Family and Rural Medicine Clerkships Flashcards

Question

USPSTF Dental Caries in Children from Birth Through Age 5 Years: Screening

Answer 1

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)

Answer 2

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)

Answer 3

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)

Answer 4

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)

Answer 5

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)

Answer 6

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.

Answer 7

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)

Answer 8

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)

Answer 9

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)

Answer 10

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)

Answer 11

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)

Answer 12

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)

Answer 13

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)

Answer 14

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)

Answer 15

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)

Answer 16

Pregnant Women: USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. (A)

Answer 17

Persons at High Risk for Infection: USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection. (B)

Answer 18

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)

Answer 19

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)

Answer 20

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)

Answer 21

Adolescents: recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. (D)

Answer 22

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)

Answer 23

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)

Answer 24

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)

Answer 25

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)

Answer 26

Asymptomatic adults at increased risk for infection: USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk. (B)

Answer 27

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)

Answer 28

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)

Answer 29

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)

Answer 30

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)

Answer 31

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)

Answer 32

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)

Answer 33

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)

Answer 34

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)

Answer 35

All Newborns: USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum. (A)

Answer 36

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)

Answer 37

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)

Answer 38

Women: USPSTF recommends against screening for ovarian cancer in women. (D)

Answer 39

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.

Answer 40

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)

Answer 41

Pregnant women: USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. (B)

Answer 42

Men: USPSTF recommends against prostate-specific antigen (PSA)–based screening for prostate cancer. (D)

Answer 43

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)

Answer 44

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)

Answer 45

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)

Answer 46

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)

Answer 47

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)

Answer 48

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)

Answer 49

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)

Answer 50

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)

Answer 51

Pregnant Women: USPSTF recommends that clinicians screen all pregnant women for syphilis infection. (A)

Answer 52

Adolescent and Adult Men: USPSTF recommends against screening for testicular cancer in adolescent or adult men. (D)

Answer 53

Adults: USPSTF recommends against screening for thyroid cancer in asymptomatic adults. (D)

Answer 54

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.

Answer 55

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)

Answer 56

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)

Answer 57

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)

Answer 58

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)

Answer 59

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)

Answer 60

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)

Answer 61

Health maintenance should be employed to prevent future disease. In general, the approach is 1) immunizations 2) cancer screening 3) screening for common diseases

Answer 62

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.

Answer 63

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.

Answer 64

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.

Answer 65

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.

Answer 66

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.

Answer 67

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

Answer 68

FOBT: recommended annually Sigmoidoscopy: every 3-5 years Colonoscopy: every 10 years

Answer 69

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.

Answer 70

FALSE. The USPSTF currently recommends against (Level D) routine screening for prostate cancer using digital examination or PSA. (both are bad)

Answer 71

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.

Answer 72

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.

Answer 73

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.

Answer 74

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.

Answer 75

- 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

Answer 76

- 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

Answer 77

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.

Answer 78

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.

Answer 79

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.

Answer 80

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.

Answer 81

Acute exacerbation of COPD Treatment: antibiotic, bronchodilators, systemic corticosteroids Reduce future episodes: smoking cessation, LABA, inhaled corticosteroids, influenza vaccine, pneumococcal polysaccharide vaccine

Answer 82

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

Answer 83

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.

Answer 84

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.

Answer 85

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

Answer 86

1) Cardiovascular disease 2) Cancer 3) COPD

Answer 87

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.

Answer 88

α1-antitrypsin deficiency

Answer 89

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.

Answer 90

1) congestive heart failure 2) COPD 3) asthma 4) interstitial lung disease 5) pneumonia 6) psychogenic disturbances (including anxiety)

Answer 91

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.

Answer 92

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

Answer 93

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).

Answer 94

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)

Answer 95

``` 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))

Answer 96

``` 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

Answer 97

``` 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)

Answer 98

``` 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.

Answer 99

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.

Answer 100

Pneumococcal vaccination and annual influenza vaccination.

Answer 101

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.

Answer 102

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.

Answer 103

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.

Answer 104

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.

Answer 105

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.

Answer 106

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.

Answer 107

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.

Answer 108

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.

Answer 109

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.

Answer 110

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.

Answer 111

True. Less side effects.

Answer 112

FALSE. Long-term oral steroids is not recommended. Long-term systemic steroids causes problems like osteoporosis, myopathy, and glucose intolerance.

Answer 113

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.

Answer 114

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.

Answer 115

Acute exacerbations of COPD are common and typically present with change in sputum color or amount, cough, wheezing, and increased dyspnea.

Answer 116

Respiratory tract infections (viral or bacterial) are the most common cause. Air pollutants are another common cause of acute COPD exacerbations.

Answer 117

Oxygen should be given with a target saturation of 88% to 92% or PaO2 levels at about 60 mm Hg.

Answer 118

Baseline arterial blood gas should be ordered to evaluate for hypercapnia, hypoxemia, and respiratory acidosis.

Answer 119

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.

Answer 120

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.

Answer 121

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.

Answer 122

Always remember to evaluate the ABCs—Airway, Breathing, Circulation—when evaluating a dyspneic patient.

Answer 123

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.

Answer 124

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.

Answer 125

False. African Americans have an increased risk of developing gout

Answer 126

1) diuretics | 2) chemotherapeutic agents

Answer 127

1) Trauma 2) Surgery 3) Large meal

Answer 128

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.

Answer 129

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.

Answer 130

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

Answer 131

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).

Answer 132

Classically, a gout attack involves the metatarsophalangeal joint of the first toe, called podagra, but it may involve any joint in the body.

Answer 133

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.

Answer 134

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.

Answer 135

1) Arthrocentesis with examination of synovial fluid 2) Blood culture 3) Gram stain 4) CBC 5) ESR

Answer 136

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.

Answer 137

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.

Answer 138

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

Answer 139

True Typically, the lower the albumin, the worse the RA.

Answer 140

1) NSAIDS 2) Glucocorticoids 3) Colchicine

Answer 141

Probenecid: increases the urinary excretion of uric acid Allopurinol: reduces the production of uric acid.

Answer 142

No. Don't give steroids until you rule out septic joint.

Answer 143

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.

Answer 144

- 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.

Answer 145

False! Should only be done every 4-6 months so as to avoid cartilage destruction.

Answer 146

- 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

Answer 147

Methotrexate and sulfasalazine

Answer 148

Infliximab and etanercept

Answer 149

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.

Answer 150

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.

Answer 151

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.

Answer 152

False A red swollen joint always needs to be aspirated to rule out infection.

Answer 153

Pregnant woman who will be 35 years or beyond at the estimated date of delivery (EDD).

Answer 154

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.

Answer 155

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)

Answer 156

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.

Answer 157

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.

Answer 158

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

Answer 159

4-6 months of age

Answer 160

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

Answer 161

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.

Answer 162

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.

Answer 163

Hematocrit Testosterone replacement therapy can cause erythrocytosis, so monitoring hematocrit at regular intervals is recommended.

Answer 164

1. African and African American - sickle cell trait 2. French-Canadian or Ashkenazi Jewish - Tay-Sachs carrier state 3. Southeast Asian and Middle Eastern - Thalassemia 4. Ashkenazi Jews and Caucasian women - Cystic Fibrosis

Answer 165

Down syndrome. Counseled about the available screening and diagnostic testing available.

Answer 166

Educate about the risks and refer to rehab/treatment centers to quit the drug prior to conception.

Answer 167

``` Proper nutrition Proper exercise Financial readiness Social support during pregnancy and postpartum period Issues of domestic violence ```

Answer 168

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.

Answer 169

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.

Answer 170

B. Clarithromycin

Answer 171

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.

Answer 172

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.

Answer 173

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.

Answer 174

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.

Answer 175

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.

Answer 176

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.

Answer 177

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%.

Answer 178

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.

Answer 179

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.

Answer 180

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.

Answer 181

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.

Answer 182

November through April Remember: In "N"orth "A"merica, the months of RSV are "N"ovember through "A"pril.

Answer 183

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.

Answer 184

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.

Answer 185

True. | It can cause problems in joints, bones, and tissues around bones.

Answer 186

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.

Answer 187

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.

Answer 188

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.

Answer 189

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

Answer 190

Obese >95th percentile Overweight 85th-95th percentile Healthy weight 5th-85th percentile Underweight <5th percentile

Answer 191

- 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

Answer 192

True Proficiency in both languages is often reached by age 5.

Answer 193

By 12 months

Answer 194

Allergic rhinitis Tx: antihistamines, decongestants, intranasal steroids Alone or in combination Mild: treat with intranasal steroids Moderate to severe: antihistamines and decongestants

Answer 195

1. “allergic shiners" which are dark circles around the eyes related to vasodilation or nasal congestion 2. "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 3. swollen turbinates 4. cobble stoning of posterior pharynx 5. "dennie-morgan lines" - prominent creases below the inferior eyelid

Answer 196

Tobacco use

Answer 197

Bupropion (wellbutrin), varenicline (chantix) Bupropion blocks uptake of norepinephrine and dopamine. Varenicline is a partial nicotinic receptor agonist.

Answer 198

True. It has been associated with neuropsychiatric symptoms including changes in behavior, agitation, depression, and suicidal behaviors.

Answer 199

True. Combination has been shown to be more effective

Answer 200

Parental smoking

Answer 201

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.

Answer 202

Iron deficiency

Answer 203

Low serum iron Low ferritin High TIBC

Answer 204

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.

Answer 205

Alcoholics

Answer 206

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).

Answer 207

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).

Answer 208

Lack of intrinsic factor from pernicious anemia

Answer 209

Several years on strict diet

Answer 210

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.

Answer 211

Acute - fewer than 2 weeks Subacute - 2-4 weeks Chronic - longer than 4 weeks

Answer 212

Staph Aureus (within 6 hours! acute... think of sketchy) Clostridium perfringens (8-12 hours) E coli (12-14 hours)

Answer 213

Salmonella or shigella

Answer 214

Vibrio, salmonella, or hepatitis A

Answer 215

Think C difficile

Answer 216

Shigella, Giardia, rotavirus

Answer 217

Consider parasitic as well as the usual

Answer 218

Patients who develop diarrhea - within 3 days of hospitalization - during abx treatment - within 3 months of discontinuing antibiotics

Answer 219

Fluoroquinolones

Answer 220

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.

Answer 221

Children, pregnant women

Answer 222

Staph aureus S aureus toxin usually causes vomiting and diarrhea within a few hours of food ingestion. Remember the sketchy.

Answer 223

E coli The most common cause of traveler's diarrhea.

Answer 224

Vibrio cholera Most common among people who eat raw seafood

Answer 225

rotavirus is the most common for watery diarrhea from daycare workers, especially in the winter

Answer 226

Metronidazole or oral vancomycin

Answer 227

Loperamide

Answer 228

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.

Answer 229

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)

Answer 230

1. Advancing age 2. Tobacco use 3. Low body weight 4. Poor nutrition 5. Caucasians 6. Asians 7. Family hx of osteoporosis 8. Low calcium intake 9. Sedentary lifestyle 10. prolonged corticosteroid use 11. chronic kidney or lung disease 12. low testosterone in men 13. hyperparathyroidism

Answer 231

Osteoporosis T score at or below -2.5 | Osteopenia T score -1.0 through -2.4

Answer 232

Women over age 65. If first scan is normal, there is no current recommendation for repeat screening.

Answer 233

If cervix was removed with hysterectomy for benign indications, discontinue pap smear screening. If cervix is left, continue screening as usual.

Answer 234

CVD Risk factors for CVD in women need to be managed as aggressively as they are in men

Answer 235

``` Dx - sprain of right ankle Further testing? none Treatment? PRICE acronym Protection, rest, ice, compression, and elevation ``` NSAIDs PRN

Answer 236

``` Protection Rest Ice Compression Elevation ``` (and NSAIDs PRN)

Answer 237

ATFL | Anterior talofibular ligament

Answer 238

Anterior talofibular ligament (ATFL), Posterior talofibular ligament (PTFL), and Calcaneofibular ligament (CFL)

Answer 239

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

Answer 240

True Near 100% sensitive, however, specificity is around 30-50%

Answer 241

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.

Answer 242

Sprain - stretching or tearing injury of a ligament Strain - stretching or tearing injury of a muscle or tendon

Answer 243

Supraspinatus

Answer 244

Infraspinatus and teres minor

Answer 245

Subscapularis

Answer 246

Large rotator cuff tear(s)

Answer 247

Examiner compresses tibia/fibula at mid-calf This tests for syndesmosis. Pain at anterior ankle joint (below where the examiner is squeezing) suggests syndesmotic ("high ankle") injury

Answer 248

Lachman - knee in 20 degree flexion, examiner pulls forward on upper tibia while stabilizing upper leg Anterior drawer - knee in 90 degree flexion, examiner pulls forward on upper tibia while stabilizing leg

Answer 249

Recommend knee x-ray with any one of the following 5 criteria: 1. age 55 or older 2. isolated patella tenderness 3. tenderness of the head of the fibular 4. inability to flex the knee at 90 degrees 5. inability to bear weight for 4 steps immediately and in the exam room (regardless of limping)

Answer 250

Rehabilitative exercises

Answer 251

X-ray Plain film x-rays are the diagnostic imaging test of choice for the initial evaluation of a painful joint. In patients who have normal x-rays and who have a suspected soft-tissue (ligament, tendon, or cartilage) injury, MRI scanning is usually the next most appropriate imaging study to perform. Adequate x-ray series must include at least 2 views at 90 degrees to each other.

Answer 252

A closed pocket containing pus

Answer 253

A blister greater than 0.5 cm in diameter (plural: bullae)

Answer 254

A closed, saclike, membranous capsule containing a liquid or semisolid material

Answer 255

A discoloration on the skin that is neither raised nor depressed

Answer 256

A small mass of rounded or irregular shape that is greater than 1.0 cm in diameter

Answer 257

A small, circumscribed elevated lesion of the skin that is less than 1.0 cm in diameter

Answer 258

A plateaulike, raised, solid area on the skin that covers a large surface area in relation to its height above the skin

Answer 259

A lesion through the skin or mucous membrane resulting from loss of tissue

Answer 260

A small blister less than 0.5 cm in diameter

Answer 261

Exposure to natural or artificial UV radiation

Answer 262

``` Family hx Fair skin Red or blonde hair Propensity to burn easily Chronic exposure to toxic compounds Suppressed immune system ```

Answer 263

Asymmetry Borders (well defined vs ragged or blurred) Color (uniform vs not) Diameter (less than 6 mm vs more) Elevation (flat surface vs raised surface.. raised being worse) Evolving (stable in size and appearance vs enlargement or bleeding))

Answer 264

1. avoid sun between 10am and 4pm 2. wear sun-protective clothing when exposed to sunlight 3. wear sunscreen with SPF (sun protection factor) at least 15 4. avoid artificial sources of UV radiation

Answer 265

True. Hematuria in adults should always be evaluated. If no source is found on a thorough initial workup, patients should be followed for at least 3 years to monitor for an underlying condition. In every case of a first-time microscopic hematuria, a repeat urinalysis with microscopy is required at 6 week interval before any other management is done. 5% turn out to have cancer. Other things on the differential are interstitial nephritis, glomerular disease, exercise induced, UTI, etc.

Answer 266

Interstitial nephritis caused by analgesics or other drugs

Answer 267

Renal glomerular disease

Answer 268

Graves disease

Answer 269

1. Propylthiouracil (PTU) 2. Methimazole 3. B-blockers to block peripheral effects of excessive thyroxine Definitive treatment is radioactive iodine. This is used only in adult patients who are not pregnant. It should not be used in children or breast-feeding mothers. Antithyroid drugs are especially useful in treating adolescents, in whom Graves disease may go into spontaneous remission after 6-18 months of therapy. Surgery is reserved for patients in whom medications and radioactive iodine ablation are unacceptable treatment modalities or in whom a large goiter is present that is compressing nearby structures or is disfiguring.

Answer 270

Acute hyper metabolic state associated with the sudden release of large amounts of thyroid hormone into circulation. Thyroid storm is a medical emergency that requires prompt attention and reversal of the metabolic demands of acute hyperthyroidism. Symptoms include fever, confusion, restlessness, and psychotic-like behavior. Exam may show tachycardia, elevated BP, fever, and dysrhythmias.

Answer 271

Autoimmune disorder caused by immunoglobulin IgG antibodies that bind to TSH receptors, initiating the production and release of thyroid hormone.

Answer 272

Autonomous thyroid nodule that secretes thyroxine. These nodules do not rely on TSH stimulation and continue to excrete large amounts of thyroxine despite low or nonexistent circulating TSH levels.

Answer 273

PTU for first trimester. Methimazole for the rest. Methimazole has adverse effects on fetal development and shouldn't be used until 2nd and 3rd trimesters.

Answer 274

PTU, methimazole, B-blockers

Answer 275

Hashimoto thyroiditis

Answer 276

True. Incidence of malignancy in solitary nodule is estimated at 5-6%

Answer 277

False. They are rarely malignant. A patient who has a thyroid nodule and is found to be hyperthyroid should have a radioactive iodine uptake study to confirm functionality of the nodule. Hyperfunctioning nodules are treated with surgery or radioactive ablation therapy, depending on the level of hyperthyroidism.

Answer 278

Biopsy (fine-needle aspiration)

Answer 279

Radioisotype scanning is contraindicated. FNA is safe during pregnancy and thyroidectomy can be performed relatively safely during the 2nd and 3rd trimester. However, because thyroid cancer is relatively indolent, it may be wise to defer definitive diagnosis and treatment until the postpartum period in patients with indeterminate lesions on FNA.

Answer 280

PTU Methimazole should not be used in the first trimester because it has adverse effects on fetal development

Answer 281

c. follow clinically until after delivery of child Thyroid cancer detected during pregnancy can usually be observed until after the pregnancy is complete. If needed, thyroid surgery can be performed safely in the 2nd or 3rd trimesters. The use of radioactive iodine is contraindicated in pregnancy.

Answer 282

c. repeat US in 6 mo For thyroid nodules that are less than 1 cm, benign appearing, and no presence of positive clinical history of thyroid cancers, observation and repeat thyroid US in 6 mo is appropriate. Thyroid nodules greater than 1 cm should undergo FNA, as this is a sensitive and specific test for thyroid nodules and can help to determine whether it is malignant

Answer 283

TSH level and thyroid ultrasound

Answer 284

FALSE Thyroid dx in pregnancy needs to be evaluated and treated as both hypothyroidism and hyperthyroidism can have serious effects on fetal development

Answer 285

Skeleton approx 98%

Answer 286

1. PTH 2. calcitonin 3. 1,25-dihydroxyvitamin D3 (calcitriol)

Answer 287

Calcitonin is produced by the thyroid parafollicular cells. When calcium levels increase, calcitonin attempts to lower calcium levels through renal excretion of calcium and by opposing osteoclast activation.

Answer 288

PTH is parathyroid hormone. It is produced by the parathyroid glands. When calcium is low, PTH causes osteoclast activation which mobilizes calcium from bone and effects calcium resorption at the kidneys, thereby retaining circulating calcium. PTH and Calcitonin do opposite things.

Answer 289

PTH increases calcium levels, decreases phosphate levels, and increases calcitriol (1,25-dihydroxyvitamin D3) levels.

Answer 290

Calcitriol is 1,25-dihydroxyvitamin D3. It acts as the GI tract to promote both calcium and phosphate absorption.

Answer 291

Hyperparathyroidism, Cancer (tumor secretion of PTH-rP)

Answer 292

1. primary hyperparathyroidism 2. malignancy (tumor secretion of PTH-rP) 3. hypervitaminosis A 4. immobilization

Answer 293

1. hypervitaminosis D 2. granulomatous disease (e.g. tuberculosis, sarcoidosis, hodgkin disease) 3. Milk alkali syndrome (excessive intake of calcium-containing antacids)

Answer 294

1. medications (thiazide diuretics, lithium) 2. rhabdomyolysis (calcium released from injured muscle) 3. adrenal insufficiency (increased bone resorption and increased protein binding of calcium) 4. thyrotoxicosis (usually very mild calcium elevation. increased bone resorption)

Answer 295

Stones, Bones, Abdominal moans, Psychiatric overtones Renal calculi, bone pain, poor concentration, weakness, fatigue, stupor, coma, abdominal pain, constipation, nausea, vomiting, pancreatitis, anorexia

Answer 296

Primary hyperparathyroidism is caused by an adenoma of one of the four parathyroid glands or hyperplasia of multiple. Secondary hyperparathyroidism is caused by parathyroid glands overproducing PTH in response to low serum calcium levels. Tertiary hyperparathyroidism is caused by parathyroid glands overproducing PTH in response to renal failure. Patients in renal failure initially present with hypocalcemia, hyperphosphatemia, and low vitamin D levels. If untreated, it leads to hyperplasia of the parathyroid glands, an increased PTH secretion, and subsequent hypercalcemia.

Answer 297

Genetic disorder related to a defect in a gene that codes for a calcium-sensing receptor. Consequently, simply measuring PTH alone may confound the diagnosis, which may be mistaken for primary hyperparathyroidism. To distinguish between these entities, a 24 hr urinary calcium level is obtained. In hyperparathyroidism, the kidneys spill calcium into the urine at a normal or elevated level. With FHH, the urinary calcium level is low.

Answer 298

Lung cancers, squamous cell cancers of the head and neck, and renal cell cancer

Answer 299

Age-related Macular Degeneration. This is characterized by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the loss of central vision. Treatment options for exudative AMD include laser photocoagulation, and intravitreal injections of vascular endothelial growth factor.

Answer 300

True However, if patients fail either of these screening tests, further testing with Folstein Mini-Mental State questionnaire should be performed.

Answer 301

Oral or written statements made by patients when they are competent that are intended to guide care should they become incompetent.

Answer 302

FALSE It's viral

Answer 303

Treat with bronchodilators, analgesics, and antitussives. Antibiotics have not been consistently shown to be beneficial. The illness is usually self-limited.

Answer 304

Acute bronchitis Treat with bronchodilators, analgesics, and antitussives. Antibiotics have not been consistently shown to be beneficial. The illness is usually self-limited.

Answer 305

1. Asthma 2. COPD 3. Malignancy 4. Postnasal drip 5. GERD 6. Medications (ACE inhibitors) 7. CHF

Answer 306

Amoxicillin and trimethoprim-sulfamethoxazole are widely used as first-line agents typically for 10 to 14 day regimens. Second-line agents include amoxicillin-clavulanic acid, 2nd or 3rd generation cephalosporins (cefuroxime, cofactor, cefprozil), fluoroquinolone, or macrocodes (azithromycin, clarithromycin)

Answer 307

FALSE Both viral and bacterial infections can cause tonsillar exudates.

Answer 308

1. abrupt onset sore throat and fever 2. tonsillar and/or palatal petechiae 3. tender cervical adenopathy 4. absence of cough

Answer 309

Features suggestive of mononucleosis include retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear.

Answer 310

FALSE Patients with infectious mononucleosis should be restricted from contact sports in which abdominal trauma may occur. Even minor trauma can cause splenic rupture from splenomegaly.

Answer 311

High specificity but low sensitivity. Positive rapid antigen would prompt antibiotic treatment while negative test should be followed by a throat culture. Rapid antigen tests can be conducted in a few minutes in the office or ED setting. Throat cultures are the gold standard for diagnosis of GAS infections. Cultures can take 1-2 days. This is acceptable in most instances as the risk of complication from GAS infections is low if treatment is instituted within 10 days of onset of symptoms.

Answer 312

``` 1 point for each: absence of cough enlarged/tender anterior cervical adenopathy fever of 100.4 or higher tonsillar swelling/exudates ``` one point is awarded if the patient is age 3-14 and one is deducted for the age of 45 or higher 0-1: no further testing and no abx indicated 2-3: perform rapid strep or throat culture and treat with abx if positive 4 or more points: consider empiric abx treatment

Answer 313

1. Rheumatic fever 2. Glomerulonephritis 3. Toxic shock syndrome 4. Peritonsillar abscess 5. Meningitis 6. Bacteremia

Answer 314

Penicillin 10 day oral therapy of penicillin V or intramuscular therapy of penicillin G. In penicillin-allergic patients, treatment options include cephalosporins and macrolides.

Answer 315

The afferent limb of the cough reflex is activated by the acid interfering with the upper respiratory system. GERD presents with a cough that gets worse in a supine position, heartburn and increased symptoms after meals. Although definitive test is 24-hour esophageal pH monitoring, GERD is usually a clinical diagnosis. A trial of PPI is both diagnostic and therapeutic.

Answer 316

DM patients

Answer 317

Surgical debridement of necrotic tissue and 4-6 weeks of IV antibiotics.

Answer 318

1. fever 2. ear pain 3. diminished hearing 4. vertigo 5. tinnitus

Answer 319

Prolonged, recurrent, or severe symptoms

Answer 320

Amoxicillin or Augmentin, trimethoprim-sulfamethoxazole, or 2nd and 3rd generation cephalosporins

Answer 321

1. mastoiditis 2. bacterial meningitis 3. brain abscess 4. subdural empyema

Answer 322

D. CXR to rule out pneumonia Acute bronchitis is a diagnosis of exclusion in the absence of clinical or radiographic findings concerning for pneumonia. In this patient with fevers, productive cough, and rales on lung examination, it is important to rule out pneumonia. If there is a strong clinical suspicion of community-acquired pneumonia, a CXR is not necessary and outpatient treatment with ABX can be initiated.

Answer 323

1. upper airway cough syndrome 2. asthma 3. GERD

Answer 324

A. treat empirically with abx Management of strep pharyngitis is frequently guided by modified Centor criteria, which calculates a probability of strep throat based on a scoring system. This patient gets one point for presence of fever over 100.8, tender cervical adenopathy, absence of cough, and age. You can reasonably consider an empiric abx treatment for GAS in her.

Answer 325

UACS is an umbrella term that encompasses a variety of upper respiratory conditions including rhinitis and sinusitis.

Answer 326

Class 1: angina only with unusually strenuous activity Class 2: angina with slightly more prolonged or slightly more vigorous activity than usual Class 3: angina with usual daily activity Class 4: angina at rest

Answer 327

Angina of new onset, angina at rest or with minimal exertion, or a crescendo pattern of angina with episodes of increasing frequency, severity, or duration.

Answer 328

MONA therapy Morphine (initiated rapidly if nitroglycerin cannot alleviate the discomfort) Oxygen (2-4 L/min nasal cannula, may discontinue after 6 hours if o2 sats normal w/o complications) Nitroglycerin (sublingually q5min x3, then advance to IV or transdermal routes) Aspirin (325mg chewed and swallowed)

Answer 329

Sildenafil and hypotension

Answer 330

Aspirin and antithrombotic treatment like heparin These reduce the risk of subsequent MI and cardiac death in patients with unstable angina. It is reasonable to give clopidogrel 300mg orally to patients with suspected ACS (without ECG or cardiac markers) who are either allergic to or have GI intolerance of aspirin

Answer 331

Diet with reduced saturated fat and cholesterol

Answer 332

ACE inhibitors Postinfarction ACE inhibitors prevent left ventricular remodeling and recurrent ischemic events.

Answer 333

Magnesium Give magnesium sulfate if levels are low

Answer 334

Pericarditis

Answer 335

Aortic dissection

Answer 336

Pneumothorax

Answer 337

Pulmonary embolism

Answer 338

Peptic ulcer disease

Answer 339

Pancreatitis

Answer 340

Costochondritis

Answer 341

Musculoskeletal The patient's chest wall must be palpated. Abdominal examination is also important as GI etiology is the 2nd most common culprit for chest pain in an outpatient setting. While the most common etiology in primary care settings is MSK, it is imperative to rule out cardiac cause of chest pain before making a msk-related diagnosis.

Answer 342

Nifedipine The patient has new onset angina. Rapid release, short-acting dihydropyridines (nifedipine) are contraindicated because they increased mortality in multiple trials. B-blocking agents are the agents of choice since they increase survival; nitroglycerin helps to abate chest pain, but has not been shown to impact survival.

Answer 343

A spectrum of processes associated with abnormal kidney function and progressive decline in GFR

Answer 344

End-stage renal disease is the irreversible loss of kidney function such that the patient is permanently dependent on renal replacement therapy (dialysis or transplantation). It is also defined as a GFR of less than 15 mL/min.

Answer 345

1. diabetes 2. HTN 3. glomerulonephritis

Answer 346

``` Normal: 90-120 Stage 1: >90 in the presence of signs of kidney disease such as proteinuria, hematuria, or abnormal renal structure Stage 2: 60-89 Stage 3: 30-59 Stage 4: 15-29 ESRD: <15 ```

Answer 347

Small kidneys

Answer 348

Renovascular disease

Answer 349

``` Hypovolemia Hypotension Infection leading to sepsis Drugs (NSAIDs, aminoglycosides, radiographic contrast) Urinary tract obstruction ```

Answer 350

CXR The patient has CKD with volume overload. Simple first step is to do a CXR to confirm what you already suspect--pulmonary edema. After initiating furosemide (lasix), the CXR may be repeated to see what degree the dieresis has improved the overload. Cardiac workup is also indicated but would not be the first step done.

Answer 351

B. stopping only clopidogrel 5 days before surgery Patients receiving DAPT who require bypass surgery should continue taking aspirin. Clopidogrel or prasugrel should be stopped 5 days before the surgery due to the increased risk of major bleeding during surgery.

Answer 352

C ph 7.5 pCO2 25 pO2 100 Anxiety, SOB, paresthesia, and carpopedal spasm are characteristic of hyperventilation Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is elevated and pCO2 is depressed.

Answer 353

c. glycemic control Optimal control of HTN, acidosis, volume depletion, and cholesterol are all important to prevent worsening renal function. DM is the leading cause of ESRD. Tight glycemic control can prevent microvascular complications of diabetes such as diabetic nephropathy, though it has not been shown to decreased significantly the occurrence of microvascular complications of DM such as CAD or peripheral vascular disease.

Answer 354

d. foley catheter The patient has an enlarged prostate that has caused urinary obstruction and potentially reversible renal failure, depending on at which point the obstruction is resolved. Placing the Foley catheter will usually allow for significant reversal of an elevated Cr. Following catheter placement, the urine output needs to be carefully monitored and the Cr repeated later. Another clue is the tense lower abdomen that is caused by a very enlarged bladder. It is especially important to rely on clinical examination skills in elderly patients who have less-than-optimal communication skills as a consequence of dementia or who have a history of stroke when evaluating for a cause.

Answer 355

FALSE Small kidneys should rarely be biopsied as the result of the biopsy will usually not alter the treatment or prognosis of the condition. Small kidneys usually reflect irreversible disease.

Answer 356

Trichomonas vaginalis Treat with metronidazole 2g by mouth in a single dose for both patient and her sexual partner. Metronidazole 500mg BID for a week is an alternate regimen.

Answer 357

1. Candida albicans 2. Trichomonas vaginalis 3. Polymicrobial mix of bacterial vaginosis (gardnerella vaginalis predominant)

Answer 358

Candida vaginitis: recent abx use, DM | Trichomonas vaginalis: hx of multiple sexual partners

Answer 359

Thick - candida Thinner, fishy - gardnerella Frothy, foul smelling, strawberry cervix - trichomonas vaginalis

Answer 360

Sample of discharge is examined both as a "wet mount" (mixed with a small amount of normal saline) and as a "KOH prep" (mixed with a small amount of 10% potassium hydroxide). On the wet mount, the examiner can evaluate the normal epithelial cells and look for white blood cells, red blood cells, clue cells, and motile trichomonads. The hyphae or pseudohyphae of candida are best seen on KOH prep.

Answer 361

It is a condition of excessive anaerobic bacteria in the vagina, leading to a discharge that is alkaline

Answer 362

Vaginal and/or vulvar infection caused by candida species, usually with heterogenous discharge and inflammation

Answer 363

Infection of the vagina caused by the protozoa T vaginalis, usually associated with frothy green discharge and intense inflammatory response.

Answer 364

Uncomplicated candidiasis can be treated with short-term intravaginal preparations (creams or vaginal suppositories) or single dose oral therapies (fluconazole 150mg). Treating of complicated or recurrent infection should begin with an intensive regimen for 10-14 days followed by 6 months of maintenance therapy to reduce the likelihood of recurrence. Treatment of sexual partners is not indicated unless symptomatic (e.g. male partners with balanitis)

Answer 365

1. multiple sex partners (as it is classified as a STD) 2. pregnancy 3. menopause

Answer 366

Although not an STD, it is associated with having multiple sex partners.

Answer 367

Treatment includes both oral and topical vaginal preparations of metronidazole or clindamycin. There are no advantages to any of these regimens with regard to cure rates or recurrence, although patients do report more satisfaction with the vaginal preparations. Treatment of sexual parters is not necessary and does not reduce the risk of recurrent infection.

Answer 368

FALSE approximately 50% of gonococcal infections and 70% of chlamydial infections are asymptomatic in women

Answer 369

Infection characterized by purulent or mucopurulent discharge from the endocervix, which may be associated with vaginal discharge and/or cervical bleeding. May be caused by gonorrhea and chlamydia.

Answer 370

Gonorrhea: Ceftriaxone 125mg IM Chlamydia: Azithromycin single 1,000mg oral dose OR doxycycline 100mg BID for 7 days. Treatment of sexual partners is advised. Typically treat for both as rate of co-occurance is significant.

Answer 371

PID is inflammation of the upper genital tract including pelvic peritonitis, endometritis, salpingitis, and tuboovarian abscess caused by infection with gonorrhea, chlamydia, or vaginal and bowel flora. The presence of lower abdominal tenderness with both adnexal and cervical motion tenderness, without other explanation of illness, is enough to diagnose PID. Other criteria that enhance the specificity of the diagnosis include temperature more than 101, abnormal cervical or vaginal discharge, elevated sedimentation rate, elevated CRP, and cervical infection with gonorrhea or chlamydia.

Answer 372

Pregnancy due to clinical similarity. Serum pregnancy test should be performed on all patients suspected of having PID

Answer 373

b. pH more than 4.5 Discharge of homogenous and fishy odor is most likely bacterial vaginosis associated with alkaline pH

Answer 374

c. oral fluconazole This patient most likely has candida vulvovaginitis, since her discharge appeared after her cystitis was treated with abx.

Answer 375

a. ceftriaxone IM and doxycycline orally An option for outpatient therapy of salpingitis (PID) is IM ceftriaxone and oral doxycycline. Could also use azithromycin over doxycycline.

Answer 376

e. all newborns The CDC recommends screening for hepatitis B in patients on hemodialysis, household contacts of individuals with chronic hepatitis B, patients on immunosuppressive therapy, and all pregnant women. Other individuals who should be screened include anyone exposed to bodily fluids of infected individuals, such as sexual partners or infants of infected mothers. Behavioral risk factors such as IV drug use are also an indication for screening. Patients from areas where HBsAg prevalence is >2% should also be screened.

Answer 377

Dilated veins in the hemorrhoidal plexus of the anus

Answer 378

Chronic constipation, straining for bowel movements, pregnancy, and prolonged sitting (e.g. truck drivers)

Answer 379

Conservative treatment: high-fiber diet, stool softeners, and precautions against prolonged straining When necessary, various surgical procedures can be performed for definitive treatment.

Answer 380

FALSE They are typically asymptomatic and found incidentally on endoscopy or bowel imaging studies. When symptomatic, they can cause massive painless bleeding.

Answer 381

Most diverticular disease is self-limited and stops bleeding on its own (75%). Recurrence rate of approximately 38%. When the bleeding is extremely heavy or fails to stop, surgical resection of the affected portion of the colon may be necessary. Asymptomatic diverticulosis is managed with dietary modification, primarily a high-fiber diet.

Answer 382

Diverticulitis is a painful inflammation and infection of a diverticulum. It frequently presents with LLQ abdominal pain with fever, nausea, diarrhea, and constipation. Perforation of a diverticulum resulting in peritonitis or intra-abdominal access formation can be a complication.

Answer 383

Diverticulitis is typically treated with bowel rest and antibiotics effective against gut flora. A combination of a quinolone and an agent for anaerobic organisms, such as metronidazole, is one commonly used regimen. I n severe cases, recurrent cases, or when perforation occurs, surgery is indicated.

Answer 384

Polyps are benign neoplasms of the colon

Answer 385

1. tubular adenomas (lowest risk of becoming malignant) 2. tubulovillous adenomas 3. villous adenomas (highest risk of becoming malignant)

Answer 386

d. start a bolus of IV normal saline The initial evaluation of this acutely ill patient is "ABC" for airway, breathing, and circulation. As he appears to be in hypovolemic shock, with tachycardia and hypotension, a bolus of a crystalloid fluid such as normal saline or lactated ringer solution is necessary before proceeding with any of the other evaluations.

Answer 387

c. high-fiber diet Asymptomatic diverticuli are common findings on screening colonoscopies. The initial management of this is a high-fiber diet. Diverticulosis by itself does not increase one's risk of developing colon cancer. Surgery is typically reserved for severe or recurrent symptomatic cases.

Answer 388

Pneumonia is an infection of lung parenchyma caused by agents that include bacteria, viruses, fungi, and parasites.

Answer 389

An inflammation of the lungs from a variety of noninfectious causes such as chemicals, blood, radiation, and autoimmune processes.

Answer 390

Upper airway colonization by potentially pathogenic organisms that are subsequently aspirated.

Answer 391

Pneumonia that occurs in persons who are not hospital in-patients or residents of long-term care facilities.

Answer 392

Influenza A and B Adenoviruses Respiratory syncytial viruses Parainfluenza viruses

Answer 393

Streptococcus pneumoniae Others: mycoplasma pneumoniae, haemophilus influenza, and moraxella catarrhalis

Answer 394

Atypical pneumonia are organisms that tend to cause bilateral, diffuse infiltrates, rather than focal lobar infiltrates on x-ray. 1. mycoplasma pneumoniae 2. chlamydia pneumoniae 3. legionella pneumophilia

Answer 395

1. hospitalization within 90 days 2. home infusion therapy 3. dialysis 4. resident of nursing home

Answer 396

1. all pathogens involved in community-acquired pneumonia 2. Pseudomonas 3. Klebsiella 4. Acinetobacter 5. Staphylococcus aureus

Answer 397

Staph. Aureus

Answer 398

Legionella

Answer 399

Pneumococcal pneumonia

Answer 400

True The presence of an infiltrate can confirm the diagnosis. Absence of an infiltrate does not rule out pneumonia as a diagnosis. A CXR can also identify a pleural effusion, which may be a complication of pneumonia

Answer 401

Pneumocystis jiroveci

Answer 402

Healthy persons: Macrolide (clarithromycin or azithromycin) or Doxycycline Patients w/ chronic comorbidities: Fluoroquinolones (levofloxacin, moxifloxacin) Combination of a B-lactam (high-dose amoxicillin, amoxicillin w/ clavulanate, cefpodoxime, or cefuroxime) plus a macrolide (clarithromycin or azithromycin)

Answer 403

25-30% And mortality rates for patients with bacteremia range from 20-30% and as high as 60% in the elderly.

Answer 404

If more than a minimal amount of fluid is present, as evidenced by significant blunting of the costophrenic angle on x-ray, it may be necessary to perform a thoracentesis with Gram stain and culture of the pleural fluid.

Answer 405

Drainage with chest tube or surgical procedure

Answer 406

1. all persons aged 65 and older (give both 23-valent and 13-valent in series) 2. all adults with chronic cardiopulmonary diseases 3. cigarette smokers 4. immunocompromised persons

Answer 407

That they increase the risk of suicidal thoughts and behaviors in children, adolescents, and young adults, especially in the first months of treatment.

Answer 408

1. nonadherence 2. inadequate duration of therapy 3. inadequate dosing

Answer 409

4-9 months

Answer 410

1. more rapid return of uterine tone with reduced bleeding and quicker return to nonpregnant size 2. more rapid return to pre pregnancy body weight 3. long-term reduced incidence of ovarian and breast cancer 4. contraceptive effects 5. convenience of always having a readily available feeding supply for the baby 6. lower cost (no need to purchase formula) 7. mother-child bonding 8. convenience

Answer 411

In breast-feeding women, the progestin-only "minipill" is recommended, as combined hormonal contraceptives can interfere with milk supply (reduce lactation)

Answer 412

3rd In breast-feeding women, ovulation and menstruation can be suppressed for much longer. Anovulation will persist for longer periods of time in women who exclusively breast-feed their babies.

Answer 413

1-4 days In breast-feeding women, this is best managed by increasing the frequency of feedings. In women who are not breast feeding, the use of ice packs, supportive bras, and SAIDs can reduce discomfort.

Answer 414

Oxytocin release assists with involution. Oxytocin increases during breast-feeding, so early breast-feeding is encouraged to assist involution. Supplemental oxytocin (Pitocin) given IV during or immediately after the 3rd stage of labor will also aid in increasing uterine tone.

Answer 415

6 weeks Assess for infection or retained placenta if involution doesn't occur by 6 weeks.

Answer 416

Loss of more than 500mL of blood after delivery. This occurs in 4% of vaginal deliveries. Early postpartum hemorrhage occurs within 24 hours of delivery, most often immediately postpartum. Late postpartum hemorrhage occurs between 24 hours and 12 weeks after delivery and is usually the result of abnormal placental site involution.

Answer 417

Tone (uterine atony) 70% Trauma (cervical, vaginal, or perineal lacerations; uterine inversion) 20% Tissue (retained placenta or membranes) 10% Thrombin (coagulopathies) 1%

Answer 418

Failure of the uterus to contract adequately results in continued bleeding from uterine vasculature. Uterine atony causes approximately 70% of postpartum hemorrhage.

Answer 419

1. prolonged labor 2. prolonged use of oxytocin during labor 3. large baby 4. grand multipara (5+ previous children)

Answer 420

Bimanual uterine compression and massage and administration of oxytocin IV or IM

Answer 421

Endometritis Treat with broad-spectrum abx that cover vaginal and GI flora such as ampicillin and gentamicin. Following C-sections, abx must also cover for anaerobes and a combination of clindamycin and gentamicin may be used.

Answer 422

Mastitis Prompt treatment with continued breast-feeding or pumping from the affected breast and antibiotics that cover staph infections are helpful in preventing breast abscess development. Mastitis should not result in discontinuation of nursing.

Answer 423

FALSE Mastitis should not result in discontinuation of nursing. Prompt treatment with continued breast-feeding or pumping from the affected breast and antibiotics that cover staph infections are helpful in preventing breast abscess development.

Answer 424

Yes. SSRIs are first-line therapy for postpartum depression as they are considered safe in breast-feeding.

Answer 425

1. ideal nutrition 2. increased resistance to infection 3. reduced risk of GI infections and atopic dermatitis

Answer 426

1. HIV infection 2. Miliary tuberculosis 3. acute hepatitis B 4. herpetic breast lesions 5. chemotherapy

Answer 427

3 weeks after delivery before starting combined OCPs as the risk of thromboembolic disease is higher after delivery. Breast-feeding women should avoid combined OCPs as they can decrease milk production. They should use progestin-only pills.

Answer 428

6 weeks after. Earlier placement is associated with increased rate of expulsion of the device.

Answer 429

True However, they should be refitted at the 6-week postpartum visit to ensure an appropriate fit.

Answer 430

99%, 6 months After 6 months, if menses start or if breast-feeding is reduced, the risk of pregnancy increases and alternate forms of contraception should be used.

Answer 431

c. institution of SSRI therapy and close follow-up This patient has postpartum depression. The symptoms are identical those of major depressive episode. The maternity blues is a self-limited condition that starts in the first postpartum week and resolves in the second. This patient still has these feelings at 6 weeks and appropriate management includes use of an SSRI, counseling, and close follow-up.

Answer 432

Cephalization of the pulmonary vasculature (upper lobe pulmonary vein dilation with lower lobe pulmonary vein constriction) which indicates increased preload. Later findings include interstitial pulmonary edema seen as perihilar infiltrates, often in a butterfly pattern. Kerley lines, which are spindle-shaped linear opacities in the periphery of the lung bases. Pleural effusions can also be found.

Answer 433

Echocardiography

Answer 434

Stabilization of the cardiopulmonary system. Supplemental oxygen, initially 100% via non-rebreather face mast, should be administered. If necessary, ventilation can be assisted with CPAP, BiPAP, or mechanical ventilation. Cardiac and continuous pulse oximetry monitors should be placed and IV access obtained.

Answer 435

Loop diuretic. Furosemide (Lasix) is generally the treatment of choice, both for its potent diuretic effect and for its rapid bronchial vasculature vasodilation.

Answer 436

Nitrates, particularly nitroglycerin when given IV, reduce myocardial oxygen demand by reducing preload and afterload. Nitroglycerin also can rapidly reduce blood pressure and is the treatment of choice in a patient who has CHF and whose BP is elevated. It should be avoided or used with caution in hypotensive patients.

Answer 437

ACEIs or ARBs These reduce preload, afterload, improve cardiac output without increasing heart rate, and inhibit tissue renin-angiotensin systems which improves myocardial relaxation and compliance. These reduce mortality and hospitalization. Survival is increased by 20% in patients with systolic CHF and with LV systolic dysfunction after MI even without signs or symptoms of CHF.

Answer 438

True Better outcomes are seen at higher doses, so patients should be maintained at the highest tolerable dose.

Answer 439

1. pregnancy 2. hypotension 3. hyperkalemia 4. bilateral renal artery stenosis 5. renal insufficiency

Answer 440

True They should preferentially be started when patients have minimal evidence f fluid retention and few symptoms. Initial doses should be low and titrated up over several weeks. B-blockers reduce sympathetic tone and the cardiac muscle remodeling associated with CHF. In combination with ACEIs, B-blockers improve mortality.

Answer 441

1. symptomatic bradycardia 2. AV block in absence of a pacemaker 3. hypotension 4. severe peripheral vascular disease 5. severe bronchospasm

Answer 442

Calcium channel blockers. The exception to this is the dihydropyridine calcium channel blocker amlodipine (Norvasc). This does not increase or decrease mortality and can be very effective in treating hypotension. Nondihydropyridine calcium blockers (diltiazem, verapamil) may be useful in heart failure caused by diastolic dysfunction, as they promote increased cardiac output by lowering heart rate, which allows for more ventricular filling time.

Answer 443

About 1/3 of patients with NYHA class 3 or 4 heart failure and reduced ejection fraction have ECG evidence of abnormal ventricular conduction, which causes ventricular dyssynchrony. This results in reductions in ventricular filling, left ventricular contractility, paradoxical septal wall motion, and worsening of mitral regurgitation. These patients can be helped with a biventricular pacemaker. This process, known as cardiac resynchronization therapy, has been shown to reduce mortality and hospitalization in patients with symptomatic CHF in spite of maximal medical therapy, as well as improve quality of life, exercise capacity, and LVEF.

Answer 444

c. B-blocker These are recommended to reduce mortality in symptomatic patients with HF. Digoxin is only recommended in patients who are already on maximal therapy. Amiodarone is used for treatment of arrhythmias.

Answer 445

D. 2-D echocardiography with doppler The most useful diagnostic tool for evaluating patients with HF is echocardiography to assess LVEF, LV size, etc. It should be performed during the initial evaluation. Chest radiography and 12-lead ECG should be performed in all patients presenting with HF but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure.

Answer 446

1. previous thromboembolic event 2. cerebral vascular disease 3. coronary occlusion 4. impaired liver function 5. known or suspected breast cancer 6. smokers (>15 cigarettes/day) older than 35 years 7. congenital HLD

Answer 447

1. severe vascular headache (classic migraine, cluster) 2. severe HTN 3. DM 4. Gallbladder disease 5. obstructive jaundice in pregnancy 6. epilepsy 7. morbid obesity

Answer 448

On the first day of menses

Answer 449

If a pill is missed, it should be taken as soon as possible and the next dose should be taken as usual. If two or more pills are missed, the patient should be directed to the package insert for instructions and additional backup contraception should be used for at least 7 days following resumption.

Answer 450

1. abx 2. barbiturates 3. antifungal meds

Answer 451

True. They should be considered irreversible. Although there has been some success in reopening the fallopian tubes and the vas deferent, the success rate is low.

Answer 452

d. condoms Protection from STDs for this patient, and prevention from transmitting HIV to her future patients is of utmost concern. Condoms are the most effective agents to prevent the transmission of STDs.

Answer 453

False Vasectomy is considered safer than tubal ligation.

Answer 454

1. ovarian cancer 2. endometrial cancer 3. iron-deficiency anemia 4. PID 5. fibrocystic breast disease

Answer 455

Marfan habits should be noted. These signs, which include arachnodactyly, an arm span greater than height, precuts excavated, tall-thin habits, high-arched palate, and ocular lens subluxations, should prompt further evaluation. Marfan patients can have aortic abnormalities that predispose to rupture during sports.

Answer 456

Left sternal boarder. Louder with standing and louder with valsalva.

Answer 457

1. adolescent with stigmata of Marfan syndrome 2. murmur suggestive of hypertrophic cardiomyopathy 3. grade 3/6 or louder systolic murmur 4. any diastolic murmur

Answer 458

Echocardiography

Answer 459

b. grade 1/6 diastolic murmur heard at the apex in a 16 y/o girl Any patient with a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of HOCM, or signs of marfan syndrome should be evaluated by a cardiologist prior to clearance to participate in athletics.

Answer 460

20/10 above 115/75

Answer 461

FALSE Elevated systolic blood pressure is a great risk for CVD complications than elevated diastolic pressure. Control of systolic blood pressure tends to be more difficult to achieve, and when it is achieved, the diastolic BP usually comes under control as well.

Answer 462

140/90, 150/90, 140/90

Answer 463

2 properly taken BP measurements at 2 or more office visits. (With appropriate technique... patient sitting quietly in chair with supported back and feet on the floor for 5 minutes with appropriately sized cuff for the patient.)

Answer 464

1. coarctation of the aorta 2. renovascular and renal disease 3. cushing disease 4. hyperthyroidism 5. hyperparathyroidism 6. hyperaldosteronism 7. pheochromocytoma 8. OSA

Answer 465

1. history 2. PE 3. cardiovascular risks 4. identification of possible 2ndary causes of HTN 5. determination of presence of end-organ damage

Answer 466

1. Funduscopic examination for signs of retinopathy 2. Oropharynx and neck signs of OSA 3. Palpation of the thyroid 4. Auscultation for carotid, femoral, and renal bruits 5. Palpation of peripheral pulses 6. Abdominal palpation for signs of organomegaly or aortic aneurysm 7. Complete cardiopulmonary examination

Answer 467

``` Serum potassium Creatinine (with GFR) Calcium Blood glucose Fasting lipids Hematocrit Urinalysis to look for proteinuria or cellular components suggestive of renal disease. ECG to evaluate for changes consistent with coronary artery disease and to screen for LVH. ``` (CMP, CBC, lipids, UA, ECG)

Answer 468

1. lose weight if overweight or obese 2. increase physical activity 3. reduce consumption of alcohol 4. smoking cessation 5. High K and high Ca diet, or Dash diet

Answer 469

They reduce BP in an amount comparable to single-agent drug therapy. Calcium and potassium are associated with lower blood pressure.

Answer 470

Eating plan rich in fruits, vegetables, and low fat or nonfat dairy. It mostly includes whole grains, lean meats (fish and poultry, nuts, and beans. It is high fiber and low to moderate in fat.

Answer 471

Thiazide diuretics or calcium channel blockers are first-line therapy in AA patients. Diuretics, calcium channel blockers, ACE inhibitor, or ARB for non-AA patients.

Answer 472

The goal of therapy is to attain and maintain goal blood pressure (140/90 in those under 60 y/o and 150/90 in those 60 y/o or greater). If goal BP is not reached with one agent after 1 month, then the physician can either increase the dose of the initial agent or add a second drug.

Answer 473

Calcium channel blocker or thiazide diuretic

Answer 474

ACE-I, ARB, thiazide diuretics, calcium channel blockers

Answer 475

Calcium channel blocker, thiazide diuretic, ACEI, ARB

Answer 476

B-blocker (especially if reduced systolic function), ACE, ARB

Answer 477

ACEI, ARB, B-blocker, Spironolactone

Answer 478

Normal blood pressure – Systolic <120 mmHg and diastolic <80 mmHg Prehypertension – Systolic 120 to 139 mmHg or diastolic 80 to 89 mmHg Stage 1 hypertension – Systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg Stage 2 hypertension – Systolic ≥160 mmHg or diastolic ≥100 mmHg

Answer 479

b. she is at risk for needing pharmacologic treatment This patient's BP falls within the definition of HTN but outside the need for immediate pharmacologic intervention, She would benefit from the institution of lifestyle modifications to reduce her risk of progression.

Answer 480

d. chlorthalidone In JNC 8 guidelines, Ca channel blockers, thiazides, ARBs, and ACEIs are first-line for non-black patients over age 60. In this case, B-blockers may worsen the depression. Thiazide diuretics may improve osteoporosis and reduce hypercalciuria which can reduce nephrolithiasis.

Answer 481

c. ACEI alone Thie patients BP goal is less than 140/90. He is above this goal so an ACEI or ARB is first-line therapy for a diabetic regardless of BMI or A1C. The dose of medication can be increased if the BP is not controlled after 1 month; or another agent can be added.

Answer 482

Renal parenchymal disease. Perform a UA, urine culture, renal US

Answer 483

Hypertrophic pyloric stenosis

Answer 484

Ongoing bowel ischemia

Answer 485

Age 3-6 weeks

Answer 486

Hypertrophic pyloric stenosis

Answer 487

FALSE Due to the early age and dramatic nature of the projectile vomiting, parents usually seek help before the infant becomes severely ill from not eating.

Answer 488

Upper GI series An upper gastrointestinal series (UGI) is a radiographic (X-ray) examination of the upper gastrointestinal (GI) tract. The esophagus, stomach, and duodenum (first part of the small intestine) are made visible on X-ray film by a liquid suspension. This liquid suspension may be barium or a water-soluble contrast.

Answer 489

Misplaced duodenum, duodenal obstruction with beak-like appearance of the contrast medium.

Answer 490

1. "button" batteries 2. foreign bodies that are lodged in the esophagus 3. sharp or elongated objects already passed through the stomach and duodenum should be tracked daily with X-rays to follow progress of the object. Those that do not advance within 3 days need surgery for removal.

Answer 491

Nasogastric tube

Answer 492

The presence of blood in the vomitus and a pneumomediastinum points to an esophageal perforation, most likely from a foreign body in the esophagus.

Answer 493

The young age, presence of projectile non bilious vomiting after feedings are the keys to this diagnosis. The diagnosis of pyloric stenosis is much more common in males than females.

Answer 494

This is the presentation of a malrotation that did not cause enough symptoms at a younger age to lead to a diagnosis.

Answer 495

An infant with bilious vomiting and abdominal pain has a volvulus until proven otherwise. The upper GI study is diagnostic of this condition.

Answer 496

The intermittent nature of the symptoms and the palpable mass are highly suggestive of intussusception.

Answer 497

These symptoms are characteristic of cholinergic syndrome, possibly caused by insecticide or nicotine poisoning.

Answer 498

1) Depression. Depression in the elderly can present with symptoms of memory disturbance known as pseudodementia. 2) hypothyroidism 3) B12 deficiency 4) neurosyphilis if there are high-risks factors or history of the disease 5) neuroimaging with noncontrast CT or MRI

Answer 499

Mild-moderate: cholinesterase inhibitors: donepezil, galantamine, rivastigmine Moderate-severe: NMDA antagonist: Memantine

Answer 500

False You can use them in combination

Answer 501

Frontotemporal lobe dementia

Answer 502

Normal pressure hydrocephalus

Answer 503

hyponatremia or abnormal calcium levels

Answer 504

1. anticholinergic medications 2. sedatives (benzodiazepines) 3. sleeping pills 4. narcotic pain medications

Answer 505

Metabolic syndrome is diagnosed when 3 or more of the following are met: - waist circumference > 102cm (M), >88 cm (F) - hypertriglyceridemia (>150mg/dL or on medications) - low HDL cholesterol (<40 if male or <50 if female) - HTN (BP >130 systolic or >85 diastolic, or on meds) - Fasting plasma glucose >100 or on meds for T2DM

Answer 506

``` Underweight <18.5 Normal 18.5 - 24.9 Overweight 25.0 - 29.9 Obese 30-39.9 Extreme obesity (aka morbid) >40 Super obesity >50 ```

Answer 507

500-1000 kcal/day This results in a weight loss of 1-2 lbs a week

Answer 508

5% 5-15% is a great goal

Answer 509

True It is very important for long-term weight management and CVD health benefits It can improve insulin sensitivity and glycemic control, decrease abdominal fat, and reduce cardiovascular risk

Answer 510

1. avoiding triggers 2. maintaining diet diaries 3. using portion-controlled plates 4. slowing rate of eating to enhance satiation 5. avoidance of high-risk situations 6. increasing physical activity 7. breaking repetitive behaviors such as watching TV while eating

Answer 511

30, 27 to 30 with comorbid conditions

Answer 512

Orlistat (selective inhibitor of pancreatic lipase resulting in reduced intestinal digestion of fat and increased fecal fat excretion) Lorcaserin (serotonin receptor agonist) Phentermine-topiramate (increased norepinephrine release)

Answer 513

Orlistat (selective inhibitor of pancreatic lipase resulting in reduced intestinal digestion of fat and increased fecal fat excretion). All others are anorexiants. Anorexiants increase satiation by affecting the monoamine system in the hypothalamus.

Answer 514

FALSE They are generally only recommended for short-term use. Their use should be tapered off after prolonged use or if there is lack of efficacy. Orlistat is the only one indicated for the long-term treatment of obesity. The pure stimulant medications should be for short-term use only.

Answer 515

40, or 35 with serious comorbid conditions

Answer 516

Restrictive (lap banding) and restrictive-malabsorptive (roux-en-y) Lap banding is a silicone gastric band that is laparoscopically placed around the upper stomach just distal to the gastroesophageal junction. The band has a balloon that is connected to a subcutaneously implanted port, which can be inflated or deflated to reduce the circumference of the band. Complications of the banding procedure are less common and less severe than gastric bypass, but the long-term weight loss may also be less. Roux-en-y gastric bypass is the construction of a small gastric pouch that empties into a segment of the jejunum. The small pouch and small outlet limits caloric intake and causes malabsorption.

Answer 517

Orlistat. All others are pure stimulant medications and should only be used short-term.

Answer 518

1. dietary restriction 2. increased activity 3. behavioral modifications

Answer 519

Subarachnoid hemorrhage

Answer 520

Temporal arteritis

Answer 521

Meningitis, encephalitis

Answer 522

Meningitis, brain abscess, metastasis

Answer 523

Vascular headaches typically throbbing unilateral in character, may be present w/ or w/o aura. High female predominance

Answer 524

The most common primary headache, typically presenting with pericardial muscle tenderness and a description of bilateral band-like distribution of the pain.

Answer 525

Unilateral headaches that have high male predominance, can be located in the orbital, supraorbital, or temporal region. Generally described as deep, excruciating pain lasting from 15 minutes to 3 hours. Headaches are episodic, but a small subset may have chronic headaches.

Answer 526

Aspirin, acetaminophen, and NSAIDS. Combination of analgesics containing caffeine are second-line options. Minimize risk of medication-overuse headaches by limiting drugs to treat acute headaches to 2-3 days per week. Avoid opioids and sedative hypnotics.

Answer 527

Ampitriptyline, mirtazapine, venlafaxine, calcium channel blockers, b-blockers

Answer 528

1st line: 100% oxygen at 6L/min and triptans

Answer 529

Formerly known as "rebound" headache may occur following frequent use of any analgesic or headache medication. This includes both prescription and nonprescription medications. Caffeine use is another culprit.

Answer 530

Nonoral medication like triptan delivered by injection or nasal spray.

Answer 531

c. call 911 and transfer patient to the nearest ER Acute onset most severe HA in a patient's life is concerning for subarachnoid hemorrhage. This is a medical emergency and the patient should be transported by EMS to the nearest emergency facility for stabilization and management.

Answer 532

``` <100: optimal 100-130: near optimal 130-160: borderline high 160-190: high 190 or greater: very high ```

Answer 533

<200: optimal 200-240: borderline high 240 or greater: high

Answer 534

<40: low | 60 or greater: high

Answer 535

1. known cardiovascular disease 2. LDL greater than 190 3. patients 40-75 y/o with DM and LDL greater than 70. 4. patients 40-75 y/o with 10-year CVD risk greater than 7.5% and LDL greater than 70.

Answer 536

No statin. Optimize other modifiable cardiovascular risk factors. Some may consider low-dose statin for greater than 7.5%

Answer 537

1. DM 2. hypothyroidism 3. obstructive liver disease 4. chronic renal failure 5. medications (progestins, anabolic steroids, corticosteroids)

Answer 538

Statins, ezetimibe

Answer 539

1. Active or chronic liver disease 2. relative contraindication with cytochrome P-450 inhibitors 3. cyclosporine 4. macrolides 5. antifungals

Answer 540

Atorvastatin Patient has known CHD

Answer 541

b. therapeutic lifestyle changes plus statin Patient has known CHD documented by recent MI. All guidelines recommend therapeutic lifestyle changes. Patients with known CHD should get high-dose statin therapy.

Answer 542

d. TSH Hypothyroidism is a potential cause of secondary dyslipidemia. TSH is reasonable to test in this setting. There is no indication to screen for CHD with an ECG or stress test as the patient is asymptomatic. Other tests to perform include fasting blood glucose, liver enzymes, and measurement of renal function.

Answer 543

Assess safety of the home situation. Direct questioning regarding levels of violence, the presence of weapons in the home, as well as the need for a plan for safety for the victim and others at home (children, elders) is critical. Resources and support, such as shelters, community-based treatment, and advocacy programs should be provided. It may be helpful to allow the patient to contact a shelter, law enforcement, family members, or friends, while still in the doctor's office.

Answer 544

FALSE The laws regarding clinician reporting of partner violence varies from state to state. Many states do not require contacting legal authorities if the victim of acute is a competent adult.

Answer 545

c. displaced posterior rib fracture. Most often the result of grabbing and squeezing the chest violently. It is very suspicious for abuse.

Answer 546

An official appointed to investigate individuals' complaints against maladministration.

Answer 547

True. Reporting of abuse of competent adults is not mandated by law in most states but suspected child and elder abuse is mandated.

Answer 548

Slipped capital femoral epiphysis. Hip pathology will frequently present with pain in the groin, thigh, or even knee.

Answer 549

Overweight adolescent males

Answer 550

Think congenital. Congenital dysplasia, dislocation, length discrepancy, bowing, etc.

Answer 551

Avascular necrosis of the femoral head

Answer 552

Treatment is usually conservative, with protection of the joint and efforts to maintain range of motion. Children who develop severe necrosis or who develop the disease at older ages may have a worse outcome and a higher risk of developing degenerative arthritis.

Answer 553

Slipped capital femoral epiphysis

Answer 554

Surgical pinning of the femoral head. Patients must be closely followed. Approximately 20-50% of them will develop avascular necrosis and 33% will develop SCFE in the contralateral hip.

Answer 555

Growing pains. This is a diagnosis of exclusion. You must rule out other diagnoses.

Answer 556

It is a self-limited inflammatory response that is a common cause of hip pain in children. It typically occurs in children ages 3-10 and is more common in boys than girls. It often follows a viral infection. A CBC and ESR should be drawn. With a normal CBC and ESR, and if follow-up can be assured, this child could be treated expectantly, given an oral nonsteroidal anti-inflammatory drug (NSAID) with the expectation of a recovery in a few days.

Answer 557

b. CBC and ESR The case presented is suspicious for transient synovitis following a viral illness. A CBC and ESR should be drawn. With a normal CBC and ESR, and if follow-up can be assured, this child could be treated expectantly, given an oral nonsteroidal anti-inflammatory drug (NSAID) with the expectation of a recovery in a few days.

Answer 558

FALSE Spiral fracture of the tibia is common resulting from twisting on a planted foot. This is classic for a toddler's fracture. Spiral fractures of other long bones (femur, humerus) are more suspicious for abuse.

Answer 559

Avascular necrosis of hip (Legg-Calvé-Perthes) This child is in the correct gender and age group with signs, symptoms, and radiologic findings associated with Legg-Calvé-Perthes disease. It is often a self-healing disorder. Treatment is focused on limiting pain and avoiding functional loss. Depending on severity and age, treatment may include watchful waiting, physical therapy, casting, and surgery.

Answer 560

Because of the high risk of bilateral disease, follow-up in SCFE cases should include examination and x-rays of the unaffected hip until the growth plate closes.

Answer 561

Fever that coincides with the administration of a particular drug and cannot otherwise be explained by clinical and laboratory findings. Resolution of the fever occurs with discontinuation of the suspected drug. Drugs that are usually implicated are β-lactams, sulfa derivatives, anticonvulsants, allopurinol, heparin, and amphotericin B.

Answer 562

1) β-lactams 2) sulfa derivatives 3) anticonvulsants 4) allopurinol 5) heparin 6) amphotericin B.

Answer 563

True As an integral part of informed consent prior to surgery, patients need to be made aware by the physician of the possibility of experiencing postoperative febrile episodes. 50% of patients who undergo major surgeries get postoperative febrile episodes. Most postoperative fevers are not infectious but require a good thorough history and physical to rule infectious causes out.

Answer 564

5 W's of postoperative fever 1) Wind (pneumonia) 2) Water (UTI) 3) Wound (SSI, surgical site infection) 4) Walking (DVT) 5) Wonder drugs (drug fever)

Answer 565

Atelectasis (partial collapse of peripheral alveoli) Instructing patients on deep inspiration and coughing, the use of incentive spirometry, and the provision of adequate pain control can facilitate the opening of alveoli. Without resolution of atelectasis, pneumonia may ensue.

Answer 566

72 to 96 (3-4 days)

Answer 567

C. Incision and drainage are the most important therapy for SSI. Antibiotics are used solely in cases of significant systemic involvement.

Answer 568

Fall and winter

Answer 569

Typically with clinical presentation. Imaging can confirm diagnosis with frontal neck x-rays showing the "steeple sign" which is indicative of subglottic narrowing of the tracheal lumen. When the diagnosis is uncertain, CT neck can offer a more sensitive evaluation.

Answer 570

Assess airway obstruction and give oxygen. Glucocorticoids and nebulizer epinephrine. Dexamethasone 0.60 mg/kg by mouth or parenterally as a single dose is beneficial for its long half-life and anti-inflammatory action. Nebulizer racemic (mixture of d-isomers and l-isomers) or L-epinephrine is typically reserved for patients with moderate-to-severe distress. It works with adrenergic stimulation which causes constriction of the precapillary arterioles, thereby leading to fluid resorption from the interstitium and improvement in laryngeal edema. Its B2 adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilator.

Answer 571

Usually Haemophilus influenzae. However, with the H influenzae type b (HiB) vaccine, Strep pyogenes is now the leading bug for epiglottitis.

Answer 572

Epiglottitis

Answer 573

It's a medical emergency. Visualization to confirm the presence of severely erythematous epiglottis is preferably done in the OR with an experienced surgeon or anesthesiologist. Endotracheal intubation should be done to reduce mortality rate. Patient should be kept calm to prevent sudden airway obstruction. Supplemental oxygen administration should be provided. Clinicians should avoid oral and throat examinations which can provoke anxiety and acute obstruction. Antibiotics (2nd or 3rd generation cephalosporins or ampicillin sulbactam), airway management, usually in setting of ICU with team ready to respond for intubation or tracheostomy.

Answer 574

"Thumb sign" or protrusion of enlarged epiglottis from anterior wall of the hypopharynx seen on lateral neck X-ray.

Answer 575

Uncommon life-threatening infection most often seen in 5-8 y/o. It often follows a URI that suddenly worsens with high fever, stridor, and cough. Treat bacterial tracheitis like epiglottitis. Abx, airway management, in ICU with team ready to respond for intubation or tracheostomy.

Answer 576

Bronchiolitis. Young kids are most affected owing to smaller, more easily obstructed airways and decreased ability to clear secretions. RSV accounts for 50-80% of cases with the rest being caused by parainfluenza, adenovirus, influenza, mycoplasma pneumoniae, chlamydia pneumoniae, and metapneumovirus.

Answer 577

Staph aureus

Answer 578

d. incision and drainage of abscess

Answer 579

Sufficient airflow is required for the airway to produced a wheezing sound. Disappearance of wheezing in a patient who initially presents with wheezing is an ominous sign that suggests complete blockage of airway or imminent respiratory failure.

Answer 580

False. Never do that plz.

Answer 581

Irritable bowel syndrome

Answer 582

Recurrent abdominal pain or discomfort at least 3 d/mo for the past 3 mo with 2 or more of the following: improvement with defecation onset associated with a change in the frequency of stool onset associated with a change in form (appearance) of stool. Criterion fulfilled for the past 3 months. Onset at least 6 months ago.

Answer 583

1. fever 2. anemia 3. involuntary weight loss greater than 10 lb 4. hematochezia 5. melena 6. family hx of ovarian or colon cancer 7. family hx of celiac or IBD

Answer 584

CBC to check for blood loss. | Age-appropriate colon cancer screening.

Answer 585

IgA tissue transglutaminase antibody | Antiendomysial antibody

Answer 586

d. colonoscopy Age-appropriate cancer screening of the colon is indicated for IBS patients due to high pretest probability.

Answer 587

Dicyclomine, an antispasmodic anticholinergic medication, can be used on a PRN basis for mild-to-moderate abdominal IBS pain. For more severe pain, low-dose TCAs, like amitriptyline, are beneficial.

Answer 588

False. Psychiatric disorders can worsen IBS symptoms but have not been shown to cause IBS directly. Successfully treating an underlying psychiatric disorder may improve IBS but will not likely resolve all symptoms of IBS.

Answer 589

Fiber supplementation (e.g. psyllium)

Answer 590

Stimulant or hallucinogen use. Withdrawal from opioids.

Answer 591

Opioid use

Answer 592

Naltrexone, acamprosate, disulfiram

Answer 593

Mitral valve prolapse. It's typically asymptomatic but can present with palpitations, fatigue, or dyspnea.

Answer 594

Get echocardiogram to establish a baseline. 2% of patients with MVP will have complications resulting in progression to mitral regurgitation with subsequent left-sided two-chamber enlargement.

Answer 595

Left atrium. It can happen 2/2 to mitral regurgitation.

Answer 596

470-men, 480-women

Answer 597

True The presence of LVH, prolonged QT, atrial enlargement, AV block, old MI, and delta waves can be detected.

Answer 598

B-blockers or calcium channel blockers (the rate control drugs)

Answer 599

1. carotid sinus massage 2. valsalva maneuver 3. cold applications to the face

Answer 600

IV Adenosine

Answer 601

B-blockers or calcium channel blockers (rate control drugs)

Answer 602

Class 1C such as flecainide and propafenone

Answer 603

Transesophageal echocardiogram (TEE) should be done prior to cardioversion in order to rule out the presence of a thrombus that might dislodge with the cardioversion.

Answer 604

Electrical defibrillation. V fib is not compatible with life and needs to be treated immediately.

Answer 605

Amiodarone

Answer 606

Amiodarone

Answer 607

Conditions that commonly result in ventricular fibrillation or tachycardia: 1. advanced dilated cardiomyopathy 2. long QT syndrome 3. hypertrophic cardiomyopathy 4. Brugada syndrome

Answer 608

Brugada syndrome is a genetically inherited condition that is characterised by abnormal electrocardiogram (ECG) findings and an increased risk of sudden cardiac death. Average age of death is 41. Usually happens in sleep. Can do genetic testing for diagnosis. Family hx important.

Answer 609

Primary rhythm disturbances. They make up about 40% of cases. While psychiatric (anxiety, panic), medication, metabolic, and structural heart disease can cause palpitations, you should never disregard the possibility of primary rhythm disturbances.

Answer 610

``` Premature atrial contractions Premature ventricular contractions Sinus tachycardia Sinus bradycardia WPW syndrome Sick sinus syndrome Supraventricular tachycardias Ventricular tachycardia ```

Answer 611

B. delta waves on ECG The presence of delta waves indicates WPW syndrome and the presence of an accessory tract that can be ablated by an electrophysiologist.

Answer 612

False Rapidly removing the stinger is preferable as leaving it in results in continued injection of the bee venom. Try scraping it off with a credit card rather than grasping it as grasping it can cause compression of the stinger causing increased venom release.

Answer 613

ABCs (airway, breathing, circulation) Intubation if necessary IV access Fluid resuscitation ASAP. Subcutaneous or intramuscular epinephrine ASAP and repeated 5-10 minutes if needed. Antihistamines, steroids, and bronchodilators may be required as well. Observation in hospital for 12-24 hours as symptoms can recur.

Answer 614

Epinephrine injector kits to carry with them for immediate access at all times

Answer 615

False. Most are not significantly dangerous. Area should be cleansed with soap and water and a cool compress should be applied to the area. NSAIDs and acetaminophen are recommended. Watch out for cellulitis from inoculated bacteria.

Answer 616

Local cleaning of wound(s) with soap and water, irrigation with sterile saline solution, and debridement of devitalized tissue should take place as soon as possible. For minor and superficial to shallow wounds, these treatments are often all that's required. Larger and deeper wounds are more likely to become infected.

Answer 617

Cats and humans - high risk Dog - 20% become infected

Answer 618

10 to 14 days of oral amoxicillin-clavulanate (augmentin)

Answer 619

amoxicillin-clavulanate (augmentin) for 5-7 days for moderate-to-severe wounds. 10-14 if cellulitis persists.

Answer 620

A punch to the mouth can cause a serious inoculation and infection to the knuckles of the puncher. Treat these wounds the same.

Answer 621

Non-contrast CT head

Answer 622

Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITHOUT acute infarction.

Answer 623

True. The complexity of the treatment regimens and frequently changing treatment guidelines warrants referral.

Answer 624

Below 200. Use TMP-SMX (BACTRIM)

Answer 625

50. Use Azithromycin or Clarithromycin

Family and Rural Medicine Clerkships Flashcards

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