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► Med Notes > Family Medicine Core Rotation - Acute Complaints_1 > Flashcards

Family Medicine Core Rotation - Acute Complaints_1 Flashcards

1
Q

What feature of a history of abdominal pain would lead you toward an emergent evaluation?

A

the fact that the pain began suddenly

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2
Q

the first priority when evaluating abdominal pain is what?

A

to determine whether the pain is acute or chronic

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3
Q

RLQ abdominal pain is suspicious for what?

A

acute appendicitis

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4
Q

a gnawing sensation in the abdomen is often described with what disease?

A

ulcer disease

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5
Q

abdominal pain that worsens after eating is associated with what?

A

pancreatitis • gallbladder disease • reflux

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6
Q

what symptom added to abdominal pain that worsens after eating would prompt emergent evaluation?

A

hemodynamic instability

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7
Q

does emesis with abdominal pain by itself warrant emergent evaluation?

A

no

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8
Q

recent onset abdominal pain that starts in the midepigastric region and radiates to the back. • nausea and vomiting • what is the most likely diagnosis?

A

pancreatitis

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9
Q

location and radiation of acute appendicitis?

A

starts from periumbilical region before moving to right lower quadrant

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10
Q

location and radiation of pain in pancreatitis?

A

settles in midepigastric region with radiation to the back • associated with nausea and vomiting

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11
Q

location and radiation of gallbladder pain?

A

epigastric or RUQ radiating to the scapula

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12
Q

location and radiation of esophageal spasm pain?

A

referred higher in the chest

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13
Q

location and radiation of GERD?

A

midepigastric and generally does not radiate

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14
Q

80yo m • mild • crampy • bilateral lower quadrant pain • decreased appetite • low grade fever • most likely diagnosis?

A

appendicitis

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15
Q

how does pain perception change with age?

A

10-20% reduction in the perceived intensity of pain per decade after age 60

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16
Q

what percentage of elderly patients with appendicitis present with classic symptoms?

A

22%

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17
Q

what symptom, combined with bilateral lower quadrant abdominal pain and decreased appetite should decrease suspicion of constipation and SBO?

A

fever

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18
Q

how does IBS differ from appendicitis in the elderly?

A

IBS is chronic and generally not associated with fever

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19
Q

how does pancratitis differ from appendicitis in the elderly?

A

pancreatitis is associated with food intolerance but the associated pain is usually in the epigastric region

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20
Q

Patient stopping inspiratory effort during deep palpation of the RUQ is suggestive of what?

A

cholecystitis

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21
Q

difference between physical exam findings in hepatitis or gallstones and cholecystitis?

A

murphy sign present in cholecystitis, tenderness present in hepatitis and gallstones but no murphy sign

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22
Q

pain from renal calculi often radiates to where?

A

shoulder

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23
Q

patient complaining of gnawing abdominal pain in the center of upper abdomen associated with a sensation of hunger. has long hx of etoh abuse. darker stool over last 3 weeks. most likely cause?

A

H pylori infection–> PUD

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24
Q

second most common cause of PUD?

A

NSAIDs

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25
Q

do alcoholism and gallstones cause PUD?

A

no they cause pancreatitis

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26
Q

does gastroparesis cause PUD?

A

may cause dyspepsia, but is a less likely cause of PUD

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27
Q

what is the appropriate next step if you suspect GERD in a patient?

A

treat with an H2-receptor blocker, PPI, or prokinetic agents and evaluate the response

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28
Q

reflux can be appropriately diagnosed by what?

A

medical history and evaluating the response to treatment

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29
Q

how often does upper endoscopy fail to reveal GERD?

A

36-50% of patients who have been found to have GERD by pH probe

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30
Q

when should EGD be ordered for a patient with potential reflux?

A

if bleeding, weight loss, or dysphagia is present, especially in an elderly patient

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31
Q

endoscopy should always be performed if which certain alarm symptoms are present?

A

bleeding • abdominal mass • weight loss • dysphagia • vomiting, • especially if in an elderly patient

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32
Q

what is the gold standard for diagnosis and treatment of choledocolithiasis?

A

ERCP

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33
Q

ERCP is usually performed in the setting of which clinical picture?

A

acute cholecystitis with increased liver enzymes, amylase, or lipase

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34
Q

Ultrasound can show gallstones, but is less sensitive for which related conditions?

A

choledocolithiasis or complications (abscess, perforation, pancreatitis)

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35
Q

which imaging studies are better than U/S to detect choledocolithiasis and its complications?

A

CT or MRI

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36
Q

a negative result on which test rules out cholecystitis?

A

cholescintigraphy

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37
Q

when is ERCP a better choice than cholescintigraphy?

A

in the setting of elevated liver enzymes

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38
Q

what causes the majority of cases of pancreatitis?

A

gallstones

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39
Q

alcohol causes what percentage of cases of pancreatitis?

A

30%

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40
Q

what percentage of cases of pancreatitis are idiopathic?

A

10-30%

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41
Q

what are the less common causes of pancreatitis?

A

hypercalcemia • hyperlipidemia • abdominal trauma • medications • infections • instrumentation (ERCP)

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42
Q

what are the 5 ranson criteria for pancreatitis that suggest a poor prognosis?

A
  1. age>55 • 2. WBC>16k • 3. glucose >200 • 4. LDH>350 • 5. AST>250
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43
Q

which 6 ranson criteria reflect the development of complications of pancreatitis?

A

↓Hct>10 • ↑BUN>5 • Ca<8 • PaO2<60 • Base Deficit>4 • Fluid sequestration >6L

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44
Q

IBS is typified by what?

A

symptoms of abdominal pain or discomfort associated with disturbed defecation

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45
Q

what are the Rome Consensus Committee for IBS diagnostic criteria?

A

symptoms present in at least 12 (needn’t be consecutive) weeks of the last 12 months, and pain characterized by 2 of these 3: • 1. relieved by defecation • 2. onset associated with change in stool frequency • 3. onset is associated with a change in the form or appearance of stool

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46
Q

even in the presence of Rome criteria for IBS, some clinicians would be reassured by the presence of what?

A

normal CBC and ESR

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47
Q

‘dyspepsia’ refers to what?

A

a set of symptoms: • chronic or recurrent discomfort around the upper abdomen– • can be associated with heartburn, belching, n/v

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48
Q

what are the common causes of dyspepsia?

A

GERD • PUD

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49
Q

no specific etiology is found for what percentage of patients presenting with dyspepsia?

A

50-60%

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50
Q

what percentage of patients with dyspepsia have ulcer disease?

A

15-25%

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51
Q

what percentage of patients with dyspepsia have GERD?

A

5-15%

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52
Q

what are the rare causes of dyspepsia?

A

gastric or pancreatic cancers

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53
Q

what can you do when a pap smear comes back with ASCUS?

A

repeat test in 4-6mo and 1y • perform HPV testing on the sample • proceed to colposcopy

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54
Q

what does it mean when HPV comes back negative after a Pap smear with ASCUS?

A

patient is at low risk for cancer

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55
Q

what do you do next when HPV comes back negative after a pap smear with ASCUS?

A

repeat pap in 1 year, especially if the patient is monogamous

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56
Q

when the results of a pap smear are reported as ASCUS and HPV is positive, what should you do next?

A

proceed to colposcopy

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57
Q

colposcopy involves what?

A

cervical examination under stereoscopic magnification and biopsy of abnormal appearing areas

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58
Q

what is the definitive test for assessing pap smear abnormalities?

A

colposcopy

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59
Q

what is Imiquimod(Aldara)

A

an immune modulator that can treat genital warts

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60
Q

what should you do when a repeat pap after a normal pap comes back again as ASCUS and HPV testing is unavailable?

A

proceed to colposcopy

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61
Q

if after a pap smear comes back as ASCUS and HPV testing is unavailable, you do colposcopy that shows no CIN, what do you do next?

A

repeat pap in 1 year then resume pap smears at normal intervals

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62
Q

if a pap smear comes back as ASCUS on a postmenopausal woman who is not taking estrogen replacement therapy what do you do?

A

4 week course of vaginal estrogen cream, then repeat pap smear 1 week after course is complete

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63
Q

in a postmenopausal woman who isn’t on hormone replacement who has a pap result of ASCUS and then another after 4 weeks of vaginal estrogen cream, what do you do next?

A

colposcopy

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64
Q

what do you do when the results of a pap smear come back ASCUS, favoring low-grade squamous intraepithelial lesion (LSIL)?

A

proceed to colposcopy

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65
Q

what do you do when a healthy young monogamous woman on OCP gets a pap smear result of atypical glandular cells with no specification as to whether they are endocervical or endometrial in origin?

A

when the results of a pap smear are reported as atypical glandular cells, proceed to colposcopy

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66
Q

what do you do when a pap smear result is reported as atypical glandular cells or endometrial origin in the absence of abnormal vaginal bleeding??

A

when the results of a pap smear are reported as atypical glandular cells of endometrial origin, an endometrial biopsy is required to rule out endometrial cancer

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67
Q

what is the most likely cause of microcytic anemia with an increased RDW?

A

iron deficiency

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68
Q

causes of microcytic anemias include what?

A

iron deficiency • anemia of chronic disease • thalassemia • sideroblastic anemia

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69
Q

why is RDW elevated in iron deficiency anemia?

A

variation in RBC size

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70
Q

which CBC findings are associated with sideroblastic anemia?

A

MCV- normal, high, or low • dimorphic red cells (usually ↑RDW)

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71
Q

what is the RDW in thalassemia?

A

normal, because cells are uniformly small

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72
Q

cell size in aplastic anemia and chronic renal insufficiency?

A

generally normocytic

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73
Q

what is the most common cause of iron deficiency anemia in a 60yo male?

A

blood loss

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74
Q

what are the less common causes of iron deficiency anemia in a 60yo man?

A

poor nutrition • inadequate absorption

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75
Q

Iron panel findings in anemia of chronic disease?

A

high/normal ferritin • low TIBC

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76
Q

what do you suspect/order for an african american male with mild anemia with disproportionate microcytosis and normal RDW?

A

think thalassemia, order hemoglobin electrophoresis

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77
Q

which clinical features are common to all megaloblastic anemias?

A

anemia • pallor • weight loss • fatigue • glossitis

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78
Q

which symptoms are specific to B12 deficiency?

A

neurologic symptoms

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79
Q

what is the typical treatment for B12 deficiency?

A

parenteral B12 administration weekly for a month, with concurrent administration of folic acid, then oral supplementation once levels are established

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80
Q

most often, B12 deficiency is the result of what?

A

inadequate absorption

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81
Q

which groups of people might be B12 deficient from a dietary standpoint?

A

strict vegans or those not consuming animal products

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82
Q

how does alcohol intake affect B12/folate?

A

alcohol can affect intracellular processing of folate, but not B12

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83
Q

what can you do for a sickle cell disease having child to prevent future pain crises?

A

adequate hydration

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84
Q

what is the most common presentation of sickle cell anemia?

A

pain crisis before age 9

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85
Q

prophylaxis for SCD pain crisis includes what?

A

ensuring adequate oxygenation and hydration

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86
Q

what abx prophylaxis is recommended in SCD children?

A

daily penicillin prophylaxis until age 5

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87
Q

can scheduled transfusions and chronic use of analgesics prevent pain crisis in SCD children?

A

no

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88
Q

what is the most likely cause of a rashin a young man that starts as pink spots on the extremities that coalesce and become purple after a trip in the mountains?

A

Rocky Mountain Spotted Fever

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89
Q

the lesions of rocky mountain spotted fever are typically what?

A

red macules on peripheral extremities that become purpuric and confluent

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90
Q

lyme disease typically presents how?

A

a slowly spreading anular lesion- erythema chronicum migrans

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91
Q

tularemia is characterized by what?

A

pain and ulceration at the bite site

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92
Q

brown recluse spider bites most often present as what?

A

local pain and itching, then a hemorrhagic bulla with surrounding erythema and induration

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93
Q

the black widow bite is characterized by what?

A

a mild prick followed by pain at the bite site

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94
Q

how do you treat early localized lyme disease?

A

PO amoxicillin or doxycycline for 14-21 days

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95
Q

how do you treat disseminated lyme disease?

A

2-3 weeks of IV ceftriaxone, cefotaxime, or chloramphenicol

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96
Q

what abx do you give for rocky mountain spotted fever?

A

chloramphenicol that continues 2-3 days after the patient is afebrile

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97
Q

how do you treat tularemia?

A

streptomycin IM

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98
Q

what is the typical presentation and physical examination finding in head lice?

A

itching scalp with erythematous papules and small black bulbs at the base of hair follicles

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99
Q

what are the treatment options for head lice?

A

premethrin and lindane

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100
Q

what is the first choice treatment for head lice?

A

premethrin 1%

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101
Q

what is the second option preferred treatment for head lice?

A

premethrin 5%

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102
Q

what is the 3rd choice preferred treatment option for head lice?

A

lindane 1%

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103
Q

if treatment failure occurs in a case of head lice, what is the second line treatment?

A

0.5% malathion

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104
Q

what is an effect oral treatment for scabies?

A

PO ivermectin

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105
Q

pruritic erythematous papules in between the fingers, on the wrists, and around the waist is the characteristic distribution for what?

A

scabies

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106
Q

what is the cause of scabies?

A

Sarcoptes scabiei burrow into intertriginous areas, wrists, or where clothing is tight next to the skin

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107
Q

what is the characteristic distribution of chigger bites?

A

linear pattern over wrists, ankles, and legs

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108
Q

what is the characteristic distribution of bed bug bites?

A

bed bugs typically infest unclothed areas- the neck, hands, and face

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109
Q

fleas typically bite which part of the body?

A

lower extremities

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110
Q

how do insect bites typically present?

A

erythematous papules or vesicles and are sometimes difficult to differentiate

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111
Q

what are the helpful differentiators in the identification of insect bites?

A

location and distribution

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112
Q

how do flea bites occur?

A

in clusters and typically on the lower extremities

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113
Q

where do you typically see bed bug bites?

A

hands, face and neck

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114
Q

do spiders bite in clusters?

A

no

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115
Q

scabies are typically found where?

A

where clothing is tight against skin-belt and wrist line • where skin touches skin- between the fingers

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116
Q

when does the itching from lice begin?

A

2-3 weeks after infestation

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117
Q

what should you do for a cat bite that has a jagged laceration, erythema, purulent discharge, no tendon involvement?

A

treat with amoxicillin/clavulanic acid as an outpatient for 5 days

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118
Q

typical local reactions to stings (bees) include what?

A

swelling, erythema, and pain at and around the site of the sting

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119
Q

in general what happens to typical stings?

A

they resolve quickly and minimal analgesia is all that is necessary

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120
Q

what are the additional features of large local reactions to stings?

A

extended areas of swelling that lasts several days

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121
Q

what is the allergic nature of large local reactions to stings?

A

they are not allergic in origin and carry a minimal risk of anaphylaxis upon re-exposure

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122
Q

with regard to bee stings, toxic systemic reactions are associated with what?

A

nausea, vomiting, headache, vertigo, syncope, convulsions, fever. • pruritis, erythema, and urticaria are less common

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123
Q

what is the risk of anaphylaxis with subsequent stings after a systemic toxic reaction to a bee sting?

A

they are at risk

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124
Q

what is the workup for gynecomastia in a 15 year old?

A

if it presents at the time of puberty, history, PE and reassurance are enough if there are no abnormalities found

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125
Q

what is the workup for gynecomastia in a male outside of puberty?

A

assessment of hepatic, renal, and thyroid functions may help uncover a cause • sex hormones are only tested if progressive enlargement is noted.

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126
Q

what is the most common benign condition of the breast?

A

fibrocystic changes

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127
Q

how big are the lesions in fibrocystic changes of the breast?

A

1mm->1cm

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128
Q

what is the typical presentation of a breast fibroadenoma?

A

rubbery, smooth, well-circumscribed, nontender, freely mobile

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129
Q

why are mammograms not necessary in young women?

A

mammograms are not necessary in women <30yo because they are less sensitive in younger women with denser breast tissue

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130
Q

mastitis generally occurs when?

A

nursing

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131
Q

mastitis is characterized by what?

A

inflammation, edema, and erythema in areas of the breast

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132
Q

what percentage of breast cancers are mammographically silent?

A

15%, so palpable mass deserves workup

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133
Q

what is the workup for a mammographically silent breast mass?

A

ultrasound and possible biopsy

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134
Q

when should biopsy follow breast ultrasound and aspiration of cystic mass?

A

if mass is palpable after aspiration, if the fluid is bloody, if the mass reappears within 1 month

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135
Q

when is genetic testing for breast cancer of value?

A

no value in workup of breast mass, but can be considered with family history of breast cancer by experienced genetic counselor

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136
Q

what is the protocol for mastitis in a nursing mother?

A

continue nursing and start on an antibiotic that covers streptococcal and staphylococcal infections

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137
Q

what recommendations can be made for women with fibrocystic breast changes to improve their symptoms?

A

reducing caffeine and methylxanthines, • using evening primrose oil

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138
Q

do you recommend heat or ice for mastitis relief?

A

applying heat may help symptoms, but ice will not have the desired effect

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139
Q

what characteristic of nipple discharge would be most suspicious for breast cancer?

A

spontaneous unilateral discharge

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140
Q

what types of nipple discharge deserve a workup?

A

bloody • serous • serosanguinous • watery

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141
Q

what is BI-RADS?

A

breast imaging reporting and data system

142
Q

what is BI-RADS 0?

A

test was incomplete

143
Q

what do BI-RADS 1 and 2 mean?

A

mammogram is benign and routine screening can be conducted at normal intervals

144
Q

what does BI-RADS 3 mean?

A

the lesion is probably benign, but that diagnostic mammogram should be performed in 3 months

145
Q

what do BI-RADS 4 and 5 mean?

A

suspicious and highly suggestive of cancer and that tissue diagnosis is needed

146
Q

hand cellulitis following a cat bite puncture wound is most likely caused by infection with which organism?

A

Pasteurella multocida

147
Q

most skin infections are due to which pathogens?

A

Strep pyogenes • Staph aureus

148
Q

which organism can lead to gangrene and is associated with crepitus on physical exam for cellulitis?

A

Clostridium Perfringens

149
Q

H. influenzae can infect the skin of which population?

A

younger children

150
Q

high school wrestler comes in with pruritic erythematous patch with central clearing. what’s the cause?

A

tinea corporis

151
Q

how can tinea infections be spread?

A

close person to person contact

152
Q

what confirms the diagnosis of tinea?

A

skin scraping and demonstration of hyphae under microscope after KOH prep

153
Q

where does tinea cruris occur on the body?

A

in the groin

154
Q

which factor included in a history of chest pain decreases the likelihood of cardiac etiology?

A

pain is worse with inspiration, • also sharp/stabbing pain, positional chest pain

155
Q

what is the likelihood ratio of pain radiating to the left arm being associated with acute MI?

A

2.3

156
Q

what is the likelihood ratio of chest pain radiating to the right arm being associated with acute MI?

A

2.9

157
Q

what is the likelihood ratio of chest pain associated with nausea or vomiting being associated with acute MI?

A

1.9

158
Q

what is the likelihood ratio of chest pain associated with diaphoresis being associated with acute MI?

A

2

159
Q

what is the likelihood ratio of pleuritic chest pain being associated with acute MI?

A

0.2

160
Q

unless a competing diagnosis can be confirm, what test is warranted in the initial evaluation of most patients with acute chest pain?

A

ECG

161
Q

which ECG feature, if present, would most markedly increase the likelihood of an acute MI?

A

any ST segment elevation greater than or equal to 1mm

162
Q

what is the lieklihood ratio that any ST segment elevation is associated with acute MI?

A

11.2

163
Q

what is the likelihood ratio that any ST segment depression is associated with an acute MI?

A

3.2

164
Q

what is the likelihood that any Q-wave is associated with an acute MI?

A

3.9

165
Q

what is the likelihood ratio that any conduction defect is associated with an acute MI?

A

2.7

166
Q

what is the likelihood that a new conduction defect is associated with an acute MI?

A

6.3

167
Q

what is the ECG finding that is the strongest predictor of acute MI?

A

ST-segment elevation

168
Q

what percentage of patients with acute coronary syndrome can have a normal ECG?

A

20%

169
Q

what do you need to get for a patient with no acute changes, but ECG findings of LVH are present?

A

treadmill stress echo

170
Q

why get stress test with imaging on a 43 yo female instead of a treadmill stress ECG?

A

for women in her age group, stress ECG are often false positive

171
Q

a crescendo-decrescendo systolic murmur with carotid pulsus parvus et tardus are very suggestive what?

A

aortic stenosis

172
Q

angina frequently occurs in aortic stenosis due to what?

A

underperfusion of the endocardium

173
Q

what is the presentation of syncope associated with aortic stenosis?

A

typically exertional and is a late finding

174
Q

what cardiac problems, other than aortic stenosis, cause syncope associated with chest pain?

A

aortic dissection • PE • LVH • MVP

175
Q

what is the most commonly used noninvasive procedure for evaluating whether chest pain is due to angina?

A

exercise ECG

176
Q

when weighing stress testing options, what is the recommended initial procedure in low risk patients without baseline ECG abnormalities? why?

A

exercise ECG because of it’s low cost and convenience

177
Q

myocardial stress imaging (scintigraphy or echocardiography) is indicated when?

A
  1. if the resting ECG makes an exercise ECG hard to interpret, • 2. for confirmation of the results of the exercise ECG, • 3. to localize the region of ischemia, • 4. to distinguish ischemic from infarcted myocardium, • 5. to assess the completeness of revascularization following an intervention
178
Q

the electron beam CT can quantify what?

A

coronary artery calcification

179
Q

is electron beam CT helpful to evaluate agnina?

A

no

180
Q

constipation is generally defined as what?

A

infrequent bowel movements of straining to achieve a bowel movement

181
Q

when is a laboratory evaluation for constipation necessary?

A
  1. if alarm symptoms are present • 2. if a specific medical disorder is likely given history and physical • 3. if the person doesn’t respond to initial treatment
182
Q

what are the alarm symptoms that should prompt laboratory evaluation for constipation?

A
  1. hematochezia • 2. fam hx colon CA • 3. fam hx IBD • 4. positive FOBT • 5. weight loss • 6. new onset constipation in pt >50yo
183
Q

what is the best first line treatment for a young healthy female with chronic constipation?

A

psyllium (metamucil)

184
Q

chronic use of milk of magnesia can lead to what?

A

hypermagnesemia

185
Q

why not give bisacodyl long term for chronic constipation?

A

stimulant laxatives work well in the short term, but research is not available to support their routine use for the treatment of chronic constipation

186
Q

what is the treatment of choice for impaction?

A

enemas

187
Q

can you use enemas for chronic constipation?

A

no

188
Q

what is the use of lubiprostone?

A

it is beneficial in the treatment of adults with chronic constipation, but not as a first line

189
Q

for whom should lubiprostone be reserved?

A

those refractory to other treatments for chronic constipation

190
Q

what are the most common causes of chronic cough?

A

asthma • postnasal drainage • smoking • GERD

191
Q

If chronic cough is caused by asthma, what will it likely respond to?

A

a bronchodilator

192
Q

If chronic cough is caused by pertussis, what will it likely respond to?

A

azithromycin

193
Q

which associated historical findings suggest that a chronic cough is due to GERD?

A

sore throat • worse when lying down • worse with alcohol or caffeine

194
Q

side effect of which medication is likely to cause chronic cough?

A

ACE inhibitors

195
Q

what is the differential diagnosis for acute cough?

A

asthma exacerbation • acute bronchitis • aspiration • exposure to irritants (cigarette smoke, pollutants) • allergic rhinitis • uncomplicated pneumonia • sinusitis with postnasal drip • viral upper respiratory infection

196
Q

what is the most common cause of acute cough?

A

viral URI

197
Q

what is the most frequent illness in humans?

A

viral URI, with a prevalence of 35%

198
Q

what are the criteria for chronic bronchitis?

A

productive cough for at least 3 months of the past 2 years

199
Q

what is the most common cause of chronic cough in smokers?

A

chronic bronchitis

200
Q

what is the most common cause of chronic cough in nonsmokers?

A

postnasal drainage

201
Q

how often do lung cancers present solely with cough?

A

rarely. • typically associated with hemoptysis and weight loss

202
Q

what is the best course of treatment for a patient with a cough persisting 4 weeks after initial treatment for acute bronchitis?

A

oral steroid taper

203
Q

what are the CDC guidelines for use of antibiotics in acute bronchitis?

A

abx are not indicated for uncomplicated acute bronchitis, regardless of the duration of the cough

204
Q

which patients should get antibiotics for acute bronchitis?

A
  1. patients with significant COPD and CHF • 2. those who are very ill appearing • 3. the elderly
205
Q

what is a likely cause of persistent cough 4 weeks after uncomplicated acute bronchitis?

A

hyperresponsive airways, AKA postbronchitic cough

206
Q

what is the best treatment for a postbronchitic cough?

A

inhaled steroid or oral steroid taper

207
Q

what is the recommended treatment for pertussis?

A

5 day course of azithromycin or 14 day course of erythromycin

208
Q

antibiotics do not alter the course of pertussis unless what?

A

they are initiated early in the illness

209
Q

why should you give antibiotics in later pertussis infection?

A

they prevent transmission and decrease the need for respiratory isolation from 4 weeks to 1 week

210
Q

are amoxicillin/clavulanate effective against pertussis?

A

no

211
Q

viral infections account for what percentage of acute infectious diarrhea?

A

70-80%

212
Q

what is the most frequent cause of acute infectious diarrhea?

A

rotavirus

213
Q

what are the second most common viruses that cause acute infectious diarrhea?

A

enteric adenoviruses

214
Q

when does rotavirus occur?

A

in the winter months and most cases occur between the ages of 3mo and 2 years

215
Q

how do you acquire norwalk virus and get acute infectious diarrhea?

A

contaminated water, salads, or shellfish

216
Q

most acute diarrhea occurs when?

A

after ingestion of contaminated food or water, or direct person to person contact

217
Q

acute diarrhea is defined as what?

A

an increased number or decreased consistency of stool lasting 14 days or less

218
Q

giardiasis is more common in which children?

A

children in daycare centers

219
Q

acute infectious diarrhea caused by Salmonella is generally due to what?

A

raw or undercooked meat

220
Q

what is the most common cause of traveler’s diarrhea?

A

enterotoxigenic E coli

221
Q

what % of patients that get traveler’s diarrhe have to alter their plans due to symptoms?

A

40%

222
Q

what % of patients that get traveler’s diarrhea will be bed bound for at least 1 day?

A

20%

223
Q

what % of patients that get traveler’s diarrhea will require hospitalization?

A

1%

224
Q

what is the antibiotic of choice for traveler’s diarrhea?

A

fluoroquinolone

225
Q

what are the acceptable alternatives to a fluoroquinolone in the treatment of traveler’s diarrhea?

A

trimethoprim/sulfamethoxazole • azithromycin

226
Q

for acute viral diarrhea, adults should be encouraged to eat what?

A

potatoes • rice • wheat • noodles • crackers • bananas • yogurt • boiled vegetables • soup

227
Q

what foods should adults with acute viral diarrhea avoid?

A

dairy products • alcohol • caffeine

228
Q

when should a patient with acute viral diarrhea drink oral rehydration salts?

A

when vomiting is a problem

229
Q

is fasting indicated in acute viral diarrhea?

A

no

230
Q

what effect can fruit juices have on acute viral diarrhea?

A

exacerbation of diarrhea

231
Q

what is vertigo?

A

a rotational sensation where the room spins around the patient

232
Q

what is orthostasis?

A

light-headedness upon rising, common with orthostatic hypotension

233
Q

what is presyncope?

A

feeling of impending faint

234
Q

what is disequilibrium?

A

a senstation of unsteadiness, or a loss of balance “in the feet”

235
Q

light-headedness is often vaguely described as what?

A

a ‘floating’ sensation

236
Q

acoustic neuroma typically presents with what?

A

constant and slowly progressive unilateral tinnitus and hearing loss followed by vertigo, facial weakness, ataxia with tumor growth

237
Q

vestibular neuronitis presents with what?

A

an acute onset of severe vertigo lasting several days, with symptoms improving over several weeks

238
Q

benign positional vertigo typically only involves symptoms in what situation?

A

with position changes only

239
Q

Meniere disease presents with what?

A

discrete attacks of vertigo lasting for several hours, associated with nausea and vomiting, hearing loss, and tinnitus

240
Q

how would a cerebellar tumor typically present?

A

dysequilibrium as opposed to tinnitus

241
Q

the dix-hallpike maneuver is often useful to distinguish what?

A

central from peripheral causes of vertigo

242
Q

with a peripheral cause of vertigo, during dix-hallpike, what is the finding?

A

3-10 seconds, with severe symptoms, and fixed nystagmus–> lessening of symptoms with repetition of maneuver

243
Q

with a central cause of vertigo what is the dix-hallpike finding?

A

no latency to onset of symptoms, no lessening of symptoms with repetition of maneuver, direction of nystagmus changes, symptoms are of mild intensity

244
Q

what is a central cause of vertigo?

A

stroke

245
Q

what are 4 peripheral causes of vertigo?

A

vestibular neuronitis • benign positional vertigo • meinere disease • acoustic neuroma

246
Q

what is a first line treatment for symptomatic relief of peripheral vertigo?

A

antihistamines

247
Q

how do antihistamines provide symptomatic relief of vertigo?

A

they suppress the vestibular end organ receptors and inhibit activation of the vagal response

248
Q

what are the commonly recommended choices for treatment of peripheral vertigo?

A

meclizine (antivert) 25mg po q4-6h • diphenhydramine (benadryl) 50mg po q4-6h

249
Q

when do you use antiemetics to treat peripheral vertigo?

A

when nausea or vomiting are a problem

250
Q

can you use benzodiazepines to treat peripheral vertigo?

A

they can provide symptom reduction, but are usually second line agents

251
Q

are antibiotics and NSAIDs useful in the treatment of peripheral vertigo?

A

no

252
Q

those at risk for obstructive lung disease include who?

A
  1. pediatric patients (asthma, bronchitis, bronchiolitis) • 2. adults with asthma • 3. adults with chronic cigarette smoking
253
Q

dyspnea due to restrictive lung disease is more likely with which cases?

A
  1. occupational exposures (farmers, cotton dust, grain dust, hay mold) • 2. severe scoliosis • 3. morbidly obese • 4. pregnancy
254
Q

what are the signs and symptoms of CHF?

A
  1. abnormal heart sounds (murmur or additional heart sound) • 2. cardiomegaly • 3. JVD • 4. basilar rales • 5. dependent edema
255
Q

what do you give an elderly man with SOB, orthopnea, DOE, basilar crackles, large apical impulse, JVD?

A

diuretics

256
Q

what is the most likely diagnosis in a 3 yo boy with recurrent SOB, nasal flaring, sternal retractions with accessory muscle use, bilateral expiratory wheezes?

A

asthma

257
Q

asthma in children is characterized by what?

A

recurrent episodes of wheezing

258
Q

how do you differentiate between asthma and bronchiolitis or pneumonia in a child?

A

all three cause wheezing but typically only asthma causes recurrent wheezing

259
Q

B-type natriuretic peptide evaluates for the presence of what?

A

CHF

260
Q

how do you interpret a B-type natriuretic peptide level <80?

A

high (99%) negative predictive value to rule out CHF

261
Q

how do you interpret the results of a D dimer ordered on an obese woman with SOB and tachycardia?

A

if it is low, reassure the patient because a low D dimer rules out, if elevated, then order confirmatory test- spiral CT, VQ scan, or pulmonary angio

262
Q

what do you give a terminal cancer patient for shortness of breath?

A

opioids

263
Q

what is the most likely diagnosis in a 23 yo female with 2 day hx of dysuria with frequency, back pain, pink discoloration of urine?

A

acute bacterial cystitis

264
Q

what are the 4 factors that correlate significantly with a diagnosis of acute bacterial cystitis?

A

frequency • hematuria • dysuria • back pain

265
Q

what 4 factors decrease the likelihood of UTI?

A

absent dysuria • absent back pain • history of vaginal discharge • history of vaginal irritation

266
Q

how do you differentiate acute bacterial cystitis from pyelonephritis?

A

pyelonephritis is often associated with fever

267
Q

how do differentiate interstitial cystitis from acute bacterial cystitis?

A

interstitial cystitis tends to be more chronic in nature and is generally not associated with back pain

268
Q

how do you differentiate vulvovaginitis from acute bacterial cystitis?

A

vulvovaginitis is a common cause of dysuria, but is associated with vaginal irritation or discharge

269
Q

when is urine culture indicated?

A

when acute bacterial cystitis is suspected, but the urinalysis leaves the diagnosis in question

270
Q

what is an acceptable prophylactic measure for a young woman with recurrent UTI that has failed voiding after intercourse, d/c diaphragm, and acidification of urine with vitamin C?

A

single dose antibiotic therapy after intercourse

271
Q

if post coital antibiotics cannot prevent frequent UTI what is the next step?

A

daily single dose antibiotic prophylaxis for 3-6 months, or 1-2 years if that fails

272
Q

what do you do for a 36 yo female with recurrent UTI that resolves with abx, but is continuously negative on urine culture?

A

order cystoscopy to diagnose interstitial cystitis

273
Q

what is a common cause of dysuria without pyuria in a postmenopausal woman?

A

atrophy

274
Q

what is a common cause of recurrent dysuria without pyuria in a young female?

A

bladder irritants- caffeine and acidic foods

275
Q

what should you suspect if you see recurrent dysuria without pyuria with associated hematuria?

A

interstitial cystitis

276
Q

what findings on cystoscopy suggest interstitial cystitis?

A

presence of ulcerations and fissures in the bladder mucosa and absence of bladder tumors

277
Q

in interstitial cystitis, urodynamic studies often demonstrate what?

A

small bladder capacity, with urge to void with as little as 150 mL of fluid in the bladder

278
Q

when is treatment for asymptomatic bacteriuria indicated?

A

a pregnant woman

279
Q

acute prostatitis is seen most commonly in who?

A

30-50yo men

280
Q

symptoms of acute prostatitis include what?

A

frequency, urgency, and back pain in an acutely ill man with pyuria

281
Q

DRE of a man with acute prostatitis reveals what?

A

boggy, tender, and warm prostate

282
Q

what should you do for a young woman complaining of a left sided earache with deep pain that worsens with eating and tenderness and crepitus of the left TMJ?

A

treat with NSAIDs

283
Q

what is a common cause of referred otalgia?

A

temperomandibular joint dysfunction

284
Q

what are the first line therapies for TMJ dysfunction?

A
  1. nsaids • 2. heat • 3. mechanical soft diet • 4. referral to a dentist if there is no improvement in 3-4 weeks
285
Q

is antibiotic therapy indicated in TMJ dysfunction?

A

no

286
Q

what is a cause of referred otalgia in which ESR would be elevated?

A

temporal arteritis

287
Q

what physical exam findings are sufficient on their own to diagnose acute otitis media in a 9 mo?

A
  1. opaque TM • 2. bulging TM • 3. impaired TM mobility • 4. purulent discharge in the ear canal
288
Q

what TM finding is insufficient to diagnose acute otitis media in a 9mo?

A

erythematous TM

289
Q

irritable baby with 100F Tm, clear runny nose and cough, what is the likely Dx?

A

acute otitis media

290
Q

what can cause erythematous TM in an irritable baby?

A

increased intravascular pressure associated with crying

291
Q

what is the positive predictive value for acute otitis media when opacity, bulging, and decreased mobility of the TM are all present?

A

90%

292
Q

how should you interpret purulent discharge in the ear canal on PE?

A

it may indicate a TM perforation, and in the face of an otherwise normal canal is more indicative of acute otitis media than otitis externa

293
Q

how long does TM effusion from otitis media take to resolve?

A

up to 3 months

294
Q

are antibiotics indicated for persistent post otitis media TM effusion in the absence of acute otitis media?

A

no

295
Q

what do you do for a persistent TM effusion lasting >3mo after acute otitis media?

A

refer to otolaryngologist

296
Q

what is the role of antihistamines in the treatment of persistent TM effusion after acute otitis media?

A

have never been documented to help effusions, but may be symptomatically helpful

297
Q

what is the first line antibiotic therapy for acute otitis media in most cases?

A

amoxicillin

298
Q

what is the first line antibiotic therapy for acute otitis media in a child with severe illness (moderate to severe otalgia with fever >102F)?

A

high dose amoxacillin-clavulanate • (90mg/kg/d in 2 divided doses)

299
Q

what is the role of azithromycin in the treatment of acute otitis media?

A

it is often used as a first line choice in 1, 3, or 5 day doses, but it should be reserved as a second line therapy

300
Q

fundamental to the treatment of external otitis is what?

A

protection from additional moisture and avoidance of further mechanical injury from scratching

301
Q

what is a very effective treatment for external otitis?

A

otic drops containing antibiotics and corticosteroids

302
Q

what is the role of oral antibiotics and steroids in external otitis?

A

reserved for recalcitrant cases

303
Q

is external otitis generally localized or systemic?

A

generally localized, demonstrating good response to local therapy

304
Q

what should you do for any case of persistent otitis externa in an immunocompromised or diabetic individual?

A

refer for specialty evaluation

305
Q

which drugs are known to cause peripheral edema as a side effect?

A
  1. Ca channel blockers • 2. β blockers • 3. centrally acting antihypertensives • 4. antisympathetic antihypertensives • 5. insulin sensitizers like rosiglitazone • 6. hormones • 7. corticosteroids • 8. NSAIDs
306
Q

do SSRI’s cause peripheral edema?

A

no

307
Q

do ACE inhibitors cause peripheral edema?

A

no

308
Q

do thiazides cause peripheral edema?

A

no

309
Q

in the workup of edema, the first thing to note is what?

A

if the edema is unilateral or bilateral

310
Q

what is the work up for bilateral edema associated with signs and symptoms of CHF?

A

CXR to rule in the Dx, followed by echocardiogram

311
Q

what do you need to order for a patient with bilateral edema when ascites is present?

A

liver function tests

312
Q

what should you check in the case of bilateral edema with no signs of CHF or ascites?

A

urinalysis

313
Q

what is the interpretation of a urinalysis with abnormal sediment in a patient with bilateral lower extremity edema?

A

nephritic syndrome or ATN is the likely diagnosis

314
Q

does edema associated with hypothyroidism cause ascites?

A

no

315
Q

for what type of edema would a lower extremity doppler study be indicated?

A

unilateral edema

316
Q

unilateral edema not associated with trauma or signs of infection requires what workup?

A

Doppler US to evaluate for the presence of DVT

317
Q

when do you order CT PE scan or V/Q scan in a patient with unilateral LE edema?

A

not unless there is suspicion of a PE

318
Q

what signs point to cellulitis in a patient with unilateral LE edema?

A

signs of inflammation including erythema

319
Q

how do you treat LE edema caused by cellulitis?

A

antibiotics

320
Q

what do you do for a patient with unilateral LE edema and varicose veins?

A

vascular surgery referral

321
Q

what do you do for LE edema caused by CHF?

A

diuretics

322
Q

what do you do for LE edema caused by venous insufficiency?

A

treatment with compression stockings

323
Q

what is the treatment of choice for LE edema caused by DVT?

A

anticoagulation

324
Q

what can aid venous return in patients with chronic venous insufficiency?

A

knee length elastic stockings and leg elevation throughout the day

325
Q

what should you limit in a patient with chronic venous insufficiency?

A

prolonged standing

326
Q

unilateral edema will not respond to which treatments that work for bilateral LE edema?

A

diuresis, Na restriction, ACE inhibitor

327
Q

how do you differentiate venous insufficiency LE edema from a DVT?

A

DVT is unlikely if the swelling is chronic in nature

328
Q

the term ‘enuresis’ refers to what?

A

repeated spontaneous nocturnal voiding of urine into the bed or clothes at least 2x/wk for 3 consecutive months in a child who is at least 5yo

329
Q

primary monosymptomatic enuresis is what?

A

bed-wetting without a history of nocturnal continence and is unassociated with other symptoms

330
Q

what is secondary monosymptomatic enuresis?

A

recurrence of bed-wetting after at least 6 months of nocturnal continence

331
Q

non-monosymptomatic enuresis is what?

A

bed-wetting associated with urinary urgency, frequency, straining, pain, chronic constipation, or encopresis

332
Q

children who have involuntary or intentional urination into clothing while awake or asleep are said to have what?

A

daytime incontinence and enuresis

333
Q

the cause of nocturnal enuresis is felt to be due to what?

A

decreased production of nocturnal antidiuretic hormone

334
Q

nocturnal enuresis is associated with what?

A

maturational delay

335
Q

what % of 5yo are enuretic?

A

25%

336
Q

the numbers of nocturnal enuretic children decrease by how much each year?

A

15%

337
Q

what % of bedwetters are female?

A

40-50%

338
Q

what is the family association with nocturnal enuresis?

A

if one parent was enuretic, there is a 40% likelihood that the child will be • if both parents, then 70%

339
Q

how many patients have an organic cause of nocturnal enuresis?

A

very few

340
Q

what has been shown to be an effective treatment for nocturnal enuresis?

A

enuresis alarms

341
Q

how effective are medications for nocturnal enuresis?

A

may be more effective than enuresis alarms in the short term, but there is a high relapse rate when medications are discontinued

342
Q

what is a barrier to effectiveness to enuresis alarms?

A

compliance with frequent night time wakening

343
Q

when is DDAVP appropriate in the treatment of nocturnal enuresis?

A

because of high relapse rate after d/c, it should be reserved for overnight visits or summercamp

344
Q

how do TCAs compare to DDAVP in the treatment of nocturnal enuresis?

A

lower initial cure rate and a high relapse rate.

345
Q

should you give TCAs for nocturnal enuresis?

A

no. can cause lethal overdose and aren’t that effective

346
Q

how well does oxybutinin work for nocturnal enuresis?

A

high relapse rate and has not been proven to be more efficacious than placebo

347
Q

in a child with monosymptomatic nocturnal enuresis, what needs to be evaluated?

A

thorough voiding history, PE, urinalysis, post void residual and nothing else

348
Q

what is the normal bladder capacity of a child?

A

age + 2 in ounces

349
Q

what is the normal post void residual in a child?

A

<10% of normal bladder capacity

350
Q

when should you order an XR of lumbar and sacral spine in a child with bed-wetting?

A

if there is suspicion of spina bifida occulta

351
Q

what should you order if you suspect anatomic abnormalities that would lead to enuresis?

A

renal US • VCUG

► Med Notes (62 decks)

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