Family Med Notes Flashcards
Which has stronger familial predisposition - type I or type II DM?
Type II DM
Stages of CKD
Stage I: GFR 90-100 Stage II: GFR 60-89 Stage III: GFR 30-59 Stage IV: GFR 15-29 Stave V: GFR <15 or dialysis
Diagnostic test to determine central vs peripheral cause of vertigo
Dix-Hallpike maneuver
Most common type of melanoma
Superficial spreading melanoma
Motor or sensory loss in all 4 limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria, and/or dysphagia — where is the stroke
Vertebrobasilar
AAA screening guidelines
One-time screening for AAA by ultrasound in MEN aged 65-75 who have ever smoked
No routine screening for women
Outpatient abx for diverticulitis
Amox/clav
TMP-SMX
Cipro
Hypertrophic cardiomyopathy gets _____ with valsalva
Worse
Only legally required immunization for travel (and only for some countries)
Yellow fever
Abx for cat bite
Amoxicillin/clav acid (5 days prevention, 10 days to tx)
Clindamycin + fluoroquinolone if allergic to PCN
What kind of drug is ezetemibe?
Decreases cholesterol by interfering with absorption in the gut
Mucopurulent cervicitis is caused by gonococcal infections 50% of the time, and chlamydial infections 70% of the time. What is the tx?
Ceftriaxone IM for gonorrhea
Doxycycline oral for chlamydia
[alternative is cipro for gonorrhea or azithromycin for chlamydia]
Excessive menstrual flow, or prolonged duration >7 days at regular intervals
Menorrhagia
[common cause is leiomyomas]
What should you monitor in pts on statins?
Liver enzymes
Causes of late decels
Uteroplacental insufficiency/maternal hypotension
Epidural anesthesia
Oxytocin, HTN, DM
GI lipase inhibitor that results in 9% weight loss
Orlistat
Gold standard for dx and tx of choledocholithiasis
ERCP
[usually performed in setting of acute cholecystitis with increased liver enzymes
H.influenzae vaccine should not be administered before age _______ as immune tolerance to the antigen may be induced
6 weeks
SVT can be treated with carotid massage, valsalva, cold application to face, or pharmacologically with ______
Adenosine
DEXA scans start at age _____, or _____ if high risk
65; 60
Growth curve shows decrease in weight first, followed by decrease in height — what 2 possibilities?
Failure to thrive
Constitutional growth delay
How do you treat elevated potassium in the setting of CKD?
Treat with sodium polystyrene sulfonate, insulin + glucose, and retention enemas
Insulin secretagogues that stimulate beta cells in the pancreas to secrete insulin; tendency to cause weight gain and lose effectiveness over time; cause hypoglycemia
Sulfonylureas
Most effective pharmacotherapy at preventing relapse of alcohol abuse
Acamprosate
[better results than disulfuram, naltrexone, and SSRIs]
Prophylaxis for recurrent UTI
Start with single dose post-coital abx
If that doesn’t work, daily single dose abx for 3-6 months
If symptoms recur, may need to continue for 1-2 years
T/F: CCBs may worsen systolic dysfunction in CHF
True — some may worsen it such as nifedipine, diltiazem, and nicardipine
[amlodipine and verapamil are fine]
DM patients are at risk for invasive external otitis (malignant) with ________ (bug)
Pseudomonas
Tx with surgical debridement and IV abx
Inflammation of eyelid with loss of eyelashes and scaling
Blepharitis
Pt presents with diarrhea and pneumonia, you suspect legionella, what is next diagnostic step?
Urine antigen test or direct fluorescent antibody test
Most common type of melanoma in african americans and asians, found under the nails, on soles of feet and palms of hands
Acral lentiginous
Best dx test when spinal stenosis is suspected
CT scan
Short acting insulin option
Regular insulin
[30-50 min onset, 60-120 min peak, 5-8 hr duration]
DASH diet is high in what 2 electrolytes?
K+ and Ca+
Ranson’s criteria assess severity and prognosis of pancreatitis, what are they?
Age >55 WBC >16,000 glucose >200 LDH >350 AST >250
Rocky mountain spotted fever presents with red macules on peripheral extremities that become purpuric and confluent. Treat with _______ that continues 2-3 days after pt is afebrile
Chloramphenicol
Stages of labor
- Onset of labor until cervix is completely dilated
- Complete dilation to delivery of fetus
- Delivery of fetus to delivery of placenta
Tx for scabies
Oral ivermectin
Blood pressure med that may cause nightmares
Propranolol
In women not breastfeeding, menstruation begins by the -___ postpartum month
3rd
5-15% of pts with colonic diverticulosis develop severe diverticular bleeding. It is unusual to find the source of bleeding during colonoscopy. ___________ should be the next diagnostic step
Tagged RBC scan
Up to what size can a skin lesion be before it is concerning for malignancy?
<6 mm
Most common type of skin cancer; pearly papules w/ central ulceration or telangiectasias; rarely metastasize
Basal cell
Growth curve shows simultaneous changes in height and weight
Familial short stature
Acute onset of severe vertigo lasting several days with symptoms improving over several weeks
A. Acoustic neuroma B. Vestibular neuronitis C. BPPV D. Meniere disease E. None of the above
B. Vestibular neuronitis
Twisting knee injury with sense of instability, feeling a “pop” and immediate effusion while still being able to bear weight
ACL
Enlargement of thyroid gland following viral illness and is often mildly tender
Subacute granulomatous thyroiditis
Skin cancer with irregularly shaped plaques/nodules w/ raised borders, bleed easily, scaly and ulcerated; higher rate of metastasis
SCC
What class of diuretic should be avoided in hypercalcemia
Thiazides
Major and minor criteria for CHF according to framingham heart study
Major (need 2) — PND, JVD, rales, cardiomegaly, pulmonary edema, S3, CVP >15, circulation time of 25 sec, hepatojugular reflex, wt loss of 4.5 kg over 5 days of tx
Minor — ankle edema, nocturnal cough, DOE, hepatomegaly, pleural effusion, decreased VC, tachycardia
Pt presents to ED with bilateral LE edema + s/s of CHF — what imaging do you order first?
CXR to rule-in CHF, followed by an echo
Tx for patellofemoral pain syndrome
Strengthen quadriceps and hip rotators
Postvoid residual that is diagnostic of overflow incontinence
> 200 ml
In pts with decreased sex drive and no other complaints or exam findings, assessment of hormone status is indicated. Testosterone levels should be checked in the morning when they peak, and free testosterone is a more accurate measure of androgen status. If free testosterone is low, workup continues to get FSH, LH, and PRL. Based on the following, what is the dx?
FSH and LH are high, and PRL is normal
Testicular failure
Most commonly reported symptom of hyperthyroidism
Tachycardia
[followed by fatigue, then weight loss, tremor, anorexia, and increased sweating]
Diabetic diagnostic criteria with HbA1c
- 5 and above = diabetes
5. 7-6.4 = pre-diabetic
When to vaccinate pregnant woman against varicella
Non-immune pregnant women or immunocompromised should not receive vaccine until after delivery
[household contacts of immunocompetent pregnant women do NOT need to delay vaccine]
Asthma symptoms <2x a week and nighttime sxs <2x a month
Mild intermittent
Which OCPs do not increase risk of venous thromboembolism?
Progestin only pills
What type of eye infection is characterized by deep boring eye pain, decreased vision, surrounding headache, and associated with autoimmune disease like RA or Wegeners?
Scleritis
[note that episcleritis is mild irritation compared to this]
Unilateral tinnitus and hearing loss; symptoms constant and slowly progressive. Vertigo, facial weakness, and ataxia can occur
A. Acoustic neuroma B. Vestibular neuronitis C. BPPV D. Meniere disease E. None of the above
A. Acoustic neuroma
Active phase of labor starts at ___cm of cervical dilation
3-4
Tx for cluster headache
Nifedipine
Mainstay of abortive tx is O2 and triptans
[other options are prednisone, indomethacin, lithium, verapamil, serotonin antagonists]
Most sensitive vs. most specific lab test for alcohol abuse
Most sensitive = GGT
Most specific = Elevated MCV
Side effects of metformin
Renal insufficiency (c/i if Cr >1.5)
Hepatic insufficiency or CHF
C/i in nursing moms
Define chronic renal failure
GFR <60 for 3+months
How do you differentiate Graves disease from thyroiditis?
T-99m radionuclide scan
Shows diffuse hyperactivity with graves
Shows patchy uptake with overall reduced activity in thyroiditis
EtOH guidelines in women, men, and pts>65
Women — no >7/week, no >3/one occasion
Men — no >14/week and no >4/one occasion
Pts >65 — no >1 drink/day
Hep A has early fecal shedding and is less infectious once patient is _______
Jaundiced
What do you do if pt complaining of classic UTI symptoms comes in and has a negative UA?
Get a culture
T/F: in pts clinically diagnosed with acute sinusitis, there is a significant difference between abx and placebo use
False — no significant difference
There IS a significant difference in pts with sinusitis dx by CT scan or bacteriology
Most common cause of hearing loss in elderly — associated with selective high frequency loss and difficulty with speech discrimination
Presbycusis
Tularemia presents with pain and ulceration at bite site; treat with ______ IM
Streptomycin
Normal fetal heart rate is 110-160, what causes bradycardia vs tachycardia?
Bradycardia = maternal hypothermia
Tachycardia = maternal fever
Tremor seen at rest and inhibited by movement
Parkinsonian tremor
Most common cause of death while traveling
Heart disease (2nd most common is accidents)
Diabetes diagnostic criteria regarding random glucose, fasting glucose and 2 hr plasma glucose
2 random glucose >200 with classic DM symptoms (polyuria, polydipsia, etc)
2 fasting glucose >125
2 hr plasma glucose >200 after 75 g glucose load
Naegles rule
Subtract 3 mo and add 7 days to first day of LMP
Fever, swollen thyroid, clinical manifestations of a bacterial illness
Suppurative thyroiditis
Which are more likely benign — hot or cold thyroid nodules?
Hot are more likely benign
Menstrual bleeding at irregular intervals
Metrorrhagia
Leading cause of severe vision loss in elderly; caused by atrophy of cells in central region of retinal pigment epithelium, resulting in loss of central vision
Macular degeneration
Growth curve shows height velocity slowing first, and may plateau before weight changes are seen. Dx?
Hypothyroidism
Women between the ages of ____-____ should get mammograms every _____
50-74; 2 years
Daily asthma sxs and nighttime sxs at least weekly
Moderate persistent
IBD characterized by continuous inflammation of the large bowel
UC
What to do if patient is currently pregnant and non-immune to rubella
Vaccinate EARLY in postpartum period
Macrocytic anemia with normal methylmalonic acid and increased homocysteine
Folate def
What lab abnormality is more suggestive of gallstone pancreatitis vs. pancreatitis due to alcohol or hypertriglyceridemia?
Elevated ALT
AAFP vs USPSTF prostate cancer screening recs
AAFP — insufficient evidence
USPSTF — recommends against
Most aggressive type of melanoma that is often invasive at the time of dx
Nodular
Palpable preauricular lymph node indicates what type of conjunctivitis?
Viral
T/F: HPV vaccine can be given in pregnancy
False
Subclinical hypothyroidism will progress at a rate of 2-5% per year. What are risk factors for progression?
Presence of autoantibodies
Old age
Female gender
TSH >10
Roux en Y is reserved for those with BMI >_____ or >______ with obesity related complications
40;35
Short acting insulin secretagogues that increase insulin secretion; taken no more than 2 hrs before meals because of rapid onset
Most valuable if fasting sugars are adequate but postprandial sugars are high
Meglitinides
Venous congestion, N/V, bloating, constipation, abdominal pain, decreased appetite, fluid retention, weight gain, edema, JVD, hepatojugular reflex, hepatic ascites, and splenomegaly
Right or left sided heart failure?
Right sided
HTN in pregnancy tx options
Methyldopa
CCBs
Tinnitus and low frequency hearing loss associated with attacks of vertigo lasting several hours that may be associated with N/V. Treat with diuretics and salt restriction
A. Acoustic neuroma B. Vestibular neuronitis C. BPPV D. Meniere disease E. None of the above
D. Meniere disease
Primary amenorrhea w/ normal secondary sex characteristics and normal initial labs. Next diagnostic step?
Progestin challenge test
If no withdrawal bleed — either inadequate estrogen production or outflow tract obstruction
Drug of choice for urge incontinence
Anticholinergics (oxybutynin and tolterodine)
______ is an osteoporosis tx that directly inhibits osteoclastic bone resorption and is considered an alternative in pts whom estrogen therapy is not recommended; also produces analgesic effect
Calcitonin
Hyperlipidemia tx that decreases TGs, increases HDL, and decreases LDL, but may increase insulin resistance
Niacin
T/F: bronchodilators improve the decline in function seen in COPD
False, symptomatic only
Asthma symptoms >2x a week but <1x a day, nighttime sxs >2x/month
Mild persistent
MOA of PTU vs. methimazole in tx of hyperthyroid
PTU — prevents peripheral conversion of thyroid hormone
Methimazole — inhibits organification
Sterile inflammation of meibomian gland of the eye; painful nodule
Chalazion
Thyroid _______ cells make calcitonin to lower Ca levels through renal excretion and by opposing osteoclast activation — decreasing Ca and P
Parafollicular
Lipid screening guidelines for women
Screen if >45 and no risk factors
[screen beginning at 20 if CAD risk factors]
IBD characterized by focal inflammation that may occur anywhere in GI tract
Crohns
Diabetes screening recommendation
Screen all pts >45 every 3 years
Gold standard diagnostic modality for CHF
Echocardiogram
Pulmonary congestion, DOE, PND, orthopnea, wheezing, tachypnea, cough, rales, S3 gallop, Cheyne stokes respiration, pleural effusion, pulmonary edema
Right or left sided heart failure?
Left sided
Rome consensus committee for IBS requires symptoms for at least _______ weeks (not necessarily consecutive) in the previous ____ months, and pain characterized by at least 2 of the following: relieved by defecation, change in stool frequency, change in form or appearance of stool
12; 12
Examples of cold thyroid nodules
Colloidal cysts
Tumors
Neurofibromas
First indication of renal compromise in DM
Increase in GFR
[followed by microalbuminuria]
Pt presents with unstable angina and EKG changes, what medication class do you give them?
Glycoprotein IIb/IIIa receptor inhibitor
Medication usually considered for NYHA class III or IV CHF or those with serum K <5
Spironolactone
Screen for Hep C in persons at high risk and a one-time screening for HCV in adults born between ______-_______
1945-1965
You find a nonfunctional thyroid nodule in a pt that is >1cm— what do you do next?
FNA
[Follicular cell malignancy cannot be distinguished from its benign counterpart]
Diabetic drugs that improve insulin sensitivity in muscle and adipose, decrease hepatic gluconeogenesis; result in decreased TGs and increase in HDL
Edema is most common side effect
Thiazolidinediones
Urinalyses used for screening for DM are highly _____ but have low _________
Specific; sensitivity
When is herpes zoster vaccine given
Age 60+
What part of MONA BASH reduces myocardial damage and limits the infarct size?
Beta blocker
Dyslipidemia tx that is c/i in severe gout
Niacin
Intermediate acting insulin option
NPH
[1-3 hr onset, 7-15 hr peak, 18-24 hr duration]
People with clinically important CAD should defer noncardiac procedures until ____ after revascularization
6 mos
Acute increase in thyroid size; nontender
Subacute lymphocytic thyroiditis
Most significant issue to consider when using nitrates for stable angina
Tolerance (develops rapidly with long acting nitrates)
when using a patch it is important to have 10-12 hrs w/o patch to retain effect
Corneal dendrites w/flourescein staining indicates what type of eye infection?
Herpes
Noradrenergic agonist that allows 3-4 kg weight loss
Phentermine
What is prehn sign?
Relief of pain upon elevation of testicle — rules out torsion as this is positive in epididymitis, hernias, orchitis, or cancer
Eye inflammation associated with photophobia, sluggish pupil, cloudy cornea, pain, and pupillary constriction
Iritis
Gradually increasing thyroid gland that is firm but is nontender
Invasive fibrous thyroiditis
______ levels are sensitive to undernutrition and would be decreased in a pt with failure to thrive
IgA
First line therapy for HTN in most settings
Thiazide diuretic
When do you give antihypertensives to a stroke pt? (What are the BP cutoffs?)
Systolic >220 or diastolic >120
[if pt suitable for thrombolytics, give antiHTN to reduce systolic >185 and diastolic <110]
Note — IV labelolol, nicardipine, and sodium nitroprusside are often used
Type of melanoma most often in elderly on chronic, sun-damaged skin, least common of the four types and is most common in hawaii
Lentigo maligna
MCC of acute wheezing in children <2, esp infants 1-3 months old
Bronchiolitis
What medication reduces short term mortality when started w/i 24 hrs of an MI and prevents cardiac remodeling?
ACE inhibitor
Abx for diarrhea d/t shigella
Fluoroquinolones or TMP-SMX
In HIV pts, give PCP prophylaxis with TMP SMX when CD4 <200. Give MAC prophylaxis with ____ or ____ if CD4<50
Azithromycin; clarithromycin
Lipid screening guidlines for men
Screen if >35 if no risk factors
[begin at 20 if CAD risk factors]
Locking or catching knee injury
Meniscal injury
Symptoms with position changes only
A. Acoustic neuroma B. Vestibular neuronitis C. BPPV D. Meniere disease E. None of the above
C. BPPV
Heavy menstrual flow or prolonged duration fo flow at irregular intervals
Menometrorrhagia
[DUB — indicates problem with HPA]
Do not do a mammogram if pt is <30, do _____ instead
Ultrasound
How do estrogen and SERMs (raloxifene) work to tx osteoporosis?
Block the activity of cytokines
T/F: Weight loss increases HDL by 5-10 pts
T
What drug has been shown to help stress incontinence?
Pseudophedrine
Rapid acting insulin options
Lispro/aspart
[15 min onset, 30-90 min peak, 3-5 hr duration]
Management of CKD in terms of protein intake, metabolic acidosis, and hyperphosphatemia
Reduce protein excretion to <500-1000 mg/day (60% of baseline)
Restrict dietary protein intake to 0.8-1.0 mg/kg/day
Treat metabolic acidosis with sodium bicarb to maintain concentration of 22 mEq/L
Oral phosphate binders if GFR <25-30
Screen for chlamydial infection in all sexually active women ages ___ and younger and in older women at increased risk
24
Macrocytic anemia with increased methylmalonic acid and homocysteine
B12 def
Beta blockers are all equally effective in treating angina. Dose should be adjusted to achieve a HR of ______ bpm
50-60 bpm
Tx for IT band syndrome
Strengthen hip abductors, internal rotators, and knee flexors
Autosomal dominant inherited condition causing progressive conductive hearing loss
Otosclerosis
Most common type of incontinence in elderly
Urge
Long acting insulin options
Glargine/detemir
[1 hr onset, no peak, 24 hr duration]
What labs do you get at first prenatal visit
CBC HBsAg HIV RPR UA UC Rubella Blood type Rh Pap GC/chlam
Treatment for alzheimers that requires monitoring of liver enzymes
Tacrine
Latency time for onset of symptoms of vertigo or nystagmus is 3-10 sec, symptoms are severe, direction of nystagmus is fixed, and repeating the manuever lessens the symptoms
Peripheral or central cause of vertigo?
Peripheral
MOA of antiemetic zofran
Serotonin receptor antagonist
AEs include dizziness and headache
In pts with decreased sex drive and no other complaints or exam findings, assessment of hormone status is indicated. Testosterone levels should be checked in the morning when they peak, and free testosterone is a more accurate measure of androgen status. If free testosterone is low, workup continues to get FSH, LH, and PRL. Based on the following, what is the dx?
FSH and LH are low, and PRL is high
Pituitary adenoma — get a CT or MRI to confirm
GERD is a common cause of wheezing in the pediatric population, what is the gold standard test?
24 hr pH probe
T/f: you can give HPV vaccine to pts who are breastfeeding or immunocompromised
True
Most commonly reported hepatitis virus
Hep A
Asymptomatic hematuria with eosinophils in urine; often caused by analgesics or other drugs
Interstitial nephritis
Most common cause of low back pain in pts <26 years of age, especially athletes
Spondylolisthesis
Variable decels are caused by
Umbilical cord compression during contractions
People born before 1957 do not need to be vaccinated with MMR and are considered immune. This vaccine is contraindicated in those with allergy to ________. It is a live attenuated vaccine that should not be given to pregnant or immunocompromised. Wait 3 mo if blood or Ig products given
Neomycin
Canadian cervical spine rules determine who needs radiography. What are some high risk factors that mean YES radiography?
Age >65
Dangerous mechanism (high speed MVA)
N/T in extremities
[low risk factors are simple rear end collision, if pt was ambulatory at the scene, absence of neck pain at scene, absence of C spine tenderness on exam — if answer is no to any of the above - get imaging]
pt should also be able to actively rotate neck 45 degrees left and right regardless of pain
Treatment goals for diabetic pts include HbA1c <6.5, fasting glucose <120, 2 hr post prandial sugar < ______, BP <130/80, LDL
140; 70
Urinary side effect of CCBs seen in elderly
Urinary retention
Cardinal movements during delivery
Flexion
Internal rotation
Extension
External rotation
Strongest risk factor for Alzheimers
Advancing age
[other RFs are family hx, female gender, low education, CV factors, hx of head trauma]
Most common cause of significant GI bleed in children
Meckel diverticulum
[presents with painless large-volume intestinal hemorrhage]
Define constipation
<3 stools per week
Patients that are US-born before year ______ are considered immune to varicella, with the exception of healthcare workers and pregnant women
1980
At what BMI do you initate tx for obesity?
BMI >25
Pts with a non-hemorrhagic stroke should get _____ in the first 48 hrs
Aspirin
H pylori triple therapy
Clarithromycin/amoxicillin/metronidazole + PPI
T/F: the prevalence of dementia doubles every 5 years after the age of 60
True
[this is the importance of cognitive screening in geriatrics — do clock draw and 3-item recall]
In pts with decreased sex drive and no other complaints or exam findings, assessment of hormone status is indicated. Testosterone levels should be checked in the morning when they peak, and free testosterone is a more accurate measure of androgen status. If free testosterone is low, workup continues to get FSH, LH, and PRL. Based on the following, what is the dx?
FSH and LH are low, but PRL is normal
Pituitary or hypothalamic failure
C-peptide should be _____ in type I DM
Low
40% of graves patients that are treated with _________ become hypothyroid; another side effect is agranulocytosis
Radioactive iodine
Most common cause of sudden cardiac death
Dilated cardiomyopathy
Pre-HTN
Stage I HTN
Stage II HTN
Pre-HTN: 120-139/80-90
Stage I HTN: 140-159/90-99
Stage II HTN: >160/100
[in Stage II, 2 drug therapy is indicated — most commonly thiazide diuretic + ACE inhibitor, ARB, beta-blocker, or CCB]
T/F: H.influenzae vaccine decreases rate of otitis media
False - most cases are caused by non-typeable Hflue
What T score indicates osteoporosis vs osteopenia?
Osteoporosis = T < -2.5
Osteopenia = T < -1 to -2.5
Pt with primary hyperparathyroidism has a calcium level >12 mg/dL. What do you need to do prior to attempting parathyroidectomy?
Lower the serum calcium prior to surgery with loop diuretics and IV saline
