Screening
Adolescents aged 12 to 18 years: USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B)
Children aged 11 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I)
USPSTF Developmental Hip Dysplasia: Screening
Infants: USPSTF concludes that evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes (I)
USPSTF Drug Use, Illicit: Primary Care Interventions for Children and Adolescents
Children and Adolescents without a Substance Use Disorder: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. This recommendation applies to children and adolescents who have not already been diagnosed with a substance use disorder. (I)
USPSTF Drug Use, Illicit: Screening
Adolescents, Adults, and Pregnant Women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.
USPSTF Falls Prevention in Older Adults: Counseling and Preventive Medication
Community-Dwelling Older Adults, Aged 65 Years or Older: USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.
No single recommended tool or brief approach can reliably identify older adults at increased risk for falls, but several reasonable and feasible approaches are available for primary care clinicians. (B)
Community-Dwelling Older Adults, Aged 65 and Older: USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (C)
USPSTF Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication
Women who are planning or capable of pregnancy: USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (A)
USPSTF Genital Herpes Infection: Serologic Screening
Asymptomatic adolescents and adults, including those who are pregnant: USPSTF recommends against routine serologic screening for genital herpes simplex virus (HSV) infection in asymptomatic adolescents and adults, including those who are pregnant. (D)
USPSTF Gestational Diabetes Mellitus, Screening
Asymptomatic Pregnant Women, AFTER 24 Weeks of Gestation: USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. (B)
Asymptomatic Pregnant Women, BEFORE 24 Weeks of Gestation: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for GDM in asymptomatic pregnant women before 24 weeks of gestation. (I)
USPSTF Glaucoma: Screening
Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma (POAG) in adults. (I)
USPSTF Gynecological Conditions: Periodic Screening With the Pelvic Examination
Asymptomatic, nonpregnant adult women who are not at increased risk for any specific gynecologic condition: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic women for the early detection and treatment of a range of gynecologic conditions.
This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou [“Pap”] smear, screening for gonorrhea and chlamydia). (I)
USPSTF Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults WITH Cardiovascular Risk Factors: Behavioral Counseling
Adults who are overweight or obese and have additional CVD risk factors: USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. (B)
USPSTF Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults WITHOUT Known Risk Factors: Behavioral Counseling
Adults without obesity who do not have known cardiovascular disease risk factors: USPSTF recommends that primary care professionals INDIVIDUALIZE the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity. Existing evidence indicates a positive but small benefit of behavioral counseling for the prevention of cardiovascular disease (CVD) in this population. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling. (C)
USPSTF Hearing Loss in Older Adults: Screening
Asymptomatic Adults Aged 50 Years or Older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older. (I)
USPSTF Hepatitis B in Pregnant Women: Screening
Pregnant Women: USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. (A)
USPSTF Hepatitis B Virus Infection: Screening, 2014
Persons at High Risk for Infection: USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection. (B)
USPSTF Hepatitis C: Screening
Adults at High Risk: USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965. (B)
USPSTF High Blood Pressure in Adults: Screening
Adults aged 18 years or older: USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment (A)
USPSTF Human Immunodeficiency Virus (HIV) Infection: Screening
Adolescents and Adults 15-65 Years Old: USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (A)
Pregnant Women: USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (A)
USPSTF Idiopathic Scoliosis in Adolescents: Screening
Adolescents: recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. (D)
USPSTF Impaired Visual Acuity in Older Adults: Screening
Adults 65 years or older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I)
USPSTF Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Screening
Women of Childbearing Age: USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services. (B)
Elderly or Vulnerable Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect. (I)
USPSTF Iron Deficiency Anemia in Pregnant Women: Screening and Supplementation
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of SCREENING for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes. (I)
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine iron SUPPLEMENTATION for pregnant women to prevent adverse maternal health and birth outcomes. (I)
USPSTF Iron Deficiency Anemia in Young Children: Screening
Children ages 6 to 24 months: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children ages 6 to 24 months. (I)
USPSTF Latent Tuberculosis Infection: Screening
Asymptomatic adults at increased risk for infection: USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk. (B)
USPSTF Lead Levels in Childhood and Pregnancy: Screening
Asymptomatic Children, 1 to 5 years: USPSTF concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. (I)
Asymptomatic Children, 1 to 5 years: SPSTF recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk. (D)
Pregnant Women: USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic pregnant women. (D)
USPSTF Lipid Disorders in Children and Adolescents: Screening
Children and adolescents 20 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. (I)
USPSTF Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication
Pregnant Women Who Are At High Risk for Preeclampsia: USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. (B)
USPSTF Lung Cancer: Screening
Adults Aged 55-80, with a History of Smoking: USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (B)
USPSTF Menopausal Hormone Therapy: Preventive Medication
Postmenopausal Women: USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. (D)
Postmenopausal Women, Who Have Had a Hysterectomy: SPSTF recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. (D)
USPSTF Obesity in Adults: Screening and Management
All Adults: USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (B)
USPSTF Obesity in Children and Adolescents: Screening
Children and adolescents 6 years and older: USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. (B)
USPSTF Obstructive Sleep Apnea in Adults: Screening
Asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults. (I)
USPSTF Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive
All Newborns: USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum. (A)
USPSTF Oral Cancer: Screening
Asymptomatic Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. (I)
USPSTF Osteoporosis: Screening
Women, 65 and Older: USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (B)
Men: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I)
USPSTF Ovarian Cancer: Screening
Women: USPSTF recommends against screening for ovarian cancer in women. (D)
USPSTF Pancreatic Cancer: Screening
Asymptomatic Adults: USPSTF recommends against routine screening for pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or serologic markers. (D)
Rationale: The USPSTF found no evidence that screening for pancreatic cancer is effective in reducing mortality. There is a potential for significant harm due to the very low prevalence of pancreatic cancer, limited accuracy of available screening tests, the invasive nature of diagnostic tests, and the poor outcomes of treatment. As a result, the USPSTF concluded that the harms of screening for pancreatic cancer exceed any potential benefits.
USPSTF Peripheral Arterial Disease (PAD) and CVD in Adults: Risk Assessment with Ankle Brachial Index
Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for peripheral artery disease (PAD) and cardiovascular disease (CVD) risk assessment with the ankle–brachial index (ABI) in adults. (I)
USPSTF Preeclampsia: Screening
Pregnant women: USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. (B)
USPSTF Prostate Cancer: Screening
Men: USPSTF recommends against prostate-specific antigen (PSA)–based screening for prostate cancer. (D)
USPSTF Rh(D) Incompatibility: Screening
Pregnant women, during the first pregnancy-related care visit: USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (A)
Unsensitized Rh(D)-negative pregnant women: USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks’ gestation, unless the biological father is known to be Rh(D)-negative. (B)
USPSTF Sexually Transmitted Infections: Behavioral Counseling
Sexually Active Adolescents and Adults: USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). (B)
USPSTF Skin Cancer: Counseling
Children, Adolescents, and Young Adults aged 10 to 24, Fair Skinned: USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (B)
Adults Older than 24: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than age 24 years about minimizing risks to prevent skin cancer. (I)
USPSTF Skin Cancer: Screening
Asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults. (I)
USPSTF Speech and Language Delay and Disorders in Children Age 5 and Younger: Screening
Children aged 5 years or younger: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for speech and language delay and disorders in children aged 5 years or younger. (I)
USPSTF Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater: USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.
Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. (B)
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 7.5% to 10%: Although statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event risk of less than 10%, the likelihood of benefit is smaller, because of a lower probability of disease and uncertainty in individual risk prediction. Clinicians may choose to offer a low- to moderate-dose statin to certain adults without a history of CVD when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 7.5% to 10%. (C)
Adults 76 years and older with no history of CVDUSPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use for the primary prevention of CVD events and mortality in adults 76 years and older without a history of heart attack or stroke. (I)
USPSTF Suicide Risk in Adolescents, Adults and Older Adults: Screening
Adolescents, Adults, and Older Adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. (I)
USPSTF Syphilis Infection in Nonpregnant Adults and Adolescents: Screening
Asymptomatic, nonpregnant adults and adolescents who are at increased risk for syphilis infection: USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A)
USPSTF Syphilis Infection in Pregnancy: Screening
Pregnant Women: USPSTF recommends that clinicians screen all pregnant women for syphilis infection. (A)
USPSTF Testicular Cancer: Screening
Adolescent and Adult Men: USPSTF recommends against screening for testicular cancer in adolescent or adult men. (D)
USPSTF Thyroid Cancer: Screening
Adults: USPSTF recommends against screening for thyroid cancer in asymptomatic adults. (D)
USPSTF Thyroid Dysfunction: Screening
Nonpregnant, asymptomatic adults: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults.
USPSTF Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
Adults who are not pregnant: USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco. (A)
Pregnant women: USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (A)
Pregnant women: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (I)
All adults, including pregnant women: USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated). (I)
USPSTF Tobacco Use in Children and Adolescents: Primary Care Interventions
School-Aged Children and Adolescents: USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (B)
USPSTF Visual Impairment in Children Ages 1-5: Screening
Children, Age 3-5 Years: USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. (B)
Children, <3 Years of Age: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age. (I)
USPSTF Vitamin D and Calcium to Prevent Fractures: Preventive Medication
Men and Premenopausal Women: USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women. (I)
Noninstitutionalized Postmenopausal Women: USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (D)
Community-dwelling Adults, 65 Years or Older, at Increased Risk for Falls: USPSTF has previously concluded in a separate recommendation that vitamin D supplementation is effective in preventing falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (B)
USPSTF Vitamin D Deficiency: Screening
Community-dwelling, nonpregnant, asymptomatic adults age 18 years and older: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I)
USPSTF Vitamin Supplementation to Prevent Cancer and CVD: Preventive Medication
Use of Multivitamins to Prevent Cardiovascular Disease or Cancer: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamins for the prevention of cardiovascular disease or cancer. (I)
Single- or Paired-Nutrient Supplements for Prevention of Cardiovascular Disease or Cancer: USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of single- or paired-nutrient supplements (except β-carotene and vitamin E) for the prevention of cardiovascular disease or cancer. (I)
Use of β-carotene or Vitamin E for Prevention of Cardiovascular Disease or Cancer: USPSTF recommends against the use of β-carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. (D)
What are the 3 main components of a healthy adult annual physical?
Health maintenance should be employed to prevent future disease. In general, the approach is
1) immunizations
2) cancer screening
3) screening for common diseases
At what age does colon cancer screening begin?
50 y/o.
If a patient has a family hx of colon cancer, colonoscopy screening should be performed 10 years prior to the age of diagnosis in the relative, or at age 50, whichever comes first.
One of the main components of a healthy adult annual physical is immunizations. What immunizations are recommended for adults?
The influenza vaccine should be recommended annually, and the tetanus vaccine every 10 years. The acellular pertussis vaccine is also recommended as many adults have had waning immunity to pertussis and occasional outbreaks of whooping cough have been noted.
What is primary prevention?
Primary prevention is an intervention designed to prevent a disease before it occurs. It usually involves the identification and management of risk factors for a disease. Examples of this would be immunization against communicable disease, public health education about good nutrition, exercise and stress management, or removal of colon polyps to prevent the development of colon cancer.
What is secondary prevention?
Secondary prevention is an intervention intended to promote early detection of a disease or condition, so prompt treatment can be initiated. Examples of secondary prevention are the use of mammography for the detection of breast cancer or eye examinations for the detection of glaucoma.
What makes for effective screening? (6)
1) disease should be of high enough prevalence in the population to make the screening effort worthwhile.
2) there should be a time frame during which the person is asymptomatic, but during which the disease or risk factor can be identified.
3) there needs to be a test available for the disease that has sufficient sensitivity and specificity
4) test should be cost-effective
5) test should be acceptable to patients.
6) there must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality of the disease process.
How do you screen for colorectal cancer? (3 ways)
Colorectal cancer screening can take the form of…
1) fecal occult blood testing (FOBT) using guaiac cards on three consecutive bowel movements collected at home
2) flexible sigmoidoscopy with or without occult blood testing
3) colonoscopy
What is the optimal interval for testing for colorectal cancer?
FOBT: recommended annually
Sigmoidoscopy: every 3-5 years
Colonoscopy: every 10 years
True or False: an abnormal test result of FOBT or sigmoidoscopy leads to the performance of a colonoscopy
True
What is tertiary prevention?
Tertiary prevention involves both therapeutic and rehabilitative measures once a disease has been diagnosed. Examples of tertiary prevention include core measure medications for congestive heart failure, rehabilitation programs for stroke patients to improve functioning, and chronic pain management programs.
True or False: USPSTF currently recommends routine digital examination for prostate cancer but not PSA.
FALSE. The USPSTF currently recommends against (Level D) routine screening for prostate cancer using digital examination or PSA.
(both are bad)
Tdap immunization for adults?
The CDC has recently recommended that all adults between 19 and 65 years of age should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis and the presence of an increasing number of cases of pertussis nationwide. Adults who have not had a Td booster in 10 years or more and who have never had a dose of Tdap as an adult should receive a booster vaccination with Tdap. Persons who may need an increase in protection against pertussis, including health-care workers, childcare providers, or those who anticipate having close contact with infants younger than 1 year, should also receive a Tdap booster.
What age to give influenza vaccine?
In a 2010 update, the CDC recommended routine vaccination against influenza for everyone 6 months of age and older. This replaced a recommendation of vaccination based upon risk factors.
Age for pneumococcal vaccines? Who else?
Pneumococcal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13) vaccination are recommended for all adults aged 65 or older. PPSV-23 and/or PCV-13 may also be recommended for previously unvaccinated adults younger than 65 in the presence of immunocompromising or certain chronic medical conditions.
Who should get hepatitis B vaccines?
High risk of exposure:
- health-care workers
- those exposed to blood or blood products
- dialysis patients
- IV drug users
- persons with multiple sexual partners or recent sexually transmitted diseases
- men who engage in sexual relations with other men.
- patients with diabetes who have not previously been immunized.
Who should get hepatitis A vaccines?
- chronic liver disease
- who use clotting factors
- who have occupational exposure to the hepatitis A virus
- who use IV drugs
- men who have sex with men
- travel to countries where hepatitis A is endemic
Who should get varicella vaccination?
- those with no reliable history of immunization or disease
- who are seronegative on testing for varicella immunity
- who are at risk for exposure to varicella virus
Who should get meningococcal vaccine?
Meningococcal vaccine is recommended for persons in high-risk groups:
- college dormitory residents
- military recruits
- certain complement deficiencies
- functional or anatomic asplenia
- who travel to countries where the disease is endemic.
Exercise counseling?
Exercise has been consistently shown to reduce the risk of cardiovascular disease, diabetes, obesity, and overall mortality. Even exercise of moderate amounts, such as walking for 30 minutes on most days of the week, has a positive effect on health. The benefits increase with increasing the amount of exercise performed. Studies performed on counseling physically inactive persons to exercise have shown inconsistent results. However, the benefits of exercise are clear and should be promoted.
Diet counseling?
Counseling to promote a healthy diet in persons with hyperlipidemia, other risk factors for cardiovascular disease, or other conditions related to diet is beneficial. Intensive counseling by physicians or, when appropriate, referral to dietary counselors or nutritionists, can improve health outcomes.
True or False: routine serum studies are done for adult annual physicals
False. There is no such thing as a “routine blood test” or a “routine chest x-ray.” All tests that are ordered should have evidence to support their benefit.
A 52-year-old man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, coughing, and wheezing.
Most likely dx?
Appropriate treatment? (3)
Interventions to reduce future episodes? (5)
Acute exacerbation of COPD
Treatment: antibiotic, bronchodilators, systemic corticosteroids
Reduce future episodes: smoking cessation, LABA, inhaled corticosteroids, influenza vaccine, pneumococcal polysaccharide vaccine
What are the 2 most common causes of dyspnea and wheezing in adults?
How do you distinguish between the two? (3)
Asthma:
1) often presents earlier in life
2) may or may not be associated with cigarette smoking
3) EPISODIC exacerbations with return to relatively normal baseline lung function
COPD:
1) tends to present in midlife or later
2) usually the result of a long history of smoking
3) slowly progressive disorder which never returns to normal baseline
True or False: patients with chronic asthma can develop COPD over time
True
True or False: when a patient presents with acute exacerbation of dyspnea and wheezing, it’s important to determine whether it is a COPD exacerbation or asthma exacerbation.
FALSE
In the setting of an acute exacerbation, the differentiation between an exacerbation of asthma and an exacerbation of COPD is not necessary for determination of the immediate management. The assessment of the patient presenting with dyspnea should always start with the ABCs—Airway, Breathing, and Circulation. Intubation with mechanical ventilation should be performed when the patient is unable to protect his own airway (eg, when he has a reduced level of consciousness), when he is tiring because of the amount of work required to overcome his airway obstruction, or when adequate oxygenation cannot be maintained.
For both asthma and COPD exacerbations, the mainstays of medical therapy are oxygen, bronchodilators, and steroids.
What are the 3 agents used to treat both asthma and COPD exacerbations? Explain their mechanisms of action
1) Inhaled β2-agonists (most commonly albuterol): can rapidly result in bronchodilation and reduction in airway obstruction.
2) Inhaled anticholinergic agent (such as ipratropium) may work synergistically with the β-agonist. Anticholinergic agents antagonize bronchoconstriction, which results in bronchodilation.
3) Corticosteroids, given systemically (orally, intramuscularly, or intravenously), act to reduce the airway inflammation that underlies the acute exacerbation.
Clinically significant effects of steroids take hours to occur; consequently, steroids should be used with bronchodilators because bronchodilators act rapidly. Steroids used in combination with bronchodilators significantly improve short-term outcomes in the management of acute exacerbations of asthma and COPD.
The 2 subtypes of COPD are chronic bronchitis and emphysema. Define each.
CHRONIC BRONCHITIS: Cough and sputum production on most days for at least 3 months during at least 2 consecutive years
EMPHYSEMA: Shortness of breath caused by the enlargement of respiratory bronchioles and alveoli caused by destruction of lung tissue
Top 3 leading causes of death in USA?
1) Cardiovascular disease
2) Cancer
3) COPD
What is the most common cause of COPD? Other etiologies? Genetic etiologies?
The most common etiology is cigarette smoking, which is associated with approximately 90% of cases of COPD.
Other etiologies of COPD include passive exposure to cigarette smoke (“second-hand smoke”) and occupational exposures to dusts (including mining, cotton, silica, plastics), chemicals, and fumes (welding, heavy metals).
Patients with symptoms of COPD, who do not smoke and work in high-risk occupations, warrant further evaluation. A rare cause of COPD is a genetic deficiency in α1-antitrypsin, which is more common in Caucasians and should be considered when emphysema develops at younger ages (<45 years), especially in nonsmokers.
COPD in younger person should make you think about?
α1-antitrypsin deficiency
COPD pathophysiology?
COPD is a disease of inflammation of the airways, lung tissue, and vasculature. Pathologic changes include mucous gland hypertrophy with hypersecretion, ciliary dysfunction, destruction of lung parenchyma, and airway remodeling. The results of these changes are narrowing of the airways, causing a fixed airway obstruction, poor mucous clearance, cough, wheezing, and dyspnea.
85% of dyspnea is caused by what 6 things?
1) congestive heart failure
2) COPD
3) asthma
4) interstitial lung disease
5) pneumonia
6) psychogenic disturbances (including anxiety)
Physical exam findings of COPD? (4)
During exacerbation? (5)
1) “barrel chests” (increased anteroposterior chest diameter)
2) distant heart sounds, as a result of hyperinflation of the lungs.
3) Breath sounds may also be distant
4) expiratory wheezes with a prolonged expiratory phase of respiration may be noted
5) During an acute exacerbation, patients often appear anxious and tachypneic; they may be using accessory muscles of respiration, usually have wheezes or rales, and may have signs of cyanosis.
Chest X-ray findings of COPD? (3)
1) increased posteroanterior (PA) diameter
2) flattening of diaphragms
3) Bullae—areas of pulmonary parenchymal destruction—can also be seen in x-rays in more severe disease
How do you diagnose COPD? Explain what the test means.
Spirometry (pulmonary function test)
In normal aging, both the forced vital capacity (FVC) (a measure of the total amount of air that can be expired after a maximal inspiration) and FEV1 reduce gradually over time. In normal-functioning lungs, the ratio of the FEV1 to FVC is greater than 0.7… meaning that in one second, a normal person can expire greater than 70% of the air that was maximally inspired within 1 second.
In COPD, both the FVC and FEV1 are reduced and the ratio of FEV1 to FVC is less than 0.7, indicating an airway obstruction. Reversibility is defined as an increase in FEV1 of greater than 12% or 200 mL. Using a bronchodilator may result in some improvement of both FVC and FEV1, but neither will return to normal, making the diagnosis of a fixed obstruction. The severity of COPD, which can help to determine treatment, can be assessed using these measurements (Gold Staging).
What is Gold Stage 0 COPD? How do you treat?
Gold Stage 0 is when someone is at risk for COPD. They have normal spirometry findings but have cough and sputum production. Treatment includes decreasing exposure to risk factors (e.g. smoking, second-hand smoke, occupational exposures, pollution, cooking smoke, etc)
What is Gold Stage 1 COPD? How do you treat?
Gold Stage 1 = mild COPD Spirometry shows: FEV1/FVC ratio under 0.7 FEV1 > or = 80% of predicted value With our without symptoms
Treatment includes short-acting bronchodilators (β2-agonists (albuterol) and anticholinergics (ipratropium))
What is Gold Stage 2 COPD? How do you treat?
Gold Stage 2 = moderate COPD Spirometry shows: FEV1/FVC ratio under 0.7 FEV1 between 50-80% of predicted value With or without symptoms
Treatment includes:
- short-acting bronchodilators (inhaled β2-agonists (albuterol) and inhaled anticholinergics (ipratropium)) for rescue
- long-acting bronchodilators (salmeterol (an inhaled β2-agonist) and tiotropium (an inhaled anticholinergic)) scheduled
What is Gold Stage 3 COPD? How do you treat?
Gold Stage 3 = severe COPD Spirometry shows: FEV1/FVC ratio under 0.7 FEV1 between 30-50% of predicted value With or without symptoms
Treatment includes short-acting bronchodilators (albuterol, ipratropium), long-acting bronchodilators (salmeterol, tiotropium), and inhaled steroids ((fluticasone, triamcinolone, mometasone, etc)
What is Gold Stage 4 COPD? How do you treat?
Gold Stage 4 = very severe COPD Spirometry shows: FEV1/FVC ratio under 0.7 FEV1 less than 30% of predicted value OR FEV1 less than 50% with chronic hypoxemia
Treatment includes short-acting bronchodilators (albuterol, ipratropium), long-acting bronchodilators (salmeterol, tiotropium), inhaled steroids (fluticasone, triamcinolone, mometasone) and long-term oxygen therapy. Surgical intervention can be considered on a case by case basis.
Oxygen therapy is recommended in stage IV COPD because chronic hypoxia leads to polycythemia, pulmonary hypertension, and peripheral edema suggesting heart failure. Oxygen therapy is the only intervention that has been shown to decrease mortality and must be worn for at least 15 h/d.
True or False: smoking cessation greatly improves pulmonary function in patients with COPD
FALSE.
All patients with COPD should be encouraged to quit smoking. The pulmonary function of smokers declines more rapidly than that of nonsmokers. Although smoking cessation does not result in significant improvement in pulmonary function, smoking cessation does reduce the rate of further deterioration to that of a nonsmoker.
Remember that COPD is a diagnosis of FIXED obstruction. This is different from asthma which is episodic with returns to normal baseline.
Which vaccinations should COPD patients get?
Pneumococcal vaccination and annual influenza vaccination.
A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea,
cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note
conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows
hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia.
Most likely agent? A. Staphylococcus species B. Chlamydia trachomatis C. Respiratory syncytial virus D. Parainfluenza virus
Chlamydia trachomatis
Chlamydial pneumonia
-usually seen in infants 3–16 weeks of age
-these patients frequently have been sick for several weeks
-nontoxic, afebrile, but tachypneic with a prominent
cough
-physical examination reveals diffuse crackles with few wheezes
-conjunctivitis is present in about 50% of cases.
-chest film will show hyperinflation and DIFFUSE interstitial or patchy infiltrates
-may have eosinophilia
Staphylococcal pneumonia
-sudden onset
-infant appears very ill and has a fever
-initially may have an expiratory wheeze simulating bronchiolitis
-Signs of abdominal distress, tachypnea, dyspnea,
and localized or diffuse bronchopneumonia or LOBAR disease may be present
-The WBC count will show a prominent leukocytosis.
Chlamydial infections can be differentiated from respiratory syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the mild wheezing. There may also be eosinophilia.
Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the
upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account
for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.
36-year-old obese female presents to your office with a chief complaint of amenorrhea. On
examination you note hirsutism and body acne. She is on no medications and a pregnancy test
is negative. Serum testosterone is at the upper limits of normal and TSH is within normal limits.
In addition to weight loss and exercise, which one of the following would be the most appropriate initial management?
A. High-dose combined oral contraceptives
B. Progestin-only contraceptives
C. Metformin (Glucophage)
D. Levothyroxine (Synthroid)
Metformin
This patient has polycystic ovary syndrome, which is characterized by hyperandrogenism on clinical and
laboratory evaluations, polycystic ovaries on pelvic ultrasonography, and ovulatory dysfunction.
Hyperandrogenism and either polycystic ovaries or ovulatory dysfunction are necessary to make the
diagnosis. The first-line recommendation in obese patients is lifestyle modification, but metformin may
improve abnormal menstruation. Low-dose combined oral contraceptives are more frequently used to reduce the risk of endometrial cancer in patients with chronic anovulation and the resulting unopposed estrogen secretion. This patient does not have thyroid dysfunction, so levothyroxine is not indicated.
A factory worker sustains a forced flexion injury of the distal interphalangeal (DIP) joint, resulting in a small bone fragment at the dorsal surface of the proximal distal phalanx (mallet fracture). Which one of the following is the most appropriate management strategy?
A. Buddy taping and early range of motion
B. Splinting the DIP joint in extension
C. Splinting the DIP joint in flexion
D. Referral for surgical repair
Splinting the DIP joint in extension
The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension. The usual duration of splinting is 8 weeks. It is important that extension be maintained throughout the duration of treatment because flexion can affect healing and prolong the time needed for treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar to those of surgical treatment and therefore is generally preferred.
Which one of the following drugs is NOT effective for maintenance therapy in bipolar disorders?
A. Haloperidol B. Lamotrigine (Lamictal) C. Lithium D. Quetiapine (Seroquel) E. Valproate sodium (Depacon)
Haloperidol
Lithium, valproate, lamotrigine, and some antipsychotics (including quetiapine) are effective treatments
for both acute depression and maintenance therapy of bipolar disorders. Haloperidol is an effective
treatment for acute mania in bipolar disorders, but not for maintenance therapy or acute depression.
A 30-year-old ill-appearing male presents with right hand and arm pain and a rapidly expanding area of redness. On examination he has a temperature of 38.9°C (102.0°F), a pulse rate of 120 beats/min, and a blood pressure of 116/74 mm Hg. He also has erythema from the dorsal hand to the elbow, violaceous bullae on the dorsal hand and wrist, and severe pain with dorsiflexion of the wrist or fingers.
Which one of the following is the most appropriate initial step in the management of this patient?
A. Oral dicloxacillin and outpatient follow-up within the next 24 hours
B. Intravenous metronidazole
C. Consultation with an infectious disease specialist for antibiotic management
D. Immediate surgical consultation for operative debridement
E. Incision and drainage with wound cultures in the emergency department
Immediate surgical consultation for operative debridement
This patient has physical findings consistent with a necrotizing skin and soft-tissue infection, or necrotizing
fasciitis. Severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration, are strong indications of necrotizing fasciitis. Antimicrobial therapy is essential but is not sufficient by itself; aggressive surgical debridement within 12 hours reduces the risk of amputation and death.
Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum levels of…
A. cortisol B. creatine phosphokinase C. creatine D. LDH E. TSH
TSH
Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a patient on amiodarone have baseline thyroid function tests (free T4, TSH) with follow-up testing every 6 months to monitor for these conditions. Hyperadrenalism and hypoadrenalism are not associated with amiodarone treatment.
A mother brings her 2-year-old daughter to your office because the child is not using her left arm. Earlier in the day the mother left the toddler under the supervision of her 12-year-old sister while she went to the store. When she returned the toddler was playing with toys using only her right arm, and was holding the left arm slightly pronated, flexed, and close to her body. The older daughter was unaware of any injury to the girl’s arm, and the child does not seem distressed or traumatized.
Physical examination of the child’s clavicle, shoulder, wrist, and hand do not elicit any signs of pain or change in function. She does seem to have some tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow.
Which one of the following would be most appropriate at this point?
A. Plain radiographs of the affected elbow
B. Ultrasonography of the affected elbow
C. Evaluation by an orthopedic surgeon within 24 hours
D. Attempted reduction of the subluxed radial head
E. Placement in a splint and follow-up in the office if there is no improvement in the next 1–2 weeks
Attempted reduction of the subluxed radial head.
Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in
children 1–4 years of age, although it can be encountered before 1 year of age and in children as old as 9 years of age. The mechanism of injury is partial displacement of the radial head when the child’s arm
undergoes axial traction while in a pronated and fully extended position. The classic history includes a
caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is
recalled.
As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt
reduction of the radial head before moving on to imaging studies. With the child’s elbow in 90° of flexion,
the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the
child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant
swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction,
then a plain radiograph is recommended.
A 12-year-old male uses a short-acting bronchodilator three times per week to control his asthma. Lately he has been waking up about twice a week because of his symptoms.
Which one of the following medications would be most appropriate?
A. Inhaled medium-dose corticosteroids
B. A scheduled short-acting bronchodilator
C. A scheduled long-acting bronchodilator
D. A leukotriene inhibitor
E. Ordering a free T 4
Inhaled medium-dose corticosteroids
This patient has moderate persistent asthma. Although many parents are concerned about corticosteroid
use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close growth plates and are the most effective treatment with the least side effects. Scheduled use of a short-acting bronchodilator has been shown to cause tachyphylaxis, and is not recommended. The same
is true for long-acting bronchodilators. Leukotriene use may be beneficial, but compared to those using inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring systemic corticosteroids.
Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?
A. Combined monophasic oral contraceptives
B. Combined multiphasic oral contraceptives
C. Subdermal etonogestrel (Nexplanon)
D. Intramuscular medroxyprogesterone (Depo-Provera)
E. NSAIDs
NSAIDS
The first-line treatment for primary dysmenorrhea should be NSAIDs. They should be started at the onset of menses and continued for the first 1–2 days of the menstrual cycle. Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized, controlled trials demonstrating pain improvement. They may be a good choice if the patient also desires contraception. Although combined oral contraceptives and intramuscular and subcutaneous
progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis, they are
not first-line therapy for primary dysmenorrhea.
While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ultrasonography. The most appropriate next step in the evaluation of this finding
is a…
A. serum calcitonin level B. serum free T3 level C. serum TSH level D. serum thyroglobulin level E. radionuclide thyroid scan
Serum TSH level
Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American Thyroid Association’s guidelines recommend that TSH be the initial evaluation and that this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study. Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended.
True or False: Inhaled medications are preferred over oral when treating COPD and asthma
True. Less side effects.
True or False: long-term oral steroids can be used to manage stage 3 and 4 COPD
FALSE. Long-term oral steroids is not recommended.
Long-term systemic steroids causes problems like osteoporosis, myopathy, and glucose intolerance.
True or False: antibiotic prophylaxis is recommended to decrease number of exacerbations in stage 3 and 4 COPD
False.
While antibiotic prophylaxis does decrease the number of exacerbations, it does not reduce rate of mortality and the risk of antibiotic resistance makes this a controversial issue.
For very severe COPD (gold stage 4), oxygen therapy is the only intervention that has been shown to decrease mortality. How any hours a day must oxygen be worn to make a difference? must be worn for at least 15 h/d.
At least 15 hours a day.
It is important for patients to prevent chronic hypoxia as hypoxia leads to polycythemia, pulmonary HTN, and peripheral edema 2/2 right-sided HF.
What is an acute COPD exacerbation?
Acute exacerbations of COPD are common and typically present with change in sputum color or amount, cough, wheezing, and increased dyspnea.
What is the most common cause of COPD exacerbation? What is another common cause?
Respiratory tract infections (viral or bacterial) are the most common cause. Air pollutants are another common cause of acute COPD exacerbations.
For COPD exacerbation, what o2 saturation level are you targeting when giving oxygen supplementation? What a PaO2 level?
Oxygen should be given with a target saturation of 88% to 92% or PaO2 levels at about 60 mm Hg.
A patient with severe COPD exacerbation is admitted to the hospital. What serum study should be ordered?
Baseline arterial blood gas should be ordered to evaluate for hypercapnia, hypoxemia, and respiratory acidosis.
A 38-year-old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators. Which of the following is the most likely etiology?
a1-antitrypsin deficiency
This patient has a fixed airway obstruction consistent with COPD. The airway obstruction of asthma would be at least partially reversible on testing with a bronchodilator. α1-Antitrypsin deficiency should be considered in a patient who develops COPD at a young age, especially if there is no other identifiable risk factor.
A 68-year-old patient of your practice with known COPD has pulmonary function testing showing an FEV1 of 40% predicted has been having frequent exacerbations of his COPD. His SaO2 by pulse oximetry is 91%. Which of the following medication regimens is the most appropriate?
A. Inhaled salmeterol BID and albuterol as needed
B. Oral albuterol daily and inhaled fluticasone BID
C. Inhaled fluticasone BID, inhaled tiotropium BID, and inhaled albuterol as needed
D. Inhaled fluticasone BID, inhaled tiotropium BID, inhaled albuterol as needed, and home oxygen therapy
C. Inhaled fluticasone BID (inhaled steroid), inhaled tiotropium BIC (inhaled long-acting bronchodilator), and inhaled albuterol as needed (inhaled short-acting rescue bronchodilator)
This patient has stage III COPD with frequent exacerbations. He is best treated by a long-acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) used regularly, along with an inhaled, short-acting bronchodilator on an as-needed basis.
A 59-year-old man with a known history of COPD presents with worsening dyspnea. On examination, he is afebrile. His breath sounds are decreased bilaterally. He is noted to have jugular venous distension (JVD) and 2+ pitting edema of the lower extremities. Which of the following is the most likely cause of his increasing dyspnea?
A. COPD exacerbation
B. Pneumonia
C. Cor pulmonale
D. Pneumothorax
Cor pulmonale
JVD and lower extremity edema are suggestive of cor pulmonale, which is right heart failure due to chronically elevated pressures in the pulmonary circulation. Right heart failure causes increased right atrial pressures and right ventricular end-diastolic pressures, which then lead to liver congestion, jugular venous distension, and lower extremity edema.
Patient presents to the ED with dyspnea. What do you do first?
Always remember to evaluate the ABCs—Airway, Breathing, Circulation—when evaluating a dyspneic patient.
45-year-old man sudden onset of knee joint pain no hx of trauma rapid onset no prior episodes vitals: 98/90/22/129.88/94RA Takes HCTZ, drank a lot of alcohol before symptoms started. Pain to movement and touch of left knee Knee is erythematous and warm to touch No other joints involved. WBC count is 10,900 cells/mm^3
What’s the next step for diagnosis?
Most likely diagnosis?
Next step in therapy?
What needs to be ruled out?
Next diagnostic step: Joint aspiration for examination of joint fluid to identify crystals and exclude infection
Most likely diagnosis: Crystal-induced gout of the left knee
Next step in therapy: Nonsteroidal anti-inflammatory drug (NSAID) and provide analgesia; may consider using colchicine
Need to rule out septic joint. A joint becomes septic by blood inoculation, by contiguous infection (such as from bone or soft tissue), or from direct inoculation from trauma or surgery. Exclusion of an infectious etiology is paramount as cartilage can be destroyed within the first 24 hours of infection. In this case, the patient’s history and clinical scenario do not favor an infectious cause, although it cannot be excluded by history and physical examination alone.
At what age does gout typically occur in men? How about in women?
Men: typically age 30-50
Women: typically age 50-70 (postmenopausal)
Premenopausal women are less likely to suffer from gout due to the increased level of female sex hormones, which aid in the urinary excretion of uric acid.
True or False: African Americans have a decreased risk of developing gout
False. African Americans have an increased risk of developing gout
What are two drug classes that can increase the risk of developing gout?
1) diuretics
2) chemotherapeutic agents
What are some factors that may increase the risk of gout attack? (3)
1) Trauma
2) Surgery
3) Large meal
True or False: for gout work-up, the gross appearance of fluid collected from joint aspiration is similar between a septic joint and a gout attack.
True
The gross appearance of fluid is not very specific, as both a septic aspirate and a heavily condensed crystal-induced arthritis may have a thick, yellowish/chalky appearance.
To diagnose crystal-induced arthritis, polarizing microscopy must reveal monosodium urate (MSU) crystals, which will look like needles and have a strong negative birefringence. Other crystals that may be seen are calcium pyrophosphate dehydrate (CPPD), calcium hydroxyapatite, and calcium oxalate.
What are monosodium urate crystals (MSU) crystals and how do they look?
What are calcium pyrophosphate dihydrate (CPPD) crystals and how do they look?
What are calcium hydroxyapatite crystals and how do they look?
What are calcium oxalate crystals and how do they look?
Monosodium urate crystals (MSU) are from gout and look like needles with strong negative birefringence.
Calcium pyrophosphate dihydrate (CPPD) crystals are from pseudogout and can be rod-shaped, rhomboid-shaped, with weakly positive birefringence.
Calcium hydroxyapatite crystals are from calcium hydroxyapatite crystal deposition disease. On electron microscopy, you can see cytoplasmic inclusions that are nonbirefringent.
Calcium oxalate crystals have a bipyramidal appearance with strongly positive birefringence. These are mostly seen in end-stage renal disease patients.
Gout vs pseudogout?
GOUTY ARTHRITIS: Condition of excess uric acid leading to deposition of MSU (monosodium urate) crystals in joints
PSEUDOGOUT: Condition of joint pain and inflammation due to calcium pyrophosphate dehydrate crystals in the joints, which can be diagnosed by noting rod-shaped, rhomboid, weakly positive birefringence by crystal analysis
What are the 4 stages of gout?
1) asymptotic tissue deposition of crystals
2) acute gout flares
3) intercritical segments (occurring after an acute flare, but before the next flare)
4) chronic gout (symptoms of chronic arthritis and/or tophi).
Which joint is most closely associated with gout flares?
Classically, a gout attack involves the metatarsophalangeal joint of the first toe, called podagra, but it may involve any joint in the body.
WBC count of joint aspirate analysis for gout vs septic joint?
With gout (crystal-induced) arthritis, the WBC count is between 2,000 to 60,000 per microliter with less than 90% neutrophils. A septic joint will have an average of 100,000 WBC per microliter with more than 90% neutrophils.
Note that even if an aspirate suggests crystal-induced arthritis, the aspirate should still be cultured to rule out a coexisting or early infection.
True or False: serum uric acid is important to evaluate a gout flare.
False.
During an acute attack, the serum uric acid level may be normal or even low, likely as a result of the existing deposition of the urate crystals. Uric acid levels are, however, useful in monitoring hypouricemic therapy between attacks.
What tests should be ordered when an infected joint is suspected? (5)
1) Arthrocentesis with examination of synovial fluid
2) Blood culture
3) Gram stain
4) CBC
5) ESR
Bacterial infections of a joint occur most commonly in persons with what disease or disorder?
Rheumatoid arthritis. The chronic inflammation of joints coupled with the use of steroids predisposes this group to Staphylococcus aureus infections.
Other populations with increased risk include HIV patients and IV drug users.
What does the range of motion of a joint tell you when working up a patient with a painful joint?
A septic joint will have a very limited ROM due to pain coupled with a joint effusion and fever. However, a nearby cellulitis, bursitis, or osteomyelitis will usually maintain the ROM of a joint.
Osteoarthritis vs Rheumatoid arthritis?
Osteoarthritis:
- most commonly found in people older than 65 years
- associated with trauma, history of repetitive joint use, and obesity (specifically for knee OA)
- primarily affects the cartilage, but ends up damaging the bone surface, synovium, meniscus, and ligaments
- dull, deep, ache-type pain
- gradual onset and progressive worsening
- activity exacerbating the pain, and rest decreasing it
- pain can be constant in later stages
- bony crepitus may be present on passive ROM
- progresses to joint deformity with decreased ROM
- X-rays are normal at first but progress to bone sclerosis, subchondral cysts, and osteophytes
Rheumatoid arthritis (RA)
- can start at any age but typically starts 30 to 55 years old.
- initial presentation is varied (monoarticular intermittent, polyarthritis progressive, etc)
- 3:1 prevalence in women vs men
- proinflammatory cytokines in synovial cells of joints destroys cartilage and causes bony erosions
- Positive rheumatoid factor (RF) and anti-citrullinated protein antibody (anti-CCP), elevated ESR, and elevated CRP
- anemia, thrombocytosis, and low albumin
True or False: The level of hypoalbuminemia usually correlates with the severity of the rheumatoid arthritis
True
Typically, the lower the albumin, the worse the RA.
For gout attacks, what 3 drugs are typically used for analgesics?
1) NSAIDS
2) Glucocorticoids
3) Colchicine
In patients with recurrent gout attacks, chronic medication therapy can be used to maintain serum uric acid levels below ? mg/dL.
5 mg/dL
For patients with recurrent gout attacks, which medications can be used to maintain lower serum uric acid levels? Name 2 and describe what they do.
Probenecid: increases the urinary excretion of uric acid
Allopurinol: reduces the production of uric acid.
Someone presents with a swollen joint suggestive of gout attack. Can you give short-term corticosteroids as a first-line analgesic?
No. Don’t give steroids until you rule out septic joint.
How do you treat a septic joint?
The preferred treatment for septic arthritis includes IV antimicrobials and surgery for drainage of the infected joint. Methicillin-resistant S aureus (MRSA) will usually require vancomycin, but coverage with antibiotics is dependent on the specific organisms isolated.
How do you treat degenerative joint disease?
- mobility exercises
- maintenance of adequate ROM
- weight loss, if appropriate
- Intra-articular corticosteroid injections may provide relief for varying amounts of time, but should only be done every 4 to 6 months so as to avoid cartilage destruction.
- Surgery, such as joint replacement, is usually reserved for people with severe disease that affects their daily functions.
True or False: Intra-articular corticosteroid injections may provide relief for degenerative joint disease but should only be done every 3 months.
False!
Should only be done every 4-6 months so as to avoid cartilage destruction.
How do you treat rheumatoid arthritis? (7)
- patient education on disease progression, treatment options, and implications to lifestyle is essential
- exercises for joint mobility and strength to combat the natural course of RA which develops stiff, disabled joints.
- PT/OT
- Disease-modifying anti-rheumatic drugs (DMARDS) are the first-line agents for treatment of RA including methotrexate and sulfasalazine.
- NSAIDS, glucocorticoids, anticytokines, and topical analgesics can be used with DMARDS during the first month of treatment.
- Infliximab and etanercept are anticytokine agents
- monitor for hepatotoxicity
Name 2 disease-modifying anti-rheumatic drugs (DMARDS) used to treat rheumatoid arthritis.
Methotrexate and sulfasalazine
Name 2 anti-cytokine medications that can be used to help treat rheumatoid arthritis (in addition to the DMARDS).
Infliximab and etanercept
26 y/o man
fever, dysuria, left knee pain
Left knee is swollen, erythematous, tender
Denies hx of arthritis
What's the next step? A. CBC with differential B. X-ray of the knee C. Aspiration of synovial fluid D. Serum uric acid level
C. Aspiration of synovial fluid
Infectious arthritis would need to be high on the differential diagnosis because of the danger of gonococcal arthritis. The history supports this diagnosis. This patient needs a joint aspiration to look for gram-negative diplococci, crystals, and to obtain a sample for culture. He will likely require surgical drainage of the swollen joint and IV antibiotic therapy.
A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a body mass index (BMI) of 40 kg/m2. Which of the following is the best therapy?
A. Allopurinol B. Ibuprofen C. Methotrexate D. IV Ceftriaxone E. Oral glucocorticoids
B. Ibuprofen
Obesity is a risk factor for osteoarthritis, which is common in the knees and typically presents with a gradual onset and worsening of symptoms. Along with exercise and efforts to lose weight, an NSAID medication, such as ibuprofen, may provide symptomatic relief.
A 35-year-old man with hypertension presents with the sudden onset of right big toe pain. Which of the following is the best treatment?
A. Ibuprofen
B. Methotrexate
C. Colchicine
D. Intravenous antibiotics
C. Colchicine
Gouty arthritis often initially presents in the big toe (“podagra”) and the use of HCTZ, a common treatment for hypertension, also can increase the risk. Colchicine can provide effective acute treatment.
True or False: a red swollen joint does not need to be aspirated if the patient is afebrile and has no clear trauma for introduction of bacteria.
False
A red swollen joint always needs to be aspirated to rule out infection.
What is advanced maternal age?
Pregnant woman who will be 35 years or beyond at the estimated date of delivery (EDD).
What is isoimmunization?
The development of specific antibodies as a result of antigenic stimulation by material from the red blood cells of another individual. For example, Rh isoimmunization means a Rh-negative woman who develops anti-D (Rh factor) antibodies in response to exposure to Rh (D) antigen.
What are the indications for performing ultrasound in pregnancy? (5)
An ultrasound is not mandatory in routine, low-risk prenatal care.
An ultrasound is indicated for the evaluation of:
1) uncertain gestational age
2) size/date discrepancies
3) vaginal bleeding
4) multiple gestations
5) other high-risk situations (radiation exposure, etc)
What lab studies are recommended for the initial prenatal visit? (8)
1) CBC
2) hepatitis B surface antigen (HBsAg)
3) HIV
4) syphilis screening with a rapid plasma reagin (RPR)
5) urinalysis and urine culture
6) rubella antibody
7) blood type and Rh status with antibody screen
8) Papanicolaou (Pap) smear and cervical swab for gonorrhea and Chlamydia.
True or False: pregnant women should be examined with ultrasound if exposed to dental x-rays
FALSE
Risk for the baby is increased once the radiation exposure is greater than 5 rad; the radiation exposure from routine dental x-rays is 0.00017 rad.
What is asymptomatic bacteriuria (ASB) and what are the risks to the mother and/or baby if gone untreated? (3 risks)
ASYMPTOMATIC BACTERIURIA (ASB): 100,000 cfu/mL or more of a pure pathogen of a mid-stream voided specimen without clinical symptoms.
ASB in pregnant women increase risk of:
1) acute pyelonephritis
2) preterm delivery
3) low birth weight
When to introduce solid foods to infant’s diet?
4-6 months of age
Cow’s milk is not recommended for children until the age of?
12 mo
Ottawa Ankle Rules?
Radiograph is required if:
1) pain upon palpation of the midfoot zone or malleolar zones and bony tenderness over an area of potential fracture (E.g. distal fibula or tibia, lateral or medial malleolus, base of the 5th metatarsal, or navicular bone)
- OR-
2) inability to bear weight immediately after the injury and when evaluated by a physician
48 y/o male
4 week hx rectal pain with minimal rectal bleeding
Examination shows small tear of the anorectal mucosa at 6 o’clock position
Initial treatment?
Topical nitroglycerin
Drugs that dilate the internal sphincter including diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures. More serious tears often require an internal sphincterotomy.
Ventilator settings for ARDS? (2)
1) Lower tidal volume (6 mL/kg instead of the traditional 10-15 mL/kg)
2) High positive end-expiratory pressure settings
ARDS mortality rate may be as high as 55%. Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival.
Which one of the following should be monitored during testosterone replacement therapy?
a. PHQ-9
b. Fasting glucose levels
c. Fasting lipid profiles
d. Hematocrit
e. polysomnograpy
Hematocrit
Testosterone replacement therapy can cause erythrocytosis, so monitoring hematocrit at regular intervals is recommended.
Women form certain ethnic background may be offered specific genetic screening. What populations can be offered screening for which disorders? (4)
- African and African American - sickle cell trait
- French-Canadian or Ashkenazi Jewish - Tay-Sachs carrier state
- Southeast Asian and Middle Eastern - Thalassemia
- Ashkenazi Jews and Caucasian women - Cystic Fibrosis
Women who will be 35 years old or older at the anticipated time of delivery should be educated about age-related risk for? What should they be counseled about?
Down syndrome. Counseled about the available screening and diagnostic testing available.
True or False: pregnant women and those looking to become pregnant should be screened for tobacco use
True
What should you do for patients who have drug, tobacco, or alcohol dependence who are looking to become pregnant?
Educate about the risks and refer to rehab/treatment centers to quit the drug prior to conception.
Preconception counseling includes? (5)
Proper nutrition Proper exercise Financial readiness Social support during pregnancy and postpartum period Issues of domestic violence
Long-term-care facility of 60 residents.
Several patients experience fever, cough, and upper respiratory symptoms
2 patients test positive for influenza A (H1N1) virus
What to do?
a. chemoprophylaxis with appropriate medications for all residents
b. treatment initiated on an individual basis once testing confirms that a resident has influenza
c. prophylaxis only for staff who have had direct patient contact with a resident with laboratory-confirmed infection
d. no chemoprophylaxis for staff or residents who have been appropriately vaccinated
Chemoprophylaxis with appropriate medications for all residents.
The occurrence of two or more laboratory-confirmed cases of influenza A is considered an outbreak in a
long-term care facility. The CDC has specific recommendations for managing an outbreak, which include chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation
is recommended; however, it cannot be strictly enforced due to residents’ rights.
Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time?
A. An allergy evaluation B. Low-dose antihistamines C. Hydrocortisone cream 0.5% D. A sepsis workup E. Observation only
This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first week or two of life. No testing is usually necessary because of the distinct appearance of the lesions. The cause is unknown.
A 30-year-old female with a history of prolonged QT syndrome presents with severe acute bacterial sinusitis. Which one of the following antibiotics should be avoided?
A. Amoxicillin B. Clarithromycin (Biaxin) C. Amoxicillin/clavulanate (Augmentin) D. Moxifloxacin (Avelox) E. Cefuroxime (Ceftin)
B. Clarithromycin
Which one of the following is associated with treatment of COPD with inhaled corticosteroids?
A. An increased risk of monilial vaginitis B. An increased risk of bruising C. Consistent improvement in FEV1 D. A decreased risk of pneumonia E. Decreased mortality
B. An increased risk of bruising
Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia.
They also have the potential for increasing bone loss and fractures. They decrease the risk of COPD
exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.
A 5-year-old white male is brought to your office with a chief complaint of chronic nocturnal limb pain. His mother states that his pain is often severe enough that it awakens him at night and she often gives him ibuprofen to help alleviate his calf pain, but she has never seen him limp or
heard him complain of pain during the day. She also has not noticed any grossly swollen joints fever, rash, or weight change. She is concerned because of a family history of juvenile rheumatoid arthritis in a distant cousin. The physical examination is within normal limits, as are a CBC and an erythrocyte sedimentation rate.
Which one of the following would be most appropriate at this point?
A. Bilateral plain radiographs of the lower extremities B. Testing for antinuclear antibody C. Testing for rheumatoid factor D. Referral to orthopedic surgery E. No further workup
This patient has benign nocturnal limb pains of childhood (previously known as “growing pains”). These crampy pains often occur in the thigh, calf, or shin, occur in up to 35% of children 4–6 years of age, and may continue up to age 19. The pathology of these pains is unknown. The pain is nocturnal, without limping or other signs of inflammatory processes. The erythrocyte sedimentation rate and CBC are normal in this condition but testing is indicated in patients with chronic joint pain to rule out malignancy or infection. Rheumatoid factor and ANA have a low predictive value in primary care settings and
are not indicated in the pediatric population without evidence of an inflammatory process. Plain radiographs are more useful for excluding certain conditions such as cancer than for making a diagnosis of arthritis in children. Reassurance of the parents is indicated in this situation, along with instruction on supportive care and over-the-counter analgesics as necessary.
According to the guidelines developed by the JNC 8 panel, which one of the following should
NOT be used as a first-line treatment for hypertension?
A. ACE inhibitors B. Angiotensin receptor blockers C. Calcium channedl blockers D. β-Blockers E. Thiazide-type diuretics
D. B-blockers
In 2014 new evidence-based guidelines for blood pressure management were published by the panel
members of the Eighth Joint National Committee (JNC 8). They looked only at randomized, controlled
trials that compared one class of antihypertensive agent to another to develop the treatment
recommendations. ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and
thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood
pressure in the nonblack population, including patients with diabetes mellitus. B-Blockers were not
recommended for the initial treatment of hypertension because one study found there was a higher rate of
the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these
drugs compared to the use of an ARB.
A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness
accompanied by upper arm tenderness. On examination there is soreness about both shoulders
and the patient has great difficulty raising his arms above his shoulders. There is no visual
disturbance, and no tenderness over the temporal arteries. C-reactive protein is elevated and the
erythrocyte sedimentation rate is 65 mm/hr (N 0–17).
Which one of the following would help to confirm the most likely diagnosis?
A. The use of published validated diagnostic criteria
B. Synovitis of the glenohumeral joint on ultrasonography
C. A response to treatment with prednisone
D. A response to NSAIDs
E. A lack of systemic symptoms
C. a response to treatment with prednisone
This patient has characteristic features of polymyalgia rheumatica, a disease whose prevalence increases
with age in older adults but is almost never seen before age 50. Most people will have accompanying
systemic symptoms including fatigue, weight loss, low-grade fever, a decline in appetite, and depression.
There are no validated diagnostic criteria available to assist in the diagnosis. The treatment response to 15
mg of prednisone daily is dramatic, often within 24–48 hours, and if this response is not seen, alternative
diagnoses must be considered. NSAIDs are not useful in the management of polymyalgia rheumatica and,
in fact, are associated with high drug morbidity. Ultrasonography may be useful in making the diagnosis,
with typical findings of subdeltoid bursitis and tendon synovitis of the shoulders, but synovitis of the
glenohumeral joint is less common.
True or False: polymyalgia rheumatica and temporal arteritis is almost never seen before age 50
True
A 65-year-old male presents to an urgent care center with a foot ulcer. His past medical history
is significant for hypertension, COPD, and diabetes mellitus. He has been hospitalized several
times in the past year for COPD exacerbations and a hip fracture. He does not have any other
current problems.
On examination he has a temperature of 37.3°C (99.1°F), a pulse rate of 105 beats/min, a respiratory rate of 16/min, and a blood pressure of 142/83 mm Hg. His examination is unremarkable except for a 2-cm ulcer on the ball of his left foot that has 3 cm of surrounding erythema and some purulent drainage. His CBC is normal except for a WBC count of 14,300/mm3 (N 4300–10,800).
Which one of the following would be the most appropriate choice for initial treatment?
A. Amoxicillin/clavulanate (Augmentin)
B. Linezolid (Zyvox)
C. Ciprofloxacin (Cipro)
D. Ceftriaxone (Rocephin) and levofloxacin (Levaquin)
E. Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)
E. Piperacillin/tazobactam (zosyn) and vancomycin (vancocin)
This patient has a severe diabetic foot ulcer. It appears to be infected and there are signs of a systemic inflammatory response. This is an indication for intravenous antibiotics. Piperacillin/tazobactam and
vancomycin would be the most appropriate choice of antibiotics because together they cover the most common pathogens in diabetic foot ulcers, as well as MRSA, which is present in 10%–32% of diabetic foot ulcers. This patient has recently been hospitalized and would thus be at high risk for a MRSA infection. Moderate to severe diabetic foot ulcers are often polymicrobial and can include gram-positive cocci, gram-negative bacilli, and anaerobic pathogens.
A 70-year-old male with hypertension, benign prostatic hyperplasia, depression, and well-controlled diabetes mellitus sees you because of increasing fatigue. His medical history also includes stent placement for coronary artery disease. A physical examination is unremarkable except for decreased peripheral pulses. A CBC, basic metabolic profile, hemoglobin A1c level, free T4 level, and TSH level are all normal, except for a serum sodium level of 125 mEq/L (N 135–145). His serum osmolality is 268 mOsm/kg (N 275–290). His urine sodium level is 50 mEq/L (N <20) and his urine osmolality is 300 mOsm/kg.
Which one of the patient’s medications is most likely to cause this problem? A. Losartan (Cozaar) B. Tamsulosin (Flomax) C. Metformin (Glucophage) D. Atorvastatin (Lipitor) E. Sertraline (Zoloft)
E. Sertraline
Patients who are euvolemic but have hyponatremia, decreased sodium osmolality, and elevated urine osmolality are likely to have SIADH. Other causes to rule out include thyroid disorders, adrenal insufficiency, and diuretic use. Renal function has to be normal as well.
Common drugs that cause SIADH include SSRIs (particularly in patients over 65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, and NSAIDs. Treatment of the problem consists of discontinuing the offending drug. Temporary fluid restriction may also be required.
Which one of the following is the most common cause of unintentional deaths in children?
A. Motor vehicle accidents B. Drowning C. Poisoning D. Fires E. Falls
A. MVAs
Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent
cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most
effective way to prevent injury or death, and the American Academy of Family Physicians and the
American Academy of Pediatrics strongly recommend that physicians actively promote the proper use of
motor vehicle restraints for all patients. Drowning accounts for 10.9% of all unintentional deaths in
children, poisoning for 7.7%, fires 5.7%, and falls 1.4%.
A 45-year-old male presents with shortness of breath and a cough. On pulmonary function
testing his FVC is <80% of predicted, his FEV1/FVC is 90% of predicted, and there is no
improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide
(DLCO) is also low.
Based on these results, which one of the following is most likely to be the cause of this patient’s problem? A. Asthma B. Bronchiectasis C. COPD D. Cystic Fibrosis E. Idiopathic pulmonary fibrosis
E. Idiopathic pulmonary fibrosis
Based on the results of pulmonary function testing, this patient has a pure restrictive pattern with a low
diffusing capacity for carbon monoxide. Pulmonary fibrosis is compatible with this pattern. A patient with
any of the other listed diagnoses would be expected to have an obstructive pattern on testing.
A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest
pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An
EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion.
Which one of the following is the most appropriate initial treatment? A. β-Blockers B. Nitrates C. Glucocorticoids D. NSAIDs
Patients with acute pericarditis should be treated empirically with colchicine and/or NSAIDs for the first
episode of mild to moderate pericarditis. B-Blockers would only be appropriate if the cause of the patient’s
chest pain were an infarction or ischemia. Nitrates do not relieve the pain of pericarditis. Glucocorticoids
are typically reserved for use in patients with severe or refractory cases or in cases where the likely cause
of the pericarditis is connective tissue disease, autoreactivity, or uremia.
A 71-year-old female comes in for follow-up of hypertension. She is worried about her heart and
says that some of her friends have had stress tests and she would like to get one as well just to
be on the safe side. She has no chest pain, shortness of breath, or exercise intolerance, and a
complete review of systems is negative.
The patient’s current medications include lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol
succinate (Toprol-XL), 25 mg daily; and omeprazole (Prilosec), 20 mg daily. Her past medical
history includes hypertension, obesity, and gastroesophageal reflux disease. A physical
examination reveals a blood pressure of 130/70 mm Hg, a heart rate of 90/min, and a BMI of
31.2 kg/m2. An EKG 2 years ago was normal.
Which one of the following should be ordered to assess this patient’s cardiovascular risk?
A. A lipid profile B. A coronary artery calcification scor C. A C-reactive protein level D. An EKG E. An exercise stress test
A. A lipid profile
There is no indication for cardiac testing in a low-risk asymptomatic person, and testing may lead to harm
resulting from false positives. The U.S. Preventive Services Task Force does not recommend resting or
stress EKG testing for asymptomatic low-risk patients (D recommendation). Asymptomatic patients should
be risk stratified to assess the risk of chronic heart disease, and this patient should have a lipid profile for
risk stratification. Low-risk patients do not benefit from nontraditional risk assessments, including
high-sensitivity C-reactive protein or coronary artery calcium assessment.
Which one of the following is true regarding respiratory syncytial virus (RSV) infection?
A. Most infections in the United States occur between August and December
B. Corticosteroids should be a routine part of treatment
C. The diagnosis is usually based on positive serology
D. It is rarely associated with bacterial co-infection
D. It is rarely associated with bacterial co-infection
Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The
infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young
infants, prematurely born infants, or those with pre-existing heart/lung conditions, the infection can be
severe. In North America, RSV season is November to April. Treatment is primarily supportive, including
a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and
antibiotics are not routinely indicated. Routine laboratory and radiologic studies should not be
used in making the diagnosis, as it is based on the history and physical examination.
What months is respiratory syncytial virus most commonly seen in North America?
November through April
Remember:
In “N”orth “A”merica, the months of RSV are “N”ovember through “A”pril.
An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now
has difficulty with normal activities such as getting out of a chair and brushing her teeth. Her
medical problems include hypertension, diabetes mellitus, and hyperlipidemia. Her medications
include glipizide (Glucotrol), simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on
examination are within normal limits except for diffuse proximal muscle weakness and normal
deep tendon reflexes. A CBC, urinalysis, erythrocyte sedimentation rate, TSH level, and serum
electrolyte levels are normal. Her blood glucose level is 155 mg/dL and her creatine kinase level
is 1200 U/L (N 40–150).
Which one of the following is the most likely diagnosis? A. Statin-induced myopathy B. Polymyalgia rheumatica C. Guillain-Barre syndrome D. Diabetic ketoacidosis
A. Statin-induced myopathy
This patient is most likely suffering from a drug-induced myopathy caused by simvastatin, which is associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated erythrocyte sedimentation rate. Guillain-Barré syndrome is associated with depressed deep tendon reflexes. This case has no clinical features or laboratory findings that suggest ketoacidosis.
3 y/o F Cough, tactile fever, mild rhinorrhea 100.8F temp, mild tachypnia Well-appearing. Non-distressed Decreased breath sounds and crackles in right lower lung field No allergies to meds.
Which one of the following would be the most appropriate treatment? A. Amoxicillin B. Azithromycin (Zithromax) C. Cefdinir D. Moxifloxacin (Avelox) E. Ceftriaxone (Rocephin)
a. Amoxicillin
Amoxicillin is the recommended first-line treatment for previously healthy infants and school-age children
with mild to moderate community-acquired pneumonia (CAP) (strong recommendation; moderate-quality
evidence). The most prominent bacterial pathogen in CAP in this age group is Streptococcus pneumoniae,
and amoxicillin provides coverage against this organism. Azithromycin would be an appropriate choice
in an older child because Mycoplasma pneumoniae would be more common. Moxifloxacin should not be
used in children. Ceftriaxone and cefdinir can both be used to treat CAP, but they are broader spectrum
antibiotics and would not be a first-line choice in this age group.
True or False: Moxifloxacin should not be used in children
True.
It can cause problems in joints, bones, and tissues around bones.
When compared to a figure-of-eight dressing, which one of the following modalities of treatment
has been shown to have similar fracture-healing outcomes and increased patient satisfaction for
nondisplaced mid-shaft clavicular fractures?
A. A shoulder sling
B. A short arm cast
C. A long arm cast
D. Operative fixation
A. shoulder sling
Compared to figure 8 dressing, shoulder sling has been shown to have similar fracture healing rates in patients with non displaced mineshaft clavicular fractures. Shoulder slings are more comfortable, easier to adjust, and have reported increased patient satisfaction.
It should be noted that a Cochrane review of interventions for clavicle fracture pointed out that the studies of this problem were done in the 1980s and did not meet current standards. One of the conclusions of this review was that further research should be done.
6 y/o male Mother observes snoring and stop in breathing for a few seconds at a time. Child has day-time somnolence. Height and weight are normal. Polysomnography confirms OSA.
Which one of the following would be the most appropriate primary treatment?
A. Methylphenidate (Ritalin)
B. Lorazepam (Ativan)
C. Fluoxetine (Prozac) on a daily basis
D. A mouthguard
E. Adenotonsillectomy
E. Adenotonsillectomy
In children, OSA is most commonly due to enlarged tonsils and adenoids. Onset typically between ages 2-8, coinciding with peak tonsil growth. Adenotonsillectomy is the primary treatment for most non-obese children with OSA.
SSRIs can treat nightmares and suppress REM sleep.
Benzos can treat sleep terrors.
Methylphenidate is a stimulant used to treat ADHD.
The use of a mouthguard at night is recommended for management of TMJ syndrome to reduce excessive teeth grinding during sleep.
Slipped capital femoral epiphysis is most likely in which one of the following patients with no history of trauma?
A. A 3-day-old male with a subluxable hip
B. A 7-year-old male with groin pain and a limp
C. A 13-year-old male with knee pain
D. A 16-year-old female with lateral thigh numbness
B. 13 y/o male with knee pain
Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt (11–13 years of age for girls, 13–15 years of age for boys). While the cause is unknown, associated factors include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral epiphysis, in addition to being overweight. African-Americans are affected more commonly as well.
The patient may present with pain in the groin or anterior thigh, but also may present with pain referred to the knee. That is also the case for Legg-Calvé-Perthes disease, also known as avascular or aseptic necrosis of the femoral head. This condition most commonly occurs in boys 4–8 years of age. In addition to hip (or knee) pain, limping is a prominent feature.
Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is
attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity or wearing clothing that is too tight in the waist or groin. Developmental dysplasia of the hip is identified
by a click during a provocative hip examination of the newborn, using both the Barlow and Ortolani
maneuvers to detect subluxation or dislocation.
43 y/o F
T2DM
Morbid obesity
Recent diagnosis of symptomatic peripheral arterial disease.
Started on atorvastatin, offered a supervised exercise program, and discussed smoking cessation and interventions.
Which one of the following should be recommended to prevent cardiovascular events in this patient?
A. Aspirin B. Cilostazol (Pletal) C. Enoxaparin (Lovenox) D. Pentoxifylline E. Warfarin (Coumadin)
A. Aspirin
Patients with symptomatic peripheral arterial disease should be started on a daily dose of either aspirin or
clopidogrel to prevent cardiovascular events such as acute myocardial infarction or stroke
Weight classifications based on BMI in children?
Obese >95th percentile
Overweight 85th-95th percentile
Healthy weight 5th-85th percentile
Underweight <5th percentile
What is failure to thrive in pediatrics?
- weight below the third or fifth percentile for age
- deceleration of growth that has crossed two major growth percentiles in a short period of time
True or False:
Children who are raised in a bilingual environment may have some language and development delay.
True
Proficiency in both languages is often reached by age 5.
First dental visit?
By 12 months
35 y/o woman
PMH asthma
Chronic nasal congestion worse in spring and fall
Most likely dx? Treatment?
Allergic rhinitis
Tx: antihistamines, decongestants, intranasal steroids
Alone or in combination
Mild: treat with intranasal steroids
Moderate to severe: antihistamines and decongestants
Physical examination findings of allergic rhinitis?
- “allergic shiners” which are dark circles around the eyes related to vasodilation or nasal congestion
- “nasal crease” which is a horizontal crease across the lower half of the bridge of the nose caused by repeated upward rubbing of the tip of the nose by the palm of the hand
- swollen turbinates
- cobble stoning of posterior pharynx
- “dennie-morgan lines” - prominent creases below the inferior eyelid
What is the single greatest cause of preventable death?
Tobacco use
Pharmacologic therapy for smoking cessation? (2) What are their mechanisms of action?
Bupropion (wellbutrin), varenicline (chantix)
Bupropion blocks uptake of norepinephrine and dopamine. Varenicline is a partial nicotinic receptor agonist.
True or False: Varenicline (chantix) should be used with caution in anyone with a history of psychiatric disorders.
True. It has been associated with neuropsychiatric symptoms including changes in behavior, agitation, depression, and suicidal behaviors.
True or False: nicotine replacement therapy (gum, inhaler, nasal spray, lozenge, patch, etc) can be used in combination
True.
Combination has been shown to be more effective
What is the strongest risk factor for smoking initiation among children and adolescents?
Parental smoking
What are the 2 most common pitfalls in using nicotine supplementation?
1) only using nicotine supplementation when having withdrawal symptoms
2) failing to use nicotine gum correctly. The gum should be chewed briefly and then parked in the cheek.
What is the most common cause of microcytic anemia?
Iron deficiency
What is the serum iron, ferritin, TIBC in iron deficiency?
Low serum iron
Low ferritin
High TIBC
What causes macrocytic anemia? (2) How can you tell which is which?
B12 deficiency and folate deficiency
Homocysteine is elevated in both vitamin B12 and folate deficiencies, whereas methylmalonic acid is only elevated in vitamin B12 deficiency.
Folate deficiency is usually seen in what population?
Alcoholics
What is different with iron studies between anemia of chronic inflammation/disease and iron deficiency anemia?
In anemia of chronic inflammation, the iron stores (measured by serum ferritin) are normal but the capability of using the stored iron becomes decreased (Low TIBC- because inflammation hides away iron).
What is TIBC?
Think of it as your body’s ability to mobilize and use iron. It is high in iron deficiency because your body is deficient in iron (low serum iron and serum ferritin) but so it’s trying hard to mobilize and use what’s not there. In anemia of chronic inflammation, TIBC is low because inflammation causes your body to store/hide iron. Anemia of chronic inflammation can have low or normal serum iron but normal or high ferritin (stored iron).
What is the most common cause of B12 deficiency?
Lack of intrinsic factor from pernicious anemia
How long does it typically take for people on strict vegetarian or vegan diets to become B12 deficient?
Several years on strict diet
40 y/o man returned from mexico
Profuse, acute, non bloody diarrhea
Dry mucous membranes on examination
Ill family member with identical symptoms
What is the dx and treatment?
Acute gastroenteritis
Treat with oral or IV fluids and send for fecal leukocyte or fecal lactoferrin testing.
Fecal leukocytes will be elevated with infection. Fecal lactoferrin suggests bacterial infection as activated PMNs release lactoferrin. Lactoferrin is low in viral infections, making this test good for distinguishing viral from bacterial diarrhea. In general, parasite and ova evaluation is unhelpful unless the history strongly points towards a parasitic source or diarrhea is prolonged. While the majority of diarrheas are viral, self-limited, and do not need further evaluation, this particular patient traveled in Mexico so traveler’s diarrhea should be strongly considered and treated with appropriate antibiotic.
True or False: up to 90% of acute diarrhea is infectious in etiology
True
Acute diarrhea vs subacute vs chronic diarrhea?
Acute - fewer than 2 weeks
Subacute - 2-4 weeks
Chronic - longer than 4 weeks
Diarrhea within 6 hours of eating salad containing mayonnaise. Cause?
8-12 hours within ingesting food?
12-14 hours within ingesting food?
Staph Aureus (within 6 hours! acute… think of sketchy)
Clostridium perfringens (8-12 hours)
E coli (12-14 hours)
Diarrhea from undercooked chicken?
Salmonella or shigella
Diarrhea from undercooked hamburger?
E coli
Diarrhea from raw seafood? (3)
Vibrio, salmonella, or hepatitis A
Diarrhea in nursing homes and hospitals?
Think C difficile
Diarrhea from daycare? (3)
Shigella, Giardia, rotavirus
Diarrhea in AIDS patients?
Consider parasitic as well as the usual
True or False: any antibiotic can cause pseudomembranous colitis (c. diff)
True
When do you test for C diff toxins? (3)
Patients who develop diarrhea
- within 3 days of hospitalization
- during abx treatment
- within 3 months of discontinuing antibiotics
What class of antibiotics is typically used for traveler’s diarrhea prophylaxis?
Fluoroquinolones
Treatment for traveler’s diarrhea? (2)
Ciprofloxacin 500mg BID for 3 days
However, avoid quonolones in children and pregnant women. Give single 1,000mg azithromycin dose in pregnant women or 10mg/kg daily for 3 days in children.
Fluoroquinolones should be avoided in which 2 populations?
Children, pregnant women
Several friends develop vomiting and diarrhea within 6 hours after eating food at a party. What is the most likely etiology?
a. rotavirus
b. giardia
c. e coli
d. s aureus
e. cryptosporidium
Staph aureus
S aureus toxin usually causes vomiting and diarrhea within a few hours of food ingestion. Remember the sketchy.
40 y/o man travels to mexico and develops diarrhea 1 day after coming back to USA. Which of the following is the most likely cause?
a. rotavirus
b. giardia
c. e coli
d. s aureus
e. cryptosporidium
E coli
The most common cause of traveler’s diarrhea.
Woman eats raw seafood and 2 days later develops fever, abdominal cramping, and watery diarrhea. What’s the bug?
Vibrio cholera
Most common among people who eat raw seafood
Young daycare worker develops watery diarrhea. Which bug?
a. rotavirus
b. giardia
c. e coli
d. s aureus
e. cryptosporidium
rotavirus is the most common for watery diarrhea from daycare workers, especially in the winter
Treatment for c diff?
Metronidazole or oral vancomycin
What is contraindicated when a patient has c diff colitis?
Loperamide
True or False: USPSTF recommends against hormone replacement therapy for treatment of menopause symptoms (hot flashes, osteoporosis, etc)
True. The use of estrogen alone or combined with progesterone increases adverse cardiovascular outcomes, stroke, and venous thromboembolic disease.
The use of estrogen hormone replacement therapy is not advised and any use of estrogen replacement therapy should be of the lowest effective dose for the shortest effective time period.
Age for HPV three-series vaccination?
11-26 y/o
When to stop pap smears? (USPSTF rec)
Stop at age 65 in women who have had 3 consecutive negative pap results or two consecutive negative HPV results within the last 10 years. Basically… either two consecutive negative co-tests (5 years in between) or three negative pap smear cytologies (3 years in between)
Risks for osteoporosis? (13)
- Advancing age
- Tobacco use
- Low body weight
- Poor nutrition
- Caucasians
- Asians
- Family hx of osteoporosis
- Low calcium intake
- Sedentary lifestyle
- prolonged corticosteroid use
- chronic kidney or lung disease
- low testosterone in men
- hyperparathyroidism
True or False: half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime
True
Osteopenia vs osteoporosis?
Osteoporosis T score at or below -2.5
Osteopenia T score -1.0 through -2.4
USPSTF recommendation for DEXA scan in women. What age?
Women over age 65. If first scan is normal, there is no current recommendation for repeat screening.
A 21-year-old woman presents for her first Pap smear. She received the full HPV vaccine series at age 19. Assuming that her examination and Pap smear results are normal, when would you recommend that she return for a follow-up Pap smear?
A. 6 months, as the first Pap smear should be followed up soon to reduce the false-negative rate associated with this screening test
B. 1 year, as she is higher risk because of her age
C. 3 years, as the Pap smear was normal
D. 5 years, as she is at low risk because she received the HPV vaccine
3 years
How does hysterectomy change pap smear screening?
If cervix was removed with hysterectomy for benign indications, discontinue pap smear screening. If cervix is left, continue screening as usual.
What’s the number 1 killer of women in america?
CVD
Risk factors for CVD in women need to be managed as aggressively as they are in men
25 y/o man
inversion injury of right ankle during basketball game
Ankle is swollen but patient able to bear weight
No focal tenderness and no ligament laxity
Whats the dx? Further testing? Treatment?
Dx - sprain of right ankle Further testing? none Treatment? PRICE acronym Protection, rest, ice, compression, and elevation
NSAIDs PRN
PRICE acronym for sprain and strain treatment?
Protection Rest Ice Compression Elevation
(and NSAIDs PRN)
Which ligament is most commonly injured in ankle sprains?
ATFL
Anterior talofibular ligament
Which 3 ligaments can be injured with inversion injury ankle sprains?
Anterior talofibular ligament (ATFL), Posterior talofibular ligament (PTFL), and Calcaneofibular ligament (CFL)
What are the 3 grades of ankle sprains?
Grade 1: stretch of single ligament, minor swelling, no mechanical instability, no significant loss of function
Grade 2: partial ligament tain, severe pain, swelling, bruising, mild to moderate joint instability, pain with weight bearing, loss of range of motion
Grade 3: complete ligamentous tear, significant joint instability, swelling, loss of function, and inability to bear weight
True or False: ottawa ankle rules have a sensitivity approaching 100% in ruling out significant malleolar and midfoot fractures
True
Near 100% sensitive, however, specificity is around 30-50%
True or False: surgery is often needed for ankle sprains in the presence of chronic pain and persistent functional instability.
False
Surgery is rarely needed. Surgery for ankle sprains has been shown to increase stiffness of the joint, lead to longer recovery times, and result in impaired mobility when compared to conservative treatment only. Therefore, surgical consideration should be a last resort when all else has failed and should be discussed in a case by case manner.
Sprain vs strain?
Sprain - stretching or tearing injury of a ligament
Strain - stretching or tearing injury of a muscle or tendon
Empty can test. Muscle(s)?
Supraspinatus
External rotation. Muscle(s)?
Infraspinatus and teres minor
Internal rotation. Muscle(s)?
Subscapularis
Patient is unable to lower his arm slowly from a raised position
Large rotator cuff tear(s)
