Family Medicine Core Rotation - Acute Complaints_2 Flashcards
1
Q
what therapy can be a very successful behavioral treatment for nocturnal enuresis?
A
moisture sensitive alarms
2
Q
how do moisture sensitive alarms for nocturnal enuresis work?
A
the first drops of urine complete a circuit, activating an alarm that will wake the child and parents, and then the parents help the child complete the voiding in the toilet. over time, a conditioned response develops, and the child awakens voluntarily with the sensation of full bladder
3
Q
what is the gender bias of efficacy of moisture sensitive alarms for nocturnal enuresis?
A
there is no gender difference in success rates
4
Q
what are the success rates for appropriately used moisture sensitive alarms for nocturnal enuresis?
A
75-84%
5
Q
how long does a moisture sensitive alarm for nocturnal enuresis take to work?
A
weeks or months
6
Q
should a child take responsibility for their treatment with a moisture sensitive alarm for nocturnal enuresis?
A
no. without parental involvement, success rates drop
7
Q
when should you be concerned about a child having failure to thrive?
A
when a child drops more than 2 percentile brackets on a growth curve and does not maintain at that area
8
Q
in the USA, the vast majority of failure to thrive is secondary to what?
A
inadequate nutrition
9
Q
how good is albumin at revealing recent undernutrition?
A
albumin has a long half life and is a poor indicator of recent undernutrition
10
Q
how sensitive is prealbumin for undernutrition?
A
prealbumin is decreased in acute inflammation and undernutrition and is therefore insensitive
11
Q
organic disease, including hypothyroidism, is found in how many cases of failure to thrive?
A
<10%
12
Q
how are IgA levels related to undernutrition?
A
IgA levels are sensitive to undernutrition and would be decreased in failure to thrive
13
Q
in a child with failure to thrive, diarrhea, and recurrent respiratory infections what Dx must be considered?
A
CF
14
Q
what should you order for a child with failure to thrive, diarrhea, and recurrent respiratory infections?
A
sweat chloride test
15
Q
what tests may be indicated in the workup of failure to thrive, but only with a reasonable degree of clinical suspicion?
A
- mantoux test for TB • 2. HIV test • 3. stool for ova and parasites • 4. RFT
16
Q
what features will you see in a child with esophageal reflux contributing to failure to thrive?
A
- wet burps • 2. frequent emesis or cough with eating • 3. occasional wheezing
17
Q
what is the best test to diagnose esophageal reflux causing failure to thrive in a child?
A
esophageal pH probe
18
Q
if a child has failure to thrive with diarrhea or melena what should you think and order?
A
think IBD • order hemoccult
19
Q
if a child has failure to thrive and diarrhea, abdominal pain, and foul smelling stools, what do you think and order?
A
think lactose intolerance • order lactose tolerance test
20
Q
what would cause you to suspect pyloric stenosis in a child?
A
projectile vomiting • abdominal distention • perhaps palpable mass
21
Q
what do you order on a child in which you suspect pyloric stenosis?
A
US
22
Q
what do you do for a 9mo child with failure to thrive, signs of minimal smiling and vocalization?
A
no tests, likely related to infant behavior and/or ineffective maternal-child bonding
23
Q
children with familial short stature have a growth curve that shows what?
A
simultaneous changes in height and weight
24
Q
what do you see on the growth curve of a child with failure to thrive and constitutional growth delay?
A
weight decreases first, then height
25
what do you see on the growth chart of a child with hypothyroidism?
height velocity slows first and may plateau before weight changes
26
what do you see on the growth chart of breast fed infants?
weight decreases relative to peers after 4-6 months, but catches up after 12 mo
27
when is hospital admission indicated for failure to thrive?
in the face of hypotension and bradycardia
28
what are the signs of severe malnutrition that necessitate hospital admission for a child with failure to thrive?
hypotension and bradycardia
29
mononucleosis is often mistaken for what?
streptococcal pharyngitis
30
both mononucleosis and streptococcal pharyngitis have which symptoms in common?
sore throat • fatigue • fever • adenopathy
31
what happens if you give ampicillin to a patient with mononucleosis?
diffuse symmetrical erythematous maculopapular rash, not to be confused with penicillin allergy or scarlet fever
32
how does scarlet fever rash compare to what happens when you give ampicillin to a patient with mononucleosis?
the rash of scarlet fever is more confluent, and has a sandpaper like texture
33
what does the rash of measles look like?
erythematous flat papules, first appearing on the face and neck, then spreading to the arms and trunk in 2-3 days
34
fatigue lasting < month is likely what?
result of a physical cause: • infection • endocrine imbalance • CV disease • anemia • medications
35
fatigue lasting >3mo is more likely to be related to what?
psychologic factors: • depression • anxiety • stress • adjustment reactions
36
physiologic fatigue happens because of what?
overwork • lack of sleep • pregnancy
37
how long does fatigue have to be present to diagnose chronic fatigue syndrome and chronic idiopathic fatigue
>6mo
38
what is one of the most common diagnoses in patients presenting with fatigue, especially when denying weakness or hypersomnolence?
depression
39
what should you screen for in a patient complaining of fatigue that has a negative depression screening?
sleep apnea • anemia • hypothyroidism • pregnancy
40
what are the 3 general categories of fatigue?
physiologic • physical • psychologic
41
what historical feature should lead you to look for a physical cause of fatigue lasting >6mo?
progressively worsening
42
initial lab workup for an uncertain diagnosis of fatigue includes what?
CRC • ESR • UA • Chemistry panel • TSH • HCG • age/gender appropriate cancer screening
43
what should you order in a patient with uncertain diagnosis of fatigue if all initial tests are negative?
CXR • ECG • HIV • drug screen
44
what is the second most common cause of lower GI bleeding in children?
intussusception
45
what is the most common cause of significant GI bleeding in children?
Meckel diverticulum
46
do anal fissures, colitis, and juvenile polyposis cause significant bleeding in children?
no
47
what is the best diagnostic testing option in the setting of acute upper GI bleed?
upper endoscopy
48
what is the use of an upper endoscopy in acute upper GI bleed?
localize the source of bleeding • potentially allow therapeutic intervention • allow for tissue diagnosis when necessary
49
how does gastric lavage compare to EGD for acute upper GI bleed?
less useful
50
what is the limitation of using barium study for acute upper GI bleed?
might interfere with subsequent intervention
51
why not order a red cell scan for acute upper GI bleed?
they are better to locate bleeding sources in the lower GIT
52
why not order angiography for acute upper GI bleed?
may miss slower bleed
53
what is the most common congenital abnormality of the GIT?
Meckel diverticulum- 2% of the population
54
how does meckel diverticulum present?
most are asymptomatic, but a common presentation is painless large volume intestinal hemorrhage
55
how is a meckel diverticulum often diagnosed?
incidentally at laparotomy
56
what is the noninvasive diagnostic test for meckel diverticulum?
technetium scan
57
what percentage of patients with colonic diverticulosis develop severe diverticular bleeding?
5-15%
58
can you localize diverticular bleeding using colonoscopy?
yes but it is unusual
59
what is the next step if you can not localize the source of bleeding in diverticulosis on colonoscopy?
tagged RBC scan, which will help guide segemental resection if necessary
60
when is a subtotal colectomy necessary for bleeding diverticulosis?
recurrent severe bleeding with no source identified
61
external hemorrhoids are defined as what?
hemorrhoids arising distal to the dentate line
62
when external hemorrhoids thrombose, they are associated with what?
acute pain and are hard and nodular on physical exam
63
what do you do for thrombosed external hemorrhoids?
the excision can be safely done in the office under local anesthesia
64
what are the advantages of local excision of thrombosed external hemorrhoids under local anesthesia?
it eliminates pain immediately and eliminates the risk of recurrence
65
what is the use of hydrocortisone for thrombosed external hemorrhoids?
not useful
66
what are the indications for rubber band ligation and sclerotherapy for hemorrhoids?
should be reserved for internal hemorrhoids
67
what are the risks of incision and drainage of an external hemorrhoid?
increases the risk of recurrence and can lead to infection of the retained clot
68
what is an anal fissure?
a split in the anoderm of the anal canal
69
when does an anal fissure occur?
generally after the passage of a hard bowel movement
70
how do patients with anal fissure present?
excruciating pain with defecation with blood on the toilet paper--> complaint of ache or spasm that resolves after a couple hours
71
when are internal hemorrhoids painful?
internal hemorrhoids are generally not painful, unless they are thrombosed because of an unreducible prolapse- pain does not resolve
72
would a perianal abscess cause bleeding like anal fissure?
a perianal abscess may not present with bleeding, but would likely be associated with systemic signs of infection
73
what are are the most studied and effective prophylactic agents for migraines?
β blockers
74
what is the only Ca channel blocker that is effective at migraine prophylaxis?
verapamil
75
when are ergotamines used for migraines?
for abortive therapy
76
the goal of prophylactic migraine therapy is what?
to reduce the frequency of headache by 50%
77
of the anti-depressants used for migraine prophylaxis, which has the strongest evidence for efficacy?
amitriptyline
78
what is the dosing of amitriptyline for migraine prophylaxis?
begin with low dose 10mg at night, then titrate up to the most effective dose that does not cause side effects (up to 150mg)
79
what are the red flags in headache necessitating additional workup?
1. onset after age 50yo • 2. very sudden onset • 3. increase in severity or frequency • 4. signs of systemic disease • 5. focal neurologic symptoms (except aura) • 6. papilledema • 7. headache after trauma
80
migraines often occur how?
in a consistent location, are severe and frequent, include a visual aura, and may be associated with severe nausea
81
when is abortive acute therapy for migraines appropriate monotherapy?
if attacks occur less than 2-4x/mo
82
what should be the first choice abortive treatment for migraine?
a triptan (because of receptor specific action)
83
what are good alternatives to triptans in abortive treatment of migraines?
ergot alkaloids
84
what do you do for migraines that fail triptans and ergot alkaloids?
rescue medications (simple analgesics)
85
when should narcotics be used for migraine?
although frequently used in emergency settings, narcotics are rarely needed in the treatment plan for migraines
86
though Ca channel blockers other than verapamil have not been shown to be effective against migraines, they be helpful with which type of headache?
cluster headaches
87
what is the rationale of therapy for cluster headaches?
provide relief from the acute attacks, then use therapy to suppress headaches during the symptomatic period
88
which medications have been shown to be effective against cluster headaches?
nifedipine • prednisone • indomethacin • lithium
89
when is ergotamine good for cluster headache?
generally only helpful in the acute stage, not for prophylaxis
90
cluster headaches characteristically develop how?
rapidly, achieving peak intensity within 10-15 minutes lasting with intense pain for about 2 hours without treatment
91
the mainstay of treatment for cluster headaches is what?
oxygen
92
which parenteral drugs help with cluster headaches?
subQ or intranasal serotonin antagonists • IV/IM ergotamine
93
many physicians diagnose tension type headaches how?
by exclusion
94
what is the most frequent of all headaches encountered in clinical practice?
TTH
95
how long does a TTH episode last?
30 min- several days
96
how often should TTH occur per months?
<15x
97
TTH diagnosis requires which characteristics?
at least 2 of the following: • 1. pressure/tightening • 2. bilateral • 3. mild to moderate • 4. not aggravated by activity
98
what is the relationship between TTH and nausea?
there is generally no nausea
99
what is the relationship between TTH and photophobia/phonophobia?
either photophobia or phonophobia may be present but not both
100
what is the treatment for TTH?
trial of NSAID's with follow up if there is no improvement
101
what is the role of narcotics in TTH treatment?
narcotics should be avoided, since the condition is generally chronic and overuse is likely
102
what is the most common presentation of bladder carcinoma?
painless hematuria without other symptoms
103
what are the risk factors for bladder carcinoma?
1. being male • 2. smoking • 3. working with aromatic amines used in dye, paint, aluminum, textile, and rubber industries
104
acute prostatitis and UTIs are associated with which symptoms?
dysuria • fever • frequency • urgency
105
pseudohematuria can be derived from what?
chemical agents, foods, vaginal bleeding
106
what are the common foods that cause pseudohematuria?
beets • blackberries • certain food dyes
107
what are the medications that discolor the urine?
chloroquine • metronidazole • phenytoin • rifampin • sulfasalazine
108
in patients <40yo with hematuria but a normal IV pyelogram, what is the next step?
urine culture and cytology, periodic monitoring, and reassurance
109
when do you order cystoscopy for hematuria?
any patient >40yo with normal IVP
110
what do you order to diagnose post streptococcal glomerulonephritis?
ASO titer
111
what should you think causes phenomenon where patient falls asleep fast but then wakes up and can't return to sleep despite d/c caffeine use?
alcohol or drugs
112
how does obesity affect quality of sleep?
obesity is a risk factor for sleep apnea, but that generally does not cause inability to return to sleep after waking
113
how does propranolol affect sleep?
propranolol is known to cause nightmares
114
how does HCTZ affect sleep?
can cause nocturia that inhibits sleep
115
how does naproxen affect sleep?
naproxen is not known to interfere with sleep
116
how does alcohol affect sleep?
alcohol is known to cause excessive wakefulness, and often allows people to fall asleep, but interferes with the ability to stay asleep
117
what is essential for treating insomnia?
good sleep hygeine
118
important aspects of sleep hygiene include what?
1. awakening at a regular hour • 2. exercising daily • 3. control of the sleep environment • 4. eat a light snack before bed time (not meal) • 5. limit or eliminate alcohol, caffeine, and nicotine • 6. go to bed when sleepy • 7. use your bed for sleep and intimacy only • 8. get out of bed if you aren't asleep within 15-30 minutes
119
when can pharmacologic agents be used for sleep problems?
in select cases of transient sleep disorders unassociated with more serious problems
120
before using any pharmacologic agents for sleep it is important that the patient maintains what?
excellent sleep hygiene
121
what are the drugs of choice for transient sleep onset problems?
zolpidem (ambien) • eszopiclone (lunesta)
122
what drug can be used for sleep maintenance problems?
zaleplon (Sonata)
123
what is the use of melatonin?
help with adjustments of the sleep wake cycle (jet lag, shift work)
124
what is the use of benadryl for sleep?
can cause excessive somnolence and may help with sleep onset but not sleep maintenance
125
what is the most commonly reported hepatitis virus?
HAV
126
how is HAV spread?
via the fecal-oral route, most commonly through the ingestion of contaminated food or water
127
can HAV cause chronic hepatitis?
causes acute hepatitis only and never results in chronic hepatitis
128
are HAV relapses common?
lifelong immunity is expected for all patients that recover, therefore relapses are uncommon
129
when is a patient with HAV contagious?
fecal shedding of the virus occurs early, and declines once jaundice develops so jaundiced patients are less contagious than those in prodrome
130
symptoms of HAV infection change with what?
age
131
what percentage of patients <5yo infected with HAV are asymptomatic?
90%
132
what percentage of adults infected with HAV are symptomatic?
80%
133
what is the mode of transmission of HBV?
transfer of blood or body fluids, vertically
134
what happens if HBV is acquired early in life?
the infection is silent, but up to 90% of those infected develop chronic disease
135
what type of patients develop chronic hepatitis from HBV easier than others?
immunocompromised patients
136
what is the percentage of adults with HBV that have spontaneous resolution?
95%
137
what percentage of patients with HAV or HBV develop fulminant liver disease?
small percentage
138
HBsAg positivity means what?
either chronic infection or early infection
139
what rules out early infection in the face of positive HBsAg?
negative IgM anti-HBc
140
HBeAg is correlated with what?
replication
141
positivity of anti-HBs indicates what?
either exposure with immunity, recovery phase, vaccination
142
what rules out past exposure or infection in a patient with positive anti-HBs?
negative IgG anti-HBc
143
what stage of disease is a patient with positive HBsAg and positive IgM anti-HBc?
early infection
144
what is the HBsAg finding in a patient in the recovery phase?
negative
145
does asymptomatic bacteriuria cause incontinence?
asymptomatic bacteriuria is common in otherwise well elderly, and does not cause incontinence
146
does a symptomatic urinary infection cause incontinence in the elderly?
it may
147
how does hyperglycemia cause secondary incontinence?
because of polyuria
148
how do you treat incontinence caused by hyperglycemia?
tighter control of blood sugar levels
149
what is the relationship between fecal impaction and urinary incontinence?
stool impaction is thought to be a causative factor in up to 10% of patients
150
can atrophic vaginitis cause urinary incontinence?
yes
151
what is the most common type of incontinence in the elderly?
urge incontinence
152
what causes urge incontinence?
destrusor hyperactivity
153
functional incontinence refers to what?
limitation that does not allow the patient to void in the bathroom
154
what are some causes of functional incontinence?
bed rest • paralysis • severe dementia
155
what is stress incontinence?
loss of urine associated with ↑ intra-abdominal pressure
156
overflow incontinence is due to what?
overdistention of the bladder
157
what is the gender bias of stress incontinence?
much more commonly seen in women than men
158
stress incontinence is most often caused by what?
urethral hypermobility resulting from weakness of the pelvic floor musculature
159
patients with stress incontinence complain of what?
involuntary loss of urine associated with increase in intraabdominal pressure (sneezing, coughing, laughing, exercising)
160
overflow incontinence is primarily what?
a loss of the ability to empty the bladder
161
what are the causes of overflow incontinence?
1. neurogenic bladder • 2. outlet obstruction
162
what are some causes of neurogenic bladder?
longstanding diabetes • alcoholism • disk disease
163
what is a cause of overflow incontinence due to outlet obstruction?
prostatic enlargement
164
in the case of overflow incontinence the patient typically complains of what?
frequent or constant leakage of a small amount
165
what is the interpretation of a postvoid residual less than 50mL?
normal
166
a postvoid residual greater than 200 mL indicates what?
inadequate bladder emptying and is consistent with overflow incontinence
167
what is the volume of an indeterminant postvoid residual?
50-200mL
168
Kegel exercise are designed to do what?
strengthen the pelvic floor musculature
169
how do you instruct a patient to do kegel exercises?
ask the patient to squeeze the muscles in the genital area as if they were trying to stop the flow of urine from the urethra. hold for 10 seconds. repeat many times a day
170
for what types of incontinence are kegel exercises useful?
stress incontinence and mixed incontinence
171
kegel exercises are not useful for what types of incontinence?
functional • urge • overflow
172
when is pharmacologic therapy indicated for incontinence?
if a behavioral approach is ineffective
173
what are the drugs of choice for urge incontinence?
anticholinergic: • oxybutinin (ditropan) • tolterodine (detrol)
174
what drug helps with stress incontinence?
pseudophedrine
175
what drug helps with prostatitis incontinence?
trimethoprim-sulfamethoxazole
176
what drugs help frequent voiding caused by BPH?
finasteride and terazosin
177
which drugs can cause urinary incontinence?
1. α blockers- urethral sphincter relaxation→leakage but not urgency • 2. β blockers- inhibit bladder relaxation →leakage and urgency
178
how do Ca channel blockers affect the urinary system?
cause urinary retention
179
how do diuretics affect the urinary system?
increased frequency and urgency, but usually not leakage
180
what urinary symptoms can alcohol cause?
diuretic effect → polyuria, incontinence
181
what urinary symptoms can decongestants and diet pills cause?
urinary retention if they include α-agonists
182
what urinary symptoms can antihistamines cause?
urinary retention or functional incontinence
183
what urinary symptoms can caffeine cause?
diuretic effect → polyuria
184
does marijuana abuse contribute to urinary symptoms?
no
185
in evaluating childhood jaundice it is important to differentiate between what?
conjugated and unconjugated hyperbilirubinemia
186
if jaundice occurs in childhood and is associated with unconjugated hyperbilirubinemia, what diseases should be considered?
1. hemolytic diseases - G6PD, HS • 2. Gilbert disease • 3. Crigler-Najar
187
if jaundice occurs in childhood and is associated with conjugated hyperbilirubinemia, what should be considered?
1. viral hepatitis- MCC • 2. wilson disease • 3. milder forms of galactosemia
188
viral hepatitis accounts for what percentage of adult jaundice?
75% in pt <30yo • 5% in pt >60yo
189
extrahepatic obstruction accounts for what percentage of jaundice in patients >60yo?
60%
190
what are the cause of conjugated hyperbilirubinemia jaundice due to extrahepatic obstruction in >60yo?
gall stones • strictures • pancreatic cancer
191
CHF accounts for what percentage of jaundice in patients >60yo?
10%
192
metastatic disease accounts for what percentage of jaundice in patients >60yo?
13%
193
when biliary obstruction is suspected, what is the most appropriate initial first test?
US or CT
194
what should you do in a patient with suspected biliary obstruction with findings of dilated ducts?
ERCP or PTC
195
in a patient with suspected biliary obstruction but no dilated ducts, so unlikely obstruction, what should you do?
evaluate for hepatocellular or cholestatic disease
196
what do you do if you still suspect biliary obstruction after negative CT and US?
MRCP
197
what is the advantage of MRCP over ERCP?
no postprocedure pancreatitis
198
primary amenorrhea is defined as what?
absence of menses at age 16 in the presence of normal secondary sex characteristics, or absence of menses at age 14 in the absence of secondary sex characteristics
199
primary amenorrhea is usually the result of what?
genetic or anatomic abnormality
200
what is the most common cause of primary amenorrhea?
gonadal dysgenesis (50% of cases)
201
what is the most well known type of gonadal dysgenesis?
Turner syndrome
202
hypothalamic failure in a girl with amenorrhea is often a result of what?
anorexia nervosa • excessive exercise • chronic or systemic illness • severe stress; • all→suppression of hypothalamic GnRH secretion
203
pituitary failure in a girl with amenorrhea may result from what?
inadequate GnRH stimulation
204
pituitary failure in a girl with amenorrhea is often associated with a history of what?
head trauma • shock • infiltrative process • pituitary adenoma • craniopharyngioma
205
how do you differentiate pituitary from hypothalamic failure in a girl with amenorrhea?
pituitary failure is accompanied by deficiency of other pituitary hormones
206
what is the relationship between PCOS and primary amenorrhea?
PCOS may cause primary amenorrhea, but is generally associated with normal breast development
207
what is the gender prevalence of constitutional delay of puberty?
common in boys, uncommon cause of primary amenorrhea in girls
208
what is the most common cause of secondary amenorrhea?
pregnancy
209
PCOS accounts for what percentage of secondary amenorrhea?
30% of cases
210
PCOS is characterized by what?
androgen excess • irregular/absent menses • hirsutism • acne • virilization
211
functional hypothalamic amenorrhea is usually a result of what?
anorexia • rapid weight loss • rigorous exercise • significant emotional stress
212
what are the less common causes of secondary amenorrhea?
hypothyroidism • hyperprolactinemia
213
anovulatory bleeding is caused by what?
continuous unopposed endometrial estrogen stimulation
214
what is the most common cause of dysfunctional uterine bleeding in women younger than 20yo?
anovulatory bleeding (95%)
215
when is anovulatory bleeding especially common?
when women are within 2 years of menarche
216
what can you do for a young woman with anovulatory bleeding?
1. watch expectantly • or • 2. OCP to regulate periods
217
ovulatory bleeding due to fluctuations in estrogen and progesterone levels accounts for what percentage of abnormal bleeding?
10%
218
what do you need to do for any postmenopausal woman with vaginal bleeding?
she needs an endometrial biopsy to rule out endometrial cancer after examination performing the examination and ruling out STI/anatomic abnormality
219
what are the contraindications for endometrial biopsy?
pregnancy • acute infection • PID • known bleeding disorder
220
primary dysmenorrhea is caused by what?
release of prostaglandin from the endometrium at the time of menstruation
221
treatment of primary dysmenorrhea focuses on what?
reduction of endometrial prostaglandin production
222
how do you reduce endometrial prostaglandin production?
1. inhibition of prostaglandin synthesis by medication • 2. suppressing ovulation
223
what is the first line therapy for dysmenorrhea?
NSAIDs
224
how should NSAIDs be used for primary dysmenorrhea?
start NSAIDs day before menstruation. No benefit of continuous daily use
225
what is the role of SSRIs in menstrual problems?
SSRI therapy is sometimes used for premenstrual dysphoric disorder, but is not a first line therapy for dysmenorrhea
226
what is a second line therapy for primary dysmenorrhea?
OCP
227
what medications can cause hyperprolactinemia leading to amenorrhea?
1. psychotropics- benzodiazepines, SSRI, TCA, phenothiazines, buspirone • 2. neurologic- • sumatriptan, valproate, ergot derivatives • 3. estrogens and contraceptives • 4. cardiovascular drugs- atenolol, verapamil, reserpine, methyldopa
228
what is the purpose of the progestin challenge test?
separates patients with estrogen deficiency from those with normal or excess estrogen
229
any bleeding in the week after the administration of Provera indicates what?
the patient has sufficient estrogen to menstruate, and that amenorrhea is likely due to anovulation as in PCOS
230
would patients with premature ovarian failure have a withdrawal bleed after progestin challenge test?
no
231
patients with amenorrhea and elevated testosterone and DHEA-S levels need what workup?
CT scan of adrenals and US of ovaries to rule out neoplasm
232
hysteroscopy and hysterosalpingogram are involved in workup of what conditions?
menstrual irregularities or infertility
233
when evaluating primary amenorrhea in patients with normal secondary sexual characteristics and normal hcg, TSH, and prolactin, it is appropriate to perform what test?
progestin challenge test
234
what can you use to differentiate between inadequate estrogen and outflow obstruction in a patient with no withdrawal bleeding after a progestin challenge test for primary amenorrhea?
estrogen-progestin challenge
235
no withdrawal bleeding after an estrogen-progestin challenge indicates what?
an outflow tract obstruction or anatomic defect
236
what is a physical exam finding seen in hypertensive encephalopathy
papilledema
237
hyperalert confusion is common with what?
alcohol withdrawal
238
amphetamine withdrawal is associated with what presentation?
psychomotor slowing
239
what is the test you order to diagnose bacterial meningitis?
lumbar puncture
240
what can you give for diabetic gastroparesis?
metoclopramide
241
mild pain followed by the acute onset of distension, nausea, and vomiting is consistent with what?
ileus or obstruction
242
what PE finding can differentiate between obstruction and ileus?
hyperactive bowel sounds → obstruction • absent bowel sounds → ileus
243
when should you suspect psychogenic vomiting?
in patients who are able to maintain adequate nutrition despite chronic symptoms
244
when is psychogenic vomiting seen?
usually during times of social stress or in patients with a past history of psychiatric disorder
245
how do you differentiate psychogenic vomiting from bulimia?
bulimia sufferers usually do not seek medical attention or treatment until concerned others bring the condition to medical attention
246
how do you differentiate psychogenic vomiting from CNS malignancy?
CNS malignancy of vomiting center causes nutritional defecit
247
what are common causes of viral gastroenteritis?
norwalk virus • reoviruses • adenoviruses
248
what is the general course of viral enteritis?
self limited and likely to resolve in 5 days
249
in the presence of pancreatitis, ↑ALT points to what?
gallstone pancreatitis
250
when is ↑ALT less likely in pancreatitis?
when alcohol or ↑TG are the cause
251
when nausea happens before eating in the morning, likely etiologies include what?
pregnancy • uremia • alcohol withdrawal • ↑ICP
252
gastroparesis and pancreatitis cause nausea with what timing?
after eating
253
what is the nature of nausea associated with cholelithiasis?
n/v and pain after eating fatty foods
254
what is the nature of nausea in vestibular disorders?
nausea without any clear association with meals or time of day
255
children with pyloric stenosis typically present how?
with weight loss • dehydration • occasional palpable olive mass in the epigastrium
256
when is pyloric stenosis usually identified?
before 7 weeks of age
257
how do you differentiate pyloric stenosis from reflux?
reflux less likely to be associated with weight loss and dehydration
258
how do you differentiate pyloric stenosis from intussusception?
intussusception is associated with significant abdominal pain and hemoccult positive stools
259
how do you differentiate SBO from pyloric stenosis?
SBO is less likely and is associated with high pitched bowel sounds
260
pancreatitis is associated with the acute onset of what?
significant nausea, vomiting, and epigastric pain
261
what is the timing of the symptoms of pancreatitis?
symptoms occur after eating, and are improved when the patient does not eat
262
what are the typical laboratory findings in pancreatitis?
amylase and lipase are likely to be abnormal, but the CBC is likely to be normal along with hemoccult, AXR, and EGD
263
what is the typical presentation of cholelithiasis?
nausea, vomiting, and pain after eating fatty meals
264
what is the diagnostic test of choice for cholelithiasis?
RUQ U/S
265
when are amylase and lipase elevated in the presence of cholelithiasis?
if the patient develops secondary pancreatitis
266
what are the hemoccult, AXR, and EGD findings in cholelithiasis?
likely normal
267
what are the side effects of the phenothiazines?
drowsiness, • dry mouth • dizziness
268
what are the side effects of tigan?
drowsiness, dry mouth, dizziness as in phenothiazines
269
what are the side effects of zofran?
dizziness and headache
270
what are the side effects of reglan?
diarrhea and extra pyramidal reaction
271
what is the lifetime prevalence of at least one episode of neck pain in the adult population?
40-70%
272
neck pain aggravated by movement, worse after activities, associated with a dull ache and with limited range of motion is consistent with what?
spondylosis or osteoarthritis
273
if neck pain were due to chronic mechanical problems, there would be what?
tenderness to palpation on examination
274
if neck pain were due to cervical nerve root irritation, there would be what?
radiation of symptoms, weakness, numbness, or paresthesias
275
in neck pain from whiplash injury, one would expect a history of what?
an acceleration injury
276
what is the presentation of neck pain due to cervical dystonia (torticollis)
neck would be laterally flexed and rotated
277
what is the presentation of spinal stenosis?
older individual • axial stiffness • paresthesias over several dermatomes
278
what is the best test to order for spinal stenosis?
CT scan
279
when are C-spine radiographs indicated?
after injury, or if there are red flags
280
what is the use of MRI for spine problems?
MRI provides the best anatomic assessment of disk herniation and soft tissue or spinal cord abnormality
281
what is the use of EMG for spine problems?
helps localize radiculopathy
282
what are the 3 questions to ask in the canadian cervical spine rules?
1. is there 1 high risk factor? • 2. is there one low risk factor • 3. is the patient able to voluntarily actively rotate the neck 45 deg to left and right regardless of pain
283
what are the high risk factors in the canadian cervical spine rules for radiographic imaging?
1. >65yo • 2. dangerous mechanism (↑speed MVA) • 3. numbness or tingling in extremities • -- if one yes, then radiography
284
what are the low risk factors in the canadian rules for cervical spine radiography?
1. simple rear end collision • 2. pt ambulatory at the scene • 3. absence of C-spine tenderness on exam • -- one NO requires imaging
285
the Spurling test is also called what?
the neck compression test
286
the spurling test requires what?
patient must bend their head to the side and rotate the head toward the side of pain while the tester exerts downward pressure
287
how do you interpret a neck compression test?
the maneuver reproduces symptoms in the affected upper extremity in the case of nerve root injury
288
what are the sensitivity and specificity of the neck compression test for cervical radiculopathy?
high specificity but low sensitivity
289
how do you interpret a spurling test when the maneuver results in neck discomfort only?
dx: nonspecific mechanical pain
290
what are the ways that torticollis in the adult is managed?
PT • stretching • gentle manipulation • use of cervical collars • ice/heat • botox
291
the most evidence points to efficacy of what treatment for torticollis?
botox injection
292
what are the characteristics of palpitations that can help you determine whether the symptoms are from a cardiac cause?
1. male sex • 2. description as irregular heart beat • 3. personal history of heart disease • 4. event duration >5min
293
when a patient describes their heart beat as rapid and irregular, it suggests what?
either atrial fibrillation or atrial flutter
294
both ectopy and atrial fibrillation can cause what?
irregular pulse
295
how is the pulse in PSVT and stable ventricular tachycardia?
rapid and regular
296
how is the pulse in stimulant abuse?
generally a sinus tachycardia
297
what arrhythmia is caused by hyperthyroidism?
hyperthyroidism may cause Afib, premature beats
298
Ventricular premature beats often occur how?
random, episodic, and instantaneous beats, often described as a flip flopping sensation
299
how do patients describe Afib?
rapid and irregular rate or fluttering in the chest
300
hypertrophic cardiomyopathy can be associated with which arrhythmias?
Afib or Vtach
301
what is the characteristic heart murmur of hypertrophic cardiomyopathy?
systolic ejection murmur worsening with Vasalva maneuver
302
what do you do for a patient with palpitations and normal H&P, 12 lead ECG, labs?
reassure the patient and continue observation
303
what is the likely cause of palpitations in a patient with normal H&P, ECG, and labs?
benign supraventricular or ventricular ectopy
304
what do you order for a patient whose arrhythmia seems to occur with exercise?
stress test
305
when are patients with WPW treated?
if they have symptomatic arrhythmia
306
what is the treatment for WPW?
usually radiofrequency ablation, but also drugs
307
classically, ovarian cysts present with what?
unilateral dull pain that can become diffuse and severe if the cyst ruptures
308
what do you feel on PE of a patient with ovarian cyst?
smooth mobile adnexal mass (with peritoneal signs if it ruptures)
309
how do you differentiate PID from ovarian cyst?
PID is associated with fever and vaginal discharge
310
how do you differentiate ectopic pregnancy from ovarian cyst?
ectopic pregnancy may present with similar symptoms, but menses would not be normal
311
how do you differentiate leiomyoma from ovarian cyst?
uterine leiomyoma are generally asymptomatic if present in this age group, would classically be associated with low midline pressure and menorrhagia or metorrhagia
312
how do you differentiate appendicitis from ovarian cyst?
appendicitis would be associated with fever, nausea, and anorexia
313
PID is classically described as which presentation?
lower abdominal pain that is gradual in onset and bilateral
314
what symptoms may be associated with PID?
fever • vaginal discharge • dysuria • occasionally abnormal vaginal bleeding
315
treatment for PID should provide coverage for what?
N. gonorrhoeae, C. trachomatis, anaerobes, enteric gram negative rods
316
what is the CDC recommended regimen for treatment of PID?
ceftriaxone 250mg IM, + doxycycline 100mg BID x 14 days +/- metronidazole 500mg BID x 14 days
317
when is inpatient treatment for PID indicated?
1. pregnant women • 2. pt w/ severe illness with fever + vomiting • 3. when you can't rule out surgical emergency • 4. those who fail appropriate outpatient therapy
318
pain associated with ectopic pregnancy is often described as what?
colicky, may radiate to the shoulder if there is significant hemoperitoneum
319
what symptom is a diagnostic clue for ectopic pregnancy?
nausea, a sign of pregnancy
320
when should you get a CBC in a suspected case of endometriosis?
if the signs are suggestive of an infectious process
321
how often is ESR elevated in PID?
75% of the time but nonspecific
322
when should you order CA-125 in a patient with symptoms of endometriosis?
if you are concerned about an ovarian mass
323
what imaging should you order for endometriosis?
transvaginal US may be helpful, but MRI is more sensitive for localization of endometriosis
324
what percentage of ovarian masses in girls younger than 15 are malignant?
80%
325
what is the protocol for ovarian mass in a girl <15yo?
bc of high potential for malignancy, any adnexal mass should be evaluated by transvaginal US and referral for surgical removal
326
in many women of child bearing age, adnexal masses are what?
commonly cysts
327
what is the protocol for adnexal mass in adult if the pain is not acute or recurrent, palpable cyst is
monitor with repeat pelvic exam
328
when should you get US for an adnexal mass in an adult?
those masses that do not resolve, or those that increase in size
329
with exudative pharyngitis, palatal petechiae suggest what?
group A streptococcal infection or infectious mononucleosis
330
how do you differentiate infectious mononucleosis from group A streptococcal infection?
posterior cervical adenopathy should point to IM as the correct Dx
331
when associated with pharyngitis and anterior adenopathy, edema swollen uvula is suggestive of what?
group A hemolytic streptococcal infection
332
what is the first line treatment for group A hemolytic streptococcal pharyngitis?
amoxicillin
333
why give liquid amoxicillin for group A hemolytic streptococcal pharyngitis?
penicillin resistance has not been seen in group A β-hemolytic strep, but liquid amoxicillin taste better than liquid penicillin
334
what should you give to a penicillin allergic patient with group A β hemolytic strep pharyngitis?
first generation cephalosporin
335
what percentage of school age children are carriers of group A β hemolytic strep?
20%
336
what is the cause and treatment of laryngitis with pharyngitis?
generally associated with a viral infection, and only supportive care is needed
337
what are the Centor criteria for adults used to determine the probability of group A β hemolytic strep infection?
1 point for each: • 1. tonsillar exudate • 2. tender anterior cervical adenopathy • 3. fever • 4. lack of cough
338
what is the most cost effective approach to treating patients with all 4 Centor criteria for gAβh- strep?
give antibiotics without lab testing
339
how likely is it that someone with 3/4 Centor criteria has strep?
40-60%
340
epididymitis is generally caused by what?
retrograde spread of prostatitis or urethral secretions through the vas
341
in sexually active males <35yo, epididymitis is usually associated with what and caused by what?
associated with urethritis and caused by N gonorrhoeae or C trachomatis
342
what are the less likely causes of epididymitis in sexually active males <35yo?
ureaplasma • mycoplasma
343
what is the more common cause of epididymitis in men >35yo who are monogamous?
enteric gram negative rods (enterobacter) associated with prostatitis
344
what is the protocol for testicular torsion?
requires emergent surgical referral
345
why does testicular torsion require immediate surgical referral?
after 12 hours without treatment, there is only a 20% chance the testicle can be saved
346
what is the nature of the reflex associated with testicular torsion?
the cremasteric reflex is absent
347
how is the cremasteric reflex elicited?
by pinching or brushing the inner thigh which causes the ipsilateral testicle to retract toward the inguinal canal
348
what is a positive prehn sign?
if pain is relieved upon elevation of the testicle when the patient is supine
349
is testicular torsion associated with a positive prehn sign?
no
350
when are the cremasteric reflex and prehn sign present?
epididymitis • hernias • orchitis • cancer
