Family Medicine EOR Exam Flashcards
1
Q
Stable Angina
A
Relieved by rest and/or NTG
2
Q
Unstable Angina
A
Stable angina that increasingly occurs at rest and is more frequent
3
Q
Prinzmetal angina
A
Coronary artery vasospasm causing transient ST-elevations
No clot
4
Q
Narrow QRS complex with absent or inverted P wave
A
PJC - Premature Junctional Contraction
5
Q
Narrow complex tachycardia with no discernable P waves
A
Paroxysmal supraventricular tachycardia
6
Q
Sawtooth pattern with narrow QRS
A
Atrial flutter
7
Q
Arrhythmia in which bradycardia alternates with tachycardia
A
Brady-tachy sick sinus syndrome
8
Q
Sinus arrest
A
Absence of sinus activity for 3+ seconds
9
Q
NSTEMI
A
St segment depression , t wave inversion, or both
Cardiac markers elevated!
10
Q
STEMI
A
Elevated Cardiac biomarkers WITH ST segment elevation
11
Q
Chest pain releived by sitting and leaning forward
A
Pericarditis
12
Q
Severe tearing, ripping, knife like pain radiating to the back
A
Aortic dissection
13
Q
Presentation of pulmonary embolism
A
Dyspnea is the MC symptom
Pleuritic chest pain
14
Q
Best initial test for a PE
A
Spiral CT scan of the chest
15
Q
Presentation of pulmonary hypertension
A
Dyspnea on exertion, fatigue, chest pain, edema and syncope
16
Q
Murmur of pulmonary hypertension
A
Loud P2, systolic ejection click and parasternal lift
17
Q
Dx for pulmonary hypertension
A
Right heart cath with mean pulmonary artery pressure above 25 mmHg
18
Q
Criteria for rheumatic fever dx
A
2 major criteria or 1 major plus 2 minor
19
Q
Titers of rheumatic fever
A
Elevated antistreptolysin titers (ASO)
20
Q
Presentation of costochondritis
A
Pain with palpation or arm movement
21
Q
Classic presentation of CHF
A
Exertional dyspnea progressing to at rest
Chronic nonproductive cough, worse when recumbent
Fatigue
Orthopnea
Nocturnal dyspnea
Nocturia
22
Q
S4 in heart failure
A
DIastolic/ HFpEF
23
Q
S3 in heart failure
A
COmpliant ventricle
Systolic/HFrEF
24
Q
Physical exam signs of CHF
A
Cheyenne stokes breathing
Edema
Rales
S3 and S4
JVD over 8 cm
CYanosis/Coolness of extremities
Ascites
25
BNP for heart failure
Lower in obese patients
Differentiates SOB of HF from other SOB
26
CXR of heart failure
Kerley B Lines
27
Best test for CHF
ECHO!!!
28
NYHA Class I
No limitation of physical activity
29
NYHA class II
Slight limitation with physical activity but comfortable at rest
30
NYHA class III
Marked limitation of physical activity still comfortable at rest
31
NYHA class IV
Unable to carry on physical activity without discomfort AND have symptoms of angina at rest
32
Management for Systolic heart failure
ACEI, BB, Loop diuretic
NO CCB
33
Management for diastolic HF
ACEI with BB or Non-DHP-CCB
NO DIURETIC
34
Effect of morphine on HF
Reduces preload
35
Major CAD risk factors`
DM
Smoking
Hypertension
HLD
Family Hx
Over 45 for men and 55 for women
36
Potenital PE findings for ACS
Mitral regurg/S4
CHF symptoms (edema, crackles)
Signs of vascular disease (bruits, diminished pulses)
37
Why might we want a CXR in ACS
To rule out aortic dissection
38
Meds for use in ACS
MONA
May use ACEI
39
Drugs to improve mortality post MI - 4 and 1 NOT TO USE
Antiplatelet (Aspirin or Plavix)
Beta blocker
ACE or ARB
Statin
NO CCB's
40
Presentation of endocarditis
Fever with a new onset heart murmur
41
MCC pathogen in Acute, Subacuite, IVDU, and prosthetic valve endocarditis
Acute and IVDU - Staph aureus
Subacute S. viridans
Prostetic valve - S epidermitis
42
Major Dukes criteria for endocarditis - 3
2 positive blood cultures 12 hours apart (staph for drug users strep for non drug users)
Vegetations are seen on Echo (tricuspid-IV drug users, mitral-non drug users
New regurg murmur
43
Minor Dukes criteria for endocarditis 2 + 4 skin signs
Risk factor
Fever 100.5
Splinter hemorrhages,
Janeway lesions
Osler node
Roth spots
44
Janeway lesions
Painless lesions, palms and soles. Assoc with endocarditis
Flat macules
45
Osler Node
Raised painful tender immunologic lesion assoc with endocarditis
Ouchy nodes!
46
Roth spots
Exudative lesions on the retina assoc with endocarditis. Immunologic
47
Diagnostic Duke criteria for endocarditis
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
48
Tx for infective endocarditis
IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
49
Drug to add to endocarditis for those with prosthetic valves
Rifampin
50
Prophylaxis for endocarditis in dental surgeries
Amoxicillin - 2 g 30-60 minutes before the procedure
51
USPSTF HLD screening guideline
Start at 35 for ALL adults
52
4 statin benefit groups
Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
Patients with primary LDL-C levels of 190 mg per dL or greater
Patients WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
Patients WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
53
Statin for benefit group 1 - Patients with ASCVD
High intensity statin if under 75
Evaluate risk/benefit if over 75
54
Statin for benefit group 2 - LDL-C of 190+ or triglycerides over 500
High intensity statin, try to reduce LDL by 50%
55
Statin for benefit group 3 - WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189
Moderate intensity if ASCVD risk under 7.5%
High intensity if ASCVD risk 7.5%+
RIsk benefit for out of age range
56
Statin for benefit group 4 - WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
Moderate to high intensity
Moderate if risk is 5-7.5%
57
Lipid goals for LDL, HDL, and Total cholesterol
LDL under 100
Total under 200
HDL over 60
58
2 high intensity statins
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
59
5 Low intensity statins
Simvastatin 10
Pravastatin 10-20
Lovastatin 20
Fluvastatin 20-40
Pitavistatin 1 mg (you read that right)
60
Elevated blood pressure
120-129 with DBP under 80
61
Stage 1 hypertension
130-139 with DBP 80-89
62
Stage 2 HTN
140+/90+
63
Elevated peds BP
SBP and/or DBP ≥90th percentile but <95th percentile, or 120/80 mmHg to <95th percentile (whichever is lower)
64
Stage 1 HTN for peds
SBP and/or DBP ≥95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg
65
Stage 2 HTN for peds
SBP and/or DBP ≥95th percentile + 12 mmHg, or ≥ 140/90 mmHg (whichever is lower)
66
ACC/AHA BP target
130/80
67
Tx guidelines for normal BP
Evaluate yearly, encourage healthy lifestyle
68
Tx guidelines for elevated BP
Lifestyle changes with 3-6 month reassessment
69
Management for Stage 1 hypertension with ASCVD risk <10%
Lifestyle management with 3-6 month follow up
70
Management for Stage 1 hypertension with ASCVD risk >10% or w/ CVD, DM, CKD
1 medication with 1 month follow up
Monthly follow up with adjustment until goal BP is met; 3-6 month follow up after that
71
Management for stage 2 HTN
2 BP medications with 1 month followed with monthly f/u until goal met then 3-6 month f/u
72
Initial agents for HTN treatment
ACE or ARB
Thiazide diuretic (chlorthalidone)
Long acting CCB (amlodipine)
73
Initial agents for HTN in African Americans
CCB and/or Thiazide diuretics
74
Contraindication for CCBs
Angina pectoris
Can cause leg edema
75
ACE/ARB contraindications
Diabetes with proteinuria
76
ACE specific contraindication
Cough and hyperkalemia
COntraindicated in pregnancy
77
Contrindication for spironolactone
Hyperkalemia
78
Contraindications for beta blockers
Asthma, may cause impotence
79
Hypertensive urgency
180/120+ BP without hypertensive urgency
Patients whould start a 2 drug regimen with frequent follow up
80
End organ damage signs that make it a hypertensive emergency - 7
(BP 180/120+)
retinal hemorrhages/ papilledema encephalopathy,
acute and subacute kidney injury,
intracranial hemorrhage,
aortic dissection,
pulmonary edema,
unstable angina or MI
81
Management for hypertensive emergency
In the first hour reduce by 10-20 percent
Reduce by 5-15 percent over then next 23 hours
First hour goal is generally under 180/120
24 hour goal is usually under 160/110
82
Management for hypertensive emergency with retinopathy or encephalopathy
Rapidly lower the mean arterial pressure by approximately 10 to 15 percent in the first hour and by no more than 25 percent compared with baseline by the end of the first day of treatment
Gradually reduce to under 130/80 over 2-3 months
83
Drug of choice for hypertensive urgency
Clonidine
84
Drug of choice for hypertensive emergency
Sodium nitroprusside
85
Drugs of choice for hypertenve emergency with retinopathy/encephalopathy
Sodium nitroprusside or clevidipine
86
Upper limits of normal, moderate, moderate to severe, and severe hypertriglyceridemia
Under 150
150-499
500-999
1000+
87
NCEP triglyceride screen recommendation
Beginning at 20 every 5 years. Fasting is best but may be non-fasting in healthy asymptomatic individuals
Yearly for CHD equivalent with fasting
Fasting should be 12-16 hours to confirm reading
88
Management option for hypertriglyceridemia
Lower below 500 to prevent pancreatitis
Fibrates and Niacin is isolated
Lipitor and FIsh oil may also help
Aspirin may help with HDL
89
Side effect of niacin administraction
May cause hyperglycemia
90
Presentation of intermittent claudication
Dull aching pain and numbness worse with exercise and relieved with rest
Thin skin, hair loss, and numbness of extremities
91
Diagnosis for intermittent claudication
ABI less than or equal to 0.9
Angiography is the gold standard
92
Management for intermittent claudication
Stop smoking - first line
Graduated exercise conditioning
May do angioplasty or bypass
93
3 meds for intermittent claudication
ASA
Clopidogrel
CIlostazol
94
Patients who need PAD screening
Over 70
Abnormal or absent pedal pulse
Aged 50-69 with smoking hx or DM
95
ABI range for no further testing
0.9-1.3
96
Management for asymptomatic PAD
Statin
ASA
Blood pressure control
97
Symptomatic PAD or PVD
Cramping, intermittent claudication with rest pain and muscle atrophy, thick toenails, hair loss
Diminished pulses
98
Diagnostics for PAD or PVD
ABI (0.9 or under diagnostic)
Doppler
Arteriography - Gold standard
99
Management of PAD or PVD
Manage chronic conditions and smoking
Graduated exercise
ASA, Cilostazol, Plavix
100
Best sugical management for PAD/PVD
Angioplasty is preferred
101
Cilostazol
Pletal - PDE-5 inhibito for peripheral vascular disease
102
Mitral valve location
Between left ventricle and atrium
103
Erbs point
Third left ICS, L sternal border
104
Murmur of aortic stenosis
Systolic ejection crescendo-decrescendo at the right upper sternal border
1st post with radiation to the neck
Split S2
105
Presentation of Aortic stenosis
Murmur is worse with squatting and expiration
Murmur decreases with valsalva
Syncope and LVH
106
Murmur of Aortic regurg
Early diastolic, soft-blowing decrescendo murmur with a high-pitch quality, especially when the patient is sitting and leaning forward heard at the left lower sternal border
107
Presentation of aortic regurg
Increases with squatting, decreases with valsalva
History of congenital heart defect or rheumatic fever
108
Murmur of mitral stenosis
Rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex
109
Presentation of mitral stenosis
Opening snap and murmur at LLSB/Apex
Left atrial hypertrophy - golden arches P wave on EKG lead II
SOB and CHF from fluid backup
Increase with squatting, decreases with valsalva
110
Murmur of mitral regurg
Blowing HOLOSYSTOLIC murmur at APEX with a SPLIT S2, radiates to the axilla
111
Presentation of mitral regurg
Previous STEMI
Low BP with tachycardia
Lung crackles
112
Murmur of pulmonic stenosis
Harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder
113
Presentation of pulmonic stenosis
SOB with split S2 and RVH
JVD. Increases with squatting and inspiration, decreases with valsalva
114
Murmur increase and expiration/inspiration
Right heart murmurs increase with inspiration
Left heart murmurs increase with expiration
115
Murmur of pulmonic regurgitation
High pitched diastolic decrescendo murmur at the LUSB that increases with inspiration
116
Presentation of pulmonic regurg
SOB and DOE
Increases with inspiration and squatting
Decreases with valsalva
117
Hand grip
Maneuver that only challenges aortic valve
118
Murmur of tricuspid stenosis
Diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid, augmented during inspiration
119
Presentation of tricuspid stenosis
RIght sided heart failure - JVD and SOB
Increased with inspiration and squatting
120
Significance of an opening snap
The valve is stenotic
121
Murmur of tricuspid regurg
A blowing holosystolic murmur along the left sternal border
122
Presentation of tricuspid regurg
A fib on EKG
JVD, DOE, Ascites
123
Murmur of HOCM
High pitched mid-systolic murmur at the left lower sternal border. Increased with Valsalva and standing
Decreases with squat/hand grip
124
Presentation of HOCM
Family history of sudden cardiac death
Syncope or presyncope with exertion
125
Murmur of MVP
Mid systolic murmur increasing in intensity with valsalva, standing, and handgrip
126
Presentation of MVP
Young female with palaitations during exercise
Progressive SOB
127
Presentation of Asthma
Young patients presenting with wheezing and dyspnea due to exercise of allergen exposure
128
Diagnostic criteria for asthma
Greater than 12% increase in FEV1 after bronchodilator therapy
FEV1/FVC ration <80%
129
Mild intermittent asthma definition and tx
Less than 2 times per week or 3-night symptoms per month
Step 1: Short-acting beta2 agonist (SABA) PRN
130
Mild persistent asthma definition and treatment
More than 2 times per week or 3-4 night symptoms per month
Step 2: Low-Dose inhaled corticosteroids (ICS) daily
131
Moderate persistant asthma definition and treatment
Daily symptoms or more than 1 nightly episode per week
Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily
Step 4: Medium-Dose ICS +LABA daily
132
Severe persistent asthma definition and treatment
Symptoms several times per day and nightly
Step 5: High-Dose ICS +LABA daily
Step 6: High-Dose ICS +LABA +oral steroids daily
133
6 steps of asthma tx
Step 1: Short-acting beta2 agonist (SABA) PRN
Step 2: Low-Dose inhaled corticosteroids (ICS) daily
Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily
Step 4: Medium-Dose ICS +LABA daily
Step 5: High-Dose ICS +LABA daily
Step 6: High-Dose ICS +LABA +oral steroids daily
134
Management for acute asthma attack
Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
135
Presentation of Bronchitis
5+ days of coughing with or without sputum production
Chest discomfort, SOB may not have fever
136
Management of bronchitis
Usually viral
NSAIDs, Cough medication, Albuterol
137
Criteria for pneumonia suspicion in bronchitis - 7
HR >100,
RR >24,
T >38°C,
rales,
hypoxemia,
mental confusion, or
systemic illness
138
Definition of chronic bronchitis
Chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
139
Presentation of chronic bronchitis
Excess mucus production that contricts airways
Blue bloaters and often smokers
Chronic hypoxia
Wheezes and inspiratory crackles
140
Labs diagnostic for chronic bronchitis
FEV1/FVC < 0.70
May have increased Hgb and Hct
Increased pCO2 on ABG
141
Management for chronic bronchitis
SABA for mild disease
LABA+ICS for moderate to severe disease
Smoking cessation
Antibiotics for acute exacerbations
Flu and pneumococcal vaccines are a must
Surgery: lung resection vs transplant
142
Inhaler of choice for COPD
Ipratropium bromide is inhaler of choice for COPD
143
Most important long term medication for COPD
Supplemental Oxygen!!
144
Presentation of emphysema
Thin, barrell chested and breathing through pursed lips.
Hypereasonant chest
Due to smoking and alveolar destruction
145
Diagnostic labs for emphysema
FEV1/FVC<.75
Hyperinflation and thin heart on CXR
TLC and FRC increased
146
Management for emphysema
NOT responsive to bronchodilators
Smoking cessation and home oxygen therapy
Steroids and ABX for acute exacerbations
May us bipap/cpap
147
Criteria for long term O2 in emphysema - 3
Pao2 55 mm Hg
O2 saturation < 88% (pulse oximetry) either at rest or during exercise
Pao2 55 59 mm Hg + polycythemia or cor pulmonale
148
Presentation of Small cell lung cancer
15% of lung cancer cases with 99% being smokers
Recurrent pneumonia with anorexia, weight loss, and weakness
149
Associated s/s of small cell lung cancer
Superior vena cava syndrome
Laryngeal nerve palsy
Horner syndrome
Malignant pleural effusion
Digital clubbing
Eaton lambert syndrome
150
Eaton lambert syndrome
MC in SCLC
Similar to myasthenia gravis (proximal muscle weakness/fatigue, diminished DTRs, paresthesias (lower extremity)
151
Diagnostics of SCLC
CXR is most important for DX
CT chest with IV contrast for staging
Definitive - Tissue biopsy—determine the histologic type
Cytologic examination of sputum if central tumor
152
Management and prognosis for SCLC
Combination chemotherapy with 10-13% survival rate
CANNOT be treated with surgery
153
3 types of NSCLC
Squamous cell 25-35%
Large cell - 5%
Adenocarcinoma - 35-40%
154
Presentation of squamous cell carcinoma
Central
May cause hemoptysis
Hypercalcemia with elevated PTH
155
Presentation of large cell lung cancer
Rapid growth with response to surgery
60% are peripheral
Gynecomastia
156
Presentation of lung adenocarcinoma
Peripheral - associated with smoking and asbestos
Peripheral with thrombophlebitis
157
Management for NSCLC
Stage 1-2 surgery
Stage 3 Chemo then surgery
Stage 4 palliative
158
Window for differentiating CAP from Hospital acquired pneumonia
48 Hours
159
MC pathogen for CAP
Strep pneumo
160
Presentation of CAP
Fever
Gradual cough with sputum production
SOB with sweats, chills, etc.
Inspiratory crackles and dullness to percussion
161
Dx for CAP
CXR with lobar consolidation - not needed outpatient
CT scan is more sensitive/specific
Urine test for legionella
162
Indication for Prevanr 13/Pneumovax 23
65+ and immunocompromised give both or any chronic illness with increased risk of CAP
Immunocompromised patients at high risk should get single revaccination of 23 6-y after the first dose, regardless of age
Immunocompetent and 65+ y get the second dose of 23 if first received vaccine 6+ y ago (<65)
163
MC nosocomial pneumonia pathogens - 4
S. aureus, K. pneumoniae, E. coli, Pseudomonas aeruginosa
164
Diagnostic criteria for nosocomial pneumonia
Requires at least 2 of the following: Fever, leukocytosis, and purulent sputum
CXR with increased parenchymal opacity
165
Labs to get for nosocomial pneumonia
Blood cultures × 2 CBC and CMP
Sputum culture and gram stain
ABG, thoracentesis if there is an effusion
Procalcitonin
166
Outpatient management for pneumonia with no comorbidities or ABX within 90 days
Azithromycin
Clarithromycin
Doxycycline
167
Outpatient management for pneumonia with ABX use in the last 90 days, over 65, or with comrobid illness/immune compromise
Levofloxacin or Moxifloxacin (Repiratory FQs)
OR
Macrolide+Beta Lactam (ie. augmentin/amoxicillin)
168
Management for pneumonia in smokers
Cefdinir
169
Inpatient or non ICU management for pneumonia without 90 day abx use or comorbidities/over 65/IC
IV levaquin or cipro
170
Management for inpatient pneumonia with ABX use in the last 90 days, over 65, or with comrobid illness/immune compromise
IV macrolide and IV beta lactam (ampicillin, cefotaxime, ceftriaxone)
171
MC pathogens and tx length for hospitalized/ICU patients with pneumonia
S. pneumoniae, Legionella, H. influenzae, Enterobacteriaceae, S. aureus, Pseudomonas
5 days min or until afebrile for 48-72 hours
172
Presentation of OSA
Apnea, snoring, excessive daytime fatigue and sleepiness
Depression, HTN, and AM headaches
Pendulous uvula with narrow oropharynx
173
Diagnosis of OSA
5+ obstructive events per hour of sleep with symptoms
15+ without
174
Management of OSA
CPAP
175
3 first line interventions for smoking cessation
Varenicline (Chantix)—best efficacy
Bupropion SR
Nicotine replacement therapy (NRT) - recommended for inpatient use
176
Half life of nicotene
1-2 hours
Increases GABA and promotes dopamine release
177
Second line tx and f/u for smoking cessation
Nortriptyline and Clonidine
1-2 weeks after starting medication
178
LOng acting and short acting nicotene replacement
Long - Patch
Short - Lozenge/Gum
179
Chantix (Varencicline)
Reduces reward aspects of smoking.
Quit smoking 1 week after starting medication
180
Buproprion for smoking
Enhances central nervous system noradrenergic and dopaminergic release
Okay for pregnancy
181
Positive TB test with 5mm induration - 5
If patient is: at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
182
Positive 10mm induration TB test - 5
If patient is: < 4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
183
Positive 15 mm induration TB test - 5
All patients
184
IGRA
Interferon gamma release assay - blood test for TB
185
CXR of TB
upper cavitary lesions, infiltrates, Ghon complexes in the apex of lungs
186
Sputum and biopsy results for tuberculosis
Need three acid fast bacteria stains to be free of TB
Caseating granulomas on biopsy
187
When to start empiric tx for TB
After PPD/IGRA and before CXR
188
Management for latent TB - 3 possibilities and how you know its latent
Positive IGRA/PPD but negative CXR
Three months of once-weekly isoniazid plus rifapentine (3HP)
Four months of daily rifampin (4R)
Three months of daily isoniazid plus rifampin (3HR)
189
2 regimens for active TB infection
Positive CXR and PPD/IGRA
4 months of: Rifapentine, Moxifloxacin, Isoniazid, and Pyrazinamide
OR
6-9 months of: RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol)
190
Baseline labs for TB therapy
All hepatotoxic - liver labs
191
Criteria for TB therapy cessation
2 negative AFB smears and cx in a row
192
TB prophylaxis
All household members for 1 year - isoniazid
193
Lung cancer screening recommendation
50-80 with 20 pack year hx and currently smoking or within 15 years of quitting
Low dose CT
194
Presentation of anal fissure
Rectal pain and bleeding after defecation
Severe pain with a superficial laceration that lasts for hours
Senitnel pile of mucous below fissure
195
Management of anal fissure
Sitz bath, stool softeners
Takes 6 weeks to heal
Botox if refractory
196
MC etiology for appendicitis
Fecalith
197
Presentation of appendicitis
Coliky pain around the navel migrating to McBurney's point in the LLQ
Rebound tenderness
198
3 PE tests for appendicitis
Rovsing – RLQ pain with palpation of LLQ
Obturator sign – RLQ pain with internal rotation of the hip
Psoas sign - RLQ pain with hip extension while laying on the left side
199
Diagnosis for appendicitis
Ultrasound or CT scan for atypical presentation
Neutrophilia supports dx
200
MCC of small bowel obstruction
Postoperative adhesions - most often in the ileum or jejunum
201
Presentation of small bowel obstruction
Colicky abdominal pain, hyperactive bowel sounds, and billious emesis
202
Lab/Imaging findings for small bowel obstruction
Multiple air fluid levels
Dilated loops of bowel
203
Management of small bowel obstruction
NG Tube for decompression
SUrgery if mechanical
204
MCC of large bowel obstruction
Cancer
Can also be volvulus, impaction, hernia
205
Presentation of large bowel obstruction
Increasing abdominal pain with longer intervals between episodes
Feculent vomiting
Tachycardia w/ fever may occur
206
Imaging for large bowel obstruction
Radiographs, then CT if non-emergent
Bird beak sign with >5cm air fluid levels, haustra that do not transverse the colon
Dilated loops of bowel
207
Difference of LBO from SBO
LBO has less vomiting, lower and less frequent pain but bouts last longer
208
Presentation of cholelithiasis
RUQ pain, radiating to the scapula (Boas sign) worse after meals and at night
Tx is elective - cholecystectomy if severe/recurrent
209
Presentation of cholecystitis
5 F's - Female, Fat, Fourty, Fertile, Fair Skinned
Positive Murphy sign with RUQ pain after fatty meal
Low grade fever, leukocytosis, jaundice
210
Initial imaging for cholecystitis
US showing 3+cm gallbladder wall w/ gallstones and percholecystic fluid
211
Gold standard for cholecystitis dx
HIDA scan (may use a CT to r/o other issues
212
Choledocolithiasis w/ gold standard
Stones in common bile duct - dx with ERCP
213
Porcelain gallbladder
Indicates chronic cholelithiasis
214
Presentation of hepatic cirrhosis
AST>ALT
Abdominal pain, ascites, hepatomegaly
Asterixis (flapping tremor) from ammonia accumulation
pulmonary edema/effusion, esophageal varices, Terry’s nails (white nail beds)
215
MCC and 2nd MCC of cirrhosis
Alcohol followed by hepatitis
216
Management for CIrrhosis
Quit alcohol
Restrict salt
Transplant
217
Monitoring for cirrhosis
Labs every 3-4 months
US every 6-12 months
218
Location of more malignant concerning polyps and time to next colonoscopy post removal of polyps
Proximal colon
3-5 years
219
Screening and management for patients with a first degree relative with familial adenomatous polyposis
Begin at 10 years - genetic screen
12 years-sigmoidoscopy
Prophylactic colectomy recommended
220
Presentation of colon cancer
Painless rectal bleeding and altered bowel habits in an individual aged 50-80
Apple core lesion on barium enema
221
MC type of colon cancer
Adenomatous
222
Colon cancer screening
45-75 years old
Colonoscopy 10 years
Sigmoid/CT - 5 years
Stool test - 1 year
223
Definition of constipation
Less than 3 bowel movements per week or any two of: Straining, lumpy hard stools, sensation of incomplete evacuation - last 3 months with onset 6 months before diagnosis
224
Diagnosis of constipation
Rectal exam and assessment for secondaty cause
225
Management for constipation
20-25 g fiber per day
Exercise and hydration
Further investigation if not resolved in 2 weeks
226
Laxatives for constipation
Bulk forming first line - Psyllium, methocellulose
Osmotic such as - Polyethylene glycol
Stimulant laxatives
227
Presentation of E. coli travelers diarrhea
Occurs in the first 2 weeks and lasts 4 days without treatment
3+ unformed stools with one of: fever, nausea, vomiting, abdominal cramps, tenesmus, bloody stools
228
Empiric treatment for travellers diarrhea
Ciprofloxacin and Loperamide (if over 2)
229
Abx for campylobacter or shigella
FQ
230
Abx for travelers diarrhea in pregnant, FQ resistant, or under 2
Z-max
231
Prophylaxis for travelers diarrhea
FQ - 90% effective
Bismuth - 50% effective
232
Etiology of viral gastoenteritis
Daycare - Rotavirus
Cruise ship - Norovirus
233
Presentation of viral gastoenteritis
Lasts 48-72 hours but symptoms may linger up to one week
Myalgias, malaise, possible low-grade fever
Headache, watery diarrhea, abdominal pain, nausea, and vomiting
Supportive tx
234
Presentation of salmonella enteric fever
Raw poultry, pork, or egg consumption
Flu like with GI symptoms
Pea soup diarrhea
Rose spots on trunk
235
Presentation of salmonella gastroenteritis
1/10,000 egg yolks
Inflammatory diarrhea 24-48 hours after consumption
236
Management for salmonella infection and when to treat vs. support
Rocephin or sometimes Azithromycin or FQ
Only treat in immune compromised
237
Presentation of shigellosis
Primarily affects children
Abdominal pain and inflammatory diarrhea with mucous and tenesmus
Large amounts of fecal leukocytes
238
Management for shigellosis
Bactrim may us FQ
Do not use antidiarrheals
239
EHEC/ETEC
Undercooked ground beef
12-60 hour onset
May have bloody or non-bloody stool
No fecal laukocytes
Abx if severe
HUS - Hemolysis with thrombocytopenia
240
Presentation of cholera
Life threatening rice water diarrhea
Seafood consumption
24-48 hour incubation
241
Abx for cholera - 5 options
Doxycycline, azithromycin, furazolidone, bactrim, or ciprofloxacin
242
Presentation and management for infectious esophagitis
In AIDS, transplant, and leukemia patients
Yellow white plaques = Candida = Fluconazole
Punch lesions/ulcers = Viral = Gancyclovire for CMV
243
Drug induced esophagitis causes and management
ALendronate or NSAIDs. Odynophagia and dysphagia with deep ulcers
Sit upright for 30 minutes after taking bisphosphonates
244
Eosinophilic esophagitis presentation
Patients with asthma symptoms and GERD unresponsive to antacids.
Dysphagia and impaction
245
Eosinophilic esophagitis dx and management
Stacked circular rings with eosinophilic infiltrations - ribbed on enema.
Remove foods and topical steroid via inhaler
246
Management of radiation or corrosive esophagitis
Dilation of radiation
Steroids for corrosion
247
Location and management of H pylori gastritis
Antrum and body of stomach
CAP! Clarithromycin, Amoxicillin, PPI (may add flagyl; may add pepto-bismol)
248
Location and management of NSAID gastritis
Stomach and duodenum
Stop NSAID
PPI for 4-8 weeks
May also be alcohol caused
249
Autoimmune gastritis
Pernicious anemia
Identified by schilling test
Fundus and stomach body
250
Gold standard for GERD dx
pH probe
251
Dividing line between upper and lower GI bleed
Ligament of treitz
252
Management for an upper GI bleed
PPI until cause is known
NPO with fluids
Blood if hgb under 7, or comorbid with 9
253
Presentation, Dx of giardiasis
Drinking from outdoor streams
Bulky foul stool
Stool for cysts and trophozooites
254
Tx for giardiasis
Tinidazole - first line
Flagyl also an option
255
Pinworm
Enterobius vermicularis
Itching with scotch tape test
Mebendazole
256
Tapeworm
Taenia saginata
GI symptoms and weight loss
Eating undercooked beef
B12 defficiency
Eggs in stool
Praziquantel to tx
257
Hookworm
Water contact, cough from lungs to GI tract
Eosinophilia and anemia, serpiginous rash
Stool for worms
Tx mebendazole or pyrantel
258
Roundworm
Pancreatic duct, common bile duct, and bowel obstruction
MC intestinal worm
Stool for eggs or worms
Albendazole, mebendazole, or pyrantel pamoate
259
Amebiasis
Entamoeba histolytica cysts and trophozoites
Metronidazole for the acute phase, followed by Paromomycin to eliminate any remaining cysts
Causes liver cysts
260
Schistosomiasis
Contaminated water
Rash, abdominal pain, bloody stools
Eggs in urine/Feces
PRaziquantel to treat
261
Defining line between external and internal hemorrhoids
Dentate line
262
Thrombosed and unthrombosed hemorrhoids w/ tx
Bleed if not thrombosed
Significant pain and pruritus but no bleeding
Treat with excision
May use sitz bath, hydration, fiber and topical anesthetic for nonthrombosed or mild
263
Presentation and management of internal hemorrhoids
Bright red blood per rectum, pruritus and rectal discomfort
Fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids
Rubber band ligation If protrudes with defecation, enlargement, or intermittent bleeding
Closed hemorrhoidectomy if permanently prolapsed
264
Hiatal hernia presentation and management
Symptoms of GERD that are worse with lying down
Barium or endoscopy
PPI with surgery needed 15% of cases
Rolling vs. Sliding (rolling is worse)
265
Presentation and dx of ulcerative colitis
Just the colon and rectum
More superficial
Hematochezia and pus-filled diarrhea, fever, tenesmus (feeling of incomplete defecation), anorexia, weight loss
Barium enema: Lead pipe appearance (loss of haustral markings) -> may lead to toxic megacolon
Colectomy is curative
266
2 medications for UC
Mesalamine and Prednisone
267
Presentation and dx for crohn's disease
Deep lesions from mouth to anus
MC in terminal ileum
Abdominal pain, nonbloody diarrhea, cobblestoning of colon
268
Management for crohn disease
Surgery NOT curative
Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin
269
Presentation of IBS
Recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria:
Related to defecation
Associated with a change in stool frequency
Associated with a change in stool form (appearance)
No organic cause
270
Management of IBS
Low FODMAP diet
Fiber
Antidiarrheals/spasmodics
CBT may help
271
Billirubin level associated with scleral icterus
2+ mg/dL
Next site to show is under the tongue
272
Diagnostics when jaundice is present
Serum total and unconjugated bilirubin
Urinary bilirubin
CBC, LFTs, albumin, PT/INR, GGT, alkaline-phosphatase, hepatitis panel
Abdominal ultrasound (preferred) or CT abdomen Liver biopsy (definitive)
273
4 prehepatic auses for conjugated hyperbilirubinemia
Alcohol
Infectious hepatitis
Drug reaction
Autoimmune
274
3 causes of unconjugated hyperbilirubinemia
Hemolysis
Hematoma
Gilbert syndrome
275
Presentation of acute pancreatitis
Epigastric pain radiating to the back, with nausea and vomiting, and elevated lipase
Cullen or Grey Turner sign
276
Ransons criteria for poor acute pancreatitis prognosis - 5
Age > 55
Leukocyte: >16,000
Glucose: >200
LDH: >350
AST: >250
277
Management for acute pancreatitis
IV fluids - most important
Analgesics and bowel rest
278
Classic triad and tx for chronic pancreatitis
Pancreatic calcification
Steattorrhea
Diabetes
Reduce alcohol and dietary fat intake
279
Presentation of PUD
Abdominal discomfort that is worse with meals and gets better an hour or so later after eating
280
Duodenal ulcer
Often better after eating with less pain than a stomach ulcer
More likely to be H pylori
281
Stomach ulcer
Gnawing burning pain that is worse with meals
Often caused by H pylori
282
Diagnostics for stomach ulcers
Upper endoscopy with biopsy if malignant appearing
283
Management for PUD
PPI 4-8 weeks
CAP tx for H pylori
d/c NSAIDs
284
Tests for H pylori
Breath or Stool test
285
HBe serology meaning
Positive ANTIGEN means they are acutely infectious
286
HBs serology interpretation
ANTIGEN - Ongoing infection
ANTIBODY - Immune
287
HBc serology interpretation
ANTIBODY - Have or have had an infection
288
Hepatitis C
Chronic with IVDU
Anti-HCV antibodies
Antiretrovirals to tx
289
Hepatitis D
Coinfection with Hep B
Suspect in severe HBV case
290
Hepatitis E
High risk of fetal mortality - 3rd world
HIV tx, HCV tx
291
ALT/AST ratio for alcoholic hepatitis
1:2
Fatty liver is usually the other way around with ALT>AST
292
Management for tylenol poisoning
N-acetyl-cysteine
293
Serology of chronic HBV
Anti HBC with HBs antigent and NO HBs antibodies
