FM CASE FILES 1 Flashcards
What is Strabismus?
ocular misalignment
Define failure to thrive.
- weight below 3rd or 5th percentile, or
2. decelerations of growth that have crossed 2 major growth percentiles, in a short period
Most common cause of amblyopia.
Strabismus
Name 2 required newborn screening tests.
PKU and congenital hypothyroidism
Name some common newborn screening tests.
hemoglobinopathies (sickle), galactosemia
How do you evaluate for iron deficiency in children?
get hemoglobin or hematocrit bt 6-12 months of age
what is the meaning of a red reflex in an ophthalmoscopic exam of a newborn
no cataracts or retinoblastoma
how do you test for strabismus
what do you do if the child tests positive
asymmetric light reflex, or
cover-uncover test
child focuses on object with both eyes, then cover one eye, if the uncovered eye deviates then it is a sign of strabisumus
refer to ophthalmologist asap to prevent amblyopia
leading cause of death in children under 1yo
SIDS
what is the car safety law for children
rear-facing car seat until 1yo and weighs 20 lbs
front-facing seat btw 20-40 lbs
booster seat when >40lbs, with shoulder belt
leading cause of death of children older than 1 yo
accidents and injuries
contraindications to vaccines
hx of anaphylactic reaction to vaccine or its component (regardless if having fever or not)
sx: nasal itching, sneezing, rhinorrhea
allegic rhinitis
signs: nasal turbinates swollen (boggy), pale/bluish color
allergic rhinitis
tx for allergic rhinitis
antihistamines, decongestants or intranasal steroids
complications of tx for allergic rhinitis
excess use of decongestants can cause rebound congestion
rhinitis medicamentosa
name sx of allergic rhinitis
sneezing itching (nose/eyes/ears) rhinorrhea - thin/watery postnasal drip congestion anosmia HA earache tearing/red eyes drowsiness
contrast the mucous secretion of rhinitis vs sinusitis
rhinitis - thin/watery
sinusitis - thick/purulent
how do you test for nasal polyps
spray a topical decongestant, the polyp does not shrink, but the surrounding nasal mucosa does
name some 1st gen antihistamines
diphenhydramine
chlorpheniramine
hydroxyzine
name some 2nd gen antihistamines
loratadine
fexofenadine
cetirizine
why do 2nd gen antihistamines have less sedative effects than 1st gen
less penetration into cns
name a decongestant and its mech of action
pseudoephredine
alpha agonst
why avoid oral decongestants
may cause tachycardia, tremors, insominia
side effects of corticosteroid nasal sprays
nosebleeds, pharyngitis, URI
describe urticaria
large, irregularly shaped
pruritic
erythematous wheals
describe angioedema
painless
deep
subcu swelling
involves:
periorbital
circumoral
describe anaphylaxis
systemic rxn: skin findings dyspnea visceral edema hypotension
immediate tx for anaphylaxis
epi
SQ or IM
what is asthma
msucle spasms
signs/sx
asthma
wheezing SOB cough increase airway sections increased expiratory phase
what 2 major triggers of asthma
viral infx
allrgens
acute relief of asthma
beta2 agonist
albuterol
tx for persistent asthma
long acting b2 agonist (salmeterol)
inhaled corticosteroids
bacterial conjunctivitis
name them
staph strep hemophilus moraxella pseudomonas
cause of pink eye
adenovirus
how is conjunctivitis spread
by direct contact
smoking cessation interventions
meds: buproprion
nicotine replacement:
gum, patch, inhaler, nasal spray
5As a physician should use to assist in smoking cessation
ask about tobacco use advise to quit (talk about risks/benefits) assess willingness to quit assist to quit arrange follow-up/support
buproprion contraindicated in what kinds of pts
seizures
eating disorders
MAO-I
can pregnant women use the nicotine or buproprion to stop smoking
yes
are physicians required to report STIs?
YES!
what is emancipation
legal process to declare a person under 18 a legal adult: housing, education, healthcare, conduct
but u still cannot drink EtOH, smoke or vote
besides emancipation, what is another way a child may consent to receive medical care w/o parents
“Mature Minor Doctor”
court may deem the child to be “mature”
what are the moral principles of ethics
autonomy - patient choice
beneficence - do right for patient
nonmaleficence - do no harm
justice - be fair and nonbiased
reliable sign of anemia in elderly
conjunctival pallor
general signs of anemia
fatigue
weaknesss
dyspnea
general signs of vit b12 def
glossitis decreased vibratory/positional senses ataxia paresthesia confusion dementia pearly gray hair
initial workup of anemia
cbc
peripheral blood smear
retic count
iron panel results for iron def anemia
low iron
low ferritin
high TIBC
how do u confirm vit b12 def
elevated methylmalonic acid
other diseases or conditions causing vit 12 def
pernicious anemia
history of gastrectomy
is associated w/ malabsorption (bacterial infxn, crohn dis, celiac)
folate def is assoc with what condition
alcoholism
causes of acute diarrhea
virus
bacteria (e coli, campylobacter, shigella, salmonella, giardia)
causes of chronic diarrhea
crohns UC gluten intolerance IBS parasites
bacterial causes of bloody diarrhea
e coli
yersinia
shigella
e histolytica
stool leukocytes is indicative of what orgs
salmonella shigella yersinia e coli c dif campylobacter e histolytica
travelers diarrhea
enterotoxigenc e coli
campers diarrhea
giardia
daycare diarrhea
shigella
giardia
rotavirus
diarrhea from nursing homes or recent hospitalization
c dif colitis from antibiotic use
how do u check for c dif colitis
stool c dif toxin
first step in tx of diarrhea
fluid resuscitation and electrolytes
best way to prevent viral diarrhea
handwashing
tx for traveler’s diarrhea
quinolone (cipro 500mg bid)
for 1-2 days
or azithromycin
bactrim is more resistant now so avoid it
bugs in each diarrhea time course:
within 6 hours
8-12 hours
12-14 hours
s aureus
c perfringens
e coli
how to reduce risk of developing osteoporosis
daily Ca2+ / Vit D
weight-bearing exercise
how often do u do mammograms
start at 40
every 1-2 yrs after that
screening for HTN in adults
starts at 18
measure blood pressure
lipid screening guidelines
lipid screen starting at 45yo for women
how long should HRT be used
lowest dose
as short as possible
when to start screening for cervical cancer
21
or within 3 yrs of having sex
how is screening for osteoporosis done
dexa scan (bone density)
which joint is most likely to be affected in osteoporosis
hip
osteoporosis is present if dexa results should a t-score is below what value
- 2.5
2. 5 SD below a young woman’s
how do u dx osteopenia
dexa scan
T value = -1 to -2.5
mech of injury of an ankle sprain
inversion of ankle while plantar flexed
most commonly injured ligament in ankle sprain
lateral ankle more injured than medial ankle
anterior talofibular ligament
what is a grade 1 ankle sprain
stretching of the ATFL
(anterior talofibular ligament)
pain and swelling
no mechanical instability or loss of fxn
what is a grade 2 ankle sprain
partial tear of ATFL
stretching of CFL (calcaneofibular lig)
severe pain, swelling, bruising
mild-to-moderate joint instability, pain with weight bearing, loss of ROM
what is a grade 3 ankle sprain
complete tear of ATFL and CFL
partial tear of PTFL (posterior talofibular ligament)
signifcant joint instability
loss of fxn
inability to bear weight
ottawa rules
when do u perform a foot x-ray
bony tenderness over:
navicular bone (medial midfoot)
base of 5th metatarsal (lateral midfoot)
unable to bear weight (immed or during exam)
posterior edge or tip of medial/lateral malleolus
management of ankle sprain
PRICE protection (splint/cast) rest ice (minimize swelling/pain) compression (reduce swelling) elevation (reducing swelling)
NSAIDs / acetaminophen
how do you test for supraspinatus injury/tear
Empty Can Test
with arm abducted, elbow extended, thumb point down
patient elevates arm against resistance
how do you test for infraspinatus or teres minor injury/tear
External Rotation
with elbows at side and flexed at 90 degrees
patient externally rotates against resistance
how do you test for subscapularis tear
Lift-Off Test
patient places dorsum of hand on lumbar back and attempts to lift hand off of back
how do you test for ATFL injury or tear
Anterior Talofibular Ligament
Anterior Drawer
pull forward on pts heel while stabilizing lower leg
excess translation of joint suggests ATFL tear
how do you test for CFL injury or tear
Calcaneofibular Ligament
Inversion Stress Test
invert ankle with one hand while stabilizing lower leg with other
excessive translation or palpable “clunk” of talus on tibia suggests ligament tear
how do you test for syndesmosis injury
Squeeze Test
examiner compresses tibia/fibula at midcalf
pain at anterior ankle joint (where you’re squeezing) suggests syndesmotic injury
how do you test for ACL injury/tear
Lachman Test or Anterior Drawer
put knee in 20 degree flexion
pull forward on upper tibia
howd you test for MCL injury/tear
Valgus Stress
in full extension and at 30 degree flexion, medial-directed force on knee, lateral directed on ankle
look for excess translation
how do you test for LCL injury/tear
Lateral Collateral Ligament
Varus Stress
in full extension and at 30 degree flexion, lateral-directed force on knee and medial-directed force on ankle
according to ottawa knee rules, perform knee x-ray when….
5 things
age 55 orolder isolated patella tenderness fibular head tenderness can't flex knee to 90 can't bear weight for 4 steps (then or now, regardless of limp)
if x-ray of joint is normal, but symptoms persist, whats the next test
MRI
most common cause of persistent stiff or painful joints following sprains
inadequate rehab
single most important risk factor for development of skin cancer
exposure to UV radiation (sun)
what are risk factors for skin cancer
prior history of skin cancer family hx of skin cancer fair skin red/blonde hair burn easily exposure to chemicals (arsenic, radium) suppressed immune system
exposure to UV radiation
most common type of melanoma
superficial spreading melanoma
radial growth phase is slower than vertical phase (grows into dermis and can metastasize)
most common type of melanoma in the elderly and hawaii
lentigo maligna
found on chronic sun-damaged skin (face, ears, arms and upper trunk)
(however this is the least of the 4 in total)
most common type of melanoma in african-american and asians
acral lentiginous melanoma
found under nails
soles of feet
palms of hands
most aggressive type of melanoma
invasive at time of dx
nodular melanoma
ABCD of Melanoma
a - asymmetry (symm vs asymm)
b - border (defined vs ragged)
c - color (uniform vs variegated)
d - diameter (less vs greater than 6 cm)
tx for benign melanoma
monitor
educate patient
tx for suspicious melanoma
excise with 2-3 mm margin
how do you excise malignant melanomas
5 mm margin
if on face, refer to plastic surgeon
what is follow-up after excising a melanoma
annual follow-up
observe for new/changing lesions
most important prognostic indicator for melanoma
thickness of tumor
(aka breslow measurement)
less than 1mm thick has low rate of metastasis
how to prevent melanomas
reduce exposure to UV radiation
clothe properly
sun-screen
describe basal cell carcinomas
pearly papules
central ulceration
multiple telangiectasias
bleeds or itches
tx for bcc
excision
rarely metastasizes
which metastasizes more: scc or bcc
scc
describe scc
irregularly shaped plaques or nodules with raised borders
scaly
ulcerated
bleed easily
tx for scc
excision
how do you image the upper urinary tract
IV Pyelo
how do you image the lower urinary tract
cystoscopy
define microscopic hematuria
> 3 RBC per HPF
from 2-3 Ua tests
freshly voided
morning
clean catch
midstream urine
eos in the urine
interstitial nephritis
how long does exercise-induced hematuria last
less than 72 hours
pt with hematuria, has repeat Ua showing hematuria again, what do you do next
full work-up
Ua
microsopy of urinary sediment
Ucx to r/o UTI
BMP to get Cr –> focus on renal cause if elevated (May need renal bx)
what exactly is an IVP
x-ray of urinary tract after administration of contrast
CT with or without contrast to look for calculi
non-con
complication of CT with con or IVP
risk factor for it
how do you prevent it
nephropathy
renal insufficiency
premedicate with N-acetylcysteine
if patient has renal insuff, whats another way to evaluate for upper urinary tract
retrograde pyelography with renal ultrasound
place catheter in the bladder and inject contrast up ureter to kidneys
how do you examine for transitional cell carcinoma
cystoscopy
patient with hematuria, but with a thorough negative work-up
what do you do now?
do BP measurements
Ua
voided urine ctyologic studies
all done at 6, 12, 24 and 36 months
basically you’re looking for any underlying lesions, after this if they are still asymptomatic, then no further tests required
however, if they still have sx (i.e. hematuria, dysuria, develops HTN, proteinuria, casts), refer to urologist
is radioactive iodine therapy safe in pregnant woman
no
radioactive isotope can cross placenta and cause fetal thyroid ablation
alternative: surgical removal of thyroid
meds for graves
antithyroid drugs (PTU and methimazole)
beta-blockers to counter peripheral effects
these are only temporary
definitive tx for graves
radioactive iodine
destroys thyroid gland
signs and sx
thyroid storm
fever
confusion
restlessness
psychotic-like behavior
tachycardia elevated BP dysrhythmias dyspena on exertion peripheral vasoconstriction
signs and sx
hyperthyroidism
nervous palpitations wt loss fine resting tremor dyspnea on exertion difficulty with concentration
50% of graves has this finding
exophthalmos
how do you diagnose hyperthyroidism
low TSH
high Free T4
you suspect graves dz
whats your next step
imaging with technetium-99
its a radionucleotide scan
tells you active/inactive areas
usually DIFFUSE uptake
radionucleotide scan in thyroiditis vs graves
graves - diffuse uptake
thyroiditis - patchy uptake
how does PTU and methimazole work?
inhibits organification of iodine
PTU also prevents peripheral conversion of T4 to T3
side effect of PTU and methimazole
agranulocytosis
is PTU and methimazole safe during pregnancy
YES
PTU is preferred however
for graves, when is surgery indicated
pregnant women
cannot tolerate side effects of PTU
large goiter compressing nearby structures
signs and sx of hypothyroidism
lethargy weight gain hair loss dry skin slow mentation/forgetfulness constipation intolerance to cold depression
in elderly, differential dx for dementia
alzheimers
hypothyroidism
side effect of PTU and methimazole
agranulocytosis
is PTU and methimazole safe during pregnancy
YES
PTU is preferred however
for graves, when is surgery indicated
pregnant women
cannot tolerate side effects of PTU
large goiter compressing nearby structures
signs and sx of hypothyroidism
lethargy weight gain hair loss dry skin slow mentation/forgetfulness constipation intolerance to cold depression
in elderly, differential dx for dementia
alzheimers
hypothyroidism
in women, differential dx for depression
depression
hypothyroidism
physical findings of hypothyroidism
low BP bradycardia nonpitting edema hair thinning or loss dry skin diminished relaxation of reflexes
most common cause of hypothyroidism
Hashimoto thyroiditis
what are secondary causes of hypothyroidism
hypothalamic or pituitary dysfxn
pts received intracranial irradiation or surgical removal of a pituitary adenoma
dx of primary and secondary hypothyroidism
primary:
high TSH
low Free T4
secondary:
low tsh and free T4
how would you distinguish between hypothalamic vs pituitary hypothyroidism
inject TRH
if TSH increases, its a hypothalamus problem
if TSH remains low, its a pituitary propblem
as you age, you may need to decrease levothyroxine dosage
why?
thyroid binding to albumin decreases b/c albumin also decreases with age
monitor TSH annually in elderly
you find thyroid nodules on PE
what do you do next?
why?
evaluate thyroid fxn (tsh/t4)
functional adenomas with hyperthyroidism are rarely malignant
to rule out malignancy in solitary nodules
risk factors for thyroid malignancy
history of head/neck irradiation
family hx of thyroid cx
cervical LA
recent development of hoarseness of voice
tx for hyperfunctioning thyroid nodules
surgery
radioactive ablation
nonfunctioning thyroid nodules
what do you do next?
assuming you found this nodule by ultrasound or physical exam
FNA biopsy
FNA of thyroid nodule is INDETERMINATE
whats the next step
you need a definitive dx by surgery only
this is b/c indeterminate means that you cannot distinguish between follicular cell malignancy from its benign equivalent
tx for thyroid malignancy
thyroidectomy
followed by radioactive ablation
pregnant woman with thyroid nodule
next step?
FNA to find out what it is
thyroidectomy is SAFE
radioisotope scan is CONTRAINDICATED
or just wait til postpartum period b/c thyroid cancer is relatively indolent
