Family Medicine Cases

Question 1

When is breast cancer risk increased?

Answer 1

If a first-degree relative has had breast cancer

Question 2

When should a breast self-examination be used?

Answer 2

When the patient chooses to do a breast self-examination and the patient is trained in appropriate technique and follow-up.

Question 3

What is the evidence surrounding breast self-examination?

Answer 3

The practice of BSE by trained women does not reduce breast cancer-specific or all-cause mortality. Likely increases the number of biopsies performed.

Question 4

When should a woman get a breast exam according to the USPSTF?

Answer 4

Clinical breast exam should be a part of a periodic health exam, which occurs about every three years for women in their 20’s and 30’s and every year for women 40 and over.

Question 5

What are the cervical cancer screening guidelines?

Answer 5

At 21 years of age, cervical cancer screening should begin. Between 21-29, screening should be performed every three years. Between 30-65 years, screening can be done every three years with cytology alone, or every five years if co-tested for HPV. If over 65 and has had adequate screening in the last ten years with normal paps.

Question 6

When should women get additional screening for cervical cancer?

Answer 6

Women who are immunocompromised, HIV positive, have a history of CIN2-3 or cancer, or have been exposed to DES.

Question 7

What are the risk factors of cervical cancer?

Answer 7

1) HPV infection (early onset of intercourse, a greater number of lifetime sexual partners) 2) DES exposure in utero 3) cigarette smoking 4) immunosuppression

Question 8

What is “accuracy”?

Answer 8

High sensitivity and specificity

Question 9

What is “sensitivity”?

Answer 9

Sensitivity measures the proportion of actual positives that are correctly identified as such (e.g. the percentage of sick people identified as having the condition). The more sensitive the test, the fewer false negative results.

Question 10

What is “specificity”?

Answer 10

Specificity measures the proportion of negatives that are correctly identified as such (e.g. percentage of well people identified as not having the condition). The more specific the test, the fewer false positives.

Question 11

What are the endometrial cancer screening recommendations?

Answer 11

At the time of menopause, all women should be informed about the risks and symptoms of endometrial cancer, and strongly encouraged to report any unexpected bleeding or spotting to their doctors. For high risk women (HNPCC for example), endometrial biopsies should be offered starting at age 35.

Question 12

What are the skin cancer screening recommendations?

Answer 12

Cancer-related checkup should include examination of the skin.

Question 13

What are the recommendations for breast cancer screening?

Answer 13

Yearly mammograms starting at age 40 per the ACS. USPSTF recommends biennial screening mammography for women aged 50-74 years old.

Question 14

How do you evaluate a breast lump?

Answer 14

-precise location of the lump -how it was first noticed -how long it has been present -nipple discharge -any change in the size of the lump (esp. during menstrual cycle) Then follow up with a physical exam. If the lump feels cystic, aspiration can be attempted and the fluid sent for cytology. If the lump feels solid, mammography is the next step. US can distinguish a solid mass from a cystic lesion

Question 15

What are the causes of nipple discharge?

Answer 15

Physiologic: Pregnancy Excessive breast stimulation Pathologic: Prolactinoma Breast cancer -Intraductal papilloma -Mammary duct ectasia -Paget’s disease of the breast -Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications use (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)

Question 16

How do you evaluate nipple discharge?

Answer 16

Color of discharge, then follow up with imaging studies (mammogram, US, bx). Consider hormonal testing to exclude endocrine reasons (PRL). Discontinue medications that may be the cause.

Question 17

What are the risk factors for breast cancer?

Answer 17

Family history of breast cancer in a first-degree relative (i.e., mother or sister) Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45 Genetic predisposition (BRCA 1 or 2 mutation) Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.) Female sex Increased breast density Advanced age at first pregnancy Exposure to diethylstilbestrol Hormone therapy Therapeutic radiation Obesity

Question 18

What are the recommendations for osteoporosis prevention?

Answer 18

Premenopausal women need approximately 1000mg of calcium daily while postmenopausal women need 1500 mg of calcium daily. This requires three to four servings of dairy products. Currently recommending against calcium and vitamin D supplementation.

Question 19

What are the recommendations for osteoporosis screening?

Answer 19

For women >65 years old, screening with DEXA. For women

Question 20

What are the risk factors for osteoporosis?

Answer 20

-low estrogen states– early menopause, prolonged premenopausal amenorrhea, and low weight and body mass index -lack of physical activity and inadequate calcium intake Family history of osteoporotic fracture Personal history of previous fracture as an adult Dementia Cigarette smoking White race

Question 21

What is the Bethesda System for reporting cervical cytology?

Answer 21

Cervical cytology results are given in three categories: specimen adequacy, general categorization of results, and interpretation of results. Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories. Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous. Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress. High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion. Squamous cell carcinoma.

Question 22

What serotypes of HPV does Gardasil protect against?

Answer 22

Quadravalant DNA vaccine 6,11, 16, and 18. Used in ages 9-25 years

Question 23

When are breast MRI recommended?

Answer 23

Indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer. May also be used as a diagnostic tool to identify more completely the extent of disease in patients with a breast cancer diagnosis.

Question 24

What is the RISE mnemonic for preventive visits?

Answer 24

R: risk factors I: immunizations S: screening tests E: education

Question 25

What are the most frequent causes of death for a 55-year old male in the US?

Answer 25

malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis

Question 26

What are the risk factors for CVD?

Answer 26

sedentary lifestyle stress premature family history excess alcohol use and many more…? Recommended to be assessed major risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.

Question 27

What are the adult immunization recommendations?

Answer 27

-yearly flu vaccine -one-time dose of Tdap for Td booster for ages 11-64 to provide additional pertussis protection, then boost with Td every 10 years -one dose of zoster vaccine at 60

Question 28

What is the controversy surrounding prostate cancer screening recommendations?

Answer 28

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA based screening in average risk males results in little or no reduction in prostate cancer related deaths and is associated with harms related to tests, procedures and treatment of the condition, some of which may be unnecessary. Other organizations, such as the American Cancer Society (ACS) recommended that physicians should have a discussion of the potential benefits and harms of screening with a PSA test.

Question 29

What are colon cancer screening options?

Answer 29

Screening colonoscopy every 10 years. Annual testing of three stools for blood and a flex sig test every 5 years. Double contrast enemas every 5 years. CT colography (experimental)

Question 30

What are the indications for exercise stress testing?

Answer 30

Asymptomatic male patients over the age of 45 with one or more risk factors (hypercholesterolemia, hypertension, smoking, orfamily history of premature coronary artery disease)

Question 31

What are the signs of dyslipidemia and atherosclerosis?

Answer 31

Changes associated with dyslipidemia: corneal arcus, xanthelasmas, acanthosis nigricans Changes associated with atherosclerosis: decreased peripheral pulses, carotid bruit

Question 32

What are the ECG changes that suggest coronary artery disease?

Answer 32

Horizontal ST segment depression or downsloping ST segment (suggests cardiac ischemia) Convex ST segment elevation (suggests acute myocardial injury) Q waves that are greater than 25% of succeeding R wave and greater than 0.04 seconds (indicates infarction)

Question 33

What are some interventions that improve quit rates for smokers?

Answer 33

Quit rates are highest when patients are engaged in a group setting. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 - 3 times the placebo quit rate. When combined with medication, a series of one-on-one counseling sessions (as in a physician’s office), enhances quit rates.

Question 34

How do you manage a high risk for ASCVD event?

Answer 34

Start aspirin and begin a moderate-to-high intensity statin. An exercise stress test can be considered to further evaluate for the presence of coronary atherosclerosis in a high risk man.

Question 35

What are the recommendations for exercise prescriptions?

Answer 35

-type of exercise or activity -precautions -specific workloads -duration and frequency -intensity guidelines

Question 36

What are the common causes of insomnia in the elderly?

Answer 36

Environment not conducive to sleep Sleep apnea Restless leg syndrome Periodic leg movement and REM sleep behavior disorder (the patient experiences involuntary leg movements while falling asleep and during sleep respectively) Disturbances in the sleep-wake cycle Depression and anxiety Shortness of breath due to cardiorespiratory disorders Pain or pruritis GERD Hyperthyroidism Advanced sleep phase syndrome

Question 37

What are the risk factors for completed suicide?

Answer 37

Sex: white male Age: increases with age Previous attempts

Question 38

What are the major depression diagnostic criteria?

Answer 38

Must have at least five of the following for a minimum of two weeks: SIG E CAPS Sleep or insomnia Interest (loss of) Guilt Energy (decreased) Concentration (decreased) Appetite (either increased or decreased) Psychomotor retardation Suicidal ideation

Question 39

Which is better for screening for dementia: the mini-cog exam or the MMSE?

Answer 39

The mini-cog exam is faster and more sensitive and specific than the MMSE

Question 40

What are some of the side effects of SSRIs/SNRIs?

Answer 40

Headaches, sleep disturbances (drowsiness), GI problems (nausea and diarrhea) Hyponatremia due to SIADH, serotonin syndrome, GI bleeding

Question 41

What are the medical conditions associated with depression?

Answer 41

-hypothyroidism -Parkinson’s disease -dementia

Question 42

How do you evaluate fatigue or depression?

Answer 42

A CMP screens for electrolyte, renal, and hepatic problems TSH, CBC

Question 43

What are the treatments for primary insomnia in the elderly?

Answer 43

Sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy Zolpidem and melatonin-receptor agonists

Question 44

Fluoxetine (Prozac)

Answer 44

Unusually long half life (two to four days), so effects can last for weeks after discontinuation. Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia

Question 45

Sertraline (Zoloft)

Answer 45

In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders. More gastrointestinal side effects than the other SSRIs.

Question 46

Paroxetine (Paxil)

Answer 46

Strong antianxiety effects. Best studied SSRI in children. Side effects can include significant weight gain, impotence, sedation, and constipation. Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

Question 47

Fluvoxamine (Luvox)

Answer 47

Particularly useful in obsessive-compulsive disorder. Greater frequency of emesis compared to other SSRIs.

Question 48

Citalopram (Celexa)

Answer 48

Most common side effects include nausea, dry mouth, and somnolence

Question 49

Escitalopram (Lexapro)

Answer 49

Approved specifically for Generalized Anxiety Disorder. Overall, fewer side effects than citalopram.

Question 50

What are the signs of limb threatening injury?

Answer 50

Pain Pallor Pulselessness Paresthesia Poikilothermia Paralysis Pain (esp disproportionate pain) is often the earliest sign and clinical hallmark of compartment syndrome. However, the loss of normal neurologic sensation (paresthesia) is the most reliable sign)

Question 51

What are the important historical features of ankle injury?

Answer 51

A patient who seeks help immediately, and is non-weight bearing is more likely to have a severe injury than one who presents a few days after an incident and is fully weight bearing (the ability to take four steps independently). A history of previous ankle sprain is a common risk factor for ankle injury. While hearing a snap or tear is diagnostically significant in an acute knee injury, it is not in an acute ankle injury.

Question 52

What are the grades of ankle sprains?

Answer 52

Grading of ankle sprains takes into consideration: the presence/absence of a ligament tear, loss of functional ability, severity of pain, presence and or severity of swelling, presence of ecchymosis, difficulty bearing weight (the ability to take four steps independently) Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress. Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point. Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.

Question 53

What is the most common mechanism of injury in ankle sprains?

Answer 53

Combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular, and posterior talofibular ligaments are most often damaged. The anterior talofibular ligament is the most easily damaged.

Question 54

How do lateral ankle sprains present?

Answer 54

Lateral ankle sprains generally present acutely (after trauma) with pain, warmth, and some swelling. Ankle sprains do not create a deformity. If there is a large amount of swelling present, however, it may appear to be a deformity.

Question 55

How do peroneal tendon tears present?

Answer 55

Peroneal tendon tear is typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain. Patient may complain of persistent pain posterior to the lateral malleolus. Swelling may or may not be present. Repetitive trauma may cause injury to the peroneal tendons

Question 56

How do talar dome fractures present?

Answer 56

Talar dome fracture is usually due to acute injury. Overall prognosis is related to potential for interruption of the blood supply. Talar dome fracture may occur in conjunction with an ankle sprain, and initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis after talar dome fracture.

Question 57

What are the Ottawa ankle rules?

Answer 57

The rules suggest that radiographs of the ankle are needed if: There is pain in the malleolar zone AND either bony tenderness along the distal 6 cm of the posterior edge of either malleolus OR inability to bear weight 4 steps both immediately after the injury and in the emergency department. Radiographs of the foot are needed if: There is pain in the midfoot region AND one of the following: (a) bony tenderness at either the navicular bone or base of the 5th metatarsal OR (b) inability to bear weight four steps immediately after the injury and in the emergency department.

Question 58

What is the most effective compression for ankle injury?

Answer 58

Semi-rigid ankle support

Question 59

What are the signs and symptoms of hyperthyroidism?

Answer 59

heat intolerance tachycardia due to increased adrenergic tone and heightened conduction fatigue weight loss due to increased calorigenesis and gut motility causing hyperdefecation and malabsorption tremor increased sweating

Question 60

What is exopthalmos?

Answer 60

(also called proptosis) is the forward projection or bulging of the eye out of the orbit. Most commonly seen in Graves’ disease and can be either bilateral or unilateral

Question 61

What are the causes of enlarged thyroid?

Answer 61

Lack of iodine, Hashimoto’s, Grave’s, nodules, thyroid cancer, pregnancy, thyroiditis

Question 62

What is clonus?

Answer 62

A series of abnormal reflex movements of the foot induced by sudden dorsiflexion causing alternate contraction and relaxation of the gastrocnemius and soleus muscles.

Question 63

What are the primary symptoms of eye manifestations of Grave’s disease?

Answer 63

Corneal irritation from eyelid retraction

Question 64

What are the most common manifestations of Grave’s ophthalmopathy?

Answer 64

Eyelid retraction and exophthalmos

Question 65

What is Grave’s disease?

Answer 65

Autoimmune disease in which thyrotroptin receptor antibodies are produced. These antibodies stimulate the thyroid gland to enlarge and produce more thyroid hormone.

Question 66

What are the symptoms of hypothyroidism?

Answer 66

Weight gain, cold intolerance, pedal edema, heavy periods, and fatigue.

Question 67

What are the common causes of hyperthyroidism?

Answer 67

Toxic diffuse goiter, toxic nodular goiter, thyroiditis (thyroid hormone leaks from an inflamed thyroid), excessive iodine ingestion

Question 68

What are the studies to determine the etiology of hyperthyroidism?

Answer 68

Radioactive iodine uptake test and scan. Measures the amount and pattern of radioactive iodine taken up by the thyroid in the 24 hours following ingestion of a set dose.

Question 69

How do you treat Grave’s disease?

Answer 69

Methimazole is the most commonly used medication to suppress thyroid hormone production. Oral dose of radioactive iodine is the other treatment option.

Question 70

What is the primary side effect of methimazole?

Answer 70

Agranulocytosis. Requires frequent bloodwork.

Question 71

What is the primary side effect of radioactive iodine?

Answer 71

Makes most patients hypothyroid. Requires twice yearly bloodwork. Need a pregnancy test before initiation–is teratogenic

Question 72

What is thyroid replacement therapy?

Answer 72

Thyroxine (1.5-1.8 mcg per kg), increasing until steady TSH

Question 73

What are the common manifestations of end-organ damage in diabetes?

Answer 73

Cardiovascular disease, retinopathy, neuropathy, nephropathy

Question 74

What are the acute diabetic decompensations?

Answer 74

IDDM: DKA T2DM: HHS

Question 75

What are the screening recommendations for diabetes according to the American Diabetes Association?

Answer 75

overweight or obese patients who have one or more of the following risk factors: -physical inactivity -race/ethnicity -first degree relative with diabetes -previously diagnosed impaired fasting flucose (100-125) or impaired glucose tolerance -PCOS -history of gestational diabetes or delivering a baby >9lbs -A1c >5.7% -history of cardiovascular disease In the absence of the above risk factors, screening should begin at 45 years of age Repeated at three-year intervals

Question 76

What are the USPSTF recommendations for screening for diabetes?

Answer 76

Asymptomatic adults with sustained blood pressure greater than 135/80

Question 77

What are the diagnostic criteria for diabetes mellitus?

Answer 77

1) random glucose of 200 or above plus symptoms of hyperglycemia like polyuria 2) fasting plasma glucose of greater than or equal to 126 3) A1c greater than or equal to 6.5%

Question 78

What do you see on fundoscopic exam with severe, non-proliferative retinopathy?

Answer 78

retinal hemorrhages cotton wool spots microaneurysms neovascularization

Question 79

How do you distinguish between HHS and DKA?

Answer 79

HHS: not a metabolic acidosis, serum pH is generally 7.3 with a bicarb > 15, plasma glucose is usually >600, ketones are absent or only mildly elevated. Severe dehydration with serum osmolality over 320 mOsm DKA: metabolic gap acidosis with a pH

Question 80

What are the four reasons for ordering lab tests at a diabetes follow-up visit?

Answer 80

Monitoring diabetic control, assessing end organ damage, monitoring side effects of treatment, and uncovering management complications

Question 81

When do you get A1c levels in a diabetic?

Answer 81

A1c levels should be taken at diagnosis, with follow-up testing at least two times per year in patients who are stable and meeting a goal of A1c

Question 82

How do you screen for diabetic nephropathy?

Answer 82

spot urine albumin-to-creat ratio for microalbuminuria at diagnosis and annually.

Question 83

What labs do you order with metformin use?

Answer 83

Metformin can cause metabolic acidosis in renal failure. It can also lead to subnormal vitamin B12 levels.

Question 84

When should TSH levels be ordered in diabetics?

Answer 84

Screening TSH in type 1 diabetics, newly diagnosed dyslipidemia, or women over age 50 as part of a diabetes evaluation

Question 85

What are the suggested lipid levels for diabetic patients?

Answer 85

Measurement of fasting lipids is recommended at the time of diagnosis of diabetes and annually for patients on statins. The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following blood cholesterol treatment for patients with diabetes and LDL-c 70-189 mg/dL: · Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (Level of Evidence A). High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated. (Level of Evidence B)· In adults with diabetes mellitus, who are 75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (Level of Evidence C). Note, the ACC/AHA recommends all patients > 21 years old (with or without diabetes) who have an LDL-c >190 should be started on statin therapy (Level of Evidence B).

Question 86

When should aspirin be used in diabetics?

Answer 86

Use aspirin as secondary prevention in diabetes patients with a history of CVD or as a primary prevention strategy in diabetics at increased cardiovascular risk (10-year risk >10%).

Question 87

What is the 1st tier for management of T2DM?

Answer 87

step 1: Diagnosis = HbA1c >6.5% = lifestyle changes plus Metformin step 2: Assessment. If HbA1c >8, continue lifestyle changes and metformin plus either add a sulfonylurea or basal insulin step 3: if HbA1c>8, continue lifestyle changes and Metformin + add basal insulin or intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia

Question 88

What are the recommended vaccines for diabetic patients?

Answer 88

influenza vaccine pneumococcal polysaccharide vaccine hepatitis B vaccine if not previously vaccinated

Question 89

When should diabetics go to the ophthamologist?

Answer 89

Type 1: first annual eye exam five years after diagnosis Type 2: when they are first diagnosed

Question 90

How long does it take warfarin to reach steady state?

Answer 90

five to seven days

Question 91

What causes foot ulceration in diabetes?

Answer 91

Impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral arterial disease)

Question 92

What is the Wagner Grading System for diabetic ulcers?

Answer 92

Grade 1: diabetic ulcer (superficial) Grade 2: ulcer extension (involving ligament, tendon, joint capsule, or fascia) Grade 3: deep ulcer with abscess or osteomyelitis Grade 4: gangrene forefoot (partial) Grade 5: extensive gangrene of foot

Question 93

What is the differential of unilateral lower extremity edema?

Answer 93

Lymphedema Cellulitis DVT Venous insufficiency Peripheral artery disease

Question 94

What is lymphedema on physical exam?

Answer 94

Generally painless, but patients may experience a chronic dull, heavy sensation in the leg. In the early stages, edema is pitting. In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic.

Question 95

What is cellulitis on physical exam?

Answer 95

Cellulitis is an acute inflammatory condition of the skin characterized by localized pain erythema, swelling, and heat.

Small breaks of skin are associated with strep infection, whereas staph is commonly associated with larger wounds, ulcers, or abscesses.

Question 96

What are the symptoms of DVT?

Answer 96

Swelling, pain, and discoloration in the affected extremity. Physical exam may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation.

Classic signs include Homan’s sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth. Chronic venous insufficiency may result from DVT and/or valvular incompetence.

Question 97

What does venous insufficiency look like on physical exam?

Answer 97

Edema of venous insufficiency can be differentiated from chronic lymphadema as venous insufficiency edema is softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli.

Question 98

What does peripheral arterial disease look like on physical exam?

Answer 98

PAD is the presence of systemic atherosclerosis in arteries distal to the arch of the aorta. As a result of the atherosclerotic process, patients with PAD develop narrowing of these arteries.

PAD patients have a history of claudication.

Use ABI to diagnose (<0.9)

Question 99

What are the Wells criteria for DVT?

Answer 99

Wells score or criteria: (possible score −2 to 9)

Active cancer (treatment within last 6 months or palliative): +1 point
Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point
Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
Unilateral pitting edema (in symptomatic leg): +1 point
Previous documented DVT: +1 point
Swelling of entire leg: +1 point
Localized tenderness along the deep venous system: +1 point
Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point
Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point
Alternative diagnosis at least as likely: −2 points[4]

Those with Wells scores of two or more have a 28% chance of having DVT, those with a lower score have 6% odds. Alternatively, Wells scores can be categorized as high if greater than two, moderate if one or two, and low if less than one, with likelihoods of 53%, 17%, and 5% respectively.

Question 100

How do you differentiate between DVT and cellulitis diagnostically?

Answer 100

Venous doppler

Question 101

How do you medically manage ulcers?

Answer 101

Grade 1-2: ulcer management can be done as an outpatient and should include extensive debridement, local wound care, and relief of pressure. Treat for infection as needed.

Grade 3: require evaluation for possible osteomyelitis as well as peripheral arterial disease

Grade 5: require emergent hospitalization and surgical consultation, often resulting in amputation

Question 102

What are the requirements for treating DVT on an outpatient basis?

Answer 102

Patient must be: hemodynamically stable, with good kidney function, and at low risk for bleeding

Home enviroment must be stable and supportive, capable of providing the patient with daily access to INR monitoring

Question 103

What are the advantages of LMWH over unfractionated heparin?

Answer 103

LMWH: longer biologic half-life so it can be administered subcutaneously once or twice daily, laboratory monitoring is not required, thrombocytopenia is less likely, dosing is fixed

Question 104

How do you titrate warfarin?

Answer 104

Monitor warfarin dose by measuring the INR and titrate the warfarin dose every three to seven days to an INR of 2.0-3.0.

Question 105

What are the recommended thromboprophylaxis durations of DVT or PE?

Answer 105

For DVT prophylaxis, the recommended method for at-risk patients is LMWH. For those who cannot be anticoagulated, or another agent is recommended, mechanical prophylaxis is an option. Duration is usually until the patient is ambulatory or discharged from the hospital, unless high risk.

Question 106

What are the criteria for recommended screening for inherited thrombophilia?

Answer 106

• Initial thrombosis occurring prior to age 50 without an immediately identified risk factor
• a family history of venous thromboembolism
• recurrent venous thrombosis
• thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins

Question 107

What is the recommended action when goal INR is overshot?

Answer 107

Warfarin should be held, and an oral dose of Vitamin K should be given to reduce INR.

Question 108

When do you screen for high blood pressure?

Answer 108

Screening for high blood pressure in patients without known hypertension starting at age 18.

Question 109

What are the classifications of high blood pressure?

Answer 109

Question 110

What are some of the causes of secondary hypertension?

Answer 110

Sleep apnea, chronic renal disease, renovascular causes, drug-induced causes, pheochromocytoma, primary aldosteronism, chronic steroid use, Cushing’s syndrome, thyroid and parathyroid disease, and coarctation of the aorta.

Question 111

What are the important elements of the physical exam in patients with hypertension?

Answer 111

• BMI
• fundoscopic eye exam
• carotid, abdominal, and femoral bruits
• thyroid gland
• lung exam
• heart exam
• lower extremity exam
• baseline neuro assessment

Question 112

What tests do you need for a new diagnosis of essential hypertension?

Answer 112

• ECG: look for LVH
• urinalysis: proteinuria
• blood glucose: for diabetes
• hematocrit: anemia may be a product of target organ damage in ESRD
• serum potassium: need a baseline before ACE/ARB/diuretic prescription. Also look for Cushing’s or primary hyperaldo

GFR/creatinine: looking for ESRD

Lipid panel: looking for lipid co-morbidities as part of metabolic syndrome

Serum calcium: looking for renal parenchymal damage due to nephrolithiasis. Increased calcium in hyperparathyroidism raises blood pressure

Question 113

How do you initially medically manage HTN in patients under 60?

Answer 113

Question 114

How do you medically manage patients initially diagnosed with HTN over age 60?

Answer 114

Question 115

What is the target blood pressure goal?

Answer 115

In the general population over 60, the goal BP is <150/90.

In the population aged >18 with CKD, lower the blood pressure to <140/90

In the population aged >18 with diabetes, lower the blood pressure to <140/90

Question 116

What are the side effects of HCTZ?

Answer 116

Can cause hyponatremia

Can precipitate gout flares

Can cause elderly patients to become incontinent of urine

Low dose are superior to high dose in effectiveness

Question 117

What is the most effective way to reduce blood pressure through lifestyle?

Answer 117

Weight reduction (5-12 mmHg/10 kg weight loss)

Question 118

When do you initiate aspirin in hypertensive patients?

Answer 118

Initiate aspirin therapy in men age 45 to 79 years to reduce MI.

Question 119

What is the stepwise approach to the treatment of hypertension?

Answer 119

Implement lifestyle interventions.

Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and CKD.

If the blood pressure is still not at goal, maximize first medication before adding second.

If at maximum doses of the double combination of medications and the blood pressure is still not at goal, continue adding agents from other classes.

Always avoid combined use of ACEI and ARB.

Question 120

What are the side effects of ACEi?

Answer 120

Watch potassium, sodium, and creatinine

Renal protective

Reduces microalbuminuria

First line agent in diabetes and renal disease

Shown to have direct heart remodeling effects

Cough and angioedema are serious side effects

Question 121

When do you use ARBs?

Answer 121

Reduces microalbuminuria and microalbuminuria.

Shown to have heart remodeling effects.

Avoid in pregnant women.

Less bradykinin production

Question 122

Calcium channel blockers

Answer 122

Often causes leg edema

Short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies

Question 123

Loop diuretics

Answer 123

Monitor electrolytes and creatinine

Question 124

Aldosterone antagonists and potassium sparing diuretics

Answer 124

May cause hyperkalemia

Low dose aldosterone antagonists reduce morbidity and mortality in CHF but increase sudden death at higher doses.

Question 125

What are the common causes of back pain?

Answer 125

Congenital: scoliosis, kyphosis, spondylolysis

Traumatic: lumbar strain, compression fracture

Metabolic: osteoporosis, hyperparathyroidism, Paget’s disease, osteomalacia

Infectious: pyelonephritis, osteomyelitis, discitis, herpes zoster, spinal or epidural abscess

Inflammatory: ankylosing spondylitis, sacroilitis, rheumatoid arthritis

Neoplastic: multiple myeloma, metastatic disease, lymphoma/leukemia, osteosarcoma

Degenerative: disc herniation, osteoarthritis, facet arthropathy, spinal stenosis

Vascular: aortic aneurysm, diabetic neuropathy

Visceral: prostatitis, PID, ovarian cyst, endometriosis, kidney stones, cholecystitis, pancreatitis

Question 126

What are the most common causes of back pain?

Answer 126

Mechanical: 97% of back pain.

Lumbar strain/sprain, age-related degenerative joint changes, herniated disc

Visceral: 2%

Remaining 1%: non-mechanical

Question 127

What are the red flags for serious illness or neurologic impairment with back pain?

Answer 127

Fever, unexplained weight loss, pain at night, bowel or bladder incontinence, neurologic symptoms

Question 128

What are the symptoms of disc herniation?

Answer 128

Exacerbation when sitting or bending, relief when lying or standing

• increased pain with coughing and sneezing
• pain radiating down the leg and sometimes the foot
• paresthesias
• muscle weakness, such as foot drop

Question 129

What are the red flags for serious underlying causes of back pain?

Answer 129

• history of cancer
• unexplained weight loss >10 kg within 6 months
• age over 50 or under 17 years old
• failure to improve with therapy
• pain persists for more than 4-6 weeks
• night pain or pain at rest
• persistent fever
• history of IV drug use
• recent bacterial infection
• immune compromise

Question 130

What are the symptoms for cauda equina syndrome?

Answer 130

• urinary incontinence or retention
• saddle anesthesia
• anal spincter tone decreased or fecal incontinence
• bilateral lower extremity weakness or numbness
• progressive neurologic deficits

Question 131

What are the symptoms of a significant herniated nucleus pulposus?

Answer 131

Major muscle weakness and foot drop

Question 132

What are the risk factors for vertebral fracture?

Answer 132

• prolonged use of corticosteroids
• mild trauma over age 50 years
• age greater than 70 years
• history of osteoporosis
• recent significant trauma at any age
• previous vertebral fracture

Question 133

What is the prognosis for acute low back pain?

Answer 133

Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three months.

Question 134

What is the differential for low back pain?

Answer 134

Lumbar strain, disc herniation, spinal stenosis, and degenerative arthritis

Pain worse with movement and sitting is suggestive of a mechanical cause of back pain, such as a lumbar strain, disc herniation, or degenerative arthritis.

Pain radiating down the leg and numbness indicate nerve involvement, such as in disc herniation.

Pain that improves with the supine position suggests spinal stenosis and disc herniation.

Question 135

When do you order an Xray for back pain?

Answer 135

• history of trauma
• strenuous lifting in patient with osteoporosis
• prolonged steroid use
• osteoporosis
• age >20 and >70
• history of cancer
• fever/chills/weight loss
• pain worse when supine or severe at night
• spinal fracture, tumor, or infection

Question 136

When do you get an MRI for back pain?

Answer 136

• neurological deficit
• radiculopathy
• progressive major motor weakness
• cauda equina compression
• suspected systemic disorder (metastatic or infectious disease)
• failed six weeks of conservative

Question 137

What is conservative therapy for acute low back pain?

Answer 137

Pharmacologic therapy (aspirin/NSAID and/or muscle relaxants)

• local therapy
• physical therapy (slightly more effective than being active at baseline)

Question 138

What is the type of knee pain seen in children and adults, respectively?

Answer 138

Children and adolescents who present with knee pain are likely to have patellar subluxation, tibial apophysitis (Osgood-Schlatter), or patellar tendonitis).

Adults are more prone to patellofemoral syndrome (a clinical diagnosis of exclusion for anterior knee pain), overuse syndromes (such as pes anserine bursitis), traumatic injuries (ligamentous sprains - anterior cruciate, medial collateral, lateral collateral - and meniscal tears) and inflammatory arthropaties, such as rheumatoid arthritis, septic arthritis, and Reiter’s syndrome.

Question 139

How do you evaluate a suspected infectious process causing knee pain?

Answer 139

If concerned about septic arthritis or an acute inflammatory arthropathy, check a CBC with differential and ESR.

Perform an arthrocentesis and send the fluid for cell count with differential, glucose and protein, bacterial culture and sensitivity, and polarized light microscopy for crystals.

Question 140

What are the side effects of NSAIDS?

Answer 140

• GI upset
• decreasing the effectiveness of hypertension medications
• increasing the effect of sulfonylureas

Question 141

What is the recommended screening for colorectal cancer?

Answer 141

Recommended yearly FOBT, flex sig every three years, or colonoscopy every 10 years for patients ages 50 to 75 years old.

Question 142

What screening is recommended for abdominal aortic aneurysm?

Answer 142

A one-time ultrasound to screen for an AAA is recommended in men 65-75 years old who have any history of smoking.

Question 143

What are the adult immunizations?

Answer 143

• tetanus: substitute one-time dose of Tdap for Td booster, then boost with Td every 10 years
• Pneumococcal polysaccharide: if >65 years, one dose
• flu: one dose annually
• zoster: if >60 years, one dose

Question 144

What does Lachman’s test assess?

Answer 144

Assesses the stability of the ACL

Question 145

What do the anterior and posterior drawer signs assess?

Answer 145

Assess the anterior cruciate and posterior cruciate ligaments, respectively

Question 146

What do the valgus and varus stress tests assess?

Answer 146

Assess functioning of the medial and lateral collateral ligaments

Question 147

What does the McMurray test assess?

Answer 147

Can assess the medial and lateral menisci, though it has low sensitivity and specificity for diagnosing meniscal tears

Question 148

What is Tinel’s sign for carpal tunnel?

Answer 148

Tapping over the median nerve at the wrist to reproduce symptoms

Question 149

What is Phalen’s test for carpal tunnel?

Answer 149

Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms.

Question 150

What is the differential diagnosis for knee pain?

Answer 150

patellofemoral pain syndrome

iliotibial band tendonitis

ACL sprain

MCL sprain

LCL sprain

Meniscal tear

Septic arthritis

Osteoarthritis

Gout/pseudogout

Popliteal cysts

Question 151

What are the major radiographic features of osteoarthritis?

Answer 151

• joint space narrowing
• subchondral sclerosis (hardening of tissue beneath the cartilage)
• osteophytes
• subchondral cysts

Question 152

What is the diagnostic test of choice for carpal tunnel syndrome?

Answer 152

Nerve conduction velocity study

Question 153

How do you manage pain for osteoarthritis?

Answer 153

exercise, acetaminophen (first line, 4 g/d in divided doses), NSAIDS, intra-articular corticosteroid injections, tramadol, hyaluronic acid injections (superior in the long term to corticosteroids), long-acting opiods, tricyclic antidepressants

Question 154

What are the recommendations on chlamydia screening?

Answer 154

Question 155

What is the preconception health care checklist?

Answer 155

Folic acid supplement (400 mcg)

Carrier screening (sickle cell, Tay-Sachs, CF)

Screen for infectious diseases : HIV, syphilis, Hep B, rubella, varicella, toxoplasmosis-avoid cat litter, CMV

For diabetics, optimize control, folic acid 1 mg, off ACEi

HTN: avoid ACEi, angiotensin II receptor antagonists, thiazide diuretics

Question 156

How do you manage an inevitable abortion?

Answer 156

Expectant management

D&C

Medical management (800mg misoprostol)

Give RhoGam

Question 157

What is a spontaneous aboriton?

Answer 157

The loss of a pregnancy without outside intervention before 20 weeks’ gestation.

Question 158

What are the classifications of alcohol use?

Answer 158

risky/hazardous drinking: patient’s alcohol consuption exceeds the National Insititute on Alcohol Abuse and Alcoholism per occasion threshold for men of 4 drinks per occasion

problem drinking: significant physical, social, or psychological harm from drinking

alcohol abuse: requires a maladaptive pattern of use with failure to fulfill obligations

alcohol dependence: requires tolerance, withdrawal, physical and pscyhological problems

Question 159

What is the psoas sign and the obturator sign?

Answer 159

Psoas sign: Passive extension of patient’s thigh as s/he lies on his/her side with knees extended, or asking the patient to actively flex his/her thigh and hip causes abdominal pain, often indicative of appendicitis

Obturator sign: examiner has patient supine with right hip flexed to 90 degrees- takes patient’s right ankle in his right hand as he uses his left hand to externally/internally rotate patient’s hip by moving th knee back and forth. Elicitation of pain in the abdomen implies acute appendicitis

Question 160

What is the differential of right upper quadrant abdominal pain?

Answer 160

• biliary colic/cholecystitis
• duodenal ulcer
• hepatitis
• acute pancreatitis

Question 161

What are the studies to evaluate RUQ abdominal pain?

Answer 161

CBC, electrolytes, UA, LFTs, amylase/lipase

Abdominal US

Question 162

How do you manage biliary colic?

Answer 162

Surgical consultation for cholecystectomy

Can also use a three-month trial of ursodiol

Question 163

What is the difference between a primary and secondary skin lesion?

Answer 163

Primary skin lesion: uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.

Secondary skin lesions: changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions

Question 164

What are the vocab words used to describe skin lesions?

Answer 164

Macule: flat lesion less than 1 cm in diameter

Patch: macule greater than 1 cm in diameter

Papule: solid raised lesion that has distinct borders and is less than 1 cm in diameter

Plaque: solid, raised, flat-topped lesion greater than 1 cm in diameter

Nodule: raised solid lesion and may be in the epidermis, dermis, or subcutaneous tissue

Tumor: solid mass of the skin or subcutaneous tissue, larger than a nodule

Vesicle: raised lesion less than 1 cm in diameter and is filled with clear fluid

Bulla: circumscribed fluid-filled lesion that is greater than 1 cm in diameter

Pustule: circumscribed elevated lesion that contains pus

Wheal: area of elevated edema in the upper epidermis

Question 165

What are the skin cancer screening recommendations?

Answer 165

Annual skin cancer screening by full body skin examination by a health care provider is an “I” recommendation by the USPSTF.

Question 166

What are the risk factors for nonmelanoma skin cancer?

For melanoma skin cancer?

Answer 166

Non melanoma skin cancer:

• 80 percent of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor) • Episodic sun exposure “probably does not increase risk” • White race • Celtic ancestry • Fair complexions • People who burn easily • People who tan poorly and freckle • Red, blonde or light brown hair • Increasing age • Use of coal-tar products • Tobacco use • Psoralen use (PUVA therapy) • No significant Family History • Male >>> female • Whites near equator (UV exposure) • Outdoor work • Chronic osteomyelitis sinus tracts • Burn scars • Chronic skin ulcers • Xeroderma pigmentosum • Human papillomavirus infection • Previous skin cancer of any type gives 36-52% 5-year risk of second skin cancer

For melanoma skin cancer:

• White race • Celtic ancestry • Fair complexions • People who burn easily • People who tan poorly and freckle • Red, blonde or light brown hair • Early adulthood and later in life • Cumulative sun exposure “probably does not increase risk” • “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk” 3/18 • Radiation exposure • Melanoma in 1st or 2nd degree relative • Familial atypical mole-melanoma syndrome (FAMMS) • Male > female (slight) • Whites near equator (UV exposure) • Indoor work • Higher incidence in those with more education and/or income • Nonfamilial dysplastic nevi • Large number of benign pigmented nevi • Giant pigmented congenital nevi • Nondysplastic nevi (markers for risk, not precursor lesions) • Xeroderma pigmentosum • Immunosuppression • Previous nonmelanoma skin cancer • Other malignancies • Previous melanoma

Question 167

What is the “ABCDE” rule of skin cancer detection?

Answer 167

Asymmetry: asymmetry in two or more axes

Border: irregular border

Color: two or more colors

Diameter: six millimeters or greater

Enlargement: enlargement of the surface of the lesion

When a hyperpigmented skin lesion shows asymmetry, irregular borders, mixed colors, a diameter of six millimeters or larger, or recent growth in size, there is a higher suspicion of melanoma.

Question 168

What are the symptoms of prostatitis?

Answer 168

• tends to occur in young and middle aged men
• pain in the perineum, lower abdomen, testicles and penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen

Question 169

What is the differential of an oval-shaped, erythematous patch?

Answer 169

eczema, squamous cell carcinomas, actinic keratoses, basal cell carcinomas, melanoma, fungal infection

Question 170

What do you look for when you are evaluating for BPH?

Answer 170

lower urinary tract symptoms (increased frequency of urination, nocturia, hesitancy, urgency, weak urinary stream), urinary tract infections, obstructive nephropathy

need to perform DRE, PSA, UA

maximal urinary flow rates and post-void residual urine volume are useful in most men suspected of BPH

Question 171

What are the different groups of topical corticosteroids?

Answer 171

Question 172

Which skin infections do you treat with local vs. systemic antifungal agents?

Answer 172

Systemic therapy: tinea capitis, tinea unguium

Local therapy: tinea pedis, tinea manuum, tinea corporis, tinea cruris

Question 173

How do you manage BPH?

Answer 173

• behavior modifications: avoiding fluids before bedtime or going out, reducing caffeine and alcohol intake, use of salts and spices, etc.
• alpha-adrenergic antagonists: decrease urinary symptoms in most men with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin, and doxazosin.
• 5-alpha-reductase inhibitors: more effective in men with larger prostates.
• don’t take decongestants or antihistamines

Question 174

What screening do you do for women in their 50’s without risk factors?

Answer 174

Mammogram

Colon cancer screening

Pap smear

Question 175

What are the risk factors for endometrial cancer?

Answer 175

• age– endometrial evaluation should occur in women aged 35 years and older who have abnormal uterine bleeding
• unopposed estrogen therapy
• tamoxifen
• obesity
• anovulatory cycles
• early menarche
• late menopause
• nulliparity
• hypertension, diabetes, and breast or colon cancer

Oral contraceptive use increases progestin levels, providing protection

Question 176

What are symptoms and findings of atrophic vaginitis?

Answer 176

Symptoms: vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritis

Physical exam findings: smoother vaginal mucosa and cervix

Question 177

What are risk factors for osteoporosis?

Answer 177

Corticosteroid use

Family history of osteoporosis, especially if a first-degree relative has fractured a hip.

Previous fragility fracture defined as a low-impact fracture

Smoking

Heavy alcohol use

Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density.

Caucasian race - At any given age, African-American women on average have higher bone mineral density (BMD) than white women.

Question 178

How much calcium and vitamin D should women over 50 consume to prevent osteoporosis?

Answer 178

Most women over 50 should consume an average of 1200 mg of calcium and 600 IU of vitamin D daily.

Question 179

What DEXA scan indicates osteoporosis?

Answer 179

T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia

T-score less than -2.5 indicates osteoporosis

Question 180

What is the differential of abnormal uterine bleeding?

Answer 180

cervical polyps (most common in postpartum and perimenopausal women)

endometrial hyperplasia

hormone-producing ovarian tumors (rare)

endometrial cancer

proliferative endometrium

Question 181

What is the treatment for osteoporosis?

Answer 181

Bisphosphonates: potent inhibitors of bone resorption and reducing bone turnover, increasing bone mineral density. Look for Alendronate and risedronate

Parathyroid hormone: anabolic drug for those with osteoporosis at high risk for fracture

Estrogen replacement therapy: used short term only

Calcitonin: shown to reduce vertebral fractures only

Question 182

What are the most effective ways to manage hot flashes?

Answer 182

Hormone therapy for women at low risk for hormone-related diseases

Antidepressants SSRIs and SNRIs

Clonidine and gabapentin

Question 183

How do you evaluate postmenopausal abnormal bleeding in women?

Answer 183

transvaginal US, endometrial biopsy, CBC, TSH

FSH and LH if menopause needs to be confirmed

Question 184

What are the common causes of headache? What are the serious causes of headache?

Answer 184

Common types of headache:

• tension type
• migraine
• medication overuse

Serious causes:

• meningitis
• brain tumor
• intracranial hemorrhage

Question 185

What are common etiologies of secondary headaches?

Answer 185

1) headache due to depression and anxiety
2) medication overuse headache

mild to moderate in severity

diffuse, bilateral headaches that occur almost daily and are often present on first waking up in the morning

Can often be aggravated by mild physical or mental exertion

May improve slightly with analgesics but worsen when the medication wears off. Tolerance develops.

Requires more than 15 headaches per month to make the diagnosis, with regular overuse of an analgesic for more than three months.

Question 186

What are important physical exam findings with headache?

Answer 186

Signs of increased ICP:

papilledema

AMS

meningeal irritation

focal neurologic deficits

Question 187

What are the differences between migraine headaches, tension headaches, and cluster headaches?

Answer 187

Question 188

How do you manage tension headaches?

Answer 188

decrease caffeine, aim for 8 hours of sleep each night, try to relieve stress

Question 189

What are the migraine medications?

Answer 189

triptans

ergot alkaloids

non-specific treatments include: aspirin/butalbital/caffeine combos, acetaminophen/butalbital/caffeine combos, acetaminophen/dichloalphenazone combos, and acetaminophen/aspirin/caffeine combos

Question 190

What medications are used for migraine prophylaxis?

Answer 190

Beta-blockers (propranolol and timolol)– best because excellent and cheap

Neurostabilizers (divalproex sodium, topiramate, gabapentin)– good but expensive

Tricyclic antidepressants (amitriptyline) – off-label, but good results

Calcium channel blocker (verapamil) – off-label, fair effectiveness, expensive

Question 191

What are agents that can cause or contribute to peptic ulcer disease?

Answer 191

• aspirin or NSAIDs
• moderate to severe physiologic stress
• H.pylori

Question 192

How can you distinguish between the symptoms of PUD vs. GERD?

Answer 192

PUD: usually characterized by episodic or recurrent epigastric “aching”, “gnawing”, or “hunger-like” pain or discomfort, symptoms occur on an empty stomach and are commonly relieved by meals

GERD: classic symptoms of heartburn and regurgitation, likely to occur when gastric volume is increased (after large meals)

Question 193

What are the complications of GERD and PUD?

Answer 193

GERD: Esophagitis develops when the mucosal defenses that normally counteract the effect of injurious agents are overwhelmed by refluxed acid, pepsin, or bile. Peptic strictures from fibrosis and constriction occur in about 10% of patients with reflux esophagitis. Replacement of the squamous epithelium of the esophagus by columnar epithelium ( Barrett’s esophagus ) may result from reflux esophagitis. Two to five percent of cases of Barrett’s esophagus may be further complicated by adenocarcinoma .

PUD: Hemorrhage or perforation into the peritoneal cavity or adjacent organs (causing severe, persistent abdominal pain). Ulcer scar healing or inflammation can impair gastric emptying leading to gastric outlet obstruction syndrome .

Question 194

When is urgent endoscopy warranted?

Answer 194

dysphagia, initial onset of upper GI symptoms occur after age 50, early satiety, hematemesis, hematochezia, iron deficiency anemia, odynophagia, recurrent vomiting, weight loss

Question 195

How do you manage GERD, gastritis, and PUD?

Answer 195

Empiric therapy with PPIs

If unresponsive to PPIs, check for contributing agents, test for H. pylori (IgG serology test at first, followed by urea breath test and stool antigen test)

Need to rule out GI bleeding

Question 196

How do you treat H. pylori?

Answer 196

Question 197

What is the McIsaac Decision Rule?

Answer 197

Used for determining whether a strep test is needed

one point is assigned for:

fever more than 38

absence of cough

tonsilar exudates

anterior cervical lymphadenopathy

age less than 15

one point is taken away if more than 45 years old

if 2 or 3 points, order a rapid strep

if 4 points, order a throat culture and empirically treat

Question 198

What are the most common complications of influenza?

Answer 198

Bacterial pneumonia (strep or staph)

Otitis media

Question 199

How do you treat strep pneumonia?

Answer 199

Amox 90mg/kg/d divided into three dosages for 7-10 days in children 3 months to adolescence

Question 200

What is metabolic syndrome?

Answer 200

Defined in adults as having at least three of the following, hypertriglyceridemia, low HDL, elevated fasting blood glucose levels, excessive waist circumference, or hypertension, affects 20 percent of adults ages 20 to 40, and 40 percent older than 40 years of age. They are at increased risk for cardiovascular disease and diabetes. While there is no agreed upon definition for metabolic syndrome in children, if we apply the diagnostic criteria to children, substituting elevated BMI for waist circumference, we have started to see increased rates in adolescents. Seven percent of overweight adolescents, 29 percent of obese adolescents, and 50 percent of severely obese adolescents meet the criteria for metabolic syndrome and will have increased health risks. Smoking also increases the risk of metabolic syndrome.

Question 201

What are pulmonary findings that indicate consolidation?

Answer 201

egophany

increased tactile fremitus

dullness to percussion

crackles

whispered pectoriloquy

Question 202

What is the differential for an acute pediatric cough?

Answer 202

URI, asthma exacerbation, and bronchiolitis

If there is fever, think pneumonia, acute bronchitis, influenza, or GAS

Question 203

What are antivirals for influenza indicated?

Answer 203

If given within the first 48 hours of illness or if the patient has moderate to severe CAP with influenza or if the patient is clinically worsening at the time of the initial outpatient visit

Question 204

How do you manage pediatric pneumonia?

Answer 204

Question 205

What are the mechansisms of TIAs or possible stroke?

Answer 205

Question 206

What is AF with rapid ventricular response? How do you treat it?

Answer 206

AF with RVR is the presence of physiologic or non-physiologic ventricular tachycardia in the presence of AF. Can be caused by fever, myocarditis, pericarditis, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction.

Treat with rate control– IV diltiazem, beta blockers, or verapamil

Rhythm control– cardioversion

Question 207

What are the symptoms of a right parietal infarct?

Answer 207

Right hand dominant patients with strokes in the area of the brain are likely to have left hemiplegia. Patients with right middle cerebral infarcts affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distance, or they may attempt to read holding books upside down. They may ignore people or objects in their left visual feild or not pay attention to that area of the room. They may also not recognize their functional impairments.

Question 208

Stroke symptoms of other regions

Answer 208

Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness.

Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke.

A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because there is bilateral central control of this portion of the facial nerve.

A peripheral injury to the facial nerve (such as Bell’s Palsy) causes facial weakness of the forehead.

Question 209

How do you treat post-stroke depression?

Answer 209

SSRIs

Question 210

What is the differential of lightheadedness with focal neurologic findings?

Answer 210

Seizure

Stroke

TIA

CAD

Medication side effect

Question 211

What are the recommended tests for the initial emergency evaluation of a patient with suspected acute ischemic stroke?

Answer 211

CT and MRI

Renal function/electrolytes

ECG (screen for afib and arrythmias)

Markers for cardiac ischemia (trops and BNP)

CBC and PT/PTT

O2 sat to monitor for hypoxemia

Question 212

How do you medically prevent stroke?

Answer 212

• adjusted dose warfarin (INR 2-3)
• antiplatelet therapy with aspirin
• dual antiplatelet therapy with clopidogrel and aspirin

Question 213

How do you medically prevent stroke in patients with a history of stroke or TIA?

Answer 213

• anticoagulation with a vitamin K antagonist
• aspirin alone for patients unable to take oral anticoagulants

Question 214

What are strategies for secondary stroke prevention?

Answer 214

Question 215

What are the complications of GABHS pharyngitis?

Answer 215

Scarlet fever presents as punctate, erythematous, blanching, sandpaper-like exanthem. Rash is found in the neck, groin, axillae. The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue).

Complications: rheumatic fever and post-streptococcal glomerulonephritis, peritonsilar abscess, mastoiditis, meningitis, bacteremia

Question 216

When do you withold vaccinations?

Answer 216

Patients with recent exposure to infectious diseases, or patients who have a mild illness should receive their vaccines. However, if a patient has moderate to severe illness (including high fever, otitis, diarrhea, and vomiting), then vaccines should be postponed until they are recovering and no longer acutely ill.

Also contraindicated when there is an allergy, or patient is immunocompromised.

Question 217

What are the elementary school admission vaccines?

Answer 217

Between four and six years of age, a child needs a booster of DTaP, IPV, MMR, and varicella.

• Three hepatitis B
• Five DTaP
• Five polio
• Two MMR
• Two varicella

Question 218

When can you diagnose ADHD?

Answer 218

Children must be at least six years old. Symptoms must be more frequent or severe compared to other children the same age. The behaviors must be present in at least two settings.

Question 219

What is the differential for pediatric fever, sore throat, cough, and rash?

Answer 219

Viral pharyngitis and GABHS

-high fever, anterior cervical lymph nodes, tonsilar exudates, absence of cough are highly suggestive of GABHS

Question 220

How do you treat GABHS pharyngitis?

Answer 220

Penicillin V (FIRST LINE), Penicillin G IM (if patient is unlikely to finish course), amox, first generation ceph, macrolides (PCN allergy)

Question 221

How do you diagnose and manage acute bacterial/pyogenic infection of a joint or bursa?

Answer 221

urgent recognition is necessary because septic joints may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone or more distinct sites by way of bacteremia

“red flags” include local complaints such as redness or swelling and/or systemic complaints such as fever, chills, and myalgias. Predisposing factors include diabetes, alcoholism, or other immune-compromising conditions

Definitive evaluation includes aspiration and culture of related fluid. Commonly staph.

Question 222

What are the likely diagnoses with loss of shoulder range of motion?

Answer 222

A patient with loss of active and passive ROM is more likely to have joint disease

A patient with loss of only active ROM is more likely to have an issue with muscle tissue.

The following joint diseases will produce restricted active and passive ROM of the shoulder:

• adhesive capsulitis: a condition common in patients with metabolic diseases in which there is contracture of the joint capsule
• glenohumeral arthritis: much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity
• Rotator cuff injuries will compromise only ACTIVE ROM (rotator cuff tear and impingement)

Question 223

What are the rotator cuff muscles?

Answer 223

Question 224

What is the difference between tendinitis vs. tendinopathy?

Answer 224

tendinitis: inflammatory etiology that occurs only in the first days after an acute tendon injury; not appropriate unless injury is very acute
tendinopathy: more general term that may imply a degenerative pathology. It is a chronic condition that is characterized by a fibroblastic response, lack of acute phase reactants, and collagenous degeneration

Question 225

What is the pathophysiology of shoulder impingement?

Answer 225

The supraspinatus tendon, and possibly other rotator cuff tendons, are being impinged upon by the roof of the subacromial space, which is formed by the acromion and the coracoacromial ligament. Processes that decrease the subacromial space, such as the weakened rotator cuff muscles or weakened scapularr stabilizers will promote this process.

Question 226

What is the order of a joint exam?

Answer 226

Inspection

Palpation

Range of motion

Strength testing

Special maneuvers

(not what Dr. Kapur taught, but what FM Cases states)

Question 227

What is the differential for subacute right shoulder pain aggravated by movement?

Answer 227

Rotator cuff tendinopathy – weakness and pain with empty can testing, limited active ROM

Torn rotator cuff –limited ROM with significant pain, significant weakness with strength testing

Impingement syndrome with bursitis– limited ROM, Neer and Hawkins-Kennedy tests rule out

Labral tear–may occur through repetitive damage from glenohumeral joint instability or secondary to frank dislocations or other trauma. Often a diagnosis of exclusion.

Question 228

How do you manage rotator cuff tendinopathy/impingement?

Answer 228

physical therapy

pain medication as needed

relative rest

Question 229

What is HEEADSSS?

Answer 229

Home

Education

Eating

Activities

Drugs

Sexuality

Suicide/Depression

Safety

Question 230

What are the scrotal exam findings?

Answer 230

Question 231

What are the causes of testicular torsion?

Answer 231

congenital anomaly – results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis causing the “bell clapper” deformity

undescended testicle

recent trauma or vigorous exercise

Question 232

What are the complications of testicular torsion?

Answer 232

Testicular loss. Surgery needs to occur within the first six hours of onset in order to preserve the testicle

Question 233

What are the guidelines for adolescent preventive services?

Answer 233

Guidelines for promoting adolescent health and positive behaviors

prevents HTN, hyperlipidemia, use of tobacco and drugs, physical fitness, etc.

Question 234

What are the symptoms of chlamydia, gonorrhea, and trich and how do you diagnose them?

Answer 234

• Patients with chlamydia present with dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, breakthrough bleeding or can be asymptomatic. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample.
• Patients with gonorrhea can be either asymptomatic, or have dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, or breakthrough bleeding. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample; gonococcal culture for rectal or pharyngeal specimens.
• Presenting symptoms of trichomonas include vaginal discharge with odor or itching, so testing for T. vaginalis should be performed in women seeking care for vaginal discharge. But trichomonas can also be asymptomatic and screening for T. vaginalis can be considered in those at high risk for infection, such as women who have new or multiple partners (the situation presented in this question), have a history of STIs, exchange sex for payment, and use injection drugs. Diagnosis is made by either saline wet mount or rapid antigen testing.

Question 235

What are the types of testicular tumors?

Answer 235

Germ cell tumors (seminomatous or nonseminomatous)– most common primary testicular tumors. Usually seminomatous.

Non-seminomatous are usually embyronal cell tumors, teratomas, or yolk sac tumors.

Other causes include non-germ cell tumors (Leydig cell and Sertoli cell tumors) and extragonadal tumors

Question 236

What is the differential of groin pain in an adolescent?

Answer 236

testicular torsion: physical findings include a swollen, tender scrotum and the cremasteric reflex is typically absent. Testicular torsion causes the orientation of the testis to change, causing a “transverse lie”.

Torsion of the testicular appendages: Appendix testis is a small vestigial structure (embryonic remnant of the Mullerian duct) located on the anterosuperior aspect of the testis. Pain is usually less severe than in testicular torsion and is localized to the region of the appendix testis without any tenderness in the remaining areas of the testis. Bluish coloration in the scrotum at the upper pole of the testis is seen.

Epididymitis: Most common cause. Symptoms are slowly progressive over several days. Caused by bacterial infection of the epididymis (UTI or STD), severe swelling and exquisite pain on the involved side with fever, rigors, and irritative voiding symptoms. On exam, scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex is usually present, and the testis is in its normal location and position.

Other less ilkely things: trauma, inguinal hernia, HSP, hydrocele, tumor, varicocele

Question 237

How do you diagnose testicular torsion?

Answer 237

Color Doppler US– if testicular torsion is present, intratesticular blood flow is either decreased or absent when appears as decreased echogenicity, as compared with the asymptomatic testis.

Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion.

Radionuclide scintigraphy is more sensitive, but US is faster and easier.

Question 238

How do you manage testicular torsion?

Answer 238

Orchiopexy – surgical fixation of BOTH testes to prevent retorsion

Question 239

What is the difference between fatigue and sleepiness?

Answer 239

• fatigue - A feeling of exhaustion or tiredness that is pervasive, not relieved by rest, and often worsened by exertion.
• sleepiness - A feeling of tiredness that gives a patient the tendency to fall asleep, and is often relieved by either rest or exertion.

Question 240

What is the PHQ-2?

Answer 240

The PHQ-2 involves asking patients, “Over the last two weeks, how often have you been bothered by any of the following problems?” (1) “Little interest or pleasure in doing things.” (2) “Feeling down, depressed, or hopeless.” For each question, the patient can answer: “not at all” (0 points) “several days” (1 point) “more than half the days” (2 points), “nearly every day” (3 points).

Screens for depression

Question 241

How can you screen for colon cancer?

Answer 241

Colonoscopy – once every ten years

FOBT yearly

Flex sig– every three years

Question 242

How do you clinically stage colon cancer?

Answer 242

Clinical staging of colorectal cancer is the depth of the invasion of the bowel wall. For colon cancers, this cannot be determined until the cancer is surgically removed (pathologic staging). In the case of rectal cancers, endorectal US provides oncologists with failry accurate estimates of the depth of invasion and may guide therapy.

Metastasis - pelvic lymph nodes, liver, and lung

CEA - elevated in many colorectal cancers. Elevation above 5 ng/m is associated with worse prognosis at each stage.

Question 243

What is the differential of fatigue?

Answer 243

• Depression
• OSA
• Anemia
• Occult malignancy
• Coronary artery disease
• Diabetes mellitus
• Sleep restriction
• Hypothyroidism
• Chronic fatigue syndrome

Question 244

What is the workup of fatigue?

Answer 244

CBC and ESR initially.

Glucose to rule out diabetes.

TSH +/- EBV titers

Question 245

How do you manage iron deficiency?

Answer 245

Ferrous sulfate 325 mg TID

Docusate sodium 100 mg BID PRN for constipation

Question 246

What are the recommended immunizations for patients with COPD?

Answer 246

Influenza and pneumococcal vaccines, TdaP

Question 247

What is the clinical distinction between acute and chronic bronchitis?

Answer 247

Acute bronchitis: productive cough lasting 1-3 weeks

Chronic bronchitis: productive cough for at least three months for the past two years

Question 248

What are some of the classic findings on physical exam for COPD and CHF?

Answer 248

Question 249

What are the four items that predict the presence of COPD?

Answer 249

Smoking more than 40 pack-years

Self-reported history of COPD

Maximum laryngeal height of 4 cm or less

Age of at least 45 years

Question 250

What are the major differences between COPD and asthma?

Answer 250

COPD is not reversible via bronchodilator therapy and asthma is.

COPD symptoms slowly progress, while asthma symptoms vary day to day.

COPD has more symptoms during exertion, while for asthma the symptoms are more common at night or early morning

Cigarette smoke is more of a causal agent in COPD. Mast cells, helper T cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma.

Macrophages, T killer cells, and neutrophils play a role in an inflmmatory and destructive process in COPD.

Post-bronchodilator FEV1/FVC ratio >12% after bronchodilator.

Question 251

What are the PFTs for COPD?

Answer 251

FEV1/FVC is decreased in COPD. (less than 70%)

Question 252

What is therapy for moderate and severe COPD?

Answer 252

Therapy for moderate COPD: FEV1 is between 50 and 80% of predicted. Maintenance therapy of inhaled anticholinergics (ipratroprium or tiotroprium) alone or in combination with short-acting beta agonists.

Therapy for severe COPD: Symptomatic patients whose FEV1 is

Risks of overuse of beta agonists include:

tachycardia, exaggerated somatic tremor, and hypkalemia

Question 253

What is the differential of shortness of breath in a middle-aged man who smokes?

Answer 253

Question 254

How do you define the level of COPD severity?

Answer 254

Measured FEV1 impairment.

FEV1 of >80% is mild.

50-79% is moderate.

30-49% is severe.

Question 255

What is a COPD exacerbation and how do you manage it?

Answer 255

COPD exacerbation: increased dyspnea, increased sputum volume, and increased sputum purulence

Treatment: inhaled bronchodilators and oral glucocorticosteroids

azithromycin if infection is suspected

Question 256

How does COPD lead to heart failure?

Answer 256

Chronic hypoxia causes pulmonary vasoconstriction, which increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased JVD.

Question 257

What are good medications for a patient with both diabetes and hypertension?

Answer 257

Question 258

What are the physical exam findings for suspected heart failure?

Answer 258

Crackles in the lung bases and dullness to percussion.

JVD

PMI that is laterally displaced from the mid-clavicular line towards the axillary line

S3 from rapid ventricular filling or poor left ventricular functioning.

Enlarged liver, hepato-jugular reflux, and distention and shifting dullness indicating ascites

Lower extremity edema

Sacral edema

Question 259

What is diastolic heart failure?

Answer 259

Diastolic heart failure occures when signs and symptoms of heart failure are present, but left ventricular function is preserved (ejection fraction >45%). It is caused by impaired LV filling and abnormal LV relaxation and is most commonly related to uncontrolled hypertension. The incidence of diastolic heart failure increases with age and is more common in older women.

Question 260

What is the pathophysiology of diastolic dysfunction?

Answer 260

The left ventricle develops an abnormality of filling and becomes stiffer and noncompliant as the disease progresses. Then there is increased pulmonary vessel pressure during exercise, increased filling pressure, and, as left atrial pressure and size increase, congestion. At this point, exercise intolerance increases and clinical signs of failure, particularly dyspnea on exertion, appear. Pulmonary congestion, hepatic congestion, and peripheral edema appear.

Question 261

Can you have systolic dysfunction without diastolic dysfunction?

Answer 261

No, all patients with systolic dysfunction also have diastolic dysfunction. A patient cannot have pure systolic heart failure.

However, certain cardiovascular diseases such as hypertension may lead to diastolic dysfunction without concomitant systolic dysfunction.

Question 262

How do you differentiate heart failure from non-cardiac conditions in patients with dyspnea?

Answer 262

BNP testing can help differentiate heart failure from non-cardiac conditions in patients with dyspnea. A normal BNP effectively rules out CHF.

Question 263

What is the differential for new onset congestive heart failure?

Answer 263

MI, arrythmias (such as a fib/flutter with rapid ventricular response. Without the atrial kick, the ventricle does not fill as well, a problem that is exacerbated by the decreased filling time that occurs with tachycardia), ischemic cardiomyopathy, uncontrolled HTN

Question 264

What radiographic findings are associated with congestive heart failure?

Answer 264

• Cardiomegaly: Defined when the width of the heart is more than half of the width of the thorax.
• Central vascular congestion and hilar fullness: Patients in failure frequently have hilar fullness on a PA chest film. Individual vessels may appear enlarged.
• Pleural effusions: Identified by a blunting of the costophrenic angles. This can be seen posteriorly on a lateral film as well. Occasionally, prominent fluid in the horizontal fissure will be seen in the right lung.
• Cephalization of pulmonary vasculature: Typically, pulmonary vessels are not well seen in the upper lung fields. In CHF, however, they become engorged and can be seen extending from the hilum.
• Kerley B lines: These are small linear densities 2-3 cm in length seen in the periphery of the lung fields on the PA view. They represent interstitial fluid in the lung tissue

Question 265

How do you diagnose patients with CAD?

Answer 265

Question 266

What are the interventions to slow the progression of CAD?

Answer 266

Glucose control, blood pressure control, aspirin, cholesterol control, weight control, immunizations, beta-blockers

Question 267

How do you manage Stage C heart failure?

Answer 267

ACEi

ARBs

Digoxin– does not improve mortality

Loop diuretics

Beta-blockers – metoprolol succinate, carvedolol, bisoprolol

Eplerenone

Question 268

What is primary dysmenorrhea?

Answer 268

Primary dysmenorrhea– painful menses without pelvic pathology. Usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours

Secondary dysmenorrhea–painful menses secondary to some pelvic pathology

Question 269

What are the risk factors for primary dysmenorrhea?

Answer 269

• mood disorders
• tobacco use
• lower state of health or other social stressors
• women who have more children

Question 270

What are the premenstrual syndrome diagnostic criteria?

Answer 270

Premenstrual dysphoric disorder is a complex disorder that occurs at a specific time in a woman’s cycle during multiple menstrual cycles in a year. A minimum of five symptoms need to begin the week prior to menses, start to improve during menses and then become minimal the week after menses. The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess. The patient must also have one of the following: food cravings, changes in sleep, being “out of control”, decreased energy, anhedonia, and some physical symptoms. The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms for the woman. It may be helpful to get the perspective of other close contacts of the patient.

Question 271

What is the differential of secondary dysmenorrhea/menorrhagia?

Answer 271

adenomyosis, chronic PID, endometriosis,uterine leiomyomas

Less likely: cervical stenosis, IBD, IBS, ovarian cysts, mood disorders or adjustment disorders, uterine polyps

Question 272

How do you evaluate secondary dysmenorrhea/menorrhagia?

Answer 272

CBC, pregnancy test, US, thyroid disorders

Question 273

How do you treat primary dysmenorrhea?

Answer 273

Ibuprofen

Mirena IUD, combined OCPs/Depo, hysterectomy, uterine artery embolization

Question 274

How do you treat PMS?

Answer 274

• Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular.
• Oral contraceptives are effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. While not always effective for premenstrual syndrome, they are a good place to start. It would be appropriate to try this in a woman also needing birth control. The most favorable pill is the formulation containing ethinyl estradiol and drospirenone. One study demonstrates potential improved effectiveness by decreasing the placebo pills to four days from seven.
• Selective serotonin reuptake inhibitors during menses are an effective treatment of premenstrual syndrome, especially if severe or mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as daily treatment for decreasing both psychologic and physical symptoms. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a woman has symptoms and continue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine can be used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior to considering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost.
• Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in women. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in women done with childrearing. Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies the effectiveness is inconsistent. If this were to be tried on a patient, the dosing would be during luteal phase. You must be cautious about causing potential electrolyte abnormalities with this drug.
• Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity. Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been evaluated with mild results. These are all worth discussing with patients, although true efficacy is not proven.

Question 275

What are the presyncope symptoms, etiologies, and management?

Answer 275

Presyncope– caused by inadequate cerebral perfusion

+acute blood loss

Question 276

What is the difference between presyncope, disequilibrium, and vertigo?

Answer 276

presyncope- feeling light-headed or faint

dysequilibrium- a feeling of being off balance

vertigo- a sensation of the room spinning

Cardiac arrhythmias/valvular heart disease can cause syncope

Question 277

What is orthostatic hypotension?

Answer 277

A drop in systolic blood pressure of >20 mmHg or a drop in diastolic blood pressure of >10 mmHg when changing position from supine to standing accompanied by feelings of dizziness or light-headedness

Question 278

What are the common causes of vertigo?

Answer 278

benign paroxysmal positional vertigo

vestibular neuritis– results when a viral infection of the inner ear causes inflammation of the vestibular branch of the eighth cranial nerve

acute labyrinthitis– occurs when an infection affects both branches of the nerve resulting in tinnitus and/or hearing loss as well as vertigo

Question 279

What is the Dix-Hallpike maneuver?

Answer 279

-one way to confirm the diagnosis of BPPV

Turn the patient’s head to 45 degrees and quickly lay him down supine with his head just over the end of the exam table. Then turn the head to the side which should reproduce the symptoms of dizziness and produce nystagmus. Observe for 20 to 30 seconds. If present, the nystagmus will have the fast component in the direction of the pathology. Next, sit the patient up and observe again for nystagmus.

Question 280

What is the differential of dizziness?

Answer 280

Vestibular neuritis, BPPV, vestibular migraine

Question 281

What is the difference between peripheral and central vertigo?

Answer 281

Question 282

How do you manage peripheral vertigo?

Answer 282

• diuretics and a low salt diet for Meniere’s disease (decrease the endolymphatic pressure and abate symptoms)
• Epley maneuver
• vestibular rehabilitation
• vestibular suppressant medications – anticholinergic vestibular suppressants such as meclizine and dimenhydrinate

Question 283

What are the important causes of school failure?

Answer 283

Sensory impairment, sleep disorder, mood disorder, learning disability, conduct disorder

Question 284

What are the “red flags” for risk of learning disability?

Answer 284

• history of maternal illness or substance abuse during pregnancy
• complications at the time of delivery
• history of meningitis or other serious illness
• history of serious head trauma
• parental history of learning disabilities or difficulty at school

Question 285

What are the adverse effects of ADHD medications?

Answer 285

Appetite suppression, tic disorders, insomnia, decrease in growth velocity

Question 286

What is SCFE?

Answer 286

Displacement of the femoral head from the femoral neck through the physeal plate.

Most commonly, it occurs at the onset of puberty in obese patients with delayed sexual maturation.

Typical symptoms include an antalgic gait due to pain referred to the hip, thigh, and/or knee, with limited ROM on examination of the hip

Question 287

What are the guidelines for screening for diabetes mellitus in children?

Answer 287

Children should be screened if the are overweight (BMI >85th %ile) plus any two of the following risk factors:

• family history of Type 2 DM in a first or second degree relative
• race/ethnicity of a high-risk group
• signs of insulin resisitance or conditions associated with insulin resistance (acanthosis nigricans, PCOS, etc.)
• maternal history of diabetes or gestational diabetes during the child’s gestation

Should be started at 10 years of age or at the onset of puberty, whichever is earlier. Screening should occur every three years with the same criteria as for diabetes in adults.

Question 288

What are the most common causes of secondary hypertension in children?

Answer 288

umbilical arterial or venous access: placement of an umbilical arterial or venous line during the perinatal period may predispose to renal vascular disease

UTI– due to renal scarring

catecholamine excess

family history of renal disease

coarctation of the aorta

Question 289

What is the caloric requirement for 1 to 2 month olds?

Answer 289

Adequate growth for a term infant require approximately 100 to 120 cal/kg/day. Average daily weight gain for a term infant is 20 to 30 g.

Question 290

When do most babies start to sleep through the night?

Answer 290

4-6 months (around the same time the Moro reflex disappears and infants can start eating rice cereal)

Question 291

When do most healthy infants double their birth weight?

Answer 291

By 4-5 months, and will triple their birth weight by 1 year of age. Most children will reach double their birth length by 4 years.

Question 292

What are the milestones for a 6-month old?

Answer 292

Question 293

What are the 12-month development milestones?

Answer 293

Gross motor: Stands alone (many can walk well). Fine motor: Has a well developed, “neat” pincer grasp. Language: Says “mama” and “dada” (specific) and 1 or 2 other words. Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner.

Question 294

What is the differential diagnosis for RUQ mass and pallor in a 9-month-old infant?

Answer 294

hepatic neoplasm

hydronephrosis

neuroblastoma – most frequently diagnosed neoplasm in infants, most likely

teratoma

Wilm’s tumor – median age is 3 years

Question 295

What lab tests would you get for suspected neuroblastoma?

Answer 295

• CBC with Differential The CBC with differential is helpful in identifying the extent of anemia and to look for cytopenia that may be associated with bone marrow infiltration. This test is not specific for any one diagnosis.
• Catecholamine Metabolites (VMA and HVA) Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma. This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection.
• Chest X-ray A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray.
• Skeletal Survey A skeletal survey can identify metastases to the bone
• Abdominal ultrasound: will identify a mass, showt he organ of origin, and determine if the mass is solid, cystic, or combined (first choice of imaging)

Question 296

What patients are most likely to benefit from statin therapy?

Answer 296

LDL cholesterol > 190

Diabetes age 40-75

estimated 10-year ASCVD risk > 7.5%

Question 297

When should you screen for lipid disorders?

Answer 297

The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening: men > 35 years old women > 45 years old if they are at increased risk for coronary heart disease.

The U.S. Preventive Services Task Force (USPSTF) recommends screening: men 20 - 35 years old if they are at increased risk for heart disease women 20 - 45 years old if they are at increased risk for heart disease

Question 298

When are high-intensity statins recommended vs. moderate intensity?

Answer 298

• Dosages that lower LDL cholesterol by 30- 50% are considered high intensity statins.
• High intensity therapy is recommended for: patients > 75 years of age with clinical ASCVD
• those with LDL cholesterol > 190 mg/dL
• diabetics aged 40-75 with estimated 10-year ASCVD risk of > 7.5%
• Moderate intensity therapy is recommended for: patients

Question 299

What calorie deficit is necessary to lose 1 pound of weight?

Answer 299

3500 calories