fitz Flashcards
What is early term in pregnancy? Full-term? Late-term? Post-term
Early = 37 - 38.6 Full = 39 - 40.6 Late = 41 - 41.6 Post = 42 >
During 3 - 8 weeks of human development/gestation, what is this most known for?
organ development aka organogenesis
A teratogenic medication affects the targeted organ at any given time during fetal development? T/F
False - the teratogenic medication is either given prior to the organ it affects or during the gestational weeks when that organ is developing (ie soft palate develops 7-8 weeks of gestation, medication must be given prior or during that time)
What is important to know about Naegele’s rule? (pregnancy EDD)
provides a reasonable estimation, but can be INACCURATE for women with irregular menses or with unclear LMP date
What is the MOST ACCURATE source of expected due date in pregnancy?
1st trimester ultrasound (up to 13.6/7 weeks - this is the first week of the 2nd trimester [1st = 0-12, 2nd = 13-26])
What is most accurate source in the 2nd trimester to determine expected due date? (up to 27.6/7 weeks)
sizing of the uterus/uterine size, fetal movement felt by mother (quickening - 17-20 weeks usually)
What occurs at 10 weeks of gestation?
fetal heart tones via abdominal Doppler
Where is the uterus at 16 weeks of gestation? **
fundal height is half-way between symphysis pubis and umbilicus (VERY HELPFUL MARKER)
Where is the uterus at 12 weeks of gestation?
rising above the symphysis pubis
Where is the uterus at 20 weeks of gestation?
fundus is at the umbilicus
What is important to know about the fundal height in pregnancy during 20 - 36 weeks?
the fundal height will increase about 1 cm per week, which is concurrent with gestational age
What is the folic acid requirement of a women WITHOUT a history or family history of neural tube defect?
0.4 - 1 mg/day
What is the folic acid requirement of a women WITH a history or family history of neural tube defect?
4 mg/day for 1 month BEFORE pregnancy and DURING
What are the elemental iron requirements of a pregnant women?
30 mg/day - best from an iron-rich diet
only add on elemental iron if hgb < 11 in 2nd trimester or <10.5 in 3rd trimester
What is the recommended weight gain for a woman with a normal prepregnancy BMI? (18.5-24.9)
total weight gain 25-35 lbs
What is the recommended weight gain for a woman with an overweight prepregnancy BMI? (25-29.9) Obese? (>30)
total weight gain 15-25 lbs
obese = 11-20 lbs
Pre-pregnancy genetic at-risk group: Ashkenazi Jews, French Canadian, Cajun ancestry are at risk for what genetic condition?
Tay-Sachs disease
Pre-pregnancy genetic at-risk group: Northern European or Ashkenazi Jews are at risk for what genetic condition?
Cystic Fibrosis - prior to or in early pregnancy need genetic screening
Pre-pregnancy genetic at-risk group: African, Latino, Arabic, Greek, Maltese, Italian, Sardinian, Turkish, and Indian ancestry are at risk for what genetic condition?
Sickle cell trait
What vaccines may be given as early as 6-8 weeks in pregnancy or anytime during pregnancy
Influenza - during summer
When is Tdap ideally given to the pregnant mother? What about spouse or household members - when should they get a Tdap?
27 - 36 weeks gestation with EACH pregnancy.
Anyone in the house/care of infant should have a Tdap within the past 10 years.
What are postpartum vaccines that should be given to a mother?
if NOT rubella or varicella immune - give MMR and varicella. NEVER give live vaccines during pregnancy, may be given preconception
What diagnostic testing should be offered to pregnant women that are at an increased risk of fetal aneuploidy with first or second trimester screening?
genetic counseling and the option of CVS or mid-trimester amniocentesis
Who is at highest risk of gestational diabetes or the development of type 2 DM during pregnancy? (6 findings)
overweight/obese, gestational DM with previous pregnancy, prior delivery of LGA infant, presence of glycosuria, PCOS history, strong family hx of type 2 DM
At what gestation should all pregnant women (non DM hx) be screened for GDM?
At 24 - 32 weeks gestation, including those with negative results in first trimester
What is the FIRST intervention for GDM mothers?
nutritional therapy - by a trained professional with formal dietary assessment
What are the pharmacological options offered during GDM, if not controlled with diet and exercise alone?
Insulin, Sulfonylureas, Metformin
How many weeks postpartum should testing for GDM be conducted? What should NOT be included in this testing?
6 - 12 weeks postpartum, NO A1C
What are the treatment options for heartburn in pregnancy?
diet (no spicy or high-acidic foods, decrease food/liquid at meals and before bed)
Sleep in semi-Fowlers
Antacids post meal (PPI decrease B12 and iron)
When does hCG peak in pregnancy?
10 weeks - n/v is caused by this. May begin by week 6-8
What 5 pharmacologic options are available for moderate to severe nausea and vomiting in pregnancy?
*Pyridoxine OTC (Vit B6 analog) 25 mg PO TID,
*Antihistamines (dimenhydrinate, diphenhydramine),
Phenothiazines (promethazine, prochlorperazine),
Prokinetic agen (metoclopramide),
Ondansetron (zofran)
How is Chlamydia trachomatis treated in pregnancy?
Azithromycin single dose. Tetracycline eye drops or 2 weeks of erythromycin.
Fitz: Ceftriazone 250 mg IM and Azithromycin 1 gm PO
(Allergy to PCN = Azithromycin 2 gm and CT alone: Azithromycin 1 gm PO)
When should you follow up diagnostic testing for chlamydia trachomatis in the pregnant patient?
test of cure in 3 - 4 weeks, rescreen in 3 months for new infection (test of cure is ONLY in pregnancy)
What is the treatment for syphilis during pregnancy? Allergy?
Benzathine PCN G IM
allergy to PCN = desensitized therapy
What can be used in a primary episode of HSV in pregnancy? Recurrent episode? Suppression? (do NOT memorize amount drug, know names)
PRIMARY: Acyclovir 400 mg TID 7-10 days or Valacyclovir 1 gm BID,
RECURRENT: either med for 5 days,
SUPPRESS: Acyclovir 400 mg TID or Valacyclovir 500 mg BID from 36 weeks until delivery
What should be done with an abnormal PAP during pregnancy?
referral for colposcopy (nonpregnant and pregnant)
When does Pap screening begin? HPV with pap?
Pap age 21,
HPV = >30 years
What 2 pharmacological treatments are available for anogenital warts during pregnancy?
TCA topical or Cryotherapy (may need C-section)
What are symptoms of placenta previa? How is this diagnosed?
PAINLESS vaginal bleeding in late 2nd or any part of 3rd trimester
Diagnosed by transvaginal ultrasound
What are symptoms of placental abruption?
PAINFUL vaginal bleeding. Tender with a contracting uterus
What are symptoms of postpartum depression? When does this occur?
depressed mood >2 weeks with change in appetite, sleep disturbance, guilt, worthlessness
Occurs within the 1st year of child’s life (2-4 months postpartum)
Is levothyroixine safe for pregnancy?
yes - may need to increase by 30 percent
What beta-lactam antibiotics are safe during pregnancy and lactation?
penicillins and cephalosporins
What macrolides are safe during pregnancy and lactation? What should be avoided?
Azithromycin and Erythromycin
AVOID clarithromycin
What antibiotic should be avoided in 3rd trimester due to a risk of the infant developing hemolytic anemia?
NItrofuratonin (Macrobid) d/t risk of hemolytic effects/anemia
What asthma medications are safe with pregnancy and lactation?
inhaled corticosteroids, short and long acting beta 2
What maybe used during an asthma flare in pregnancy and lactation?
short term systemic corticosteroids
What drug class of antibiotics should NOT be used during the third trimester of pregnancy due to a risk of the infant developing kernicterus?
Sulfonamides, such as sulfamethoxazole
What two medications maybe used during pregnancy and lactation for allergic rhinitis care?
intranasal corticosteroids and 2nd generation antihistamines (loratadine)
What analgesic is approved during pregnancy?
acetaminophen ONLY. no NSAIDS (1st trimester = loss, >20 weeks = renal dysfunction)
What SSRI should be AVOIDED during pregnancy? What can this cause?
Paroxetine - causes risk for fetal atrial septal defect
What antimicrobials (4) should be AVOIDED during pregnancy and lactation?
Fluoroquinolones (-floxacin suffix),
Trimethoprim-sulfamethoxazole (Bactrim),
Clarithromycin,
Tetracyclines (doxy, mino = teeth staining)
What are 8 known teratogens during pregnancy?
ACE inhibitors (pril), ARB (sartan), Carbamazepine (tegretol), Valproic Acid (depakote), Lithium, Isotretinoin (accutane), Thalidomide, Statins
How will teratogens affect the body?
select target organs in a predictable manner
What is an alternative medication safe for pregnancy that can treat an uncomplicated UTI?
Cephalexin
When is pump and dump of breastmilk helpful or advised?
When a mother takes a drug that is not safe (ie cocaine, PCP). Needs to pump 3-5 half lives of medication/drug
What birth control may be given to the lactating mother?
Medroxyprogesterone (depo-provera)
Infant: What is the treatment of hemangioma?
propranolol (benign tumor), can watch and wait
Rapid growth in first days of life to 6 months
Infant: What will a port wine lesion present as? What syndrome may present with this lesion?
a blanchable red to dark pink lesion, grows proportionally with child (DOES NOT REGRESS), consider genetic/congenital syndromes (Sturge-Weber)
Infant: What are blue-black-gray macular lesions on lower back and buttocks?
Mongolian Spot(s), common on Asian, African, Native American. Lights over time and requires NO TREATMENT.
Infant: What are raised white bumps, mainly on the nose and cheeks?
Milia - no treatment, resolves spontaneously, DO NOT PICK
Infant: What may present in the first 48 hours of life and resolves by 5-7 days of age?
Erythema Toxicum Neonatorum - no treatment, very common
Infant: What may present as red and crusty on extensor surfaces? What management is best?
Atopic Dermatitis - face <2 years, hands and feet 2-12
Eliminate triggers, hydrate skin (no lotion), control itch
Infant: What presents on the scalp of an infant as erythematous plaques that are greasy and yellow scales?
Seborrheic dermatitis - cradle cap
Infant: What is the management of seborrheic dermatitis, cradle cap
Emollient (petrolatum, vegetable or mineral oil) overnight then remove with soft brush.
Other areas - ketoconazole 2% cream once daily or hydrocortisone 1%
Infant: A rough skin texture (gooseflesh or chicken skin) usually on the outer aspect of the upper arm
Keratosis Pilaris - worst with cold/dry weather
Elder: What are 6 normal age-related changes?
Decreased body weight as water, Lean muscle mass, Increased body weight as fat, Decreased serum albumin, Decreased kidney weight, Decreased hepatic blood flow
Elder: What drug is highly bound to albumin?
Coumadin (Warfarin) - 99% albumin-bound,
Others: phenytoin, valproic acid, diazepam
T/F When compared with a healthy 40-year-old adult, CYP450 isoenzyme levels can drop by up to 30% in elders after age 70.
TRUE
T/F CYP450 1A2’s activity is influenced by the presence or absence of estrogen in women.
TRUE - counsel about caffeine intake to be decreased
Elders: systemic anticholinergic effects present with symptoms of?
confusion, urinary retention, constipation, visual disturbance, and hypotension = polypharmacy and risk of delirium.
DRY MOUTH*, sedation, agitation, mydriasis
Elder: What medications that are used to treat overactive bladder cause systemic anticholinergic effects?
Oxybutynin (Ditropan) - Sustained release may have better tolerance in older adult
Elder: What SSRI is preferred in the elderly?
Sertraline (Zoloft)
Elder: What is a major risk with tricyclic antidepressants?
hypotension - amitriptyline, nortriptyline, trazodone, mitrazapine
T/F The risk of torsades de points with erythromycin or clarithromycin is greater in females than males
TRUE - any drug that prolongs the QT interval = greater risk of ventricular tachycardia
Elderly: Citalopram should NEVER exceed what mg/day? What if the patient is over the age of 60, what is the maximum dose?
40 ! - causes >QT interval prolongation
>60 = 20 mg/day
Elderly: What should NEVER be given with citalopram in an adult over the age of 60 years?
Any CYP2C19 inhibitors - PPIs or Cimetidine (Tagamet). Consider escitalopram instead (zero drug-drug interaction)
Elder: What SSRI has the shortest half life but the greatest systemic anticholinergic effects?
Paroxetine (21 hours)
Elder: aspirin for PRIMARY prevention of cardiac events
NO! especially if >80 years old, lack of evidence of benefit
Elder: When should daily aspirin be considered?
As a secondary prevention for CAD. Unsure about >80 year old population
Elder: An older adult women with recurrent UTI, what should be considered?
Alternative therapy other than chronic antimicrobial therapy. Estrogen with or without progestins
Elder: Management of dyspareunia, lower urinary tract infections, and other vaginal symptoms for women postmenopausal
Topical vaginal cream - low-dose estrogen. (acceptable for atrophic vaginitis)
T/F Vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at low doses
TRUE
Elder: What is the A1C goal for older adults who are frail or with limited life expectancy
<8%
Elder: What medications work well since beta2-agonists (albuterol, salmeterol) work less effectively. What is the alternative?
Inhaled muscarinic antagonist/anticholinergic (Tiotropium, Ipratropium bromide; work well as broncho dilators)
Elder: What alternative class of medication works well once beta blockers have decreased effectiveness in older adults?
Calcium channel blockers (Dihydropyridine: Amlodipine)
Elder: Should statins be started or continued in older adults?
Avoid high-intensity in >80 years, impaired renal function, frailty, multiple comorbidities, with fibrate.
Moderate-intensity is 1st line and preferred.
USPSTF: >76 years and no hx CVD = no evidence
What percent of LDL-C is reduced by high intensity statins?
> 50%
What percent of LDL-C is reduced by moderate intensity statins?
30-49%
Elder: What are the consequences of long-term (>2 months) PPI use?
Rebound hypersecretion = increased GI symptoms.
Decreased absorption of Iron and B12.
Increased fracture risk (lower calcium absorption, BUT not calcium citrate!).
Decreased magnesium absorption
Elder: What medication will become toxic in a person with low magnesium? What are 2 medications that deplete magnesium?
Digoxin,
Thiazide and Loop diuretics
Elder: How long should a PPI be prescribed according to Beers Criteria? Who are (6) high-risk patients?
Avoid PPI use >8 weeks, unless high-risk.
High risk = oral corticosteroids, chronic NSAID use, erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory condtion, or other need for maintenance treatment (failure to discontinue PPI trial)
Elder: What medication causes induced hyperkalemia? What happens on EKG?
TMP-SMX (bactrim), especially when on spironolactone, ACEIs or ARBs
EKG - tall tented T waves
T/F If the prescribing information about a given medication includes a warning about the need for dose adjustment in the presence of renal impairment, then that product is likely nephrotoxic
FALSE
Elder: What are adverse effects of cholinesterase inhibitors?
Increased rates of syncope, bradycardia, pacemaker insertion, and hip fracture in older adults with dementia.
Donepezil/Aricept, Galantamine/Razadyne ER, Rivastigmine/Exelon
nausea, diarrhea, vomiting, decreased appetite, dyspepsia, anorexia, muscle cramps, fatigue, insomnia, dizziness, bradycardia (falls) headache, and asthenia.
Elder: What DOAC medication has a greater risk of bleeding in comparison to warfarin in adults >75 years?
Dabigatran (Pradaxa) - caution use/Beers Criteria
FP: What birth control methods are safe for women that smoke? <35 years vs >35 years
<35 = POP, DMPA, implants, IUDs. COC/P/R - MEC 2
> 35 = POP, DMPA, implants, IUDs (NO COC for >15 cigarettes/day and >35 years)
FP: What is the pharmacologic action of progestin?
Ovarian and pituitary inhibition
Thickening of cervical mucus
Endometrial atrophy/transformation
Cycle Control
FP: What are the pharmacologic actions of estrogen?
Ovarian and pituitary inhibition
THINS or increases cervical mucus
Endometrial proliferation
Cycle control
FP: What exam/test is necessary before starting combined oral contraceptives?
blood pressure
FP: What exam/tests are necessary before starting IUD or diaphragm/cervical cap?
Bimanual examination and cervical inspection, STD screening (not a criteria)
FP: Should a pregnancy test be conducted prior to initiating birth control?
No, not necessarily. If NO symptoms of pregnancy AND <7 days after start of normal menses, no intercourse since last menses start, correct/consistent reliable method of contraception, or <7 days after spontaneous or induced abortion. Within 4 weeks postpartum, fully/near breastfeeding (>85%), amenorrheic, and <6 months postpartum.
Dependent upon health history findings
FP: What are 2 standard methods for starting oral birth control? Which one requires no backup method?
Sunday start (COC, patch, ring) after menses begin, backup for 7 days. First day of menses start, NO BACKUP. Others: quick start, jump start (if had unprotected intercourse since LMP)
FP: Who can take combined oral contraceptives?
<35 year old that smokes, 29 year old with PID, <45 with recurrent tension-type headache
NO - HTN with adequate control or with poor control
FP: What antibiotic is most likely to reduce oral contraceptive effectiveness?
Rifampin only - any other antibiotics tell pt to continue birth control, do not be surprised if you spot, and use a backup method for duration of time plus an additional 7 days
FP: The reduction in free androgens in a woman taking combined oral contraceptives can improve what condition?
Acne vulgaris
FP: What is considered a category 3 (exercise caution) for combined oral contraceptives?
History of gastric bypass surgery - medications are absorbed in the duodenum
FP: A breastfeeding mother may have what type of birth controls? (4)
progestin-only, Depo-provera, Nexplanon, or cooper IUD (ParaGard). Absolutely NO COCs
FP: Who can have an IUD?
45 and nulliparous, smoker, seizure disorder, HIV
FP: What are the effects of nexplanon or implanon? What is a common adverse effect and what are 2 ways to manage this?
low dose progestin, replace q3 yr, best for teens
AE: irregular bleeding, can be managed with COC use x3 months or timed NSAIDs use x2 weeks
FP: What are 3 emergency contraception options?
IUD - cooper
Pills - UPA single dose (Ella) or Levonorgestrel (Plan B)
FP: How many days after unprotected intercourse can an emergency contraceptive be given?
3 days
FP: What emergency contraceptive is available over the counter?
Levonorgestrel or Plan B - inhibits transport of egg or sperm, inhibits/delays ovulation; interferes with fertilization
FP: What are the most common adverse effects of progestin-only emergency contraception? What are facts about this medication?
nausea and/or vomiting. Repeat dose if vomiting occurs within 2 hours of taking medication. Effective if taken within 72-120 hours post intercourse. OTC by anyone, any age
FP: What is the mechanism of action of Ella, emergency contraception?
progesterone agonist/antagonist = inhibits effect on follicular development of ovum release. Changes endometrium that alters implantation.
RX ONLY. Within 120 hours/5 days after unprotected intercourse.
FP: What is the advantage of cooper IUD?
it can be left in place for 10 years. Contraindicated in PID.
MS: Redness at the first metatarsophalangeal joint, what diagnosis is suspected
Gout
MS: What 3 medications are most effective for acute treatment of gout?
Intraarticular corticosteroid injection, NSAIDs, Colchicine (used to prevent and relieve pain of gout attacks)
MS: What are 2 control drugs, not used for an acute attack, in gout?
Febuxostat (Uloric) and Allopurinol
MS: What are potential triggers of acute gouty arthritis?
Thiazide diuretic, consumption of organ meats/purines, or alcohol consumption
MS: What is the McMurray test?
Meniscal tear
MS: What is the Talar tilt?
Ankle instability
MS: What is the Spurling test?
cervical nerve root compression
MS: What is the Tinel’s sign?
Carpal tunnel syndrome
MS: What is Lachman test?
Anterior cruciate ligament tear
MS: What is straight-leg raise test?
lumbar nerve root compression
MS: What is drop arm test?
rotator cuff evaluation - abduct arm (lift arm manually above patient’s head), ask patient to bring arm down slowly. Any loss of control = positive test
MS: What is finkelstein test?
De Quervain’s tenosynovitis - caused by chronic overuse of the wrist/repetitive movements. People with wrist pain, use this test: thumb bent into palm of hand with fingers wrapped around thumb, bend wrist to little finger.
MS: A 2 month history of fatigue, aching sensation with morning stiffness in hips and shoulders. Weight loss without trying and struggling to get dressed, especially shirt and pants. Anemia of chronic disease and elevated ESR
Polymyalgia rheumatica
MS: Lumbar spinal stenosis will present with what symptoms?
Older (>50),
Standing discomfort improved with BENDING forward,
Pseudoclaudication (leg pain worsening with activity, improves with rest),
Bilateral lower-extremity numbness/weakness
MS: What diagnosis is associated with intermittent anterior knee pain that is worse with squatting and walking up or down stairs? Pain improves with rest.
Osgood-Schlatter disease, typically found in growing teenagers/after a growth spurt
MS: What are symptoms of reactive arthritis
An inflammatory arthritis seen days or weeks after an episode of acute bacterial diarrhea or STD.
Pain/swelling of knees, ankles, heels, toes/fingers with persistent low back pain. Conjunctivitis. Urinary problems.
Can’t see, can’t pee, can’t climb a tree
MS: What are causes of reactive arthritis
Infection, STD (Chlamydia - NAAT), Genetic HLA-B27 gene
MS: What are common symptoms of lumbar radiculopathy?
sharp, burning, ELECTRIC-shock sensation. WORSE when increased spinal fluid pressure.
Sneeze, cough, straining = SHARP PAIN
(present just like LS strain but abnormal neuro exam)
MS: What abnormal neuro exam findings present with lumbar radiculopathy? How will this be treated?
abnormal straight-leg raise, sensory loss, or altered DTRs.
Conservatively, further evaluation if no resolution after 4-6 weeks of conservative therapy
MS: What diagnostic tests should be included for a patient with low back pain?
NO imaging (XRAY, MRI, CT) during 1-2 month trial of standard conservative therapy. Particularly if normal neurological exam, absence of acute trauma, and low risk for vertebral compression fracture. *MRI is reserved for persistent s/s, candidates for surgery or epidural injection*
MS: What diagnostic tests should be included for a patient with low back pain?
NO imaging (XRAY, MRI, CT) during 1-2 month trial of standard conservative therapy. Particularly if normal neurological exam, absence of acute trauma, and low risk for vertebral compression fracture. *MRI is reserved for persistent s/s (>4-6 weeks of therapy)*
MS: What is osteopenia BMD?
1.0-2.5
MS: What is osteoporosis BMD?
2.5
MS: What are non-dairy sources of calcium?
Spinach, sardines, tofu, nuts like almonds
MS: What age is appropriate for BMD testing in a woman? Man?
Women: 65 years
Men: 70 years regardless of risk factors
MS: What are risk factors associated with osteoporosis?
Women: younger postmenopausal
Both: >50 years who has broken a bone, Diseases (RA, SLE, DM, CF, CHF), on medications (long-term glucocorticoids, corticosteroids, thyroid hormones). Risk factors of physical inactivity, low calcium intake or alcohol abuse.
MS: What age is appropriate for BMD testing in a woman? Man?
Women: 65 years
Men: 70 years, regardless of risk factors
MS: Anemia of chronic disease (RA, SLE, OA)
RA and SLE
MS: Elevated C-reactive protein (RA, SLE, OA)
RA and SLE
MS: Joint space narrowing on XRAY (RA, SLE, OA)
OA
MS: Positive antinuclear antibody titer (RA, SLE, OA)
RA (less commonly) and SLE
MS: Where are Heberden’s nodes located?
Distal interphalangeal joints
MS: Where are Heberden’s nodes located?
Distal interphalangeal joints (DIP)
MS: Where are Bouchard’s nodes located?
Proximal interphalangeal joints (PIP)
MS: Symptoms of progressive aches of hands and fingers, particularly after strenuous work. Heberden’s and Bouchard’s nodes present.
Osteoarthritis
MS: What are expected symptoms of a scaphoid fracture? What diagnostic testing is standard?
pain radial of wrist and proximal to thumb (snuff box), decreased grip and strength.
XRAYS (PA, lateral, oblique) with a repeat within 7-10 days. CT, MRI, bone scan - xray may miss findings.
TX: thumb spica splint, analgesia, ortho referral
MS: What are expected symptoms of a scaphoid fracture? What diagnostic testing is standard? Interventions?
pain radial of wrist and proximal to thumb (snuff box), decreased grip and strength.
XRAYS (PA, lateral, oblique) with a repeat within 7-10 days. CT, MRI, bone scan - xray may miss findings.
TX: thumb spica splint, analgesia, ortho referral
MS: A grade I ankle sprain is best described as? What should be included in recovery?
Microscopic tears, no joint instability on exam and can bear weight with mild pain
TX: RICE, crutches, PT, analgesia. Does not require immobilization
MS: A grade II ankle sprain is best described as? What should be included in recovery?
An incomplete tear of a ligament, mild to moderate joint instability, decreased ROM, weight bearing and ambulation are painful. Mild to moderate pain, swelling, tenderness and ecchymosis.
TX: immobilize with aircast or splints. Recovery 4-6 weeks. Analgesia. PT, Ortho referral
MS: A grade III ankle sprain is best described as? What interventions may be necessary?
A complete tear, pain, swelling, tenderness, ecchymosis and loss of function/motion. Unable to bear weight and ambulate
TX: cast, splint, boot, ortho referral
Cardiac: What symptoms will WOMEN most likely report with suspected acute coronary syndrome?
Unusual fatigue** (before an event)
sleep disturbances, SOB, weakness
Cardiac: What is expected in clinical presentation of an elder (>75 years) with acute coronary syndrome
Dyspnea
neurological symptoms (syncope, weakness, acute confusion)
chest pain or pressure
Cardiac: What does a displaced PMI indicate? Causes?
Usually laterally displaced.
Indicates increased left ventricular volume.
May be caused by pressure overload or HTN
Cardiac: What is a maneuver that enhances PMI that is not palpable?
Place them in left lateral decubitus position.
Caused by obesity, thick chest wall, and COPD
Cardiac: What marks the beginning of systole, produced by events surround closure of mitral and tricuspid valve, and heard with carotid upstroke.
S1
Cardiac: What marks the end of systole, produced by events surrounding the closure of aortic and pulmonic valves, and heard best at the base of the diaphragm.
S2
Cardiac: Physiologic versus pathologic meaning
Physiologic - no underlying cause, no symptoms
Pathologic - typically presents with symptoms
Cardiac: Define a physiologic split S2
Benign finding. Increases on inspiration. Majority of adults <30 years and best heard in pulmonic region.
Cardiac: Define a pathologic split S2
fixed split vs paradoxical split. NO change with inspiration. Uncorrected septal defect in fixed. Delay aortic closure in paradoxical.
Cardiac: Define a pathologic S3 heart sound
Marker of ventricular overload and/or systolic dysfunction.
Causes: HF with symtpoms, pregnancy
1-2-3: lub dub-dub
Cardiac: Define S4 heart sound. What may cause this?
Poor diastolic function that can be resolved with treatment of underlying cause.
Cause: poorly controlled HTN or recurrent Myocardial ischemia
4-1-2 - dub-lub dub
Cardiac: Define a pathologic S3 heart sound
Marker of ventricular overload and/or systolic dysfunction.
Causes: HF with symptoms, pregnancy
1-2-3: lub dub-dub
Cardiac: Define S4 heart sound. What may cause this (2)?
Poor DIASTOLIC function that can be resolved with treatment of underlying cause.
Cause: poorly controlled HTN or recurrent Myocardial ischemia
4-1-2 - dub-lub dub
Cardiac: A mid systolic click murmur is heard
MVP = mitral valve prolapse, systolic murmur, pectus excavatum or connective tissue disease, >supine than standing
Cardiac: Murmur that is HOLOSYSTOLIC with same intensity and radiates to axilla
MR - mitral regurgitation
Cardiac: Murmur most commonly described as a rumble
Mitral stenosis
Cardiac: Murmur most commonly described as HARSH
Aortic stenosis
Cardiac: Murmur most commonly described as a RUMBLE
Mitral stenosis
Cardiac: Murmur most commonly described as a BLOWING sound
Aortic Regurgitation
Cardiac: Murmur that radiates to the neck
AS - aortic stenosis
Cardiac: Murmur that is crescendo-decresendo
AS - aortic stenosis
Cardiac: What are common findings of systolic murmurs
benign
negative hx, lower grade, no radiation beyond precordium, no heave/thrill, PMI WNL, softens or disappears with supine to stand position change
Cardiac: When should a murmur be considered pathologic? What is the next step?
abnormal hx, higher grade, radiation beyond precordium to neck, axilla, etc. Thrill/heave, displaced PMI, increased intensity with supine to stand
ECHO!
Cardiac: Diastolic murmurs (mnemonic)
MS. ARD
Mitral Stenosis
Aortic Regurgitation
Diastolic = bad
Cardiac: What is the difference between a carotid bruit and a radiating murmur?
Carotid bruit - softer, unilateral
Radiating murmur - louder, bilateral, same sound and timing as found in chest
Cardiac: What risk factors are associated with abdominal aortic aneurysm? When should a provider screen?
Advanced age,
male sex,
white,
positive family history,
smoking,
other large vessel aneurysms and atherosclerosis
Screening: men 65-75 who have ever smoked by US once
Cardiac: What are symptoms of aortic dissection?
Sudden tearing or ripping sensation (may spread to neck or down the back),
BP differences between R & L upper,
LE pulses < UE
**Genetic Turner or Marfan. RF: HTN uncontrolled, AAA, cocaine, >60 years, men*
What is the average age for menopause in the US?
51 years
What are classic signs/symptoms of HTN target organ damage?
visual changes, chest pain, SOB, and dizziness
Establishing the diagnosis of hypertension requires what in the absence of target organ damage?
> 2 abnormal readings on 2 different occasions
PCV13 is given today, when should PPSV23 be given?
in 1 year given PPSV23
What are findings of a normal retinal exam? (disc shape/color, vessel size, fundus)
Sharp disc margins that is yellowish orange to creamy pink and is round or oval
Vessels: AV ratio is 2:3 (width of arterioles to venules)
Fundus: no exudates or hemorrhages with red to purplish colors
No papilledema, no narrowing of arterioles
What findings may present on a retinal exam of a patient with poorly controlled hypertension?
Narrowing of arterioles, flame-shaped hemorrhages, papilledema, holes/tears, AV nicking, COTTON WOOL spots, HARD exudates
What is CN III
Oculomotor - eyelid and eyeball movement
What is CN IV
trochlear - turns eyes downward and laterally
What is CN V
Trigeminal - chewing, pain & touch of face/mouth
What is CN VI
Abducens - turns eye laterally
What is CN VII
Facial - expression, tears, saliva
What is CN VIII
Acoustic - hearing, equilibrium
What is CN IX
Glossopharyngeal - taste, BP
What is CN X
Vagus - BP, HR, taste
What is CN VII
Facial - expressions, tears, saliva
What is CN XII
hypoglossal - tongue
A patient with unilateral facial paralysis and benign neurological exam otherwise, inability to raise eye brow or smile on the affected side. Flat nasolabial fold. What CN is affected? DX? First line treatment?
CN VII, facial.
Bell’s Palsy.
Initiate course of oral corticosteroids
Presents with primary and secondary lesions including vesicles and crusts
zoster and varicella
A unilateral dermatomal pattern (Z vs V)
zoster
Mild to moderate systemically ill with fever (Z vs V)
varicella (vaccine 12 mo, 4 yr)
miserable with pain, itch, and usually without fever (Z vs V)
zoster (shingrex vaccine)
A condition limited to the scalp, eyelids, and nasoflods that may have mild symptoms of itch and irritability
Seborrhea
A condition limited to the scalp, eyelids, and nasofolds that may have mild symptoms of itch and irritability
Seborrhea
1st line tx = antifungal
A condition that presents with Auspitz sign, scaly silver plaque lesions mostly on knees and elbows
Psoriasis
TX = corticosteroids
What is the international normalized ratio (INR) goal of a 65-year old with atrial fibrillation on Warfarin therapy?
2.0 - 3.0
Does amoxicillin potentially increase bleeding risk during Warfarin therapy?
YES! - all antibiotics due to altered gut flora
Does st. john’s wort potentially increase bleeding risk during warfarin therapy?
NO! - may lower INR due to CYP450 enzymatic induction/inducer
Does gingko biloba potentially increase bleeding risk during warfarin therapy?
YES! - antiplatelet effect
What is the treatment for pelvic inflammatory disease?
IM ceftriaxone and PO doxycycline
What is the treatment for syphilis? Pregnant with allergy? Allergy and not pregnant?
Penicillin
admit to hospital for desensitization
PO doxycycline if allergic to pcn and not pregnant
What is the treatment for external genital warts? What if it is a pregnant woman?
Imiquimod cream
TCA - trichloroacetic acid - if pregnant this is the best option
What is the treatment for pelvic inflammatory disease? What sequelae may present r/t PID?
IM ceftriaxone and PO doxycycline with/out metronidazole 2 weeks
complications: tubal scarring, INCREASED risk for ectopic pregnancy or infertility
What are the most common strands of HPV that causes genital warts
HPV 6 and 11
in the US - HPV 16 and 18 are the most common cause of cancer
HPV vaccine protects against 6, 11, 16, 18, 31, 33, 45, 52, 58. Approved 9-45 years
A palpable ovary on bimanual examination on a 62-year old woman
highest link to ovarian cancer. Ovaries should not be palpable, especially postmenopausal
Vaginal pH should increase with age
What overactive bladder medication may worsen dry mouth and constipation, especially in the older adult
Oxybutynin (Ditropan)
A teenager with sudden onset of left-sided scrotal pain for the past 4 hours. C/o mild intermittent unilateral testicular pain in the past, but not like this. He has vomited once. No fever or history of scrotal trauma. What are expected findings of testicular torsion?
Unilateral loss of cremasteric reflex on the affected side.
Affected testicle is held higher in the scrotum.
Testicular swelling.
A teenager with sudden onset of left-sided scrotal pain for the past 4 hours. C/o mild intermittent unilateral testicular pain in the past, but not like this. He has vomited once. No fever or history of scrotal trauma. What are expected findings of testicular torsion?
Unilateral loss of cremasteric reflex on the affected side.
Affected testicle is held higher in the scrotum.
Testicular swelling.
NO RELIEF of pain with elevation.
PED: 4 year old with intermittent fever as high as 104.5F (40.3C) for the past 8 days and complaining of sore throat. Increased throat pain with swallowing, but no difficulty taking fluids. Little appetite, no N/V, diarrhea/constipation. You find extensive cervical lymphadenopathy, injected conjunctiva, oral erythema and a peeling rash on hands. What disease do you suspect?
Kawasaki disease
Systemic vasculitis of medium vessels (heart, kidneys, eyes) HIGH FEVER (5 days) & 5 criteria: Conjunctival without exudate, Macular rash, Inflammation of lips/oral cavity, Cervical lymphadenopathy, and Changes in extremeties with edema and desquamation of hands and feet
PED: A mild 3-4 day flu-like illness followed by 7-10 days of a red rash that begins on the face with a “slapped cheek” appearance that spreads to the trunk and extremities. What disease do you suspect?
Fifth’s Disease
“Slapped Cheek” rash or LACEY, macular rash that BLANCHES
PED: A mild 3-4 day flu-like illness followed by 7-10 days of a red rash that begins on the face with a “slapped cheek” appearance that spreads to the trunk and extremities. What disease do you suspect? What is a confirmation test? (the virus you test for)
Fifth’s Disease
“Slapped Cheek” rash or LACEY, macular rash that BLANCHES
Contagious before rash. Supportive care
Confirmation = Parvo virus B19 IgM
PED: A child under the age of 5 years with fever, malaise, sore mouth with oral vesicles on mucous membranes that ulcerate and crust, and decreased appetite. What disease do you suspect? When can this child return to daycare?
Hand, foot, mouth disease
Lesions show 1-2 days after. May cause conjunctivitis or pharyngitis.
May return to daycare once the fever free for 24 hours or until blisters are dry
PED: What age should iron supplementation begin in the child only consuming breast milk?
age 4 - 6 months
PED: In the child >12 months, what is the most potent risk factor for iron deficiency anemia? What about the <9 month old child?
> 12 months = Cow’s milk intake >16 oz per day
<9 months = maternal iron depletion or prematurity
PED: What children would be at greatest risk for iron deficiency anemia?
> 12 months old, drinking > 16 oz of cow’s milk, premature infant that is exclusively breastfed without additional supplements
PED: When should 400 IU vitamin D supplementation begin?
All exclusively and partially breastfed infants shortly after birth until weaned then consume >1000 mL/day of vitamin D fortified formula or whole milk
Any infants that ingest <1000 mL/day of vitamin D fortified formula or milk = supplementation
PED: What are 3 key facts about diagnosing ADHD in children? (onset age, setting, evidence of)
Symptoms must be present before age 12
Impairment must be present in at least 2 settings
Evidence of functional interference
PED: A airway condition that is caused by upper airway obstruction, air is more difficult to get in and a characteristic sound heard on inspiration
Stridor
PED: What are 5 airway diagnoses that may cause stridor in children?
Croup, Foreign body, Congenital obstruction, Peritonsillar abscess, Acute epiglottitis
PED: What are key features of croup? Treatment?
Viral/allergic in orgin
ages 6 months - 5 years
TX: supportive treatment, maybe systemic corticosteroids (PO dexamethasone)
PED: What are key features of foreign body?
sudden onset from mechanical obstruction
TODDLERS
PED: What are key features of peritonsillar abscess?
bacterial
older child or adult
“hot potato” voice, difficulty swallowing, trismus (pain opening jaw), CONTRALATERAL uvula deviation
TX: airway, referral to ED, antimicrobial therapy, needle aspiration of abscess
PED: What are key features of acute epiglottitis?
organism = H. Influenza (Hib vaccine)
age 2 - 7 years
abrupt onset of high-grade fever, sore throat, dysphagia, and drooling
leaning forward, drooling AIRWAY EMERGENCY
PED: What are 3 potential differential diagnoses of wheeze in children?
Acute bronchiolitis,
Acute bronchitis,
Asthma
PED: What has a viral etiology, commonly caused by RSV, that results in a short-term illness with wheezing that may persist for 3 weeks
Acute bronchiolitis
TX: supportive
PED: What condition is often allergic with an inflammatory etiology that presents with wheeze and recurrent symptoms or persist without treatment.
Asthma
PED: What are the symptoms of moderate persistent asthma? At what age will FEV1 start to be a component of severity?
daily symptoms, 3-4x/month of nighttime awakenings, daily SABA use, and some limitation in normal activity
Age 5 and up, start measuring lung function. Moderate is 60-80%
PED: What are 3 organisms that cause acute bacterial otitis media?
S. Pneumoniae* - most common, makes kids the sickest
H. Influenza
M. Catarrhalis
PED: To make the diagnosis of AOM in children, what findings must be present?
- Moderate or severe BULGING of TM OR new onset of otorrhea not related to otitis externa with otaligia
- Mild bulging of TM AND recent (<48hrs) onset of ear pain OR intense TM erythema with otalgia
PED: What qualifies for watchful waiting in children that have AOM?
> 6 months old with nonsevere illness and UNILATERAL AOM
Age must be >6 months, must be nonsevere illness, and/or must be unilateral
PED: What is the first line treatment for AOM? What if antibiotic treatment fails after 48-72h?
Amoxicillin 80-90 mg/kg/d PO BID
or
*Amoxicillin-clavulanate 90 mg/kg/d PO or Ceftirazone for failure with amoxicillin
PED: What is the first line treatment for AOM with penicillin allergy?
3rd generation Cephalosporins Cefdinir Cefuroxime Cefpodoxime Ceftriaxone
PED: What is otitis media with effusion in children? What is first line treatment? What type of hearing loss is expected (S or C)?
fluid in the middle ear WITHOUT s/s of ear infection.
First line = watchful waiting, should resolve in 3 months
Consider conductive hearing loss if persistent >3 months
PED: What is the most appropriate treatment that can prevent further dehydration for a child with acute gastroenteritis (vomiting) and mild dehydration?
A 5HT antagonist (Ondansetron/Zofran)
PED: What are expected findings of mild dehydration?
slightly dry lips and thick saliva and slightly decreased urine output.
Exam is normal otherwise - turgor, fontanels, eyes, capillary refill, mental status, thirst (might be increased)
PED: What are the expected findings of moderate dehydration?
<2 second recoil of skin turgor, slightly depressed fontanels, dry lips and oral mucosa, slightly sunken eyes, delayed capillary refill, deceased UO, moderately increased thirst
PED: For mild to moderate dehydration, what is the in office treatment?
oral rehydration therapy, 50-100 mL/kg over 3-4 hours. Small, frequent volumes in office or urgent care setting
PED: In a febrile child, the degree of temperature reduction in response to antipyretic therapy is NOT predictive of presence or absence of bacteremia.
TRUE
PED: The absence of tachypnea is the most useful clinical finding for ruling out pneumonia in children.
TRUE
PED: What is the treatment for community acquired pneumonia of children <5 years? >5 years old? What is an alternative treatment?
Amoxicillin 90 mg/kg/day BID (<5 years or >5 years)
alternative = amoxicillin-clavulanate
Atypical = macrolide = Azithromycin
PED: What are 3 treatment options for UTI in febrile children age 2 to 24 months old?
Amoxicillin
Trimethoprim/sulfamethoxazole
Cephalosporin - cefixime, cefpodoxime, cefprozile, cephalexin
PED: When does concrete thinking with early moral concept struggles, progression of sexual identity development and reassessment of body image. Emotional separation from parents.
Early adolescence 10-13
PED: When does increased abstract thinking begin. Views themselves as “bullet proof” and identifies . Strong peer identification. Increased health risk behavior.
Mid adolescence 14-17
PED: When does complex abstract thinking begin? Increased impulse control. Development of personal identity. Social autonomy.
Late adolescence 18-21
PED: What tanner stage will breast buds develop?
Tanner 2, age 8-13
PED: What tanner stage will testes enlarge with scrotal skin reddening and change in texture occur?
Tanner 2
PED: What tanner stage will the growth spurt start?
Tanner stage 3, peaks in Tanner 4
PED: What tanner stage will menarche commonly occur?
Tanner 4
PED: What tanner stage will the breast mound enlarge?
Tanner 3
PED: What tanner stage may physiologic gynecomastia present?
Tanner 3 - 50% of males 13-14 tanner stage 3-4 will develop gynecomastia for about 6-24 months.
PED: What tanner stage will the penis length, but minimal change with width occur? “pencil penis”
Tanner 3 - also the onset of growth spurt
PED: What are two medications that can be offered PO for females ONLY for the treatment of acne vulgaris?
Combined estrogen-progestin hormonal contraceptive
Spironolactone (aldactone)
both reduce androgen levels to decrease sebum production
PED: What is the most common cause of adolescent death?
Accidental injury
PED: What is the CRAFT questionnaire tool?
a brief screening test for adolescent substance abuse
PED: What age does the USPSTF recommend screening for depression?
12 - 18 years
PED: What are 5 medically emancipating conditions? (legal rights of the adolescent patient)
Contraception Pregnancy Sexually transmitted infection Substance abuse Mental Health
PED: Screening for type 2 diabetes mellitus is what type of prevention?
Secondary
PED: What are risk factors associated with adolescent development of type 2 diabetes mellitus?
obesity, pacific Islander ancestry, personal family history of PCOS or DM2 (first or second degree), race/ethnicity (everyone EXCEPT European)
PED: When should testing for type 2 be considered by the provider?
any child that is overweight or obese (>85th percentile for age and sex, weight for height, or weight >120% of ideal height)
PLUS 1 other risk factor
family hx of T2DM, race/ethnicity, signs/conditions indication insulin resistance, SGA at birth, maternal hx of DM or gestational DM
PED: What a signs of insulin resistance and risk factors to assess for in children?
Acanthosis Nigricans HTN Dyslipidemia PCOS SGA at birth (child's history) Maternal history of DM or gestational DM
PED: At what age or at onset of _____, whichever occurs first, should testing for type 2 diabetes mellitus occur? What will this testing consist of and how often should these values be checked?
at age 10 years
onset of puberty (tanner stage 2 if before age 10)
check A1C, FBS, 2h oral GTT - EVERY 3 YEARS
PED: What is the recommended treatment option for a child with low HDL, elevated triglycerides, and an acceptable A1c, that is also obese.
weight loss
this will be a first line therapy especially with dyslipidemia
PED: A 15 year old with a one day history of “sore throat and swollen glands” as well as a low-grade fever and rash. The rash is diffuse maculopapular that is mildly tender, posterior cervical and postauricular lymphadenopathy, and pharyngeal erythema without exudate. She has not received any immunizations since age 6 months. What diagnosis do you suspect?
Rubella (3-day German Measles)
most teratogenic virus
MMR given at 1 year
NOTIFIABLE DISEASE to state/public health. IgM serum laboratory confirmation.
PED: A child with exudative pharyngitis, fever, headache and tender, localized anterior cervical lymphadenopathy presents today. Rash is a sandpaper texture. What do you suspect? What virus causes this?
Scarlet Fever
Group A strep
(rash usually erupts on day 2 of pharyngitis and often peels. Treat with amoxicillin, just like strep throat)
PED: A child with a rosy-pink maculopapular rash lasting hours to 3 days that follows a HIGH fever. Rash will not present on the face. What do you suspect? What virus causes this rash?
Roseola
Human herpesvirus-6
young child 6 - 24 months
PED: A child with fever, generalized lymphadenopathy, conjunctivitis, nasal discharge (coryza) or congestion, and cough. What do you suspect? What type of lesions may be present on the hard and soft palate?
Rubeola (Measles)
fever, malaise & 3 C’s
Koplik spots - whitish, bluish, gray on buccal mucosa that blanches and resembles grains of sand
PED: A 16 year old with 3 day history of pharyngitis, minimally tender anterior and posterior cervical lymphadenopathy, and right and left upper quadrant abdominal tenderness. What do you suspect?
Infectious mononucleosis
PED: How long should contact sports be avoided with infectious mononucleosis? What medication should be AVOIDED with this condition?
> 1 month, risk of splenic rupture
Amoxicillin = rash
PED: What diagnostic test detects mononucleosis? What virus causes this?
Heterophil antibody test (Monospot)
Epstein-Barr virus (human herpes 4)
PED: Define neonate versus infancy
neonate is the first 28 days of life
Infancy is the first year of life
PED: What are expected findings of a healthy full term infant? (vision range, scleral, eyes, reflex)
Hold baby 8-12 inches, best visual range
Bluish scleral tint regardless of ethnicity for first months
Newborn eyes light and glare sensitive
Defensive blink reflex
PED: What are expected findings in a 2 week old
visual preference for the human face
hears high-pitched voices best
will react to the cry of other neonates
highly developed sense of smell
PED: What are education points about sleep safety
back to sleep
firm sleep surface
no bed-sharing
PED: What are some facts about neonatal jaundice
Jaundice starts on the face then progresses to the trunk/extremities
Physiologic jaundice onset is >24 hours of life
Encourage breastfeeding every 2-3 hours and avoid dextrose/water feedings reduces risk of jaundice
PED: What are expected findings of physiologic galactorrhea (cause, finding, onset, resolves)
Maternal hormonal influences are likely the cause
Breast engorgement is common/universal
Onset is day 3-4 of life
Resolves spontaneously without intervention within the first 2 months of life
PED: An infant with bilateral lid swelling, chemosis, and mucoid eye discharge. The infant received standard care including ocular chemoprophylaxis. What do you suspect?
Chlamydial conjunctivitis
presents 5-14 days post exposure. Ocular chemoprophylaxis prevents gonococcal conjunctivitis (blindness). Confirm with culture. Treat with oral erythromycin to prevent pneumonia (Staccato cough)
PED: A mother is HBsAG-positive, what should be done for the infant?
given hepatitis B immunization AND hepatitis B immune globulin to infant
PED: What reflex presents as walking motion made with legs and feet when held upright and feet touching the ground? How long will this present?
Stepping reflex
first 3-4 months, then reappears 12-24 months
PED: What reflex presents as turning of the head and sucking when cheek is stroked? When does this go away?
Rooting reflex
stops 6-12 months
PED: What reflex presents as throwing out arms and legs followed by pulling them back to the body following a sudden movement or loud noise? When does this stop?
Moro reflex
16 weeks of age (4 months)
PED: What reflex presents as grasping of an object when placed in the palm? When will this reflex disappear?
Palmar grasp
2-3 months
PED: What reflex presents when an infant’s foot is stroked and elicits a fanning of the toes? When is this no longer seen?
Babinski reflex
by 6 months of age
PED: At what age should the anterior fontanel close?
by age 9 to 18 months
PED: At what age should the posterior fontanel close?
by age 1 to 2 months
PED: When does an infant smile?
by 2 months
PED: When does an infant roll from stomach to back? Reach for a toy with one hand and recognizes familiar people at a distance.
by 4 months
PED: When does an infant roll from back to stomach and to back again?
by 6 months
PED: When will an infant be able to sit up, but still needs support
6 months
PED: Can lift self up on both arms
2 months
PED: Can transfer an object from hand to hand
6 to 8 months
PED: Able to walk on 2 legs
12 months
PED: Says “no”, copies work an adult would do
18 months
PED: builds a 2 block tower
24 months
PED: Can follow a 2-step command
24 months
PED: Can draw a circle, can speak in 3 word sentences
3 years
PED: What age should the family introduce the concept of “time out.” How long should the child remain in time out?
18-24 months
1 minute for each year of life
PED: What percentage of speech should be intelligible by people who are not in the daily contact with a 3 1/2 year old healthy child
nearly 100%
3-4 years, speech should be intelligible
75% 2-2 1/2
50% 19-21 months
more than one language may be slightly behind
PED: When does separation anxiety begin?
7-8 months
PED: When will the lower central incisors erupt? Upper?
6-10 months - lower is first
8-12 months
time of first tooth eruption or age 1 = first dental visit
PED: How long should an adjusted age calculation be utilized for assessing developmental milestones in the premature infant?
until 24 months of age
if healthy. A condition may never allow the infant to catch up developmentally
PED: A 2-month old healthy newborn that the foreskin cannot be retracted. What should you consider?
the foreskin is not easily retractable until the child is about 3 years old
PED: An enlarged scrotal sac on an infant that transilluminates, nontender, and testes are descended. What do you suspect? When will this resolve?
Noncommunicating Hydrocele
should resolve by age 2 years, no intervention needed
PED: Pyloric stenosis.
Presentation? Most common age? Abdominal mass? First line diagnostic tool?
most common in males. Nonbilious vomiting. Post-fed projectile vomiting and baby is eager to eat again post emesis. Age: 3 weeks (first few months) Mass: olive-shaped in RUQ Ultrasound = 1st line
PED: Intussusception.
Presentation findings? Age? Abdominal mass? First line diagnostic tool?
most common in males. s/s: sudden-onset, colicky, severe and intermittent abdominal pain, knees drawn to chest. Loose stools of "currant jelly" (blood and mucous). Age: 6-12 months Mass: Sausage-shaped Ultrasound is 1st line
PED: When should immunizations be delayed?
Moderate to severe illness with or without fever.
PED: T/F preterm infant should be immunized at the scheduled with their extrauterine age or birth age
TRUE
PED: When can children start to be immunized for flu?
6 months old, should get 2 doses
PED: Describe metatarsus adductus. What is the intervention?
Pigeon toed
forefoot that turns inward, high arch and wide gap between big toe and second toe
TX: depends on severity. Observation, stretching/exercises, casting, shoes, surgery
PED: Define club foot. What intervention method should be included? (name the method)
talipes equinovarus
foot is turned inward and bottom of foot facing sideways.
TX: ponseti method, manipulation/casting, surgery
PED: What is the presence of an extra digit? What is the fusion of 2 or more digits or webbing of the skin?
Polydactyly
Syndactyly
PED: When does the American Academy of Pediatrics recommend screening for autism?
at 18 and 24 months of age
PED: What is suspected with behaviors of restricted, repetitive patterns of behavior, interests, or activities that shows persistent deficits in social communication and social interaction across multiple contexts?
DSM-5 criteria for Autism Spectrum Disorder
PED: What type of bone fracture should be suspecting of abuse?
spiral
GU/GYN: Women that presents with white, clear, flocculent (physiologic leukorrhea). pH is 3.8 - 4.2
Normal/healthy women of reproductive age
pH 3.8-4.2 = normal
GU/GYN: A women with white, curdy, “cottage cheese” like with c/o itching and burning. Vaginal pH is _____
Candida vulvovaginitis
pH is usually normal, <4.5
GU/GYN: Microscopic exam of vaginal discharge via saline wet mount shows mycelia and pseudohyphae with KOH prep. What do you suspect?
Candida vulvovaginitis
GU/GYN: A women presents with thin, homogeneous white, gray, adherent that has increased. There is a foul odor and itch present. What is this? What is the pH? What test would be positive?
Bacterial vaginosis
pH 5 - 7
KOH = fishy odor
GU/GYN: Microscopic exam of vaginal discharge via saline wet mount shows clue cells. What do you suspect?
Bacterial vaginosis - overgrowth of organisms
GU/GYN: What medication is best to treat bacterial vaginosis?
PO Metronidazole (Flagyl) clindamycin or flagyl cream
GU/GYN: What condition occurs related to aging and postmenopausal? What is the best treatment for recurrent UTIs?
Atrophic Vaginitis - estrogen deficiency
Vaginal pH >5
Symptomatic or recurrent UTI = Topical and/or vaginal estrogen
GU/GYN: A woman with a personal history of breast cancer, can she use vaginal estrogen?
YES! - ACOG approves of low dose vaginal estrogen if c/o atrophic vaginitis or recurrent UTIs postmenopausal
GU/GYN: What is the first line therapy for genital herpes?
PO Acyclovir, famciclovir, valacyclovir
length of therapy, dose is dependent on infection type (first, recurrent, suppression - this is look up information)
GU/GYN: A woman presents with irritative voiding symptoms, and occasional mucopurulent discharge. Women cervititis, men clear discharge. Under microscope, large number of WBCs. What do you suspect and what is the treatment?
Nongonococcal urethritis and cervicitis = CHLAMYDIA
Doxycycline or Azithromycin 1 g PO
GU/GYN: A woman presents with irritative voiding symptoms, sometimes asymptomatic. Microscopic exam of discharge shows a large number of WBCs. What do you suspect? What is the first line treatment?
Gonococcal urethritis and vaginitis (gram negative)
1st line = ceftriaxone IM and doxycycline if chlaymdia has not been ruled out
GU/GYN: A woman presents with dysuria, vulvovaginal irritation with yellow-green discharge, occasional frothy and strawberry spots on cervix. What do you suspect?
Trichomonas vaginalis
alkaline pH
(men are always asymptomatic)
GU/GYN: On microscopic exam, motile organisms are present and a large number of WBCs. What is suspect? What is the first line therapy?
Trichomonas
Metronidazole (Flagyl) or Tinidazole
GU/GYN: What should be included in the patient teaching of a patient on metronidazole (flagyl) therapy?
avoid alcohol during treatment. Continue for 24 hours after completion of flagyl = abdominal pain
GU/GYN: What are expected findings in men with genital candida albicans infection? What test may be helpful to determine cause?
groin-fold involvement, balanitis (inflammation of penile glands, raw/irritated), scrotal excoriation
Blood glucose (especially if high BMI)
GU/GYN: What is the best treatment for an acute, uncomplicated UTI in nonpregnant women?
What if there is local E. coli resistance?
Sulfa allergy (this is ___ line)?
TMP/SMX (Bactrim)
E. Coli resistance = Nitrofurantoin (Macrobid) or Fosfomycin (Monurol)
Sulfa allergy = Ciprofloxacin or Cefdinir = 4th line!
add phenazopyridine for symptom control
GU/GYN: What is a potential complication of epididymo-orchitis?
infertility potential post infection
GU/GYN: What is the Prehn’s sign?
a relief of discomfort with scrotal elevation - epididymo-orchitis
GU/GYN: What are expected findings of benign prostatic hyperplasia?
obliterated median sulcus
size is >2.5 cm
symptoms improve with alpha-1 receptor blockade (Tamulosin)
dribbling after urination, excessive urination at night, frequency, incomplete emptying, urge and leaking, slow/weak stream
GU/GYN: A nodular, firm, nontender prostate on digital rectum exam indicates
prostate cancer
normal is firm, smooth and nontender
GU/GYN: Describe urge incontinence. What is the most appropriate management?
Caused by detrusor overactivity causing uninhibited bladder contractions; reports strong sensation of needing to void. Most common cause in older adults.
Behavioral therapy. Oral anticholinergic - fesoterodine (toviaz)
GU/GYN: Describe stress incontinence. What is the most appropriate management?
caused by weakness of pelvic floor and urethral muscles; associated with lifting, coughing, sneezing. Most common in women.
Pelvic floor rehabilitation.
GU/GYN: Describe transient incontinence. What is the most appropriate management?
Occurs during an acute illness, such as delirium, UTI, or medication use.
Treat the underlying illness
GU/GYN: Describe functional incontinence. What is the best treatment?
Occurs in the presence of mobility problems, inability to get to toilet, or lack of awareness of need to void.
An assistant that recognizes voiding cues
GU/GYN: A pap screening test reveals atypical squamous cells of unknown significance (ASCUS) and high-risk HPV positive on a 32-year old patient. No history of abnormal cytology, last screening 2 years ago. What is the most appropriate next step?
Referral for colposcopy
GU/GYN: What type of cancer is this (ovarian, cervical, endometrial): minimal, nonspecific symptoms such as bloating, bladder pressure, constipation, vaginal bleeding, indigestion, lethargy, weight loss.
Ovarian
GU/GYN: What 2 types of cancer is this (ovarian, cervical, endometrial): abnormal vaginal bleeding. Are there any discrepancies?
Cervical (post intercourse bleeding) and Endometrial (postmenopausal bleeding)
GU/GYN: What are the risk factors of ovarian cancer?
older age (post-menopause)
obesity
nulliparity or first pregnancy >35 years
estrogen use post-menopause
family history and genetic factors (BRCA1/2)
GU/GYN: Risk factors of this cancer include obesity and personal history of PCOS
Endometrial cancer
GU/GYN: Risk factors of this cancer include long-term infection with HPV-16 and/or -18
Cervical Cancer
GU/GYN: What medication provides the most symptom relief in treating vasomotor symptoms?
conjugated estrogen
What is PEP therapy? When is PEP considered? What individuals should be treated with PEP?
PEP is postexposure prophylaxis
It is the use of ART AFTER a single high-risk event to minimize possibility of HIV seroconversion. This is for individuals that DO NOT have HIV but may have been exposed within the past 72 hours to body fluids (healthcare workers, sexual assault victim)
What is PrEP? When is PrEP considered? What individuals should be treated with PrEP?
PrEP is pre-exposure prophylaxis
It is the use of ART for individuals who DO NOT have HIV but at at a SUBSTANTIAL RISK of being infected (based on high-risk activity). Individuals that ARE NOT HIV infected who are at high risk due to sex or injection drug use.
Mental: To diagnose major depressive episode ____ symptoms must be present in the same ___-week period. What mnemonic helps recall symptoms of MD?
> 5 symptoms present in the same 2-week period
SIGECAPS
Sleep (staying), Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide
Mental: To diagnose generalized anxiety disorder ___ symptoms occurs on most days for ____ months. What mnemonic helps recall symptoms of GAD?
> 3 symptoms occurring on most days for >6 months.
WATCHERS
Worry, Anxiety, Tension in body, Concentration difficulty, Hyperarousal, Energy loss, Restlessness, Sleep disturbance (falling)
Mental: Choosing the best therapeutic agent. What drug class of medications is best for lifting and smoothing mood?
SSRIs
Mental: What SSRI is the most energizing, best effect on lifting and smoothing mood?
**Fluoxetine (Prozac) **
CAUTION/DO NOT USE in older adults, already highly energized.
Setraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) - most sedating *in order from most to least energizing*
Mental: What SNRI has the best effect on lifting and smoothing mood plus an increasing focus effect?
SNRIs **Venlafaxine (Effexor)** Duloxetine (Cymbalta) Desvenlafazine (Pristiq) **helpful in anxious and/or resistant depression, potentially energizing**
Mental: What SDRI (selective dopamine reuptake inhibitor) is best on improving mood when there is an insufficient response with SSRI or as a solo agent?
Bupropion (Wellbutrin)
*potentially energizing, helpful as add-on therapy with SSRI with incomplete treatment response**
Mental: What are the most common adverse effects with psychotropic medications?
Sexual effects
Anorgasmia, erectile dysfunction, altered libido
Mental: What FDA-mandated warning is advised on medications for anxiety and depression?
increased risk of suicidal thinking and behavior in children, adolescents and young adults age <24 years
Mental: What SSRI has the longest half life?
Fluoxetine (Prozac) - 84h ! (7-15 days)
Mental: What SSRI may increase the risk of abnormal heart rhythms in higher doses? What is the maximum dose? What is the maximum dose for adults >60 years and/or hepatic impairment?
Citalopram (Celexa)
max = 40
>60 years = 20 mg/d
box warning = QT prolongation
Mental: What SSRI is the most sedating?
Paroxetine (Paxil)
caution/do not use in older adults
Mental: What SSRI has the least potential for drug-drug interaction?
Escitalopram
Mental: What symptom is a common short-term problem with early SSRI use?
Frontal headache
pt teaching is important, drink more fluids, try tylenol, etc
Mental: What symptoms present with serotonin withdrawal syndrome or antidepressant discontinuation syndrome? (mnemonic)
FINISH mnemonic Flu-like symptoms Insomnia Nausea Imbalance (dizziness) Sensory disturbances (nightmares) Hyperarousal **restart medication at same dose, taper for 6 weeks or more, also not necessary since symptoms only last for 7 or less days**
Mental: What tests should be checked periodically while on Olanzapine (Zyprexa)?
Second Generation Antipsychotics - all
Blood sugar (insulin resistance)
Lipid profile
weight gain is also present
Mental: What medication should be considered to start along with any second generation antipsychotics?
Metformin
OA: What is the most common electrolyte that will cause delirium in older adults?
Low sodium - hyponatremia
OA: What is the most common reason for delirium in older adults? Name two specific examples
Infection
UTI and CAP - usually presents as a change in mental status
OA: What diagnostic tests are ordered to rule in/rule out in evaluation of new-onset altered mental status?
UA, urine c&s CBC with diff serum electrolytes glucose BUN/creatinine vitamin B12 Thyroid function Liver Function Depression screening
OA: What are two interventions to slow decline Alzheimer-type dementia according to American Academy of Neurology Standards?
Vitamin E 1,000 international units BID or
Selegiline 5 mg BID
(no added benefit to using both)
OA: What class of medications is best for mild to moderate stage Alzheimer’s disease and considered the mainstay of treatment?
Cholinesterase inhibitors
Donepezil, Rivastigmine, Galantamine - increase the availability of acetylcholine
OA: What class of medications is best for moderate to severe Alzheimer’s disease?
NMDA receptor antagonist
Memantine/Namenda - can be used with Cholinesterase inhibitor
OA: What is the most common adverse effects of cholinesterase inhibitor use?
nausea and diarrhea
OA: What screening tools are best evaluators of frailty syndrome?
meets 3 or more of the following:
Unintentional weight loss (at least 10 lbs or greater than 5% of body weight in prior year)
Muscle weakness, measured by grip strength
Physical slowness based on a measured time to walk a distance
Poor endurance - self reported
Low physical activity
OA: What are first line interventions in Frailty Syndrome?
treat underlying cause to AVOID frailty - an irreversible condition regular physical exercise/activity caloric/protein support vitamin D supplementation reduce polypharmacy
OA: Beers criteria states Zolpidem (ambien) should be avoided because of what risk?
Increased risk in falls and fracture risk
OA: Beers criteria states Amitriptyline (Elavil) (all TCAs) should be avoided because of what risk?
significant risk of orthostatic hypotension
OA: Beers criteria states Naproxen sodium or NSAIDs should be avoided because of what risk?
potential to promote fluid retention and minimize effect of many anti-HTN medications
OA: Beers criteria states Sertraline (Zoloft) should be avoided because of what risk?
Increased risk for hyponatremia, especially when used with a diuretic
OA: Beers criteria states Oxybutynin (Ditropan) should be avoided because of what risk?
significant systemic anticholinergic effects when compared to other medications in its class
OA: What is a reason for dizziness in the older adult?
“I feel lightheaded”
reduced circulating volume including overdiuresis, orthostatic hypotension, neurologic conditions (parkinson’s), medications, anxiety, hypoglycemia, hyperthermia, dehydration
OA: What are causes for vertigo in the older adult?
“The room is spinning”
sensation of motion with eyes closed/surroundings are moving.
Usually an inner ear disturbance (small crystals).
Inflammation of inner ear, Meniere’s disease, head trauma, stroke, multiple sclerosis, tumors, migraines
OA: A patient complaining of “cramping” in lower posterior legs bilaterally when walking for an extended period of time, but is relieved by rest. What do you suspect? Common findings?
Intermittent claudication - Peripheral Artery Disease
s/s - pain with walking, relieved by rest. Diminished bilateral pedal pulses with thinning of the skin. Persistent infections/sores of leg and feet. Hx of HTN, dyslipidemia, stable angina, smoke/ing
OA: What diagnostic test is best to evaluate peripheral artery disease?
ankle-brachial index (ABI)
Doppler ultrasound or MRI, treadmill test, arteriogram
OA: What are common symptoms of venous insufficiency?
burning, swelling, throbbing, cramping, aching, and HEAVINESS in the legs
Restless legs and leg fatigue
Telangiectasis
OA: What are common complaints of peripheral neuropathy?
a gradual onset of numbness and tingling in the hands and feet Burning pain Sharp electric-like pain Muscle weakness Extreme sensitivity to touch
CV: What is the blood pressure equation?
BP = HR X SV X PVR (peripheral vascular resistance)
CV: What is the most common form of high blood pressure in the older adult?
systolic HTN - systolic is elevated, diastolic is normal
CV: What hypertension medications are considered first line agents? (4)
Thiazide diuretics
Calcium Channel Blocker
ACE inhibitor or ARB
CV: What hypertension medications are considered first line agents for black adults?
Thiazide diuretic or CCB
CV: What hypertension medications are considered first line agents for non-black adults?
Thiazide diuretic, CCB, ACE inhibitor, or ARB
CV: What hypertension medications are considered first line agents for individuals with Chronic Kidney Disease?
must include ACE inhibitor or ARB
CV: HTN guidelines recommendations - JNC-8 recommends BP < __/__ for all individuals whereas AHA/ACC recommends BP
JNC-8 = < 140/90 AHA/ACC = < 130/80
CV: Why is a urinalysis ordered at initial diagnosis of primary hypertension?
to assess for protein in the urine (kidneys are not functioning properly = protein leak into urine [RAAS])
CV: Aspirin use is reserved for what type of patients? Is this a primary prevention consideration?
High-risk patients ONLY, risk > benefit = GI bleeds.
NO! secondary for patients with a hx of CVD, stroke, etc
CV: Why is chlorthalidone a preferred diuretic in comparison to HCTZ?
Longer half life!
CV: What has been observed in women who take long-term thiazide diuretics for hypertension?
good for Osteoporosis. Less rates of fractures in comparison to loop diuretics. However, LOOPs remain effective with lower GFR
CV: What is the most adverse effect of aldosterone antagonist, Spironolactone?
Gynecomastia with prolonged use in men, libido is negatively effected as well
CV: What is the most important hypertension medication class to start a patient on that has diabetes mellitus?
ACE inhibitor or ARB, per ADA
CV: What class of hypertension medications should be AVOIDED during pregnancy?
ACE inhibitors or ARBs
CV: What are 3 risk factors associated with the adverse effect of ACE inhibitor induced angioedema?
African
Latino
history of NSAID allergy
CV: What is an adverse effect of ACE inhibitors or ARBs, especially in an adult with inadequate fluid intake?
Hyperkalemia - CAUTION in older adults!
CV: What is the most common adverse effect of calcium channel blockers?
ankle edema
CV: Who should NOT be given beta blockers for hypertension? What medication drug name is okay to use with this condition?
anyone with LOWER AIRWAY DISEASE
lower CV-selective effects with Metoprolol = ok with COPD or asthma
CV: What 3 medications are SAFE for treatment of hypertension in pregnancy?
Methyldopa
Hydralazine
Beta Blockers
CV: What class of HTN medication will cause constipation in the Older adult?
CCB
CV: What class of HTN medication will mask hypoglycemia?
Beta blockers
CV: What is a normal eGFR?
90 - 120
CV: What medication should be AVOIDED in a poorly-hypertension patient that is requesting medication for the common cold?
Pseudoephedrine! - will elevated blood pressure.
Consider treatment with guaifenesin, dextromethorphan, or chlorpheniramine (all are safe for HTN)
CV: A patient presents today with 210/122 blood pressure today and states they have been out of their medication for the past 3 months. Denies visual changes, chest pain, SOB, and feels well. What is this condition and what is your best intervention at this time?
HTN urgency!
TX: restart medications! f/u within week with labs.
DO NOT send to ED, DO NOT treat with in-office clonidine, hydralazine, nitroglycerin.
CV: What lab value is the best indicator to have a patient fast for lipid panel labs?
if the triglycerides are >400, then repeat lipid panel in a FASTING state. Otherwise, nonfasting lipid panel is acceptable even in CVD, DM, obesity, etc
CV: What are two statin medications reserved for high-intensity treatment?
Atorvastatin 40-80
Rosuvastatin 20-40
reduces LDL-C by >50%
CV: When and how often should hepatic enzymes be checked when a person is on a statin medication?
When: prior to initiation to establish baseline.
Frequency: NEVER - routine hepatic enzyme monitor is NOT NECESSARY.
CV: What 2 medications have been shown to reduce triglyceride levels?
Omega 3 fatty acid (Vascepa = rx)
Fibrates (Fenofibrate and fenofibric acid) may also increase HDL
CV: What medication is used as an add-on to statin therapy for familial hypercholesterolemia?
PCSK9
Evolocumab, Alirocumab
$$$, LDL-C >60%, SC injection only
CV: Who needs to be started on a high-intensity statin?
LDL-C >190 mg/dL - no risk assessment needed
Those with >20% ‘high risk’
CV: Who needs to be started on a moderate-intensity statin?
All DM patients age 40-75 years
Anyone 40-75 with LDL-C >70-190, without DM
Anyone with ‘intermediate risk’ >7.5%
CV: What is stage A heart failure? What are some examples of conditions that apply to this stage?
Individuals at high risk for Heart Failure BUT without structural heart disease or symptoms of HF.
Examples = HTN, ASCVD, DM, Obesity, Metabolic syndrome
CV: What is stage B heart failure? What are some examples of conditions that apply to this stage?
Individuals WITH structural heart disease BUT without signs/symptoms of HF.
Examples = previous MI, LV remodeling (LVH, low EF), or asymptomatic valvular disease
DM: What type is insulin resistance with eventual insulin deficiency?
Type 2 DM
Type 1 is autoimmune process involving beta cell destruction resulting in insulin deficiency
DM: If a patient has NO risk factors of diabetes, when should screening for diabetes begin? How often should testing be repeated?
Age 45, if normal then repeat every 3 years
DM: What are common risk factors of diabetes?
Overweight (BMI >25)
Physical inactivity, first degree relative with T2DM, high risk ethnicity, Women of baby >9lbs or GDM, HTN >140/90, <35 HDL level, >250 Triglyceride level, PCOS, A1c >5.7%, Insulin resistance, history of CVD
DM: A fasting glucose >___ qualifies as a diagnosis of Diabetes Mellitus
> 126
DM: A random glucose >___ qualifies as a diagnosis of Diabetes Mellitus
> 200
100-125 is pre-DM
DM: An A1c >___ qualifies as a diagnosis of Diabetes Mellitus
> 6.5%
5.7 -6.4 is pre-DM
DM: What is the goal A1C for a frail older adult?
<8%
DM: When the eGFR is
<30, especially in frail older adults or Advanced age (INCREASED LACTIC ACIDOSIS RISK)
DM: What is a first line medication, if no contraindications, for type 2 Diabetes Mellitus?
Metformin
DM: What is the greatest adverse effect of sulfonylureas? (-zide, -mide, -ride)
hypoglycemia
NO OLDER ADULTS
DM: What drug class is best for older adults due to minimal risk of hypoglycemia?
DPP-4 inhibitor
-GLIPTIN
DM: What drug class should be AVOIDED in gastroparesis or pancreatitis?
GLP-1 agonist
-TIDE (peptide = TIDE, ie Exenatide)
DM: What drug classes will cause weight gain?
TZD (zones)
SU - sulfonylureas
Insulin
DM: What drug classes will cause weight loss?
GLP-1 agonist (TIDE)
SGLLT-2 inhibitors (-gliflozin)
possibly Metformin
DM: What drug class should be AVOIDED with heart failure?
TZD - zones
Piaglitazone
DM: What drug class should be monitored for adverse effects of UTI or GU infection?
SGLT-2 inhibitors (-gliflozin)
DM: What 2 drug classes have proven to show benefits with use in ASCVD, HF, and CKD?
GLP-1 agonist (-tides)
SGLT-2 inhibitors (-glifozin)
DM: What 4 types of patients will qualify for insulin usage?
Type 1 diabetes
T2DM with A1C >9% at time of diagnosis with symptoms
T2DM using >2 agents at optimized doses are inadequate
When acutely ill
DM: What are 5 key findings to diagnosis of Metabolic Syndrome?
Increased waistline circumference >35 cm, >40 cm Hypercholesterolemia Low HDL cholesterol High blood pressure High glucose
HA: What mnemonic is helpful for assessment of “red flags” of primary headaches?
SNOOP
s - systemic symptoms (fever, weight loss, infection)
n - neurologic (newly acquired neuro, confusion, papilledema)
o - onset (sudden, abrupt, THUNDERCLAP, with exertion/sex/cough/sneeze)
o - onset age (>50 years, <5 years)
p - positional (changes in freq/quality, positions)
HA: Type of headache - constant pressure or pressing and nonpulsatile pain, bilateral characteristics
Tension-type
HA: Type of headache - a pulsating quality that is aggravated by normal activity with c/o nausea, photophobia, or phonophobia
Migraine
HA: Type of headache - often is located behind one eye, mostly in males and occurs at the same time everyday
Cluster
HA: Abortive or Prophylactic therapy? NSAIDs and acetaminophen
abortive or acute therapy
HA: Abortive or Prophylactic therapy? Beta blocker
prophylactic or preventative
HA: Abortive or Prophylactic therapy? Triptans
abortive or acute therapy
HA: Abortive or Prophylactic therapy? injectable CGRP antagonists
prophylactic or preventative
HA: Abortive or Prophylactic therapy? Ergot derivatives
abortive or acute therapy
HA: Abortive or Prophylactic therapy? oral CGRP antagonists
abortive or acute therapy
HA: Abortive or Prophylactic therapy? Topiramate/Topamax
prophylactic or preventative therapy
HA: What are 3 contraindications to taking triptan medications?
abortive therapy:
NO pregnancy, CVD, poorly controlled HTN
HA: When should prophylactic therapy be considered?
when using any product >3 times per week
>2 migraines per month with disabling symptoms >3 days
poor symptom relief with abortive therapy
HA: What type of birth control should be AVOIDED in migraines?
combined oral contraceptives
HA: What types of birth control are best for the migraine individual?
progestin - IUD or Implant (nexplanon)
or hormone-free = cooper IUD
HA: Abortive or prophylactic therapy? Oral gepant (Ubrogepant/Ubrelvy) Who benefits the most from this medication?
Abortive therapy
A patient with a history of acute coronary syndrome (cannot take triptan)
HA: Prophylactic medication that is best for tension type headaches and is limited by insurance cost.
Oral TCA - nortriptyline
HA: Describe expected findings of giant cell arteritis.
Severe unilateral headache with accompanying jaw pain
Hard to wash/brush hair - SCALP IS PAINFUL
normal neurological exam
Tender/nodular PULSELESS vessel at temple
Vision blurring, diplopia, eye pain, sudden loss of vision
Age 50-85 years, Females
HA: What is the best initial test of giant cell arteritis? What test will confirm diagnosis?
Erythrocyte sedimentation rate
gold standard confirmation test is Arterial Biopsy
HA: What is the treatment of giant cell arteritis?
this is an autoimmune vasculitis =
**High-dose systemic corticosteroid therapy until stable then 6 months to 2 years.
Aspirin to reduce stroke. GI - PPI. Bone - bisphosphonate to reduce long-term effects of corticosteroid therapy.
DERM: Skin lesion - a single, uniformly brown-colored, slightly raised, irregularly-shaped with defined borders, 6 mm in diameter. Has not changed in years.
Papule
DERM: skin lesion - single, flat, non-palpable area of discoloration, irregularly-shaped and 0.5 cm at the widest diameter. Present for years.
Macule
DERM: skin lesion - single, firm, smooth, raised, dome-shaped, fluid-filled, flesh-colored encapsulated lesion of 1.5 cm in diameter on back of neck
Cyst
DERM: skin lesion - linear-like cleavage with sharp walls through the epidermis
Fissure
DERM: skin lesion - flat, non-blanchable, confluent, purple-colored irregularly-shaped lesions on skin ranging 2-20 mm in size
Purpura
DERM: skin lesion - clustered, smooth, slightly-raised, circumscribed, pruritic skin-colored lesions of various sizes up to 2cm, surrounded by area of erythema
Wheal
DERM: Scaling flesh-colored lesions in a cluster, ranging in size from 3-10 mm on dorsal aspect of the HAND, present for a number of months, without patient complaint. Sometimes tender. Usually presents on sun-exposed areas
Actinic Keratosis
most common on light-colored skin, >40 years, a lot of time outdoors without sun protection
diagnosed by CLINICAL DIAGNOSIS
TX: topical 5-fluorouracil, imiquimod cream, diclofenac gel, cryosurgery
DERM: What is a possible complication of actinic keratosis?
development of squamous cell carcinoma if UNTREATED (second most common skin cancer)
DERM: A well-demarcated round to oval erythematous coin-shaped plaques approximately 10 mm in diameter on the anterior aspects of the lower legs described as intermittently itchy, present for a number of months.
Nummular eczema
DERM: A painless ulcerated lesion approximately 1.5 cm in diameter over the sternum that has been present for a number of weeks. Dome-shaped nodule.
Squamous Cell Carcinoma
DERM: Pearly or waxy papules or plaques with rolled distinct borders, with or without telangiectasis, and ulceration. Nonhealing scab.
Basal Cell Carcinoma
DERM: Has a “stuck on” waxy or scaly appearance with varying degrees of pigmentation
Seborrheic Keratosis
DERM: A loss of pigment (depigmentation) in patches of skin, present for weeks to months
Vetiligo - this is autoimmune Type I
DERM: What condition is treated with permethrin lotion?
Scabies, treat the entire body
DERM: What is the treatment for psoriasis vulgaris? Where does this most commonly occur?
medium potency topical corticosteroid
Elbows and Knees
DERM: What condition is treated with imiquidmod cream?
Verruca Vulgaris - WARTS - CANNOT be pregnant for this treatment.
DERM: What is a treatment of tinea pedis?
topical ketoconazole - antifungals
DERM: What is a treatment of rosacea?
Topical Metronidazole
DERM: Where is eczema commonly seen on the body?
antecubital fossa - bends of elbow
DERM: Where is rosacea commonly seen on the body?
over the cheeks and nose
DERM: Where is scabies commonly seen on the body?
waistband! also web folds of fingers, under breasts, upper arm, thighs
DERM: What condition is usually preceded by a herald patch on the trunk of the body?
Pityriasis Rosea
always ask where is the oldest lesion? Where did the first lesion occur?
DERM: A hyperpigmented plaque with a velvet-like appearance at the nape of the neck and axillary region. May have skin tags within the lesion as well. No itch or pain.
Acanthosis Nigricans
will probably have a high BMI, insulin resistance, presents at onset of puberty follow up with A1C
DERM: Where will acanthosis nigricans present on the body?
groin folds, over the knuckles, neck, axillary folds, and elbows
DERM: What is the preferred treatment for phytodermatitis (poison ivy/oak) when it covers >20% of the total surface area, as a severe rash, or if the rash impacts the face/genitals/hands
Systemic Corticosteroid - PO Prednisone
DERM: What is preferred for topical treatment of phytodermatitis (poison oak/ivy)?
OINTMENT! never cream. Ointment allows medication to contact skin longer
Mid or high-potency topical corticosteroids (Triamcinolone or Clobestasol)
RISK of skin atrophy with 2-3 weeks or > with high-potency use.
DERM: An erythematous macule that rapidly evolves into vesicle or pustule. This ruptures then dries and leaves a crusted, honey-colored exudate. What is this condition? What is a likely organism? Treatment?
Impetigo - nonbullous
Staphylococcus Aureus or Streptococcus Pyogenes
TX: Mupirocin, consider systemic antimicrobial if extensive/topical fails.
DERM: An infection of dermis and subcutaneous fat that feels warm to touch, is red, and painful. What condition is this? What is the likely organism? Treatment?
Cellulitis
Streptococcus Pyogenes (possible MSSA or MRSA)
TX: systemic antimicrobial
DERM: A skin infection involving a hair follicle and surrounding tissue that is warm to touch, red, and painful. What condition is this? What is the likely organism?
Cutaneous abscess Staphylococcus Aureus (MRSA, MSSA) TX: varies based on organism. Likely systemic
What antibiotic commonly causes C. Diff diarrhea?
Clindamycin
LRT: What are the most likely causative pathogens of community acquired pneumonia (CAP) in individuals WITHOUT significant comorbidities (no COPD, DM, HF, CRD, asplenia, or alcohol use disorder)?
S. Pneumoniae (gram positive) #1 for ARB & otitis media.
M. Pneumoniae (atypical)
C. Pneumoniae (atypical)
Viruses: influenza, RSV, etc
LRT: What are the most likely causative pathogens of community acquired pneumonia CAP in individuals WITH comorbidities? (HF, CLD, liver disease, renal disease, DM, alcohol use, malignancy, or asplenia)
S. Pneumoniae (gram positive) H. Influenzae (gram negative) M. Pneumoniae (atypical) C. Pneumoniae Legionella spp Viruses: influenza, RSV, etc
LRT: What are two gram negative pathogens that cause CAP. Symptoms of dry cough or “walking pneumonia”
Atypical pathogens!
M. Pneumoniae & C. Pneumoniae
People: correctional facilities, college dorms, long-term care facilities, small offices, etc
LRT: How is legionella, an atypical pathogen, spread? What are major risk factors?
Through inhaling mist or aspirating liquid that comes from a water source contaminated. NOT person to person.
RF: older, male, smoking, diabetes mellitus
LRT: What is the minimum diagnostic evaluation to be completed outpatient for suspected community acquired pneumonia?
CBC with diff
BUN/Creatinine
Chest X-ray
(other tests are based on presentation/symptoms and comorbidity)
LRT: What is the minimum length of treatment for the afebrile patient with community acquired pneumonia?
5 days, average is 5-7 days
must be afebrile for 48-72 hours prior to antimicrobial discontinuation
LRT: What 3 medication drug classes are recommended to treat community acquired pneumonia in the outpatient setting WITHOUT significant comorbidities? (mnemonic for drug name)
AABCDE - not listed in priority, these are your options
1. Tetracycline: Doxycycline**
2. Macrolide: Azithromycin, Clarithromycin, Erythromycin
3. Penicillin: Amoxicillin**
(DO NOT use macrolide if resistance rate is >20%)
LRT: What medication drug classes are recommended to treat community acquired pneumonia in the outpatient setting WITH significant comorbidities? (COPD, DM, Renal or Heart failure, asplenia, or alcohol use disorder)
- Fluoroquinolone: Moxifloxacin, Levofloxacin (-ACIN)
or
2a. Tetracycline: Doxycycline AND Beta-lactam: Amoxicillin-clavulanate (T & B)
2b. Macrolide: Azithromycin or Clarithromycin AND Beta-lactam: Amoxicillin-clavulanate (M & B)
2c. Tetra or Macrolide AND Cefpodoxime or Cefuroxime
LRT: What symptom is the MOST sensitive and specific finding of pneumonia?
Tachypnea/elevated respiratory rate
especially with children or elderly
LRT: What are other symptoms/findings of pneumonia?
beside tachypnea…
Crackles/rales (diff from HF - fever, no JVD, no S3)
Consolidation (dull to percussion with increased tactile fremitus)
Pleuritic friction rub (sharp, localized pain, worse with deep breath/cough)
LRT: What are the 5 components of CURB-65?
Confusion of new onset, Blood UREA nitrogen >19, Respiratory rate >30 b/min Blood pressure <90 mm hg systolic or diastolic <60 Age - 65
LRT: What CURB-65 score allows a patient to be treated in the outpatient setting? Hospital?
0-1 = oral antibiotics
2 - consider close outpatient treatment if adequate home support. Otherwise hospital. 3-5 = hospital
LRT: What medication drug class increases the QT interval?
Macrolide (-MYCIN)
LRT: A patient with a cough for more than 5 days (with/without sputum production), absence of fever or tachypnea, and no history of asthma/COPD, or other airway diseases. What do you suspect? What 3 medications would you consider for a protracted, problematic cough?
Acute Bronchitis - usually follows an URI
cough = inhaled bronchodilator via MDI such as SAMA (Ipratropium) or SABA (Albuterol) or short course oral corticosteroid (prednisone).
LRT: What are common symptoms of asthma? When are symptoms worse?
recurrent cough
wheeze
SOB and/or chest tightness
WORSE AT NIGHT, or with exercise, Viral RTI, aeroallergens, and pulmonary irritants (smoke)
LRT: What is the best tool to diagnose asthma? What monitors asthma?
Spirometry = diagnosis
Peak flow meter = monitor
LRT: Asthma is an airflow obstruction that is at least partially reversible. An increase in the FEV by ___% from baseline post ______ use should confirm this.
An increase in FEV >12% from baseline post short acting beta agonist use (SABA)
LRT: With all asthma diagnosis, what medication is necessary? If the patient uses this >___ days a week (except exercise) suggests a need for better airway inflammation control.
an acute reliever/rescue - SABA
>2 days/week = reevaluate medication plan
LRT: Classifying asthma severity: >12 years of age at initial diagnosis with moderate persistent symptoms
Symptoms = daily Nighttime = >1x/week (NOT nightly) SABA use = daily Activity = some limitation Lung function = FEV >60% but <80% or FEV/FVC reduced by 5% Exacerbations needing OSC = >2/year
LRT: Classifying asthma severity: >12 years of age with Moderate Persistent Asthma symptoms, what is the first step? Reevaluate in?
Step 3 = Medium dose ICS or Low ICS AND LABA
Reevaluate in 2-6 weeks
LRT: Assessing asthma control (reevaluating the patient) in >12 years of age patients. What is considered well-controlled symptoms? How long must the patient be well-controlled before step down?
Symptoms: <2 days/week Nighttime: <2 x/month NO interference with normal activity SABA us: <2 days/week FEV: >80% of personal best Exacerbations: 0-1 /year ***Maintain current step, consider step down after 3 months of controlled.
LRT: Assessing asthma control (reevaluating the patient) in >12 years of age patients. What is considered very poorly controlled symptoms?
Symptoms: throughout day Nighttime: >4x/week Activity: Extreme limitation SABA: several times per day FEV: <60% Exacerbations: >2/year **oral systemic corticosteroids, step up 1-2 steps, reevaluate in 2 weeks**
LRT: What is the diagnostic tool utilized for COPD? What is the classical finding?
Spirometry is required for diagnosis
FEV:FVC <0.70 post bronchodilator = CONFIRMS
Classified by FEV1 (GOLD 1,2,3,4)
LRT: Patients with COPD, should not be given inhaled corticosteroids because?
there is an increased risk of pneumonia
LRT: What is the first line therapy for each stage of COPD? Group A, B, C, D
A: SABA or SAMA PRN
B: LABA or LAMA on schedule
C: LAMA on schedule
D: 3 options: 1. LAMA and LABA or 2. ICS and LABA or 3. ICS/LABA/LAMA on schedule
What antimicrobial drug should be AVOIDED with use of ACEI or ARB, especially with CKD and/or dehydration, due to hyperkalemia risk?
TMP/SMX - Bactrim
What antimicrobial drug class increases the risk of QT prolongation, especially in individuals with higher CVD risk?
Macrolides -MYCIN
What antimicrobial drug class is associated with tendon rupture risk, especially when given with a systemic corticosteroid?
Fluoroquinolones -ACIN
What antimicrobial drug class has less than 1% cross-risk with penicillin allergy?
2nd generation cephalosporins: Cefpodoxime
LRT: What is a major indication to initiate long-term oxygen therapy in the COPD patient?
hypoxia for >15 hours/day!
PaO2 <55 or SaO2 <88% with/out hypercapnia
LRT: What are common risk factors of developing COVID19?
older age, chronic kidney disease, COPD, immune-compromised state, BMI >30, serious heart condition, type 2 diabetes, sickle cell anemia, African/Latino/Native American ethnicity
LRT: What are common symptoms of COVID19 in mild to moderate disease?
up to 50% are asymptomatic
s/s: mild fever, cough, sore throat, nasal congestion, malaise, headache, new loss of taste or smell, muscle pain, pneumonia
LRT: What is best for outpatient treatment of COVID19?
supportive: acetaminophen/NSAID, guaifenesin, hyrdate
SABA/SAMA ONLY IF PRE-EXISTING AIRWAY DISEASE
F/u at 5 day of symptoms
ENT: What diseases are commonly caused by S. Pneumoniae? (mnemonic)
COMPS conjunctivitis otitis media meningitis pneumonia sinusitis (second cause organism of same disease = H. influenza)
ENT: What are the findings of acute bacterial rhinosinusitis? (VERY IMPORTANT to know each component of ARB)
URI like symptoms AND
- persistent/not improving (>10 days)
- severe with fever >102/39, purulent nasal discharge, facial pain, >3-4 days
- Worsening/double-sickening = improvement in URI symptoms, then worsens with fever, headache, nasal discharge
ENT: What are risks of antibiotic resistance (reason for 2nd line antimicrobial therapy) related to acute bacterial rhinosinusitis?
Age <2 or >65, attends daycare
Prior systemic antibiotics within past month
ENT: What is the first line therapy versus controller treatment of allergic rhinitis?
#1 = avoid allergen. #1 controller =intranasal corticosteroids
ENT: What is the initial empiric therapy of acute bacterial rhinosinusitis in adults?
Amoxicillin-Clavulanate 500/125 TID or 875/125 BID 5-7 days
Improvement should occur in 3-5 days, complete full 5-7 day course.
ENT: What are 2 choices of therapy for patients with an allergy to beta-lactams in treatment of acute bacterial rhinosinusitis in adults?
- Tetracycline: Doxcycline - PREGNANACY RISK D!
2. Fluoroquinolones: Levofloxacin, Moxifloxacin - consider for allergy and/or drug resistant S.P. use
ENT: What is the FDA-mandated warning with leukotriene modifier therapies for allergic rhinitis?
this is an additional therapy - NEUROPSYCHIATRIC warning. Leukotriene modifiers (Montelukast/Singulair) is best as add-on therapy. Consider 2nd generation oral antihistamines before this.
A woman taking combined oral contraceptives is requesting more information on St. John’s wort for mild depression treatment. Should you be concerned?
YES! - St. John’s wort will decrease effectiveness of COC. Potential contraceptive failure.
ENT: What is conductive hearing loss? Sound is being _____. Common causes include? Weber test results? Rinne? Treatment?
an outer or middle ear hearing loss. The sound is being BLOCKED
Causes = earwax, foreign object, damaged eardrum, otitis media, bone abnormality
Weber = buzzing sound heard louder in affected ear. LATERALIZED.
Rinne = negative.
Tx = self-resolves usually
ENT: What is sensorineural hearing loss? Sound loss is due to what? Common causes include? Weber test results? Rinne? Treatment?
an inner ear hearing loss (CN VIII - Vestibulocochlear)
Due to: inner ear or nerve DAMAGE.
Causes: Age, ototoxic medications, immune disorders, trauma.
Weber = LATERALIZED sound to UNAFFECTED ear. Buzzing sound heard lower or not at all in affected ear.
Rinne = positive or normal
TX = this is PERMANENT loss - hearing aids, cochlear implants
ENT: Rope-like pale yellow discharge of the eyes is most commonly seen with what condition?
allergic conjunctivitis - offer ocular antihistamine
ENT: A patient complaining of sudden vision changes such as halos around lights and blurred vision with red, painful eye(s). What would you suspect?
Angle-closure Glaucoma
peripheral vision loss is suggestive of open-angle glaucoma
ENT: What is the most common form of oral cancer?
Squamous cell carcinoma
ENT: What is the most common form of oral cancer?
Squamous cell carcinoma - expect to find a painless ulcerated lesion with indurated margin and accompanied by a firm, nontender submandibular node.
ENT: What is presbycusis? What are expected findings?
An age-related hearing loss/alteration. Sensorineural loss (CN VIII)
Background noise makes hearing worse, may have tinnitus, vertigo, disequilibrium. Person can hear but CANNOT understand what is said.
ENT: What condition presents in the older adult with a long history of diabetes that is experiencing a gradual peripheral vision loss/tunnel vision? This is often painless and gradual.
Open-angle glaucoma
ENT: What condition presents as a gradual onset of blurring of near vision in a person over the age of 45 years complaining of never needing glasses, but needs them now?
Presbyopia - normal eye changes, stiffening/hardening of lens
ENT: What condition presents commonly as a central vision loss that is noted in the older adult that was a former smoker with blue eyes? What is found on fundoscopic exam?
Macular degeneration
Soft, yellow deposits in macular region.
ENT: What are expected findings of viral pharyngitis?
clear nasal discharge,
hoarseness,
scattered small vesicles on soft palate and tonsils,
GENERALIZED BODY ACHES,
“sore throat started AFTER my nose started to run”
ENT: What are expected findings of a bacterial (GABHS) pharyngitis?
Significant anterior cervical lymphadenopathy, frontal headache without body aches, patchy exudates in posterior pharynx, "sore throat started all of a sudden" (commonly seen ages 5-15)
ENT: What is first line therapy to treat confirmed group A beta hemolytic strep? Severe allergy?
Penicillin or amoxicillin with supportive therapy. Wait for confirmed results by swab or culture to treat with abx.
Allergy = Macrolide, Cephalosporin, or Clindamycin
ENT: What condition is often found in high environmental humidity areas or the diabetic patient that is complaining of ear pain with tenderness over the tragus and/or pinna with ear canal swelling and erythema? Treatment?
Otitis externa (Swimmer's ear) Treat with acetic acid/propylen glycol and hydrocortisone drops or ciprofloxacin/hydrocortisone drops IF TM IS NOT PUNCTURED. DO NOT USE NEOMYCIN on punctured TM.
GI: What are common risk factors of GERD?
Overweight/obesity,
tobacco smoking,
fatty food,
alcohol and/or caffeine or carbonated beverages,
drugs that relax LES - estrogen, calcium channel blockers, etc
GI: What are findings that will indicate a upper endoscopy? (mneumonic) What will NEVER indicate a upper endoscopy?
NEVER = GERD. You diagnose this based on clinical findings alone, unless pt fails to improve/worsens.
ALARM.
Anemia, Loss of weight (involuntary), Anorexia, Recent onset of progressive symptoms without risk or with therapy, Melena (tarry/bloody) or hematemesis, Swallowing difficulties (dysphagia, odynophagia)
GI: What is the first line therapy for GERD? Patient education?
Proton Pump Inhibitors
Take PRIOR to first meal of day for maximum effect.
GI: What are protracted PPI use adverse effects?
protracted = >8 weeks. Micronutrient malabsorption (B12, calcium, magnesium, iron), increased fracture, pneumonia, C. difficile risk
GI: What are common symptoms of GERD?
Hoarseness, recurrent cough, chronic pharyngitis, reflux with acid taste into mouth, sour/bitter taste after meals, burning sensation in chest especially after meals or once lying down/bending over
What do you suspect of a microcytic hypochromic anemia with an elevated RDW? <80 MCV,
Iron deficiency
- *An elevation in RDW can be an early finding of IDA**
- *Thalassemia, Sideroblastic, and Lead are also common microcytic anemias** Order ferritin, serum iron, TIBC, and transferrin for further evaluation.
What findings do you suspect on a CBC in a patient with anemia of chronic disease?
low RBC/Hct with: normocytic (MCV 80-100), normochromic (MCH 24-32), normal limit RDW WITH UNDERLYING DISEASE PROCESS.
What diagnostic test is indicated for thalassemia?
Hgb electrophoresis
What diagnostic test is indicated for sickle cell anemia?
Hgb electrophoresis
What diagnostic test is indicated for hemolytic G6PD?
peripheral smear
GI: What is obturator and psoas signs?
Obturator = Internal rotation of flexed right thigh causes pain in RLQ.
Psoas = extending right thigh in left lateral position elicits pain in RLQ.
Rovsing is present with appendicitis as well, L side pressure with palpitation causes pain in RLQ.
GI: What are expected findings in primary care of acute appendicitis?
12-hour history of epigastric discomfort and anorexia
Nausea
RLQ abdominal pain
Positive obturator and psoas signs
GI: What is the most helpful imaging tool to evaluate acute appendicitis, especially in the overweight/obese individuals? Slender body type or child with healthy BMI?
CT with contrast
Ultrasound to protect sexual organs
GI: What are expected findings of acute pancreatitis? What signs can you assess for, although not always found/common?
Alcohol use is significant
12-hour sudden onset epigastric pain RADIATING to back with bloating, nausea, vomiting.
Epigastric tenderness, hypoactive bowel sounds, distention, hypertympanic. Confirm with lipase** (elevated longer) and amylase
SIGNS: Cullen - periumbilical blue discoloration, Grey-Turner - blue flanks, Chvostek - facial muscle spasm
GI: What are risk factors and expected findings of diverticulitis? Diagnostic tool of choice? Treatment?
RF: >50 years, low dietary fiber.
A couple of days of intermittent LLQ abdominal pain accompanied by fever, cramping, nausea, and 4-5 loose stools/day.
Dx: colonoscopy
TX: diet, gut rest, oral antimicrobial
GI: What are risk factors and expected findings of duodenal ulcer? (describe pain, relief, meds) Diagnostic testing? Treatment?
RF: H. pylori infection, NSAID use, smoking.
A 3-month history of intermittent upper abdominal pain described as “burning” or “gnawing.” Relief 2-3h POST meals and relief with food or antacids. Awakening at 1-2 am with symptoms.
Tender at epigastrium with hyperactive bowel sounds at LUQ.
DX: H. pylori or urea breath test, stool h. pylori, endoscopy
TX: PPI therapy with antibiotics (Clarithromycin/Amoxicillin or Metronidazole) if H.pylori positive. Negative = PPI and underlying cause.
GI: What are the risk factors and expected findings of cholecystitis? Objective assessment findings? Diagnostic? Treatment?
RF: diabetes, gallstones.
24-hour/acute history of significant epigastric and RUQ constant abdominal pain with 2-3 minutes of increased pain, accompanied by nausea, episodes of vomiting, and intermittent fever.
Positive Murphy’s sign, Elevated AST, ALT, ALP.
DX: RUQ abdominal US
TX: dependent on gallbladder inflammation. NPO, IV, antibiotics, surgery.
GI: HBsAg positive inidicates what? Discuss acute versus chronic.
s = stays in people hepatitis B virus Ag = ALWAYS GROWING. Hepatitis B infection.
This can be in an acute or chronic hepatitis B patient.
Look for symptoms of Acute: hepatic enzymes >5x ULN, fatigue, RUQ discomfort, etc. VS Chronic: modest elevation in hepatic enzymes, asymptomatic
GI: Anti-HAV positive indicates what? Anti-HAV negative?
Anti-HAV positive indicates an IgG (GONE) that is gone, either by vaccine or disease itself. (Hepatitis A in this case)
Anti-HAV negative = NO past/present infection or immunity.
GI: Should a HBsAg positive patient get a vaccine against hepatitis B?
NO! - stays Always growing = this person has acute or chronic hepatitis B and the vaccine would not do anything/change existing disease.
HBsAg, Anti-HBc, or HBsAb (b=bye) negative would indicate no immunity and the need for vaccine.
GI: Should a anti-HAV positive patient get a hepatitis A vaccine?
NO! - antibodies are present, either from a prior infection or vaccine. Another Hepatitis A vaccine would not change this finding. Other positive findings of PAST disease are: HAV IgM (miserable), HAV IgG (gone). Chronic Hepatitis A disease does not exist, only findings of acute or past disease.
Anti-HAV negative = vaccine
GI: T/F - The USPSTF recommends hepatitis C screening all adults between ages 18 and 79 without regard to HCV risk factors.
TRUE!
GI: What is the post-exposure prophylaxis available for hepatitis B exposure?
give both hepatitis B vaccine AND HBIG, hepatitis B immune globulin
GI: How is irritable bowel syndrome (IBS) different from inflammatory bowel disease (IBD)?
IBS - no rectal bleeding, fever, weight loss, no CRP/ESR elevation. Presence of altered GI motility.
IBD - yes to rectal bleeding, diarrhea, fever, weight loss, elevation of CRP or ESR, leukocytosi (flares). Biologics need to be considered in treatment.
A patient admits to taking Omeprazole (PPI) daily for GERD for the past year or so, what should you anticipate?
-prazole = PPI
Chronic PPI use can cause micronutrient malabsorption, particularly B12 and Iron
SUSPECT RBC PRODUCTION REDUCUTION/ANEMIA.
A patient is taking Metformin for prediabetes and has been on this medication for years now, what should you anticipate?
Vitamin B12 malabsorption, check levels. A nutritional deficit of B12 can cause a reduction in RBC production as well.
HEM: What are common primary care conditions that are characterized by chronic low-volume blood loss?
Erosive gastritis,
Menorrhageia,
GI malignancy
HEM: What lab value indicates the red blood cell size?
MCV - mean corpuscle volume, normally 80-100
microcytic = <80 (IDA, thalassemia, lead, sideroblastic)
macrocytic = >100 (Vitamin B12, Folate, Substance abuse)
HEM: What lab value indicates the red blood cells’ hemoglobin content or color?
MCH - mean cell hemoglobin
Hypochromic = pale (IDA, thalassemia)
Normochromic = normal (Chronic disease anemia, aplastic, blood loss)
HEM: In an evolving microcytic anemia, as MCV ______, RDW ________.
MCV decreases (size), RDW increases (variation in RBC size) >15%
IDA and Lead - elevate ferritin levels next.
*Thalassemia WILL NOT have elevated RDW!
HEM: In an evolving macrocytic anemia, as MCV ______, RDW ________.
MCV increases (size), RDW increases (Variation in RBC size) >15%
Vitamin B12, Folate, Substance abuse/alcoholism
HEM: What is commonly seen with hemoglobin and hematocrit in a severely dehydrated patient?
hgb: normal and hct: HIGH
HEM: What are the most common reasons for normocytic (MCV 80-100), normochromic (MCH, color) anemia with a normal RDW lab finding? (mnemonic)
MR B CALM Marrow failure Renal failure Blood loss (acute) Chronic disease*** Aplastic anemia Leukemia Metastasis (cancer)
HEM: What do you anticipate the MCV, MCH, and RDW to present with suspected thalassemia? What is the next step to confirm/further evaluation?
Thalassemia = microcytic (size/MCV low), hypochromic (color/MCV pale) and normal RDW (<15%).
Hemoglobin electrophoresis is the next step
HEM: What are the most common reasons for macrocytic (MCV >100), normochromic (MCH, color) anemia with a elevated RDW lab finding? (mnemonic)
FAT RBC Fetus (pregnancy, rare) Alcohol excess Thyroid (hypo) Reticulocytosis B12 and Folate deficiency ***most common. Cirrhosis and chronic liver disease
HEM: What is the most common type of anemia in childhood?
Iron deficiency anemia
HEM: A vegan should supplement with what to prevent anemia?
vitamin b12
HEM: What is the most common type of anemia in pregnancy?
iron deficiency anemia
HEM: What is the most common type of anemia in a woman during her reproductive years?
Iron deficiency anemia
HEM: What is the most common type of anemia in the elderly?
Anemia of chronic disease then IDA then pernicious anemia
HEM: To maximize the effectiveness of oral iron therapy, what should be advised to the patient?
TAKE ON AN EMPTY STOMACH!
may take with OJ to help with absorption.
NEVER: take with antacid, never take with large meals, never take with glass of milk.
look for key words: optimize, maximize
HEM: What type of murmur may occur when a patient has profound anemia, severely dehydrated, or has a high fever?
hemic murmur - especially in slender/thin individuals or strep throat. This will resolve with underlying cause treatment.
HEM: What nutritional supplements are potentially associated with increased bleeding risk and should be discontinued at least 7-10 days prior to elective surgery?
Ginseng, Gingko, Garlic, Fish oil, Feverfew (possibly St. John’s Wort)
increased bleeding of aspirin, DOAC, Apixaban/eliquis, warfarin.
HEM: Discuss the most likely WBC response to a significant viral infection such as mononucleosis or viral meningitis? (Neutrophils, lymphocytes, bands)
Total WBC will be normal to low
Neutrophils (polys, segs): 40% decreased
Lymphoctes: 55% increased with reactive forms
Overall, Neutrophils and Lymphocytes are closer in numerical range
Bands 3% elevation to normal typically
lymphocytosis = virus
HEM: Discuss the most likely WBC response in a serious bacterial infection such as appendicitis or bacterial pneumonia? (Neutrophils, Lymphocytes, Bands)
Total WBC is elevated
Neutrophils: 71% increased with toxic granulation
Lymphocytes: 20% decreased
Bands: 6% increased (bands are BAD).
Neutrophilia with leukocytosis = left shift
Neutrophilia = bacterial
Wide values between neutrophils and lymphoctes.
What is primary prevention health care? Examples?
preventing health problem(s). The most cost-effective form of healthcare
Examples: immunizations, counseling or teaching about safety/injury/disease prevention.
What is secondary prevention health care? Examples?
the detecting of disease in early, asymptomatic, or preclinical state to minimize its impact.
Examples: Screening tests - BP check, mammography, colonoscopy, skin survey, lipid panel, etc
What is tertiary prevention health care? Examples?
the minimizing of negative disease-induced outcomes.
Examples: established disease - adjust therapy to avoid further target organ damage.
What 3 vaccines should NOT be given if a person has an anaphylactic reaction to neomycin?
IPV, MMR, Varicella
What 2 vaccines should NOT be given if a person has an anaphylactic reaction to streptomycin, polymyxin B, neomycin?
IPV, Vaccinina (smallpox)
What vaccine should NOT be given if a person has an anaphylactic reaction to baker’s yeast?
Hepatitis B
What vaccine should NOT be given if a person has an anaphylactic reaction to gelatin and neomycin?
Varicella Zoster (Zostavax) ***Shingrix is the newer shingles vaccine given in two doses***
What vaccine should NOT be given if a person has an anaphylactic reaction to gelatin?
MMR
What are the immediate interventions for anaphylaxis in the primary care setting?
Assess ABC Place in supine position Activate EMS, transfer to ED Administer IM epinephrine and give H1/H2 blocker (diphenhydramine or ranitidine) Initiate IV access, oxygen, monitor
Previously unvaccinated adults with diabetes mellitus type 1 or 2 should be vaccinated against ___________ as soon as possible after diabetes diagnosis.
Hepatitis B
What are 3 live attenuated virus vaccine examples? Who should NOT be given these vaccines?
MMR, Varicella, intranasal influenza
NO pregnancy, severely immunocompromised
Who is a contraindication for the rotavirus vaccine?
infants with severe combined immunodeficiency (SCID) or history of intussusception
Should a patient that had shingles 3 months ago and no longer presents with symptoms be vaccinated with Shingrex?
YES! - wait 6 weeks post outbreak
give shingrex to all individuals that got the older vaccine, anyone on biologics, anyone over the age of 50
What are 3 expected and common side effects of vaccines?
discomfort, erythema and swelling
What age is recommended for routine mammography in women?
At age 50, may begin at 45 annually to 54 then biennially if expected to live of at least 10 years.
Choice as early as 40-44 years
What is precontemplation? What should you do as the provider?
a person that is NOT INTERESTED in change and may not be aware that the problem exists or minimizes the problem’s impact.
Help them move toward thinking about changing the unhealthy behavior
What is contemplatation? What should you do as the provider?
A patient considering change and looking at positive and negative aspects. Reports of feeling “stuck” with problem.
Help them examine benefits and barriers to change.
What is preparation? What should you do as the provider?
Patient exhibiting some change behaviors or thoughts. Often reports they do not have the tools to proceed.
Assist them with finding and using tools to help change and continue to work on lowering barriers to change.
What is the action stage? What should the provider do?
Patient is ready to make change, takes concrete steps to change. Often inconsistent.
Help them use tools, encourage change, praise positives, acknowledge reverting back to former behavior as common.
What is maintenance/relapse stage? What should the provider do?
Patient learns to continue the change and has adopted/embraced healthy habit. Person learns to deal with backsliding/relapse.
Continue positive reinforcement for behavior change, put backsliding into perspective but not an insurmountable problem.
What is the number one leading cause of death in the US in children/adolescents?
Unintentional injury #2 suicide
What is the leading cause of death in the US in all ages?
Heart disease #2 neoplasms (cancer), #3 unintentional injury
What is the number one cancer diagnosis in males?
Prostate #2 lung #3 colon/rectum
What is the number one cancer diagnosis in females?
Breast #2 lung #3 colon/rectum
What is the leading cause of cancer related death in both men and women?
lung cancer
What age will cervical cancer screenings begin? HPV?
21 years old, pap q3 years, HPV 30-65 years Total hysterectomy (no cervix) = no screening unless surgery was done as a treatment of cervical cancer/pre-cancer. Partial hysterectomy (still has cervix) = screening
How long must a person must have quit smoking in order to not be screened for lung cancer via low-dose CT?
> 15 years quit smoking regardless of pack-year history
What does the USPSTF recommend for PSA-based screenings for prostate cancer?
stop after age 70 years!
for men 55 to 69 years, PSA screening is an individual choice (Grade C). Make this decision based on family history, race/ethnicity, medical conditions, benefits/harms, etc. Clinicians should not screen men who do not express a preference for screening.
When is screening indicated for colorectal cancer?
ACS - age 45 (FIT, stool DNA, colonoscopy, sigmoidoscopy, CT, DCBE) UNTIL age 75 years.
USPSTF - age 50 until 75
Individual choice after 75
When is screening for lung cancer indicated?
ACS - age 55-74 years LDCT in >30 pack-year history AND currently smoke or <15 years since quitting.
USPSTF - 55-80 years in >30 pack-year history AND currently smoke or quit within past 15 years
THYROID: What is the most common thyroid disorder encountered in primary care? What mnemonic helps remember the signs/symptoms of this disorder?
hypothyroidism MOMS SO TIRED Memory loss Obesity (modest weight gain <10 lbs) Menorrhagia - new onset Slowness (mental/physical) Skin and hair dryness Onset gradual Tiredness Intolerance to cold Raised BP - modest, reversible Energy levels fall Depression/Delayed relaxation of all reflexes
THYROID: What are 3 etiologies of hypothyroidism?
Hashimoto (autoimmune), Post-radioactive iodine tx for Graves or cancer, medication use (lithium, amiodarone, interferon)
THYROID: What is the expected clinical presentation of hyperthyroidism? (mnemonic)
SWEATING Sweating Weight loss (muscle and fat) Emotional lability -racing mind or Exophthalmos Appetite increased but losing weight Tremor/tachycardia Intolerance of heat, irregular menstruation, irritable Nervousness Goiter, GI problems
THYROID: What are 4 common etiologies of hyperthyroidism?
Graves (autoimmune), toxic adenoma, thyroiditis (transient - pregnancy), medication use (amiodarone, interferon)
THYROID: What is the single MOST reliable test to diagnose all common forms of hypothyroidism and hyperthyroidism?
TSH ! - high sensitivity and specificity, WNL = thyroid disease is ruled out.
THYROID: What lab value should be ordered to follow up confirmation of an abnormal TSH value?
free T4 - supports the diagnosis
THYROID: What lab value is best to detect an autoimmune thyroid disease after an abnormal TSH value?
Thyroid peroxidase antibody TPO Ab
THYROID: What is prescribed for hypothyroidism? How should the dose be initiated?
Levothyroxine (Synthroid) - dose based on IDEAL body weight if overweight or obese. Elderly 1.0 mcg/kg/day
THYROID: What patient teaching is specific to levothyroxine? When should TSH levels be rechecked?
-empty stomach with water, same time everyday
-never within 2 hours of calcium, iron, aluminum, magnesium
check 8 weeks with therapeutic therapy.
Dose is increased by 12.5 to 25 mcg/day if TSH >4, decreased if TSH <0.5
THYROID: What is the treatment for hyperthyroidism? What is safe for pregnancy?
beta-adrenergic antagoinist - beta blocker (Propranolol)
Methimazole or PTU (safe for pregnancy)
Once normal = RAI use, ablation
THYROID: What is subclinical hypothyroidism? How should this patient be treated?
an elevated TSH with a normal free T4 level.
Usually asymptomatic/feels well, incidental finding.
Treat with levothyroxine if TSH >5, assess for goiter or TPO antibodies, assess for infertility, imminent pregnancy for reason to treat, and f/u as hypothyroid patient
