general Flashcards

Question

when to consider antiviral in elderly

Answer 1

Severe disease (requiring hospitalization or evidence of lower respiratory tract infection, eg. dyspnea, tachypnea, oxygen desaturation) High risk for complications (pregnancy) start within 48h

Answer 2

Hemoptysis Pleuritic chest pain Dyspnea Systemic symptoms (fever, tachycardia >100, tachypnea>24) Abnormal physical exam (crackles, decreased breath sounds, bronchial breathing)

Answer 3

Anatomic or functional abnormality of urinary tract (enlarged prostate, stone, diverticulum, neurogenic bladder) Immunocompromised host Multi-drug resistant bacteria Pyelonephritis

Answer 4

Klebsiella pneumoniae E Coli – most common (75-95%), especially in women Enterococci – most common in LTC facilities Proteus mirabilis – most common in men Staph saprophyticus

Answer 5

Age Female Neurogenic bladder/urinary incontinence, vesicoureteral reflux, posterior urethral valves, prolapse, BPH Indwelling catheter, recent surgery/instrumentation Diabetes, other comorbidities Sexual activity

Answer 6

Infectious Cystitis, Pyelonephritis, Urethritis Vulvovaginitis, Cervicitis Prostatitis, epididiymo-orchitis Foreign body Urolithiasis Dermatologic Irritant/Contact dermatitis, lichen sclerosus, lichen planus, psoriasis, Stevens-Johnson, Behçet syndrome BPH, urethral stricture Neoplastic Trauma/surgery Interstitial cystitis (bladder pain syndrome)

Answer 7

pregnant, co-morbidity, exposure to antibiotics in past 3 months, travel, previous drug-resistant infection, children, diabetes, urolithiasis

Answer 8

post-coital urinary tract infection, atrophic vaginitis, retention

Answer 9

true When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.

Answer 10

if history not clear Both LE/Nitrites PPV+ 95% LE alone consider urethritis

Answer 11

Urine culture indicates UTI only if accompanied by symptoms Without indwelling catheter >10^5 cfu/mL of <2 species by void, or >10^2 by in-and-out With indwelling catheter >10^5 cfu/mL taken from new catheter or <14d since insertion

Answer 12

Nitrofurantoin 100mg PO BID x 5-7d (careful in reduced creatinine clearance) TMP-SMX DS 1 tab BID x 3d (if resistance <20%, Quebec has 15% resistance) Fosfomycin 3g PO x 1 (appropriate but inferior efficacy)

Answer 13

Nitrofurantoin 100mg PO BID x 7d Amoxicillin 875mg PO BID x 3-7d Avoid TMP-SMX in first trimester and at term

Answer 14

Acute Pyelonephritis or complicated cystitis Ciprofloxacin 500mg PO BID x7d or Levofloxacin 500mg PO daily x 7d Can consider initial intravenous dose: Ceftriaxone 1g IV or 24h dose of aminoglyocoside If complicated pyelonephritis consider inpatient IV antibiotics initially and longer 14d course

Answer 15

Consider r/o prostatitis, urethritis Empiric antibiotics Fluoroquinolones (eg. Cipro 500mg PO BID or Levofloxacin 500mg PO daily) x 7-14d If afebrile, consider 7d course rather than 14d as per latest JAMA 2021 Consider shorter courses of fluoroquinolones for uncomplicated pyelonephritis (eg. 7d as per ACP) Consider TMP-SMX DS 1 tab BID if culture sensitive

Answer 16

Ideally remove catheter prior to antibiotics Otherwise intermittent catheterization if possible Otherwise replace catheter after antimicrobial therapy started 7-14 day antimicrobial treatment generally adequate

Answer 17

Hydration, nutrition Perineal hygiene Healthy voiding habits Avoid unnecessary urinary catheters (consider intermittent cathterization) Aseptic technique for urinary catheters May consider cranberry prophylaxis (eg. juice or tablet) May consider discussing antibiotic prophylaxis (continuous x 1 year or postcoital) vs. self-treatment in recurrent UTI (eg. 2+/6mo, 3+/12mo) May consider vaginal estrogen therapy in peri/post-menopausal women

Answer 18

Mental health disorders/Anxiety/Depression/Stress/Adjustment Hormonal changes/perimenopause/menopause Substance use/alcohol/illicit drugs/caffeine Pain Restless Legs Syndrome Obstructive sleep apnea Hyperthyroidism

Answer 19

Keep a sleep diary Regular exercise: 150 mins/wk of moderate intensity cardiovascular exercise + resistance training 2 days per week Avoid large meals close to bedtime Develop/Engage in a wind-down routine Turn off electronics 1/2 hour before bedtime Do not watch the clock Ensure comfortable temperature Sleep in a dark room Minimize alcohol use Use bedroom only for sleep and intimacy Keep regular sleep-wake schedule 7 days per week Avoid caffeine later in the day

Answer 20

Cognitive behavioural therapy

Answer 21

Trazodone (FYI: Serotonin antagonist and reuptake inhibitor (SARI), Mirtazepine (FYI: Atypical antidepressants/tetracyclic antidepressants), triazolam/lorazepam/temazepam/nitrazepam (FYI: Benzodiazepines), zopiclone/zolpidem (FYI: Benzodiazepine receptor agonists), amitriptyline/doxepin (FYI: Tricyclic antidepressants), tryptophan (FYI: Serotonin precursors) Writing Benzodiazepines (BDZ) as an answer might have made you nervous, and for good reason! These are not good medications, but the way the question is worded ("drugs that could be used to treat her insomnia") makes them applicable answer. If the question was worded, "what are the preferred mediations to prescribe when someone has exhausted non-pharmacologic approaches?" then BDZs are not on the list. Also, suggest avoiding meds that are often used for sleep but are off-label, such as quetiapine (atypical anti-psychotics). In this case you also might have wondered about using hormone replacement therapy or oral contraceptive pills to normalize hormonal patterns. Those medications did not make the answer key because there is not enough information to know if they are appropriate. Melatonin is not on the answer key because it is over-the-counter.

Answer 22

Blurred vision/visual acuity Photophobia Exudate/Discharge Itching Coloured halos in the visual field Sensation of a foreign body Double vision/Diplopia eye pain redness

Answer 23

Autoimmune: Iritis Keratitis Acute angle-closure glaucoma Foreign body Blepharitis Subconjunctival hemorrhage Pterygium Abrasion/trauma Chalazion/Hordeolum/Stye Chemical burn/irritant Allergic

Answer 24

Cataracts Elevated intraocular pressure Optic nerve damage

Answer 25

Acute angle-closure glaucoma

Answer 26

Measurement of intraocular pressure/Tonometry

Answer 27

Surgical peripheral iridectomy/ Laser peripheral iridectomy/Iridectomy

Answer 28

Since there is no evidence of a bacterial infection, and that viral conjunctivitis is far more common, there is no indication for antibiotic drops. She will likely get better at the same rate with or without drops Even if it was bacterial, it is usually a self-limiting condition Bacterial super-infection in viral conjunctivitis is uncommon

Answer 29

Return To Work: Do not return to work until symptoms have resolved. Prevention of transmission to her other eye: Recommend do not touch her eyes. Prevention of transmission to others: Recommend frequent hand washing

Answer 30

AOM, acute mastoiditis, acute facial nerve palsy, labyrinthitis, venous sinus thrombosis, meningitis, trauma, cholesteatoma, tumor, otitis externa, r/o necrotizing/malignant otitis externa, Herpes zoster , Secondary otalgia, otitis media with effusion, otitis externa

Answer 31

S pneumoniae , M catarrhalis and H influenzae

Answer 32

Smoking exposure Upper respiratory tract infection Daycare (sick contacts) Bottlefeed Pacifier Personal history, family history of AOM

Answer 33

Non-anaphylactic: Cefuroxime 30 mg/kg/day ÷ BID-TID Anaphylactic: Clarithromycin 15mg/kg/day PO ÷ BID x5-10d or Azithromycin 10mg/kg PO day 1, then 5mg/kg PO x 4d

Answer 34

recurrent AOM 3x/6 months or 4x/1 year Chronic OME >3 months With risk of speech/learning problems Bilateral OME with Hearing loss Symptoms attributable with OME (vestibular problems, poor school performance, behavioural problems, ear discomfort) AOM resistant to second-line antibiotics Perforated TM non-resolved after 6w

Answer 35

Language Executive function Complex attention Perceptual-motor Social cognition

Answer 36

dressing, eating/self-feeding, ambulating/transferring, toileting, hygiene/grooming, bath/shower)

Answer 37

shopping, housework, accounting/finances, food prep, telephone, transportation, taking meds

Answer 38

Alzheimer (most common 50%) Gradual onset, normal CNS, initial and most prominent deficit = amnestic (associated with impairment in learning and recall of recently learned information) Mixed Alzheimer and vascular (20%) Vascular (15%) Abrupt, stepwise, cardiovascular risks (HTN, DLP), dysexecutive syndrome, focal neurological features Lewy Body (5%) Core features: Fluctuating cognition, detailed visual hallucinations, REM sleep behaviour disorder, Parkinsonism (bradykinesia, rest tremor, rigidity) Other suggestive: Severe neuroleptic sensitivity (irreversible parkinsonism, impaired consciousness), postural instability, falls, syncope, autonomic dysfunction, hypersomnia, hyposmia, delusions, apathy, anxiety, depression Frontotemporal (1%) Behavioural problems (disinhibition, loss of social awareness), language impairment Parkinson disease with dementia Impaired executive dysfunction and visuospatial function Differentiate from Lewy Body as parkinsonism is present >1y prior to dementia (whereas in DLB dementia occurs before or at the same time as the parkinsonian signs) Other: Progressive supranuclear palsy (vertical supranuclear gaze palsy and postural instability), Huntington disease Other ddx; delirium, depression, neuro: seizures, stroke/TIA

Answer 39

Labs (low yield <1%) CBC, TSH, electrolytes (Glucose, Cr, Ca), B12, Lipids Neurosyphilis screen only if high clinical suspicion Consider EKG prior to treatment Avoid AchEI if LBBB, 2nd/3rd degree block, sick sinus, HR<50

Answer 40

<60yo Abrupt, rapid decline Focal neurological symptoms (headache, seizure, hemiparesis, babinski reflex) Urinary incontinence, gait disorder (r/o normal pressurehydrocephalus) Previous malignancy, trauma Anticoagulants/Bleeding disorder or history of bleeding disorder If presence of cerebrovascular disease would change management

Answer 41

Highly educated -Hopkins Verbal Learning test -Word List Acquisition test MMSE <24 suggests dementia/delirium (1 in 10 false positive) MoCA <26 (MCI 78%, AD 100%,1 in 4 false positive) Clinical Dementia Rating (Lengthy) Mini-Cog (Brief) -Clock drawing task and uncued recall of three unrelated words

Answer 42

Refer to Alzheimer society Discuss will, power of attorney, personal directives Safety issues (driving, stove, smoke detector, microwave) Occupational Therapy Hearing and vision screen Social work / Homecare services Healthy diet, smoking cessation Exercise program Eliminate medication (narcotics, anticholinergics, benzodiazepines) Alternative therapy: Aromatherapy Multisensory stimulation Music/dance therapy Animal‑assisted therapy Massage/touch therapy Outdoor activities

Answer 43

No pharmacotherapy for mild cognitive disorder Acetylcholinesterase inhibitors may be considered only in mild to moderate Alzheimer's Disease (lower quality evidence in Lewy bodies, vascular, Parkinson), where Healthcare professional has expertise in diagnosing and treating Alzheimer's Disease Adequate support and supervision Adequate adherence and monitoring of adverse effects, which generally requires the availability of a carer Baseline structured cognitive and functional assessment Follow up should be carried out on regular basis at least every 3 months Taper slowly before stopping May restart if decline shortly after stopping May reduce all-cause mortality in patient with dementia

Answer 44

AchEI, eg. Donepezil (Aricept) 5mg-10mg PO daily, Rivastigmine, Galantamine Consider in mild to moderate (eg. MMSE 10-26) Titrate q4 weeks Discontinue when risks outweigh benefits (taper, and monitor 1-3 months, if declines can restart) 2-NMDA receptor antagonists (Memantine) in severe AD

Answer 45

GI (nausea, diarrhea, vomiting) Bradycardia, hypotension, dizziness, syncope Insomnia / sleep disturbances QT prolongation and torsades de pointes (EKG prior to treatment as above)

Answer 46

SSRI (paroxetine) or trazodone No evidence for AchEI

Answer 47

Manage HTN, DM, smoking No evidence for AchEI

Answer 48

Can consider AchEI (eg. Rivastigmine (Exelon) 1.5-6mg BID) Avoid antipsychotics Risk of NMS

Answer 49

Trial of antidepressant, consider Citalopram (max 40mg po daily)

Answer 50

Can consider AchEI levodopa

Answer 51

1-r/o medication side effects or interactions, treatable medical conditions such as sepsis or depression 2-Severe agitation/Violent behaviour Correct underlying Physical (pain, constipation, infection) Environmental (set routines, sound/lights, position, daytime activity) Psychiatric conditions (depression) Review medications 3-Intervention Relaxation, social contact, sensory (eg. music/aromatherapy) Increased services/care 4-Consider newer antipsychotics (less EPS), eg. Risperidone, Olanzapine, Seroquel Caution as increased risk of death, CVA, EPS, falls, somnolence, weight gain, diabetes

Answer 52

Gait Neurological signs Extra pyramidal symptoms Parkinson (cogwheel rigidity, tremors)

Answer 53

Functional/IBS (no organic cause) - 60% PUD - 25% -Upper abdominal pain prominent, back pain atypical -Gastric worse with food, Duodenal better with food -Postprandial belching, epigastric fullness, early satiation, N/V GERD -Retrosternal pain/regurgitation GI Malignancy Age Dysphagia, odynophagia Systemic signs (anemia, fatigue, weight loss) Drug-induced dyspepsia (NSAIDs and COX-2 inhibitors) Other: Celiac, chronic pancreatitis, gastritis, Crohn's, cardiac

Answer 54

Vomiting Weight Loss (Involuntary) Blood loss (melena, hematemesis, anemia) Age >50 Anemia Abdominal mass or lymphadenopathy Dysphagia, odynophagia, early satiety Family history of upper GI cancer Jaundice

Answer 55

>50yo with new-onset dyspepsia Atypical features or red flags No response (or limited) after 4-8w of adequate PPI Consider in chronic GERD with 3 risk factors for Barrett's esophagus (male > 50 years old, Caucasian, central obesity, smokers and family history of BE)

Answer 56

Weight loss if overweight Stop smoking, excessive alcohol Stop NSAID/ASA Avoid food/drinks that trigger (Alcohol, fried foods, spicy foods, garlic/onion, orange/citrus, chocolate/peppermint, coffee/caffeine, tomatoes) Eat smaller meals Elevate head of bed, avoid meal 2-3h before bedtime if nocturnal GERD

Answer 57

<50yo with dyspepsia but no red flags (especially if family history of peptic ulcer or cancer) -Active PUD (gastric or duodenal). -Confirmed history of PUD (not previously treated for H. pylori). -Gastric MALT lymphoma (low grade). -After endoscopic resection of EGC -functional dyspepsia -low dose ASA -idiopathic thrombocytopenic purpura (ITP) -Long term NSAIDS use -Iron deficiency anemia >no indication to test a pt with typical GERD

Answer 58

bisphosphonate, iron, prednisone, potassium suppl, NSAIDS, ASA, MTF, opiates, antibiotics (erythro, metronidazole)

Answer 59

* H. Pylori * Hb * Iron studies * ALT, ALP, AST, GGT (possibly add liver function) * Calcium * Possibly Gluc AC/screen for diabetes * Possibly anti-TTG if suspect Celiac

Answer 60

Immigration from a developing country * Poor socioeconomic conditions * Family overcrowding

Answer 61

Gastritis * Peptic ulcers * Gastric cancers * Gastric MALT (mucosa-associated lymphoid tissue) lymphoma

Answer 62

Quadruple therapy: bismuth, clarythromycin or tetracycline, metronidazole, PPI x 14 days

Answer 63

test at least 4 weeks after completion of antibiotics, with PPI withheld for 1-2 weeks

Answer 64

The rate of response to placebo in trials 30% to 40% * A meta-analysis showed that PPIs were effective in reflux-like or ulcer- like FD but not with dysmotility-like FD * Prokinetic agents, including cisapride, domperidone, and itopride, have been shown to be more effective than placebo in a meta-analysis of 24 RCT (**but adverse effects) (lacking high quality studies for metoclopramide) * No benefit of venlaxafine or sertraline but some data suggest benefit of amitriptyline * Mirtazapine showed significant improvements compared to placebo in early satiety (not correlated to changes in anxiety/depression) but not in epigastric pain. * Possible benefits of psychological therapy * Attention to stress reduction is important, and dietary advice should be provided (e.g., ingestion of small, regular, low-fat meals and avoidance of foods that precipitate symptoms

Answer 65

delayed initiation of method, illness, medications, specific lubricants

Answer 66

recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo–Provera

Answer 67

emergency contraceptive pill, intrauterine device time limits

Answer 68

Irregular bleeding 9% pregnancy risk

Answer 69

9% pregnancy risk 17% skin reaction

Answer 70

9% pregnancy with regular use perfect use 0.3% May remove for 3h (eg. during coitus) 5% vaginitis, leukorrhea

Answer 71

6% pregnancy risks Irregular bleeding, weight gain, decrease bone density Consider supplemental low-dose estrogen to reduce irregular bleeding if persists past 3 cycles

Answer 72

<0.1% pregnancy 44% amenorrhea at 6 months Risk of expulsion/perforation postpartum until 6 weeks

Answer 73

very effective likely <0.1% Very rare risk of implant migration 15% bleeding irregularities Not studied in overweight >130% IBW

Answer 74

Tubal Ligation - 0.15% Vasectomy - 0.15%

Answer 75

Pregnancy test >2w after last episode of unprotected intercourse ≤7d after start of normal menses or spontaneous/induced abortion No sex since start of last normal menses Correctly, consistently using reliable contraception 4w postpartum Fully breastfeeding and <6 months postpartum Back-up contraception for 7d if >7d after menses started

Answer 76

1-Copper IUD - failure rate of <1% (>95% effective) Effective up to 5 days (limited evidence up to 7 days) after unprotected intercourse, provided pregnancy ruled out Hormonal/oral (less effective if BMI>30 or weight ≥80kg), side effects include headache, irregular bleeding , N/V 2-Ulipristal acetate 30mg PO x1 - failure rate of 1.4% (~75% effective) Effective up to 5 days Hormonal contraception can be initiated up to 5 days after unprotected sex with backup for first 14d 3-Levonorgestrel 1.5 mg PO x1 (or 0.75mg q12h x2) - failure rate of 2.2% (~50% effective) Effective up to 72h (proven efficacy up to 96h, limited efficacy up to 120h) Hormonal contraception can be initiated the day of (or after) with backup for first 7d 4-Combined OCP (Yuzpe) 100-120mcg ethinyl estradiol plus 500-600 mcg levonorgestrel (5 pills of Alesse) q12h x2 - least effective Effective up to 72h ___________ Note: Approx. 5% risk of pregnancy if unprotected sex, but up to 30% if 1-2d prior to ovulation Only contraindications are pregnancy (and active pelvic infection/cervicitis for IUD)

Answer 77

Standard 30mcg (Marvelon, Yasmin), 35mcg (Ortho 1/35) Low 25mcg (Tri-Cyclen Lo), 20mcg (Alesse) Very Low 10mcg (Lo Loestrin Fe)

Answer 78

Migraine with aura (≥5 min reversible visual/sensory/speech/motor symptom that is accompanied within 60 mins by a headache) Smoker age ≥35 years and smoking ≥15 cigarettes per day Uncontrolled hypertension (>160/100) Acute DVT/PE History of DVT/PE, not on anticogulation, with risk factor (history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome/SLE, active cancer with the exception of non-melanoma skin cancer, history of recurrent DVT/PE) Current or history of vascular disease, ischemic heart disease, stroke, complicated valvular disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis) Liver disease (severe cirrhosis, hepatocellular adenoma, malignant hepatoma) <4 weeks postpartum or peripartum cardiomyopathy Major surgery with prolonged immobilization Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy) Active breast cancer

Answer 79

current breast cancer, relative contraindications include liver disease

Answer 80

Decreased effectiveness with anticonvulsants (phenytoin, phenobarbitol), antiretrovirals, rifampin (not other antibiotics)

Answer 81

Nausea - Take pill at bedtime or with meal (consider lower estrogen) Breast tenderness (consider lower estrogen) Headache Breakthrough bleeding (r/o smoking, noncompliance, cervical/uterine disease, pregnancy, consider increase estrogen) No evidence of weight gain

Answer 82

Cycle regulation, predictable bleeds Decreased menstrual flow, anemia Decreased acne, hirsutism Decreased dysmenorrhea, premenstrual symptoms Decreased perimenopausal symptoms Decreased risk of fibroids, ovarian cyst

Answer 83

VTE RR 2-3 (compared to pregnancy RR 6 and postpartum RR 115) 10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users) UNCLEAR risk of gallbladder disease, possible increase in symptomatic gallstones when used for 15 years NOT associated with increased risk of MI or CVA if no risk factors NOT associated with increased risk of major birth defects if taken before/during pregnancy

Answer 84

Decreased ovarian, endometrial, colorectal cancer Possible association with cervical cancer (causation not demonstrated) Decreased risk of benign breast disease Possible increase in breast cancer in current/recent COC users 5 / 1000 COC-users vs. 4 / 1000 non-users will be diagnosed with breast cancer before 39 years-old

Answer 85

-If missed pill <24h in any week Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack -If missed pills in first week Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack Back up x 7d* -If missed pills during second or third week Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack and start new cycle of OCP without a hormone-free interval Back-up contraception if 3 or more consecutive doses/days of OCP missed *if unprotected intercourse in last 5 days and not on active hormone x 7 consecutive days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

Answer 86

Missed Progestin only pills >3h delay Take most recent pill ASAP and continue taking remaining pills until end of pack Back-up x 48h If unprotected intercourse in last 5 days, Emergency contraception recommended

Answer 87

-Speech pathology treatment -Neuromodulating medication Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w -CT scan if suspect lung cancer, bronchiectasis or ILD -Referral to specialty

Answer 88

., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis

Answer 89

1 Precontemplation (Not ready) Highlight advantages for change and problems with current behaviour, Harm reduction 2 Contemplation (Getting ready) Weigh pros and cons, explore ambilance/alternatives, identify reasons for change/challenges, increase confidence 3 Preparation - Action (Ready) Goal setting, start date and strategy for change, as well as address challenges Support and praise, stress that episodes of relapse are normal 4 Maintenance (Sticking to it) Help identify and use strategies to prevent relapse 5 Relapse (Learning) Help renew process of contemplation and action without becoming demoralized

Answer 90

Ask "Would you mind if I talked to you about your smoking? How often do you smoke/exercise/wear a seatbelt?" Advise "As your doctor, I strongly recommend that you ____. It is one of the most important things you can do for your health." Assess "Are you ready to quit smoking in the next 30 days?" Assist "Quitting smoking can be a real challenge. I can help you with this change, as well as pharmacotherapy/community resources/spousal support may help.” Arrange 'I'd like to see you again/call you next week to see how the plan is going."

Answer 91

Reassure Relaxation techniques (deep breathing) Focus on coping mechanisms that were successful in past Resources: Support system (friends/family) and Community resources Consider short-term anxiolytics/hypnotics Discourage inappropriate coping mechanisms (denial, withdrawal, harmful behaviours/substances)

Answer 92

Prior thromboembolism Recent major surgery Trauma Immobilization Antiphospholipid antibodies Malignancy Pregnancy Oral contraceptives Myeloproliferative disorders

Answer 93

Factor V Leiden Prothrombin gene mutations Protein S or C deficiency Antithrombin deficiency

Answer 94

Paralysis, paresis or recent orthopedic casting of lower extremity Bedridden >3 days recently or major surgery within 4 weeks Localized tenderness of the deep veins Swelling of entire leg Calf swelling 3 cm greater than other leg (measured 10 cm below the tibial tuberosity) Pitting edema greater in the symptomatic leg Non-varicose collateral superficial veins Active cancer or cancer treated within 6 months Previously documented DVT -2 points for alternative diagnosis at least as likely as DVT (Baker's cyst, cellulitis, muscle damage, superficial vein thrombosis, post-thrombotic syndrome, inguinal lymphadenopathy, extrinsic venous compression)

Answer 95

Central venous catheter, recent pacemaker, malignancy

Answer 96

Anticoagulate for initial 3 months, consider indefinite in unprovoked and cancer (and low risk bleeding) LMWH or IV heparin (5000 units bolus then 20 units/kg/hr target aPTT 2-3x control aPTT) overlap with warfarin for minimum 5 days and INR >2 for minimum 2 days Subcutaneous LMWH (eg. Dalteparin 100 U/kg SC daily or Enoxaparin 1.5mg/kg SC daily) or IV heparin x 5-10 days, then dabigatran 150mg PO BID LMWH x 1 month then DOAC or warfarin DOAC

Answer 97

Consider Warfarin in valvular A Fib, CrCl<30, Antiphospholipid syndrome, Weight >120kg, Gastric bypass, Liver failure

Answer 98

Apixaban 10mg PO BID x 1 week, then 5mg PO BID (can decrease to 2.5mg PO BID after 6 months) Rivaroxaban 15mg PO BID x 3 weeks then 20mg PO daily (can decrease to 10mg PO daily after 6 months) Note: Dabigatran and Edoxaban require 5-10 day initial treatment bridge with LMWH

Answer 99

LMWH preferred in Cancer and in Pregnancy, advantages include fixed/simple-dosing and lower HIT There is some evidence that apixaban can be used as an alternative for patient with cancer who do not want injections (but avoid in upper GI malignancy due to increased rate of bleeding)

Answer 100

Only consider Aspirin in those who are adverse to long-term anticoagulation (32% reduction of recurrent VTE vs 82% when on oral anticoagulants)

Answer 101

if symptomatic and risk factors for extension (severe symptoms, >5cm in length, multiple deep veins, close to popliteal veins, no reversible risk factor, previous VTE, in-patient, positive D-dimer) or progression on imaging

Answer 102

topical/oral NSAIDs for symptoms, if >5cm consider low-intermediate dose LMWH

Answer 103

Urgent surgical intervention for phlegmasia cerulea dolens (extensive thrombosis which can cause irreversible ischemia, necrosis, gangrene)

Answer 104

Hip/knee arthroplasty, hip fracture = 14-35 days Major orthopedic trauma, Complicated Spine Surgery, Isolated below-knee fracture, L/E amputation, bedrest = until discharge

Answer 105

Signs of chronic venous insufficiency (usually 6 months) after a DVT (extremity pain, heaviness, cramps, paresthesias, pruritus, venous dilation, edema, pigmentation, skin changes, and venous ulcers) Occurs in 50% of patients within one year of thrombosis, 5-10% severe PTS

Answer 106

Elderly, obesity Smoking Primary venous insufficiency, varicose veins Proximal DVT, residual thrombus after treatment, recurrent DVT, inadequate anticoagulation

Answer 107

(similar to chronic venous disease) Smoking cessation, weight loss if obesity Elevation Exercise training Compression stockings/bandages (30-40mmHg) or Compression device

Answer 108

If at risk of PTS, consider compression stockings (start within two weeks of diagnosis, after anticoagulation started, and continue for two years)

Answer 109

Increased thirst Decrease urine/sweating/tears Weight loss Altered mental status, lethargy, irritability

Answer 110

Vital signs Orthostatic vitals (HR↑ >30bpm, sBP ↓> 20 or dBP ↓> 10mmHg) Tachycardia, tachypnea Hypotension in severe hypovolemia Altered mental status Dry mucosa Sunken eyes Skin turgor Capillary refill >3s Decreased urine output

Answer 111

Mild (3-5% volume lose) - Absent clinical signs Home-based treatment Moderate (6-9% volume loss) - Tachycardia, orthostatic hypotension, decreased skin turgor, dry mucous membranes, irritability, delayed capillary refill, deep respirations, possible decreased urine output/tearing and sunken fontanelle ORT (eg. Pedialyte, Enfalyte, breastmilk) x 1 hour, re-assess If concerned, see treatment for severe Severe (≥10% volume loss) - "Near-shock" hypotension, lethargy, altered mental status, delayed capillary refill, cool/mottled extremities, tachypnea Requires aggressive isotonic fluid resuscitation to prevent tissue injury 20-40mL/kg IV NS over one hour Consider labs (concern if pH < 7.32, bicarb ≤ 17 mEq/L)

Answer 112

Inability for oral intake (mental status, ileus) Inability to administer ORT (eg. no caregiver) Persistent vomiting Electrolyte abnormalities where ORT cannot be monitored Medications Can consider one dose of oral ondansetron to reduce vomiting and facilitate ORT

Answer 113

Venous or Capillary Blood Gas (pH, electrolytes) +/- serum electrolytes

Answer 114

Maintenance in Children (4-2-1 rule) 1-10kg = 4 x Wt (kg) mL/hr >10-20kg = 40 + 2 x (Wt over 10kg) mL/hr >20kg = 60 + 1 x (Wt over 20kg) mL/hr Max of 100mL/hr Can use D5NS

Answer 115

Acute illness GI (N/V/D) Skin (Fever/burns) New medications (diuretics)

Answer 116

Screen with FPG and/or A1C q3 years if ≥40 years old or high risk (33% chance of DM2 within 10y) Consider screening more frequently (q6-12 months) if very high risk (50% chance of DM2 in 10y) A1C not recommended for diagnosis in children, pregnant women or suspected DM1

Answer 117

≥40 years old First degree relative with DM2 High risk population (eg. Aboriginal, African, Asian, Hispanic, or South Asian descent) Prediabetes (IGT, IFG, A1C 6-6.4%) Gestational diabetes mellitus (GDM) or delivery of a macrosomic infant Presence of end organ damage associated with DM Microvascular – retinopathy, neuropathy, nephropathy Macrovascular – coronary, cerebrovascular, peripheral vascular disease Presence of vascular risk factors HDL cholesterol level <1.0 mmol/L in males, <1.3 mmol/L in females Triglycerides 1.7 mmol/L Hypertension, Overweight, Abdominal obesity Presence of associated diseases PCOS, Acanthosis nigricans, OSA Psychiatric disorders (bipolar, depression, schizophrenia), HIV Use of drugs associated with DM Glucocorticoids, atypical antipsychotics, HAART Other secondary causes

Answer 118

Diagnose Diabetes if two tests confirm (may do same test twice on different days) FPG ≥7.0 mmol/L (8h fasting) A1C ≥6.5% (falsely ↑ in anemia; ↓ in pregnancy and renal disease; ↕ in hemoglobinopathy) 2hPG in 75g OGTT ≥11.1 mmol/L or random PG ≥11.1 mmol/L Consider 2hPG in 75g OGTT to identify IGT (2hPG 7.8-11) vs. diabetes (2hPG ≥11.1) If FPG 6.1-6.9 or A1c 6-6.4% If FPG 5.6-6 or A1c 5.5-5.9% and ≥1 risk factor Diagnose Prediabetes if A1c 6–6.4% IFG (FPG 6.1-6.9) IGT (2hPG 7.8-11)

Answer 119

Elevated waist circumference Elevated TG Reduced HDL-C Elevated BP Elevated FPG

Answer 120

If A1c <1.5% above target, consider 3-6mo lifestyle Biguanide - Metformin Sulfonylurea (avoid with short-acting insulin) Gliclazide (Diamicron) -Least hypoglycemias out of sulfonylureas DPP4i (rare risk of pancreatitis) Sitagliptin (Januvia) 100mg PO daily / Janumet (Combo with metformin) Linagliptin (Trajenta) 5mg PO daily / Jentadueto (Combo with metformin) Saxagliptin (Onglyza) caution in heart failure / Komboglyze (Combo with metformin) GLP1R agonists (weight loss, contraindicated in thyroid cancer, rare risk of pancreatitis) Liraglutide (Victoza) 0.6mg SC daily x 1 week then 1.2mg SC daily (max 1.8mg SC daily) Dulaglutide (Trulicity) 0.75mg SC weekly (max 1.5 mg SC weekly) Semaglutide (Ozempic) 0.25mg SC weekly x 4 weeks then 0.5mg SC weekly (max 1mg SC weekly) SGLT2i (risk of genital infections/UTI, hypotension, caution with loop diuretics) Empagliflozin (Jardiance) 10mg PO daily x 1 week then 25mg PO daily / Synjardy (Combo with metformin) Canagliflozin (Invokana) Dapagliflozin (Forxiga) If clinical CVD consider empagliflozin (or canagliflozin) and liraglutide If comorbid NAFLD consider semaglutide, liraglutide, thiazolidinones If symptomatic hyperglycemia or DKA/HHS Consider starting insulin +/- metformin Long-acting: Glargine (Lantus) or Detemir (Levemir) Intermediate-acting: Humulin N, NPH Short-acting: Novorapid, Humalog, Apidra

Answer 121

Diabetes Canada recommends 6.5 in healthy A1c ≤7.0 in most patients 7-8.5 in elderly, limited life expectancy, or recurrent severe hypoglycemia

Answer 122

Target preprandial 4-7 mmol/L, 2hr postprandial 5-10 mmol/L (or 5-8 if A1C not at target)

Answer 123

Missed dose, wrong dose (fear of hypoglycemia) Injection Technique, Lipodystrophy Insulin conservation (temperature exposure, expired) Infection/inflammation

Answer 124

Macrovascular: CVD, CVA, PAD Microvascular: Retinopathy, nephropathy, neuropathy Other: Erectile dysfunction (macro/microvascular) Foot complications (ulceration, Charcot arthropathy) Infection

Answer 125

A1c q3 months (until stable) Each visit BMI (18.5-24.9)/waist circumference BP<130/80 Depression screening (PHQ-9) Erectile dysfunction (Consider PDE-5 inhibitor if no contraindications)

Answer 126

Nutrition (Mediterranean diet, low glycemic index) Physical activity (aerobic >150mins/week, resistance 3 sessions/week) Smoking cessation Pre-conception counselling Enquire about hypoglycemia Driving safety

Answer 127

-Lipid profile q1y (until statin started) EKG -Nephropathy q1y (if evidence of nephropathy - follow q6months) eGFR (creat) and Urine ACR (albumin:creatinine ratio) At least 2 of 3 random urine ACR abnormal to diagnose nephropathy (2-20 microalbuminuria, >20 overt nephropathy) -Retinopathy optometry q1-2y If established retinopathy, refer to ophthalmology and consider fenofibrate/statins to slow progression -Neuropathy q1y Monofilament - Score 0, 0.5, 1 point x4 per foot arrhythmically Score 3/8=likely neuropathy, 3.5-5/8 = high risk in next four years, >5.5/8 = low risk neuropathy in next four years Vibration perception tests (tuning fork, one point if perceived, one point for when stopped) Treatment for pain: Consider Nortriptyline as first-line -Foot Care q1y Skin changes, structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and PAD, ulcerations and evidence of infection Foot care education (including counselling to avoid foot trauma), professionally fitted footwear and early referrals to a healthcare professional trained in foot care management if foot complications occur Treat ulcerations with glycemic control, infection, offloading of high-pressure areas, lower-extremity vascular status and local wound care.

Answer 128

Age >40 years Duration of diabetes >15 years and age >30 years End organ damage (microvascular, macrovascular) Cardiac risk factors

Answer 129

Typical or atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort) Signs or symptoms of associated diseases Peripheral arterial disease Carotid bruits Transient ischemic attack Stroke Resting abnormalities on ECG (e.g. Q waves)

Answer 130

symptoms of hypoglycemia, a low plasma glucose level (<4.0 mmol/L for patients on antihyperglycemic agents), and symptoms responding to the administration of carbohydrate

Answer 131

Neurogenic (autonomic) Trembling Palpitations Sweating Anxiety Hunger Nausea Paresthesias -____________ Neuroglycopenic Difficulty concentrating Confusion Weakness Drowsiness Vision changes Difficulty speaking Headache Dizziness

Answer 132

Treatment (if glucose if <4.0 mmol/L) 15g carbohydrate (glucose or sucrose tablets/solution), recheck glucose 15 minutes and if <4.0 mmol/L can repeat If severe (unconscious), Glucagon 1mg SC/IM or D50W 20-50mL IV over 1-3 minutes (Glucose 10–25g)

Answer 133

statin+ACEi/ARB+ ASA: if CAD, PAD, cerebrovasc/carotid disease statin+ACEi/ARB: if reinopathy, kidney disease, neuropathy, over 55 yo with other CV risk factors If over 40 yo or if over 30 yo with db over 15 years: statin

Answer 134

under 130/80

Answer 135

A A1C targets GUIDELINE TARGET (or personalized goal) A1C ≤7.0% If on insulin or insulin secretagogue, assess for hypoglycemia and ensure driving safety B BP targets BP <130/80 mmHg If on treatment, assess for risk of falls Cholesterol targets LDL-C <2.0 mmol/L ACEVARB (If CVD, age 255 with isk factors, OR diabetes complications) Statin (if CVD, age >40 for Type 2, OR diabetes D Drugs for CVD risk reduction complications) ASA (if CVD) SLGT2i/GLP1ra with demonstrated CV benefit (if have type 2 DM with CVD and A1 C not at target) 150 minutes of moderate to vigorous aerobic activity/ week and resistance exercises 2-3 times/week E Exercise goals and healthy Eating *Follow healthy dietary pattern (i.e. Mediterranean diet, low glycemic index) Cardiac: ECG every 3-5 years if age >40 OR diabetes complications Foot: Monofilament/Vibration yearly or more if S Screening for complications abnormal Kidney: Test eGFR and ACR yearly, or more if abnormal Retinopathy: yearly dilated retinal exam If smoker: Ask permission to give advice, arrange S Smoking cessation therapy and provide support Set personalized goals (see "individualized Goal S Self-management, Setting" panel) stress, other barriers Assess for stress, mental health, and financial or other concerns that might be barriers to achieving goals

Answer 136

Polyuria, polyphagia, polydipsia Headache, fatigue, decreased LOC Nausea/vomiting Abdominal pain If abdominal pain does not improve as ketoacidosis improves, consider other pathologies for abdominal pain

Answer 137

Dehydration, postural hypotension, tachycardia, tachypnea Resp: Kussmaul respiration, acetone-odoured (fruity) breath Abdo: Diffuse abdominal tenderness Neuro: LOC, pupils

Answer 138

Develops over days Plasma glucose >33 pH >7.3, Bicarb >15, no ketones Serum osmolality >320mOsm/kg

Answer 139

Develops over hours Typically, anion gap metabolic acidosis (although vomiting may cause a normal pH and normal bicarb) -Arterial/venous pH ≤7.3 -serum bicarbonate ≤15 mmol/L -anion gap >12 mmol/L Positive ketones in serum and/or urine (acetoacetate) -β-hydroxybutyrate level >1.5 mmol/L has a sensitivity of 98-100% and specificity of 78.6-93.3% Ketosis differential: -DKA -Alcoholic ketoacidosis -Starvation ketoacidosis -Isopropyl alcohol ingestion Plasma glucose usually ≥14.0 mmol/L -Can be euglycemic DKA (eg. SGLT2, pregnancy, chronic pancreatitis, bariatric surgery), will need immediate dextrose infusion

Answer 140

Infection (30%) New diagnosis of diabetes (25%) Insulin non-adherence (20%) Infarction (ACS, CVA, mesenteric ischemia) Alcohol Trauma Medications (eg. glucocorticoids, diuretics, atypical antipsychotics) Abdominal pathology Pregnancy

Answer 141

Blood gas, including lactate Anion gap = [Na+] – [Cl−] – [HCO3−], if >10-12mEq/L consider elevated anion gap differential Serum osmolality (HHS) CBC, Chem-10 (Ca, Mg, Phos) LFTs, albumin, CK bhCG Capillary Ketones Serum ketones +/- serum beta-hydroxybutyrate level Urinary ketones (more false negatives and false positives) Consider Lipase (note can be increased by DKA) Infectious work-up UA Blood/urine cultures CXR EKG Troponin (only if EKG suggests ischemia) Serum ketons (β-hydroxybutyrate) if diagnosis unclear

Answer 142

ABC, vitals Fluid resuscitation Bolus NS 10mL/kg (or 1L) bolus IV If persistent tachycardia or hypoperfusion, repeat until euvolemic (HR<100) Maintenance See table below for rates in pediatrics In adults, eg. 0.9% NS 250mL/h x 4-6h then 0.45% NS 250mL/h (to avoid hyperchloremic metabolic acidosis Add IV dextrose when serum glucose <14.0 mmol/L (maintain glucose 12-14) eg. D5W 0.5%NS or D5W 0.45%NS If glucose <4, provide 1 amp of D50 and increase dextrose infusion Avoidance of hypokalemia Add KCl 40 mmol/L when serum K<5.0 mmol/L and patient has urinated (cardiac monitoring needed, caution in renal failure- ensure urine output) Consider oral potassium Magnesium/phosphate replacement as needed Insulin administration (avoid initially in HHS) Hold insulin if K<3.3 If mild-moderate DKA (pH 7.1-7.29, HCO3 5-14.9) After one hour of fluids, Humalog 0.15 Units/kg/dose (or 10 units) q2h If severe (pH<7.1, HCO3<5) After one hour of fluids, Humulin R infusion of 0.1 units/kg/h (0.05 units/kg/h for HHS) If glucose does not fall by 3mmol/L in first hour, check IV access and if normal consider doubling insulin Bolus may increase hypoglycemic events without clinical benefits If hypoglycemia give more glucose, do not stop insulin (to avoid more ketoacidosis) Avoidance of rapidly falling serum osmolality (risk of cerebral edema) Suspect cerebral edema if sudden headache, altered LOC and lethargy, irritability in young children, Cushing's triad (high BP, low HR, low RR) Manage ABC, raise head of bed 30 degrees, restrict fluid Consider mannitol 0.25-0.5g/kg IV over 30 mins OR hypertonic 3% NS 5-10mL/kg over 30 mins Search for precipitating cause (infection, drugs, thyrotoxicosis, adherence to medication, new diabetes, MI, stroke)

Answer 143

Repeat serum glucose q1h Repeat VBG (pH, electrolytes), plasma osmolality (for HHS) q2-4h until stable Anion gap = [Na+] – [Cl−] – [HCO3−] (may consider adjust for albumin with other more complicated formulas) Monitor for Osmolality Calculating osmolality Measure or calculate osmolality (2 [Na+] + [glucose] + [urea] in mmol/L) Aim for gradual decline, especially in patients under 40 years old (eg. 3 mmmol/kg/hr or 20mOsm/kg/day) If osmolality increase Fluid balance inadequate, increase rate of 0.9%NS Fluid balance adequate, consider switch to 0.45%NS If osmolality decreasing >8mosmol/kg/h, consider reducing IV fluids

Answer 144

Avoid overly aggressive therapy which will cause complications (hypokalemia, cerebral edema) Most patients with DKA (especially those with HHS) probably need admission and observation, DKA: Normalization of the plasma anion gap <12 mEq/L Ketoacidosis resolved Normalization of bicarbonate Glucose controlled <14 mmol/L HHS: Mentally alert, and osmolality <315 mOsmol/kg Patient eating and ideally hungry -Received full daily dose of long-acting insulin >2 hours (Consider SC insulin regimen once glucose <11.1)

Answer 145

Acute: 2-14 days of looser and more frequent stools (>3 stools/day or >200g stool/d) Parasitic - Giardia, cryptosporidia, cyclospora, isospora, amoebiasis Bacteria - Campylobacter, salmonella, shigella, listeria, C diff, S Aureus, Clostridium perfrigens Symptoms suggestive of invasive bacterial diarrhea include fever, tenesmus, gross bloody stool Viral - Hep A, rotavirus, norovirus Travel - ETEC, norovirus, shigella, salmonella, campylobacter, giardia Daycare - Campylobacter, cryptosporidia, parvum Hospital - C Diff, norovirus, rotavirus (children)

Answer 146

Chronic: >4 weeks Function - IBS (10-20%), overflow constipation, incontinence Osmotic - Lactose, sugars (sorbitol, mannitol), laxatives Inflammatory - IBD, microscopic/collagenous colitis Metabolic - Addison's, hyperthyroid, uremia, cystic fibrosis Malabsorption - Pancreatitis, celiac, short bowel syndrome, bacterial overgrowth Neoplastic - Colorectal cancer, carcinoid, gastrinoma, medullary thyroid Iatrogenic - Drugs, alcohol, caffeine, surgery, radiation, laxatives

Answer 147

Secretory: Continues despite fasting Osmotic: Decreases with fasting (malabsorption, drugs) Large Bowel: Small volume, frequent, pus, blood Small Bowel: Large volume, infrequent, watery

Answer 148

Travel Immunocompromised Food outbreaks Antibiotics Family History Laxatives

Answer 149

Age >50 (think of acute mesenteric ischemia, obstruction, diverticulitis, malignancy) Immunocompromised (HIV, steroid) Inflammatory features (fever, bloody, mucoid stool) N/V, fever, arthritis, skin rash, anorexia Night sweats, weight loss Nocturnal (pathologic) Recent antibiotics (C-diff)

Answer 150

Diarrhea onset, duration, severity, frequency, quality (watery, bloody, mucus, purulent, bilious) Signs of dehydration (decreased urine output, altered mental status) Vomiting (viral or toxin) Fever, tenesmus, bloody (invasive bacterial) Food/Travel Pregnant (12x risk of listeriosis - cold meats, soft cheeses, raw milk) Recent sick contacts, antibiotics, medications Immunosupression Exposures (daycare, fecal-oral sexual contact, hospital admission)

Answer 151

Usually not indicated unless severe illness or red flags Consider CBC, CRP, TSH, Celiac (IgA, anti-TTG) FOBT or FIT Stool leukocytes/lactoferrin/calprotectin (r/o IBD) Stool cultures if leukocytes positive or risk factor/red flag (eg. symptomatic bloody diarrhea) C-diff toxins A/B done if unexplained diarrhea after 3d of hospitalization or high risk (eg. antibiotic use) Ova and parasites if high-risk (travel to high-risk area, infants in day care, immunosuppresssed, MSM, waterborne outbreak, bloody diarrhea with few fecal leukocytes) If available, consider Giardia antigen test or PCR C-scope if altered bowel habit +/- rectal bleeding

Answer 152

Rehydration (oral if possible) Consider reduced oral rehydration solution (ORS): water with salt and glucose Early refeeding No clear evidence for BRAT diet (banana, rice, applesauce, toast) and avoidance of dairy Loperamide/simethicone in non-bloody stool and afebrile Consider empiric antibiotics in severe symptomatic bloody diarrhea or immunocompromised Fluoroquinolone or Azithromycin (if resistance, eg. from South East Asia) Antibiotics effective in shigella, campylobacter, C diff, traveler's diarrhea, protozoal Avoid use in toxin (bloody, history of eating seed sprouts, rare beef, outbreak) risk Hemolytic uremic syndrome

Answer 153

Hygiene (handwashing, diaper changing, water purification), safe food preparation, clean water Vaccine (rotavirus, typhoid fever, cholera) No clear evidence for probiotics, zinc supplementation Return to school ≥48h last diarrhea/vomiting (NICE)

Answer 154

Vertigo: Sustained (r/o stroke) vs. Episodic Non-vertigo: Syncope (r/o CVS, seizure, hypoglycemia) Pre-syncope (r/o CVS) Disequilibrium (r/o neuromuscular) Lightheadedness

Answer 155

Acute prolonged severe vertigo (Stroke, demyelinating disease, vestibular neuronitis) Recurrent spontaneous attacks, minutes-hours (Meniere, Vestibular Migraine) Recurrent positional, seconds-minutes (BPPV) Chronic persistent dizziness (Psychogenic, cerebellar ataxia) arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis measure postural vital signs to r/o orthostatism Exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) prescription and over-the-counter medications

Answer 156

Diplopia, Dysarthria, Dysphonia, Dysphagia, Dysmetria Multiple transient prodromal episodes of dizziness over weeks/months Headache, neck pain, recent trauma (vertebral artery dissection/aneurysm) Auditory symptoms (despite mimicking benign peripheral causes, hearing loss in acute vestibular syndrome is frequently associated with stroke) Neuro signs: Facial palsy, sensory loss, limb ataxia, hemiparesis, oculomotor (Internuclear ophthalmoplegia, gaze palsy, vertical nystagmus) Gait unsteadiness

Answer 157

Peripheral: Unidirectional, Horizontal nystagmus, Suppressible with visual fixation, Positional Central: Uni or Bi-directional, Purely vertical/horizontal/torsional nystagmus, Not suppressible, Not positional (ie. Central is usually Spontaneous)

Answer 158

HINTS+ only in Acute Vestibular Syndrome (to differentiate stroke from vestibular neuritis) in patients with current nystagmus Head Impulse - Rapid head rotation towards mid-line with eyes fixed on object (normal suggests central cause) Nystagmus - Vertical/bidirectional/torsional (note torsional is expected in episodic BPPV, but not in acute vestibular syndrome due to peripheral cause) Test of Skew - Skew deviation or misalignment on cover-uncover test Presence of one INFARCT (impulse normal or fast-phase alternating or refixation on cover test) may be more accurate to diagnose stroke than urgent MRI Negative INFARCT (abnormal head impulse, horizontal unidirectional nystagmus, no skew deviation), but may not be enough to rule out stroke in the emergency room + Hearing loss, rule-out AICA infarct If no nystagmus, will need to rely on detailed neurological exam (CN, hearing, anisocoria, phonation, facial sensation, cerebellar ataxia, gait)

Answer 159

EKG (r/o Arrhythmia, MI) CBC, Lytes, TSH (Low yield) MRI (83% sensitive), CT (16% sensitive) MRI can miss stroke (20% false negative) until 48h after symptom

Answer 160

General acute symptomatic management of vertigo: Antihistamines, Benzodiazepines, Antiemetics Peripheral (early ENT referral as needed, and vestibular rehab) BPPV (episodic seconds, head position) Epley maneuver Sermont maneuver Gufoni maneuver in horizontal canal BPPV Betahistine 24mg PO BID limited evidence Meniere's (episodic minutes-hours, hearing loss, tinnitus/ear fullness) Limit salt, caffeine, nicotine, alcohol Betahistine, Diuretic Vestibular neuritis and Labyrinthitis (single acute onset, lasts days, possible viral syndrome) Methylprednisone 22-day tapering dose schedule Supportive Central Vestibular migraine (episodic minutes-hours with migraine headache) Brainstem or cerebellar infarct (persistent over days-weeks, vascular risk factors, prominent gait impairment) or TIA (episodic minutes-hours, vascular risk factors) MRI Evaluation for Thrombolysis/Thrombectomy Secondary risk management Antihypertensives if BP >140/90 Aspirin or clopidogrel Atorvastatin 80mg/day (SPARCL trial) Carotid endarterectomy for recent symptom Holter-24-48h r/o Afib Echocardiography Lifestyle Glucose control if diabetic Eliminate alcohol, smoking Exercise Referral ENT, Neurology, Psychiatry Vestibular rehab PT/OT

Answer 161

Young female (<24yo) Low SES Pregnancy Disability Unemployment Witnessing or experiencing violence as a child Substance abuse (alcohol/drug use) History of mental illness

Answer 162

Unemployment Witnessing or experiencing violence as a child Substance abuse (alcohol/drug use) History of mental illness

Answer 163

In general, how would you describe your relationship? No tension, some tension, a lot of tension? Do you and your partner work out arguments with no difficulty, some difficulty, or great difficulty? Do arguments ever result in you feeling down or bad about yourself? Do arguments ever result in hitting, kicking, or pushing? Do you ever feel frightened about what your partner says or does? Does your partner ever abuse you physically? Does your partner ever abuse you emotionally? Does your partner ever abuse you sexually? Listen Acknowledge the injustice "This is abuse" "I am very sorry this is happening to you" Frame the violence due to perpetrator's behaviour and not the survivor's "You do not deserve this, and it is not your fault" Respect autonomy and patient's decisions "I want to help you through this in any way I can."

Answer 164

Violent outside the home Violent to children Threatening to kill Escalating threats Drugs, alcohol Abusive during pregnancy Obsessive, controlling relationships Serious prior injury Owns weapons, especially handguns Threatened others (family/friends)

Answer 165

Safety planning, resources, community services including local shelters Emergency kit with important documents, keys, money, essential items - stored outside the home Place to go (friend, family shelter) Signal to alert others (children/neighbours) to call 911 Document findings Quotes from patient Physical exam findings and photographs Labs/radiology Mandatory reporting may be required in the following instances: Abuse involving children Contact Youth Protection Abuse of elderly (in retirement home) Abuse of disabled persons Weapon use Frequent follow-up Counsel on possible escalation/cycles of violence (tension build up, violent outburst, honeymoon phase) Update safety plan

Answer 166

Restriction of energy intake relative to requirements, leading to a significantly low body weight (BMI<18.5 or <5th percentile in children, or rate of weight loss) in the context of age, sex, developmental trajectory, and physical health. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Answer 167

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Answer 168

Recurrent episodes of binge eating, characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Answer 169

An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements. Marked interference with psychosocial functioning. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

Answer 170

Does your weight/body shape cause you stress? Recent weight changes? Dieted in the last year? SCOFF Do you make yourself Sick (induce vomiting) because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? Have you recently lost more than One stone (14 lb {6.4 kg}) in a three-month period? Do you think you are too Fat, even though others say you are too thin? Would you say that Food dominates your life?

Answer 171

Early puberty Poor or abnormal growth curves in children and adolescents Low or high body mass index, or weight fluctuations Weight concerns among normal weight individuals Activities and occupations that emphasize body, shape, and weight (e.g. ballet, gymnastics, modeling) Amenorrhea (primary or secondary) Type 1 diabetes Family history of ED

Answer 172

Exertional or chronic fatigue, weakness, dizziness, pre/syncope, hot flashes, cold intolerance, depression Cardio: Palpitations, CP, SOB, peripheral edema Dental: Tooth pain (decay/cavities), mucosal bleeding/trauma and parotid gland enlargement GI: Abdominal pain, early satiety, bloating, constipation Endo: Amenorrhea, decreased libido, infertility Derm: Hair loss, brittle nail and skin changes, poor healing (other questions to ask: Rate/amount of weight loss Dietary intake (quantity, restriction) Compensatory behaviour (vomiting, laxatives, diuretics, exercise) Attitudes about weight / Body image Mood symptoms, suicidality Menstrual history)

Answer 173

Vital Signs (eg. HR<60, BP<90/60, Temp<36) Orthostatic vitals (supine, standing) General Appearance Height/Weight and BMI; weight in kilograms divided by height in meters squared Hydration status HEENT Enlargement of parotid or submandibular salivary glands in BN Dental erosion due to frequent vomiting Cardiac, r/o murmur Skin Brittle hair and fingernails Lanugo hair Dry skin Pretibial edema Russell sign (callous on MCP from teeth abrasion during self-induced emesis) MSK Muscle strength Sit-up Squat Stand test (muscle weakness)

Answer 174

Determine level of medical acuity EKG Bradycardia, non-specific ST-T wave changes including ST segment depression, U waves in the presence of hypokalemia and hypomagnesemia CBC (hemoglobin, leukocytes, platelets) Serum electrolytes (Na, K, Glucose, Blood urea nitrogen, Creatinine, Calcium, Magnesium, Phosphate) TSH, T4, T3 Liver function tests (AST, ALT, bilirubin) Amylase/lipase Albumin, transferrin UA BhCG r/o pregnancy Consider celiac screen If underweight > 6 months Bone densitometry to assess for osteopenia and osteoporosis Abdominal ultrasound to assess maturity of ovaries and uterus FSH, LH, and estradiol levels in females Testosterone levels in males

Answer 175

Suicide risk, food refusal Vitals unstable Core temperature < 35.5°C or 95.5°F Heart rate < 40 beats per minute or severe bradycardia Blood pressure < 90/60 mm Hg or orthostatic hypotension ECG arrhythmia Electrolyte abnormalities Sodium < 127 mmol/l Potassium < 2.3 mmol/l Hypoglycaemia; blood glucose < 2.5 mmol/l Hypophosphataemia; phosphorous below normal on fasting Magnesium < 0.6 mmol/l (normal above 0.7 mmol/l) Rapid and progressive weight loss Acute medical complications of malnutrition Signs of inadequate cerebral perfusion (confusion, syncope, loss or decreased level of consciousness, organic brain syndrome, ophthalmoplegia, seizure, ataxia) Seizure Heart failure Pancreatitis Severe acrocyanosis Dehydration that does not reverse within 48 hrs Muscular weakness Comorbid psychiatric or medical (poorly controlled diabetes type 1) Pregnancy with an at risk foetus Inadequate weight gain, failure of outpatient treatment

Answer 176

SSRI / Fluoxetine at higher doses (60mg/d) in BN Multivitamins with iron and Vitamin D Consider Zinc 50mg PO daily (aids in weight gain) Treat acne (as patient re-experience puberty as they gain weight)

Answer 177

SSRI / Fluoxetine at higher doses (60mg/d) in BN Multivitamins with iron and Vitamin D Consider Zinc 50mg PO daily (aids in weight gain) Treat acne (as patient re-experience puberty as they gain weight)

Answer 178

Medical stabilization Assess outpatient vs. admission if needed for safety Assess and treat coexisting psychiatric conditions (MDE, anxiety, substance use) Nutritional rehabilitation with multidisciplinary approach Family-based treatment Individual Psychotherapy, FBT/CBT (TRY THIS FISRT) Psychiatry Dietician / nutritional rehab School Support groups / resources Consider referral to specialiset child and adolescent eating disorder team Target weight range in AN (90% of expected weight) Gradual weight gain in AN (1lb/week) Limit exercise Regular appointments with vitals, weight/BMI, and blood tests repeated Complications (tooth decay, amenorrhea, electrolyte) Disease activity (eating patterns, exercise, laxative)

Answer 179

Establishing rapport: Open-ended questions such as, “How have things been going with your eating?” or “Do you have concerns about your eating?” or “What is most important to you about your eating and health?” Assessing Readiness: “How do you feel about making changes to your eating?” or “How do you feel about making changes to improve your physical health?” Provide Feedback: “What is your reaction to these test results?” or “Would more information be helpful?” Offer further support targeted to level of readiness for change: For clients who are not “ready” to make change: “What would it take for you to consider thinking about change?” For clients who are unsure about change: “What are the things you like and don’t like about your eating disorder?” For clients who are ready to make change: “What would you like to work on changing?”

Answer 180

Metabolic changes during refeeding of a malnourished patient Risk of hypophosphatemia leading to heart failure, arrhythmia, respiratory failure Prevent with careful slow refeeding/monitoring and phosphate supplementation

Answer 181

anorexia nervosa, bulimia,Avoidant/Restrictive Food Intake Disorder (ARFID) diabetes, coeliac disease, hyperthyroidism, malignancies, depression, anxiety, OCD< alcohol misuse/depensdance

Answer 182

Eating patterns, relationship with food, body image, distress Underlying mental health, alcohol, and substance use problems, including previous psychological trauma Use of prescribed and over-the-counter medications, tobacco, caffeine, laxatives, and supplements

Answer 183

amenorrhea, electrolite imbalance, muscle weakness, spinal compression/osteoporotic fractures, decreased height/weight, slow pulse, depreased core temperature, postural hypotension, gastric dilation, pressure sores, depression/SI, cardiac arrythmia, prolonged QTc, sinus bradycardia, signs of electrolyte disturbance on EKG malnutrition: -anemia, thrombocytopenia, neutropenia, hypophosphataemia, low ca/mg/po4, hypoglycemia,

Answer 184

Chronic, relapsing dermatitis Typical morphology of the lesion: erythematous, rough/scaly, patchy Pattern of distribution: facial and extensor involvement, joint surfaces Pruritus/ Intense itching Personal history of asthma Personal history allergic rhinitis Family history of atopy Hyperactivity to environmental triggers Age of onset (most common age 2-4)

Answer 185

Psoriasis Seborrheic dermatitis Contact/irritant dermatitis Impetigo Systemic viral illness Neurodermatitis Dermatitis herpetiformis Dermatophytic infection Immunodeficiency disorder

Answer 186

Avoid dry skin / Optimal use of emollients/moisturizer Topical corticosteroid cream/ointment Avoidance of known triggers: soaps, fabrics, cleansers, metals, sweat/heat, sunscreens, stress Topical calcineurin inhibitors/protopic/tacrolimus Antimicrobial if infected Oral anti-histamine for pruritus

Answer 187

Non-alcoholic fatty liver disease/steatohepatitis (NASH) - recommend do not abbreviate this Chronic alcohol use/alcoholic liver disease medication toxicity/prolonged acetaminophen use hemochromatosis autoimmune hepatitis Wilson’s disease Alpha-1-anti-trypsin deficiency Primary biliary cirrhosis

Answer 188

1. Blood exposure/blood transfusion/direct contact with infected blood/Sharing personal hygiene products (razors, nail clippers, toothbrushes, jewelry)/Intravenous drug use/needle sharing/needlestick injuries 2. Sexual/unprotected sex/semen/vaginal secretions 3. Perinatal/vertical transmission/trans-placental 4. Exposure to open sores of an infected person

Answer 189

cirrhosis end-stage liver disease/liver failure hepatocellular carcinoma

Answer 190

HBeAg ALT AST Hepatitis B DNA abdominal ultrasound Fibroscan Biopsy This is a tough one. The question states there is no doubt about the diagnosis and wants to know how we assess the phase of chronic infection. That is why Hep B core antibody, Hep B IgG and Hep B IgM are not on the answer key.

Answer 191

Acute Cholecystitis /Cholecystitis /Biliary colic

Answer 192

Choledocholithiasis/Jaundice/Biliary obstruction Hydrops Empyema Emphysematous cholecystitis Duodenal perforation Gallstone ileus Pancreatitis Hepatitis Ascending cholangitis Peritonitis/Perforation of the gallbladder/Necrosis/Gangrene Sepsis This question only asks for three answers. The exam could ask for more. Use this answer key as a study guide

Answer 193

Endoscopic retrograde cholangiopancreatography (ERCP) Hate to say this, but better to write out "Endoscopic retrograde cholangiopancreatography" than to rely on "ERCP" alone as your answer. It is possible that ERCP is acceptable, but since answers keys are not released, it's hard to know for sure.

Answer 194

White blood cell count (WBC) Total Bilirubin Alkaline phosphatase Lipase International Normalized Ratio (INR)/ Prothrombin time (PT) measurement Partial thromboplastin time (PTT) GGT Alanine transaminase (ALT)

Answer 195

bladder changes/retention bowel changes/incontinence saddle anesthesia radiation pattern severity quality of pain timing of pain/is it worse at night aggravating factors: for example, is it worse with certain movements alleviating factors: for example, positional changes associated features: rashes associated features: eye/vision changes is he taking pain killers?/need for analgesics radicular symptoms: leg weakness radicular symptoms: sensory changes morning stiffness changes in sexual function/erectile dysfunction One buzzword in this question is "other". It is subtle, but it means you cannot use historical items from the preamble as answers. For history questions, most of them will relate to the history of present illness (HPI), which means that past medical history, surgical history, allergies etc are not what the question is looking for. Read the question carefully. Using a mneumonic to help you remember an approach to HPI questions can be helpful, such as OD PQRST AA. O - onset; D- duration; P - pain, Q - quality, R - radiation, S - severity, T - timing; A - associated features (rash/GI/eye etc), A - aggravating and alleviating factors. Or use another system if you have one.

Answer 196

recommend physical activity/exercise/core strengthening encourage walking education about self-limiting nature of most cases of back pain education: avoidance of bed rest symptomatic strategies: heat/cold encourage weight loss (goal of 10% of body weight) ergonomic assessment at work As per guidelines, most causes of low back pain are self-limiting. The guideline in the links document suggests not referring for physiotherapy or chiropractic right away, but rather waiting for natural resolution of symptoms before embarking on formal therapy. Since there are no red flags identified in this case, expectant management as above is indicated.

Answer 197

Tylenol/acetaminophen ibuprofen/Advil cyclobenzaprine/Flexeril

Answer 198

Acceptable answers: lumbar x-ray AP and lateral (oblique not required given no pain with extension so you are not worried about a pars interarticularis fracture) Imaging may be considered now because his symptoms have become chronic.

Answer 199

Autism spectrum disorder Child abuse Rett’s syndrome Hearing problems

Answer 200

Gross Motor Fine Motor Speech/language Social/emotional Cognitive/problem solving

Answer 201

Social/emotional speech/language

Answer 202

inability to participate in social/emotional interactions deficits in nonverbal communication: no/limited understanding of gestures/body language poor eye contact difficulties in developing relationships evidence of repetitive movements evidence of repetitive speech inflexibility/adherence to routines restricted/fixated interests Altered/Hyper-/hypo-reactivity to sensory input

Answer 203

selective serotonin re-uptake inhibitors (SSRI) atypical anti-psychotics anticonvulsant mood stabilizers stimulants alpha 2 antagonist (mirtazapine) melatonin

Answer 204

selective serotonin re-uptake inhibitors (SSRI) atypical anti-psychotics anticonvulsant mood stabilizers stimulants alpha 2 antagonist (mirtazapine) melatonin

Answer 205

1. type and crossmatch for 2-4U of packed red blood cells 2. Two large bore IVs with 1L normal saline running in each 3. 100% oxygen by rebreather mask

Answer 206

Hemoglobin Hematocrit Platelet count PT/INR PTT Bleeding time

Answer 207

Little's area/anterior inferior nasal septum/Kisselbach's plexus

Answer 208

Hemophilia A, Hemophilia B, Von Willebrand's disease

Answer 209

von Willebrand disease

Answer 210

fresh frozen plasma/cryoprecipitate, tranexamic acid, DDAVP

Answer 211

packing with petrolatum gauze packing with lidocaine soaked in epinephrine packing with cocaine packing with sponge/merocel/nasaspore packing with hemostatic balloon

Answer 212

toxic shock syndrome acute sinusitis bacterial rhinitis putrefication of packing

Answer 213

Acceptable answer: 150-200mg/kg (anywhere within this range) You will not be asked many numbers on this exam, and usually the answer will only be worth 1 point, so not enough to make you fail the case if you get it wrong. Most number-related answers will accept a range. If one of your two numbers is outside the range, you risk being marked wrong, so the safest approach is to give a specific number rather than a range.

Answer 214

Acceptable answer: 1-2 hours (anywhere in this range)

Answer 215

Lithium, lead, solvents, iron, alcohols, hydrocarbons, potassium, pesticides, alkali, acids There are mnemonics to help remember this list. It is unlikely that any question will ask you for the whole list.

Answer 216

diaphoresis, vomiting Poisoning pearls: Know indications for dialysis (AEIOU), causes of anion gap (MUDPILES) Other poisonings/toxidromes to review: alcohol, opioids, TCAs, anti-cholinergics, cholinergics, ASA, hallucinogens (unlikely to show up on the exam), sedatives, sympathomimetics (ie cocaine: more likely to show up on the exam), salicylates, serotonin syndrome, benzodiazepines, dilantin, carbamazepine Some years there are a couple of poisoning questions, and other years none. Best to prepare to that you will get at least one.

Answer 217

aspartate aminotransferase (AST) alanine aminotransferase (ALT) international normalized ratio (INR) partial thromboplastin time (PTT) Alkaline phosphatase gamma glutamyltransferase (GGT) total bilirubin direct bilirubin serum albumin serum creatinine serum sodium serum bicarbonate serum phosphate serum glucose serum lactate (via arterial blood gas) serum/arterial pH (via arterial blood gas) Arterial blood gas is considered a grouped test and is never an answer on this exam. Choose the part of the ABG that you want, and use that as your answer. In this question, I recommend not populating all six of your answers with liver tests. Choose the most important two or three.

Answer 218

Bacterial pneumonia Viral pneumonia Influenza COPD exacerbation Acute bronchitis The reference to Covid-19 vaccination status is meant to communicate that this is most likely NOT Covid-19 infection. Users have asked whether "asthma exacerbation" could be an answer, but this is less likely as he has no history of asthma, and this diagnosis doesn't explain his fever. The way the question is worded, it is pointing to an infectious cause. It is hard to know whether each answer should be a different type of infection (ie mycoplasma pneumonia, streptococcal pneumonia etc) or whether the answers should be more broad. Specific types of pneumonia could populate all four answers, but you don't want to exclude reasonable options such as COPD and acute bronchitis. Therefore, in this case, the recommendation is to stay broad and use categories of viral vs bacterial pneumonia only.

Answer 219

serum white blood cell count and differential chest x-ray, PA and lateral serum hemoglobin serum creatinine serum sodium Sputum cultures are rarely helpful and therefore are rarely collected in pneumonia. The culture takes at least a week and sometimes two to come back, by which time the information is usually irrelevant. Additionally, the patient is not sick enough for blood cultures (usually the patient would be admitted and septic). See the links document for exam 2 for more information.

Answer 220

diminished chest expansion increased tactile fremitus increased vocal fremitus/vocal resonance dullness on percussion diminished air entry on auscultation bronchial breath sounds whispering pectoriloquy crackles pleural rub egophony bronchophony

Answer 221

doxycycline amoxicillin or amoxicillin/clavulanate (clavulin for comorbidities - smoking could be considered a comorbidity) azithromycin/clarithromycin/erythromycin Note: 1st line use of fluoroquinolone not recommended Canadian guidelines in this area are old. In general, newer resources (such as Bugs and Drugs) are steering away from macrolides as a first-line choice due to mounting resistance. Having said that, macrolides still make the list as a first-line option with a caveat to avoid in areas where there is evidence of mounting macrolide resistance. Macrolides are still recommended for inpatient or severe pneumonia. Here is a link to an American guideline (which I usually do not prefer to recommend) which is far newer than anything we have in Canada. See table 3. Let's hope the exam only asks for TWO answers. In that case, it's easy: amoxil and doxy in healthy patients; clavulin + doxy or clavulin + azithro in patients with co-morbidities.

Answer 222

NO side: You would not admit him because he doesn’t meet criteria as per the PSI /Curb-65 score. Not hemodynamically compromised. Other than smoking no active significant co-morbid conditions. No hypoxemia (considered to be 02 sat <90%). You may also explain answer using Curb-65, but PSI has been validated whereas Curb-65 has not been. However, PSI has higher specificity than Curb-65 YES side: You may get points as long as you explain your rationale: ie he appears septic. Then support why you feel that he is septic. You will not be asked to regurgitate the Curb 65 or PSI criteria on the exam, but you may be asked to make a decision that utilizes the scores so you should memorize one of them (Curb 65 much easier to memorize than PSI). On this question, most previous exam writers have answered NO.

Answer 223

6-8 weeks (any answer in this range is acceptable)

Answer 224

smoking cessation avoidance of 2nd hand smoke limit the spread of viral infections/handwashing/hand hygiene annual flu shot pneumococcal vaccine

Answer 225

migraine, migraine headache, migraine without aura, classic migraine

Answer 226

regular sleep/optimize sleep regular meals regular exercise: 30 mins/day 5d/wk to goal of 150mins/wk aerobic activity stress management avoid dietary triggers (ie. caffeine, MSG, chocolate, alcohol) stay well hydrated avoid analgesic overuse (>9d/month)

Answer 227

aspirin, ibuprofen, naproxen (or any other NSAID) metoclopramide sumatriptan (or any other listed triptan) acetaminophen intravenous fluids/normal saline

Answer 228

amitriptyline/nortriptyline divalproex/valproic acid propranolol/metoprolol/nadolol topiramate gabapentin candesartan lisinopril verapamil/flunarizine pizotifen venlafaxine B-blockers and TCAs are considered first line. Some resources indicate that anti-convulsants are also first line, but there is not general consensus on this, so if they ask for classes of meds, stick with TCAs and B-blockers as preferred classes, and anti-convulsants next, followed by CCB/ACEI. Botox is recommend for prophylaxis when there are over 15 headache days per month, as per Headache Society of Canada. Since botox is not an oral medication, it is not an answer for this question. If the question reads, "What pharmacologic agents could you use for prevention?" then botox is an answer. There are newer injectable immunologic agents (Aimovig) that are also gaining popularity. Again, these are injectable agents so not on this answer key

Answer 229

Butterbur Magnesium Vitamin B2/riboflavin Coenzyme Q10

Answer 230

Red flags include recent onset, rapidly increasing frequency and severity of headache; headache causing the patient to wake from sleep; associated dizziness, lack of coordination, tingling or numbness, new neurologic deficit; new onset of a headache in a patient with a history of cancer or immunodeficiency; new headache disorder in patient over 50. "The yield of neuroimaging in patients with typical recurrent migraine attacks is very low. Any imaging study, particularly MRI, can identify incidental findings of no clinical significance which may lead to patient anxiety and further unnecessary investigation. For patients with typical migraine and a normal clinical examination who desire reassurance, careful explanation of the diagnosis and patient education may be more advisable." - Choosing Wisely

Answer 231

Height, weight, head circumference (WHO Canadian Growth Chart) Correct percentiles if born <37w until 2-3yo Max 10% weight loss by 4-5d, regain birthweight by 2w 30g/d until 3 mo, 20g/day until 6 mo, 10g/day until 12 mo Double BW by 4mo, triple BW by 1y

Answer 232

Recommended at 1 week, 2 months, 4 months, 6 months, 12 months, 18 months, 4-5 years

Answer 233

Posterior closed by 2mo, anterior closed by 18mo

Answer 234

Hip exam until walking 0-3 months: Ortolani, Barlow >3 months: Limited hip abduction, Galeazzi

Answer 235

6 months (4-12 months) Refer if undescended (palpable, ectopic, nonpalpable) at 6 months Consider earlier if ascended testis, bilateral nonpalpable, or associated hypospadias/ambiguous genitalia Ultrasound not recommended as unhelpful Retractile testis can be followed until puberty

Answer 236

Decrease Penile cancer (NNT 900-322,000) Phimosis (NNT 67) UTI (NNT 111) HPV (NNT 5), HIV (NNT 298), HSV (NNT 16) Decrease cervical cancer and STI in partner

Answer 237

Surgery risks: Infection (NNH 67), bleeding (NNH 67) Meatal stenosis (NNH 10-50) Ethical concerns Contraindicated: Hypospadias

Answer 238

Exclusive breastfeeding recommended for first 6 months and continued into second year of life Breastfed babies should receive Vitamin D 400 units PO daily Vitamin D 800 units daily if high risk (limited sun exposure, darker skin, obesity) Express breast milk can refrigerate up to 3d and freeze up to 6mo Warm milk by placing in warm water Switch from formula to homogenized milk at 500-750 mL/day at 12 months Discontinue bottle by 18 months Transition to 1-2% milk (500mL/day) at 2-3 years

Answer 239

No evidence to delay food beyond 6-12 months Introduce foods one at a time q3d (monitor for reactions) Avoid solid round smooth dry/sticky foods risk of choking Avoid sugary food/drinks No beets, carrots, spinach, turnips before 6 months (nitrates) No honey in first year Inquire about vegetarian diets Iron-containing foods should be encouraged when introducing solids Iron-fortified cereals and grain products Consider screen at 6-12mo for anemia in at-risk (eg. low SES)

Answer 240

Safe crib (no soft objects/loose items, firm mattress) On Back Room sharing for <6 months Pacifier if <6 months Avoid bed sharing (consider bed box)

Answer 241

Rear-facing car seat -Infant must use rear-facing car seat -Use a larger seat once baby outgrows infant seat, and keep rear facing until at least 2 years of age or reaches the maximum weight or height limit of the rear-facing seat, as stated by the manufacturer Forward-facing car seat with a 5-point harness -Once child outgrows larger rear-facing seat and is at least 2 years old, use 5-point harness seat until at least 18kg (40lbs) and can sit straight/tall without moving out of position or unbuckling (this may be 4-6 years old) Booster seats with belt-positioning -When child has outgrown forward-facing car seat with a 5-point harness, use a booster seat until 145cm (4'9") tall and they safely fit in adult seat belt without slouching (for most children this is 9-12 years old) Rear seat with adult seatbelt until 13 years old

Answer 242

Acetaminophen 10-15mg/kg/dose q4-6h Ibuprofen 4-10mg/kg/dose q6-8h in >6mo Avoid OTC medication (especially if using acetaminophen/ibuprofen)

Answer 243

Mothers should breastfeed when infant shows signs of hunger or q4 hours (8-12 feeds in first 24h, which decreases slowly to seven feeds per day by 1-2 months) Infant should urinate one void per number of days of life until 6-8 times daily by day 5 Suspect inadeqaute milk intake if >7% weight loss or if the infant does not regain their weight by 2w

Answer 244

Inadequate milk production -Breast development (previous surgery, radiation, endocrine -prolactinoma) -Delay in lactogenesis within first 5d -Usually due to obesity, hypertension, PCOS -Medications (oxytocin, SSRI, estrogen) -Offering only one side per feeding Poor milk extraction -Infrequent feeding -inadequate latch-on -Maternal-infant separation -Use of supplemental formula

Answer 245

Trauma Vasoconstriction Engorgement/Excessive milk supply Plugged ducts Infection Dermatitis/psoriasis

Answer 246

Proper positioning and latch Support breast with hand in shape of "C" (fingers under breast, thumb on top) Place baby's chin below areola Top and bottom lips wide open Lower lip turned outward against breast Chin touching breast, nose close to breast Full cheeks Re-try latch if discomfort, noisy sucking, does not swallow rhythmically If unable to get proper latch, consider pumping with expressed breastmilk until problem is addressed Lactation consultant No data for galactogogues (domperidone, metoclopramide, fenugreek) over breastfeeding technique interventions Cool or warm compresses, breastmilk to nipple

Answer 247

Antibiotic ointment (bacitracin or mupirocin) on cracked nipples to prevent infection and form a barrier All Purpose Nipple Ointment (APNO) Mupirocin ointment 2%: 15 grams Betamethasone ointment 0.1%: 15 grams Miconazole powder added to a concentration of 2% miconazole Total ~30g, Apply sparingly after each feeding. Do not wash or wipe off.

Answer 248

Natural weaning or “child-led weaning” happens when your baby starts to accept more—and different types—of solid foods while still breastfeeding on demand. With this type of weaning, you watch your baby’s cues and wean at their pace. Babies who are weaned naturally usually stop breastfeeding completely sometime between 2 and 4 years of age. Planned weaning or “mother-led weaning” happens when mothers decide to start the weaning process. A “partial wean” means substituting one or more feedings with a cup or bottle and breastfeeding at other times. This can work well if you are going back to work or school, but still want to breastfeed. Early morning, evening and night feedings can continue even if you are separated from your baby during the day.

Answer 249

follow baby cues do it gradually start by substituting one feed and continue this way hold and cuddle your baby: never prop a bottle watch the cues you give to your baby

Answer 250

-explain that Vaccines are made with a tiny amount of dead or weakened germs. They help the immune system learn how to protect itself against disease. Vaccines are a safe and effective way to keep your child from getting very sick from the real disease. -consequences of not vaccinating: congenital rubella, death, possible complications of preventable disease -no third world country travel

Answer 251

depends on each province.

Answer 252

Young Male Low SES History of violence Legal history History of physical abuse Substance use disorder Mental illness Victimization

Answer 253

hypoxemia/hypoxia, hypoglycemia, neurologic disorder (injury, hemorrhage, cva, seizure), schizophrenia, infection (meningitis, encephalitis, sepsis), metabolic (hyponatremia, hypoglycemia, thiamine deficiency, hypercalcemia), hyper/hypothermia, liver/renal failure, withdrawal (alcohol, benzodiazepine), medication/substance (amphetamine, steroids, alcohol), psychiatric

Answer 254

CBC, electrolytes (glucose), LFT, renal function Blood alcohol level, urine drug screen UA, urine culture CT head +/- LP

Answer 255

Consider personal safety at all times Never turn back to individual (don't walk ahead of patient) Ensure adequate personal space Ensure access to personal duress alarm Ensure you have a safe escape route Remove dangerour objects Consider safety of other patients and visitors Place patient in quiet secure area, inform other staff

Answer 256

Empathic nonconfrontational approach, but set boundaries Address agitation directly (name the emotion) Listen to the patient, avoid excessive stimulation Recruit family, friends, case managers to help Address medical issues (pain, discomfort) Ascertain the patient's wishes and the level of urgency

Answer 257

Prevent harm to patient/other patients/caregiver/staff Prevent serious damage to the environment Assist in assessment and management of patient Never use restraints for convenience

Answer 258

Benzodiazepines (avoid in elderly) Diazepam 5-10mg PO/IV (max 30mg per event) Lorazepam 2mg (max 10mg in 24h) Midazolam 5-10mg IM (max 20mg per event) Short-acting, rapid sedation (peak in 10mins, lasts up to 2h) Antipsychotics Olanzapine 5-10mg oral (max 30mg per event) Quetiapine 25-200mg PO Risperidone 0.25-2mg PO/SL Haloperidol 5-10mg IM (max 20mg per event) Risk of dystonia Acute dystonia - Benztropine 2mg PO or IM or IV

Answer 259

Comorbid medical disorders (CAD, Hypothyroidism) Comorbid psychiatric disorders (anxiety, substance use) Chronic pain Low SES Postpartum

Answer 260

Hospitalization vs. close outpatient follow-up Emergency psychiatric consultation and in-patient treatment if unsafe to self/others If low risk of suicide, consider safety plan*** -Keep home environment safe (remove access to weapons) -Recognize early warning signs -Coming up with ways to cope personally with suicidal thoughts -Identify people to contact for help/distraction -Identify place to go to for safety (eg. hospital) **provide specific instructions for follow up Consider psychiatric referral for substance use disorder or psychiatric comorbidity (bipolar, anxiety, personality) Persistent subthreshold depressive symptoms or mild-moderate depression -CBT, CCBT (computerized), structured group physical activity program Drug treatment if -Past history of moderate/severe depression -Long period (>2y) of subthreshold depressive symptoms -Persistent symptoms after other interventions -Moderate/severe depression in combination with CBT or IPT

Answer 261

≥ 5 (with depressed or decreased interest) for >2w with change in functioning Depressed mood most of the day Sleep Interest Guilt Energy Concentration Appetite Psychomotor agitation/retardation Suicidal ideation

Answer 262

Bipolar (≥1w of energy/activity with ≥3 GST PAID) Depressive disorder due to another medical condition Persistent Depressive Disorder (>2y of 2SIGECAPS, with no MDE) Adjustment disorder with depressed mood (stressor <3mo, resolves in <6mo) Grief reaction (loss, usually <3mo) Schizoaffective Anxiety ADHD

Answer 263

Adrenal insufficiency, hypercortisolism, hypothyroidism, Mononucleosis, Multiple sclerosis, Huntington disease, Parkinson disease, systemic lupus erythematosus Obstructive sleep apnea Stroke, traumatic brain injury Vitamin B12 insufficiency Medication: Corticosteroids, interferon, antiretrovirals Substance-induced

Answer 264

CBC (anemia), electrolytes (creat), TSH, B12/folate, LFTs B-hCG UA, urine toxicology EKG (QT) Neuroimaging if focal neurological sign or elderly

Answer 265

SADIPERSONS Sex (male) Age>60yo Depression Previous attempts Ethanol abuse Rational thinking loss (psychosis) Suicide in family Organize plan No spouse/support Serious illness/pain

Answer 266

Passive vs. Active ideation Plan (time/place), Intent (would you actually carry out this plan) Past Attempts (Practiced/Aborted) Access to means Provocative/Protective factors

Answer 267

Regular exercise, adequate food, housing, sleep Stress management (mindfulness-based stress reduction, engaging in ≥1 pleasurable activity per day) Avoiding substance abuse

Answer 268

Cognitive behavioural therapy Interpersonal psychotherapy Behavioural activation Group (less effective than individual but lower costs)

Answer 269

Side effects: Nausea (21%), xerostomia (20%), diaphoresis (20%), drowsiness (18%), insomnia (15%), sexual dysfunction (up to 50%), weight gain, headache

Answer 270

Serotonin syndrome, suicidality, upper GI bleed, osteoporosis, hyponatremia, prolonged QT

Answer 271

Acetaminophen and ASA also consider attempted suicide in patients with trauma

Answer 272

Use objective scales (eg. PHQ-9) to monitor improvement -If >20% improvement at 2-4w continue treatment and reassess at 6-8w -If <20% improvement at 2-4w ---Increase dose ---Switch to another medication: Consider Escitalopram, Mirtazapine, Sertraline, Venlafaxine ---Adjunct/Augment (if ≥ 2 antidepressant trials, well tolerated, partial response, specific symptoms to target, less time to wait (severe, functional impairment), patient preference) -Consider Aripripazole, Quetiapine, Risperidone -Other options may include lithium, thyroid hormone

Answer 273

Consider Aripripazole, Quetiapine, Risperidone Other options may include lithium, thyroid hormone

Answer 274

Maintenance until 6-9 months minimum after remission -Consider 2y minimum especially if high risk (frequent/recurrent episodes, severe, chronic, comorbid, residual symptoms, difficult to treat) Discontinuation by slow taper over weeks

Answer 275

-Symptoms include FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal) -Typically resolves in 1-2 weeks

Answer 276

Neurostimulation -Repetitive transcranial magnetic stimulation (rTMS) if failed ≥1 antidepressant ECT if severe (active suicidal ideation), psychotic, treatment-resistant -Consider in medication intolerance, catatonic features, rapidly deteriorating physical status (eg. malnutrition due to food refusal) Complementary: Light therapy (phototherapy) -10,000 lux for 30 minutes per day during early morning up to 6 weeks (response usually within 3 weeks) -Consider especially in seasonal, shift work, sleep dysregulation Acupuncture Sleep deprivation (total for 40h or partial allowing 3-4h of sleep per night, employed 2-4 times over one week) Natural health products St John's Wort (care for medication interactions) Omega-3 fatty acids (3-9g/day) or 1-2g of EPA + 1-2g of DHA per day SAM-e Zinc Social skills training, vocational rehabilitation

Answer 277

First line CBT/IPT or internet-based psychotherapy Second line Level 1 evidence: Fluoxetine Level 2 evidence: Escitalopram, sertraline, citalopram

Answer 278

Pregnancy/Breastfeeding First line CBT/IPT Second line Citalopram, escitalopram, sertraline

Answer 279

Most antidepressants not linked to major congenital malformations Paroxetine: CV malformations (OR 1.5) Fluoxetine: Small increase in congenital malformations Very modest link for spontaneous abortion (OR 1.5) , 4-day shortened gestational duration and reduced birth weight (74g) Exposure to antidepressants in breastfed infant is 5-10 times lower than in utero Sertraline has lowest relative infant dose (milk-to plasma ratio)

Answer 280

First line Desvenlafaxine CBT

Answer 281

Level 1 evidence: Duloxetine, mirtazapine, nortriptyline Level 2 evidence: Buproprion, citalopram/escitalopram, desvenlafaxine, sertraline, venlafaxine, vortioxetine

Answer 282

hypothyroidism/thyroiditis

Answer 283

weight gain fatigue Hypoventilation Intolerance to cold Slow HR tongue swelling Infertility Menorrhagia memory impairment Mood change: (depression) Constipation dry, thickened skin (previously, this answer said cold, clammy skin, which is more likely for hyperthyroid rather than hypo) course hair brittle nail Paresthesia periorbital edema goitre myalgias delayed reaction phase of deep tendon reflexes

Answer 284

TSH Free T4 Hemoglobin Mean corpuscular volume low density lipo-protein (because a high TSH can cause high LDL) serum creatinine ferritin

Answer 285

0.05 - 2.0 ug/kg (FYI: standard starting dose is 1.6ug/kg - this is the safest option for the exam, unless your patient is old with co-morbidities, then you would start lower. Also, a question asking for this dose would be unusual on the exam.)

Answer 286

Depression Decreased mental function Physical tiredness Paresthesia Hypokinesis Hyporeflexia Weight gainA Coarse, dry skin Periorbital edema Hoarseness Bradycardia Isolated diastolic hypertension Goitre Diminished sweating Cold intolerance Constipation Menorrhagia

Answer 287

Anxiety, irritability, restlessness Fatigue, restless sleep Increased appetite Decreased attention span Tremors Proximal muscle weakness Hyperreflexia Weight loss Hair loss Palpitations, tachycardia Atrial fibrillation Isolated systolic hypertension Goitre Increased sweating Heat intolerance Blurred or double vision Dry eyes, conjunctivitis, proptosis or dysconjugate gaze Increased frequency of stools Amenorrhea/oligomenorrhea

Answer 288

Risk factors for thyroid disease include1: men: age ≥ 60 years2 women: age ≥ 50 years2 personal history or strong family history of thyroid disease diagnosis of other autoimmune diseases past history of neck irradiation previous thyroidectomy or radioactive iodine ablation drug therapies such as lithium and amiodarone dietary factors (iodine excess and iodine deficiency in patients from developing countries); or certain chromosomal or genetic disorders (e.g., Turner syndrome3, Down syndrome4 and mitochondrial disease5)

Answer 289

thyroid stimulating hormone free T4 free T3 rarely indicated, only relevent if thyroid disease is suspected clinically and TSH is abnormal, but fT4 is inappropriately normal. anti-thyroide peroxidase (TPO): not routinely indicated -can be used in goitre or mildly elevated TSH to see if cause is autoimmune thyroiditis -TPO antibody positivity increases the risk of developing hypothyroidism in patients with subclinical hypothyroidism, autoimmune diseases (e.g., type 1 diabetes), chromosomal disorders (e.g., Turner syndrome and Down syndrome) or patients who are on certain drug therapies (e.g., lithium, amiodarone) or are pregnant or postpartum (see Thyroid Disease in Pregnancy section below)13, 14. Once a patient is known to be TPO antibody positive, repeat analysis is not indicated. thyroid ultrasound scan is not routinely recommended in patients with abnormal thyroid function tests, unless there is a palpable abnormality of the thyroid gland

Answer 290

6 weeks after start or change in treatment if there is a change in patient's clinical status annually once TSH is stabilized q 6 months if patient is taking lithium and amiodarone(3-6m) q 6-12 months in subclinical hypothyroidism

Answer 291

A decision to treat is often made if the TSH is >10 mU/L even if the fT4 is within the reference range. Treatment can be considered when TSH is between the upper limit of the reference interval but ≤10 mU/L and any of the following are present13: symptoms suggestive of hypothyroidism elevated TPO antibodies evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases; or pregnancy (see Thyroid Disease in Pregnancy section below)

Answer 292

autoimmune hypothyroidism subclinical hypothyroidism recovery from non-thyroidal illbess (sick euthyroid syndrome) rare: pituitary disease, resistance to thyroide hormone

Answer 293

Hyperthyroidism or other causes of thyrotoxicosis Excessive thyroid hormone replacement (levothyroxine) Graves’ disease Subacute thyroiditis (viral) Painless/postpartum thyroiditis (autoimmune) Toxic (multinodular) goitre Hyperthyroidism or other causes of thyrotoxicosis T3 thyrotoxicosis (e.g., autonomous nodule) Excessive thyroid hormone replacement (liothyronine or desiccated thyroid) Subclinical hyperthyroidism Recovery of hyperthyroidism Pregnancy related14, 20 Assay artefactB Sick Euthyroid Syndrome Hospitalized patients, recovery from severe illness Very rare causes Central hypothyroidism (hypopituitarism) Assay artefactB

Answer 294

Hyperthyroidism or other causes of thyrotoxicosis Excessive thyroid hormone replacement (levothyroxine) Graves’ disease Subacute thyroiditis (viral) Painless/postpartum thyroiditis (autoimmune) Toxic (multinodular) goitre Hyperthyroidism or other causes of thyrotoxicosis T3 thyrotoxicosis (e.g., autonomous nodule) Excessive thyroid hormone replacement (liothyronine or desiccated thyroid) Subclinical hyperthyroidism Recovery of hyperthyroidism Pregnancy related14, 20 Assay artefactB Sick Euthyroid Syndrome Hospitalized patients, recovery from severe illness Very rare causes Central hypothyroidism (hypopituitarism) Assay artefactB

Answer 295

hyperthyroidism bone loss in post menopausal women atrial fibrillation (in elderly)

Answer 296

atrial fibrillation osteoporosis other endrocrine disorders

Answer 297

age > 30 years more than 2 prior pregnancies history of pregnancy loss, preterm delivery, or infertility type 1 diabetes or other autoimmune disorders morbid obesity (BMI ≥ 40 kg/m2) history of hypothyroidism/hyperthyroidism or current symptoms or signs of thyroid dysfunction family history of autoimmune thyroid disease or thyroid dysfunction (1st degree relative32) history of head or neck radiation or prior thyroid surgery known TPO antibody positivity or presence of a goitre currently receiving levothyroxine replacement33 use of amiodarone or lithium, or recent administration of iodinated radiologic contrast residing (or recently resided) in an area of known moderate to severe iodine insufficiency

Answer 298

connection between untreated overt maternal hypothyroidism and neuropsychological impairment in the offspring3 A preconception TSH between the lower reference limit and 2.5 mU/L is recommended in women being actively treated for hypothyroidism If hypothyroidism has been diagnosed before or during pregnancy, treatment should be adjusted to achieve a TSH level within the normal trimester specific reference interval. If the TSH value is above 2.5 mU/L but within the reference interval, some practitioners would consider treating if the TPO antibody is positive.

Answer 299

TSH high (>4-5mU/L) TSH low (<0.2mU/L)

Answer 300

Thyrotropin receptor antibodies (TRAb) Radioactive iodine uptake (contraindicated in pregnant/breastfeeding) Ultrasound with thyroidal blood flow Thyroid ultrasound (if abnormal thyroid size, nodules) FNA for nodules >1cm or 5mm and suspicious features (r/o cancer)

Answer 301

thionamides, lithium, amiodarone, interferon-alfa, interleukin-2, perchlorate, tyrosine kinase inhibitors

Answer 302

Consider treatment if TSH <0.1 mIU/L and Symptomatic (palpitations, tremor, nervousness) >65yo Comorbidities such as heart disease or osteoporosis Postmenopausal (<65yo) and not taking estrogen/bisphosphonates

Answer 303

NSAIDs, steroids, beta blockers for sx treatment

Answer 304

Altered mental status, hypoventilation, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia

Answer 305

Levothyroxine (T4) loading dose 200-400mcg IV, then 1.6mcg/kg/day IV Liothyronine (T3) 5-20mcg followed by 2.5-10mcg q8h given with T4 Glucocorticoids (hydrocortisone 100mg IV q8-12h x2d) until coexisting adrenal insufficiency can be excluded Supportive measures (ventilation, fluids, correction of hyponatremia and hypothermia)

Answer 306

(TSH receptor antibodies=TRAb) Thionamides (Methimazole - MMI or Propylthiouracil - PTU) If persistently high TRAb, consider continuing MMI or radioiodine/sugery beta blockers for sx control

Answer 307

First-line: Radioiodine or surgery May consider thionamide initially for short-term Beta-blockers for symptomatic treatment

Answer 308

Hyperthermia, tachycardia, N/V/D, dehydration, delirium, coma Causes: Trauma, surgery, RAI Treatment B-Blockers (Propranolol 60-80mg q4-6h) PTU 200mg PO q4h Iodine solution (delayed 1h after PTU) Iodinated radiocontrast High-dose IV hydrocortisone 100mg IV q8h

Answer 309

Allergies, Meds, PMH, Last meal, Events

Answer 310

Urine output goal of 0.5mL/kg/h in adults (1mL/kg/h in pediatric, 2mL/kg/h in <1yo)

Answer 311

Tension pneumothorax Needle thoracostomy at 2nd ICS mid-clavicular line or 5th ICS anterior/mid axillary line, do not wait for X-ray (can do bedside ultrasound) Chest tube at fifth intercostal space at anterior axillary line Cardiac tamponade -Penetrating chest wound, ----Beck triad (hypotension, distended neck veins, muffled heart sounds), pulsus paradoxus, Kussmaul sign (rise in JVP on inspiration) -Confirm with echochardiogram, guide pericardiocentesis Hemothorax Flail chest Upper airway obstruction Aorta lesion

Answer 312

hypovolemic -hemorrhagic -Non-hemorrhagic (GI, skin-burns, renal, third space, pancreatitis) distributive -Sepsis -Neurogenic (TBI, spinal cord injury) -Anaphylactic -Inflammatory obstructive -Pulmonary vascular (PE) -Mechanical (Tension pneumothroax, pericardial tamponade) cardiogenic -Cardiomyopathic (MI) -Arrhythmogenic (tachy/bradyarrhythmia) Mechanical (valvular) neurogenic: -trauma to spinal cord endocrine -adrenal insufficiency, thyrotoxicosis, myxedema coma metabolic: -acidosis, hypothermia Drugs: -CCB, BB, Digoxin

Answer 313

Danger: check if it is safe Response: chceck response to stimulus to determine level of consciousness Circulation: pulse -Consider defibrillation, hemorrhage control, leg elevation, IV access, fluid therapy Airway: check if patent consider C spine immobilisation, simple airway maoeuvers, suctionning, basic and advanced airway adjuncts Breathing: consider Oxygen and IPPV

Answer 314

obtain Hx using OPQRST and SAMPLE vital signs, EKG, GCS PE from head to toe and fast echo

Answer 315

previous hx of difficult intubation trauma on face, upper airway or C spine early difficulty to ventilate with face mask severe aspiration risk small mouth, short mandibule, large tongue, short neck, prominent central incisors limited mouth opening C spine decrased ROM, trauma, degenerative changes obesity, Mallampati score thyromental distance laryngeal oedema (infection, inhalation thermal injury)

Answer 316

unprotected airways, trauma to the airway, a Glascow Coma Scale (GCS) less than eight, a rapid decline or loss of consciousness, and procedural sedation and paralysis

Answer 317

facial trauma

Answer 318

seizure, drug intox, hypoglycemia, attempted suivide

Answer 319

ff. In such cases, patients having the greatest chance of survival and requiring the least expenditure of time, equipment, supplies, and

Answer 320

Use ABCDE for transfer consideration: -airway compromise, high risk for airway loss, tension PTx, hemothorax, open PTX, hypoxia, hypoventilation, hypotension, pelvic fx, vascular injury, open fx, abdo distension or peritonitis, GCS under 13, secvere hypotermia, depressed skull fx or penetrating injury, eye injury, complex lacerations, complex traumas is important not to delay transfer to perform an indepth diagnostic evaluation. Only undertake testing that enhances the ability to resuscitate, stabilize, and ensure the patient’s safe transfer e. Patients who exhibit evidence of shock, significant physiologic deterioration, or progressive deterioration in neurologic status require the highest level of care and will likely benefit from timely transfer Stable patients with blunt abdominal trauma and documented liver or spleen injuries may be candidates for nonoperative management, requiring the immediate availability of an operating room and a qualified surgical team. r. Patients with specific injuries, combinations of injuries (particularly those involving the brain), and/or a history indicating high-energy-transfer injury may be at risk for death and are candidates for early transfer to a trauma center. Elderly patients should be considered for transfer for less severe injuries (e.g., multiple rib fractures and patients on anticoagula

Answer 321

do no drive drunk, use seatbelts, helmetsfhypo

Answer 322

Hypothermia is defined as a core body temperature below 35°C (95°F). In the absence of concomitant traumatic injury, hypothermia may be classified as mild (35°C to 32°C, or 95°F to 89.6°F), moderate (32°C to 30°C, or 89.6°F to 86°F), or severe (below 30°C, or 86°F). in the presence of injury, different thresholds for classification are recommended: mild hypothermia is 36° C (96.8° F), moderate hypothermia is <36° C to 32° C (< 96.8° F to 89.6° F), and severe hypothermia is < 32° C (89.6° or stage 135°C to 32°C stage 2 32-28 stage 3 24-28 stage 4 below 24

Answer 323

* Dry patient * Warm environment * Shivering * Blankets or clothing * Cover head External * Heating pad * Warm water, blankets, and warm water bottles * Warm water immersion * External convection heaters (lamps and radiant warmers)

Answer 324

External * Heating pad * Warm water, blankets, and warm water bottles * Warm water immersion * External convection heaters (lamps and radiant warmers) Internal * Heated intravenous fluids * Gastric or colonic lavage * Peritoneal lavage * Mediastinal lavage * Warmed inhalational air or oxygen

Answer 325

Extracorporeal Rewarming * Hemodialysis * Continuous arteriovenous rewarming (CAVR) * Continuous venovenous rewarming (CVVR) * Cardiopulmonary bypass

Answer 326

General assessment of alertness, eye opening, and responsiveness Intracranial hemorrhage, head injury Height, weight, head circumference (compared with past measurements, if possible) Failure to thrive, neglect, or growth failure with concurrent physical abuse Mouth and teeth examination Dental caries suggestive of neglect Scalp examination Patchy hair loss caused by traumatic alopecia or severe malnutrition Funduscopic examination of the eyes Retinal hemorrhages Skin examination for bruising or burns Multiple patterns of bruising suggestive of abuse: bruise in child younger than four months; bruise in torso, ear, and neck areas; ear bruising (suggests “boxing ears”); buttocks bruising; patterned bruises (hand, cord, belt, object); bruises at different stages of resolution; burn injuries Palpation for tenderness, especially of the neck, torso, and extremities Occult fracture Deep tendon reflexes, muscle tone, or responsiveness to tactile stimuli Spinal cord injury

Answer 327

Highly specific injuries* Classic metaphyseal lesions Rib fractures, especially posteromedial Sternal, scapular, and spinous process fractures Moderately specific injuries* Multiple fractures Fractures in different stages of healing Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures Common but low specificity Clavicular fractures

Answer 328

cbc, fibrinogen, von willebrand factor, platelet aggregation studies, clotting factor assyas, ALt, AST, amylase, lipase, tox screen, UA, renal and lytes, ca, alk phosp, phosphorus, albumin, PTH for malnutrition, rickets

Answer 329

get up to date information from reliable travel website discuss prevention of accidents, safer sex, alcohol, safe travel for women provide prevention and treatment advice and prescribe meds for common conditions (traveler's diarrhea, altitude sickness) ensure pts know how to manage their chronic disease update routine vaccinations check insurance coverage have adequate medical supply, put in carry on bags

Answer 330

Sick contact (TB) Fresh water (shistosomiasis, leptospirosis) Unclean water, unpasteurized milk, raw food (Traveler's diarrhea, giardiasis, nontyphoidal salmonellosis, enteric fever, shigellosis, campylobacter, hepatitis A and E, brucellosis, listeriosis) Skin contact with soil - walking barefoot (Strongyloidiasis, melioidosis) Farm animals Sexual contact (Herpes virus, HIV, Hep A/B/C, syphilis, gonorrhea, Zika, viral hemorrhagic) IVDU, tattoo, piercing (Hep B/C, HIV, CMV, malaria, babesiosis) Insect bites/Animal bites

Answer 331

Clothing, DEET, bed nets with permethrin

Answer 332

7 days to months after anopheles mosquito bite

Answer 333

atovaquone, proguanil (malarone) daily (start 1 day prior and 7 days after), avoid in children under 5 kg Mefloquine (Lariam) weekly -Start 3w prior, continue 4w after -AE: Severe intolerance in some patients Chloroquine weekly -Start 1-2w prior, continue 4w after -Resistance Doxycycline also option for prophylaxis (risk of sun sensitivity, and avoid in children <8yo due to teeth staining) treatment: IV antimalarials (Quinidine with doxycycline or Artesunate) Consider outpatient treatment if <4% parasitemia and no severe features as above Chloroquine (if sensitive) 600mg base orally immediately, then 300mg base orally 6, 24, 48h (total of 1500mg base) Artemisinin combintation therapy if Chlororoquine-resistant region (eg. Artemether-lumefantrine) Monitor parasitemia with daily blood smears until no parasitemia

Answer 334

Escherichia Coli Campylobacter jejuni Salmonella Shigella Yersinia Norovirus Rotavirus Giardia Entamoeba histolytica Bacterial causes: 50-80% of travel-related diarrheal illness Viral causes: 5-25% Protozoal causes: <10%

Answer 335

Avoid pregnancy after return from Zika area (2 months for women, 6 months for men)

Answer 336

Wash hands with soap and water before eating/frequent hand hygiene Only eat fruit that they can peel themselves Avoid uncooked vegetables (FYI: because these have likely been exposed to local tap water) Avoid salads (FYI: because these have likely been exposed to local tap water) Heat food to piping hot Eat only thoroughly- and recently-cooked meats and fish Drink only boiled or bottled beverages Purify drinking water/Boil drinking water for 1 minute Only eat pasteurized dairy products Avoid food from street vendors/unknown sources Avoid ice cubes Only use purified/bottled water for brushing teeth and washing face

Answer 337

No, the vaccine (dukoral) is not recommended. It is no more effective than placebo for prevention of diarrhea. It is no more effective than placebo for prevention of enterotoxigenic E. Coli (ETEC)

Answer 338

use oral rehydration solution or salts/ensure adequate hydration loperamide/Imodium bismuth subsalicylate/Peptobismal 2 bismuth subsalicylate tablets 4 times daily (prevents up to 60%)

Answer 339

Ciprofloxacin 500mg PO BID x 3 days Azithromycin 1000mg PO x 1 in children, pregnant women, or travellers to Asia (resistance to fluoroquinolones)

Answer 340

CBC (anemia, lymphopenia, thrombocytopenia, eosinophilia) Thick and thin blood smear r/o Malaria (consider repeat q12h until three negative smears as parasitemia is cyclical) Liver/Renal studies Electrolytes Blood culture x2 Urinalysis/Urine culture CXR Consider ESR/CRP PPD r/o TB Dengue Serology Widal test r/o typhoid fever LP If >10-14d, stool culture and O+P should be done for targeted therapy

Answer 341

Doxycycline

Answer 342

organ dysfunction, anemia, electrolyte abnormalities, altered mental status, seizure, coma

Answer 343

General travel vaccines Hepatitis A/B Rabies vaccine (adventure trips lasting more than 4 weeks) Country specific vaccines Typhoid vaccine (South Asia) Meningitis vaccine (Meningitis belt, Hajj) Yellow fever vaccine (African, South American countries) -Must be given at designated clinic for official certificate Japanese encephalitis vaccine (Rural Asia) Antimalarials-arge areas of Africa and Asia. Central and South America.

Answer 344

Consider symptomatic treatment (analgesic, antiemetic) Consider prophylaxis, Acetazolamide 125mg PO q12h In High Altitude Cerebral Edema (encephalopathy and ataxia, usually above 4000m) consider immediate descent, dexamethasone and oxygen

Answer 345

Visual cues congruous with vestibular cues (eg. view the horizon from the deck of a ship) Lying supine Ginger, acupressure Anticholinergic medication (care in elderly or risk of angle closure glaucoma) Dimenhydrinate, diphenhydramine, transdermal scopolamine (patch 72h)

Answer 346

fever (which may be periodic), chills, rigors, sweating, diarrhea, abdominal pain, respiratory distress, confusion, seizures, hemolytic anemia, splenomegaly, and renal abnormalities

Answer 347

Analgesics (Acetaminophen/NSAIDs) Combination products (Antihistamine, decongestant, analgesics) Consider Zinc lozenges 75mg PO daily, Pleragonium sidoides, Andrographis paniculata Risk of irreversible anosmia in intranasal zinc preparations Nasal symptoms Nasal saline irrigation (poor evidence) Intranasal cromolyn sodium 1 spray (5.2mg) in each nostril q2h PRN x 2 days then 4 times daily x 5 days Intranasal ipratropium bromide 0.06% solution two sprays (42mcg/spray) in each nostril 3-4 times daily PRN x 4 days Cough suppressant Brompheniramine plus sustained-release pseudoephedrine Ipratropium bromide inhaled Dextromethorphan 30mg PO q6-8h PRN

Answer 348

Handwashing Flu vaccine (6mo-5yo, ≥65yo, chronic disease, pregnancy/postpartum, healthcare worker, frequent contact with above) Pneumococcal 23-valent ≥65 years old, or if specific risk factors

Answer 349

Zanamivir (Relenza) two inhalations (10mg) PO BID x 5d or oseltamivir (Tamiflu) 75mg PO BID x 5d Amantadine not first-line due to high rates of resistance May extend therapy in severely ill patients Treatment with antiviral should be considered for the following patients Severe disease (requiring hospitalization or evidence of lower respiratory tract infection, eg. dyspnea, tachypnea, oxygen desaturation) High risk for complications (pregnancy) Most efficacious within first 48h of illness, but indicated to treat if severe illnessor pregnancy Indications to consider X-ray

Answer 350

Hemoptysis Pleuritic chest pain Dyspnea Systemic symptoms (fever, tachycardia >100, tachypnea>24) Abnormal physical exam (crackles, decreased breath sounds, bronchial breathing)

Answer 351

Compassionate communications Describe infection as viral illness Discuss expected course of illness and cough duration (2-3w) Explain antibiotics do not shorten illness duration, and may cause adverse effects and antibiotic resistance Treatment plan including symptom management (analgesia, antiinflammatory) Consider -Delayed prescription strategies (agree on time frame, eg. 1 week that symptoms should improve - and only to use prescription after the specified time) -Immediate prescribing if suspect pneumonia or high-risk (immunosuppressed)

Answer 352

COPD, cancer, immunodeficiency virus infection

Answer 353

bulging or distorted light reflex (i.e., not all red eardrums indicate OM).

Answer 354

AOM, acute mastoiditis, acute facial nerve palsy, labyrinthitis, venous sinus thrombosis, meningitis, trauma, cholesteatoma, tumor, otitis externa, r/o necrotizing/malignant otitis externa, Herpes zoster , Secondary otalgia, otitis media with effusion, otitis extera Herpes zoster (Ramsay Hunt syndrome) Secondary otalgia Sinusitis / Stomatitis / Parotitis / Pharyngitis Dental infection / abscess TMJ dysfunction syndrome Auricular lymphadenopathy Facial nerve palsy Trigeminal neuralgia Temporal arteritis*

Answer 355

Acute mastoiditis (pain/swelling over mastoid bone) Acute facial nerve palsy - associated with temporal bone inflammation Sixth CN palsy (failure of ipsilateral eye abduction) due to petrous bone inflammation or infection (Gradenigo's syndrome) Labyrinthitis Venous sinus thrombosis Meningitis

Answer 356

Keep dry (Avoid water sports x 7-10d) Clean ear canal Analgesia Mild, Buro-Sol 2-3 drops TID-QID Moderate, Ciprodex 4 drops TID If perforated consider systemic antibiotics.

Answer 357

r/o necrotizing/malignant otitis externa (elderly, diabetic, immunocompromised, otalgia despite antibiotics, granulation tissue in ear canal) ESR, CRP, osteomyelitis on CT/MRI Ciprofloxacin 750 mg PO BID PLUS Ciprodex 4 drops BID x 4-8w

Answer 358

loss of light reflex impaired mobility bulging TM acute perforation with purulent discharge

Answer 359

Immediate therapy if < 6months of age -Send to ER if <3 months old with T>38, suspect meningitis or mastoiditis, toxic looking Healthy children ≥6 months with mild disease, consider: Watchful waiting, and reassess in 24 to 48h (return if worsens anytime within 48h) Antimicrobial prescription to start course if child does not improve Pediatric: Amoxicillin 75 to 90mg/kg/day (max 2000mg) ÷BID Adults: Amoxicillin 500mg PO TID x 5-10d (can use 1g PO TID if high risk) in adults Acetaminophen 10-15mg/kg/dose q4-6h (max 75mg/kg/day) Ibuprofen 5-10mg/kg/dose q6-8h (max 40mg/kg/day) Bulging TM, febrile (≥39°C), moderately systemically ill, or severe otalgia, or significantly ill for 48h should be treated with antimicrobials

Answer 360

Amoxicillin-clavulanate (7:1 formulation, 400 mg/5 mL suspension) 45 to 60 mg/kg/day ÷ TID (max 500mg PO TID) x 10d Adults: 875/125mg BID or 2000/125mg BID x 10 days Ceftriaxone 50 mg/kg IM/IV daily (max 1000mg) x 3 days

Answer 361

Drooling/Secretions Dysphonia Dysphagia Muffled "hot potato" voice Neck swelling

Answer 362

Submandibular space infections (Ludwig's angina - woody induration, crepitus) Primary HIV (mucocutaneous ulcerations) Peritonsillar abscess (trismus) Epiglottitis (out of proportion to findings on exam) Retropharyngeal space infection infectious mononucleosis (fever, pharyngitis, fatigue, lymphadenopathy, splenomegaly, palatal petechiae) HIV, Gonorrhea CMV, toxoplasmosis Suppurative complication (peritonsillar abscess) Infectious thrombophlebitis of the internal jugular vein (Lemierre's) Fusobacterium necrophorum (in 15-30yo)

Answer 363

WBC, AST, ALT, Monospot (or EBV serologies)

Answer 364

CENTOR: Cough absent Exudate/erythema tonsils, Neck nodes, Temp, Range of age (3-14=+1, 15-45=0, >45=-1) If CENTOR ≥3 (>30%): Rapid Antigen Detect Test (RADT) and/or culture Negative RADT consider throat culture back-up in children or immunocompromised (sensitivity 86%) Positive RADT do not need back-up culture (specificity 96%)

Answer 365

Acetaminophen/NSAIDs Topical (Benzocaine 10mg lozenge q2h PRN, Benzydamine 0.15% 15mL gargle q3h PRN) Consider Dexamethasone 0.6mg/kg (max 10mg) PO x 1 (NNT 12) After full dose of amoxicillin, 91% of children the next morning had negative RADT/culture Consider returning to school on Day 2 of antibiotics if improved/afebrile

Answer 366

Penicillin V (50mg/kg/day ÷ BID) 600mg PO BID x 10d Can consider Pen V QID x 5d Pediatrics: Amoxicillin 50 mg/kg PO daily (max 1g) x 10d if allergy: Cephalexin (50mg/kg/day ÷ BID) 500mg PO BID x 10 days If anaphylactic Clarithromycin (15mg/kg/day ÷ BID) 250mg PO BID x 10d

Answer 367

Diagnosed clinically using symptoms and signs >7d duration Must have one of "OD" and one other "PODS" symptom Facial Pain (or pressure), Nasal Obstruction, Discharge, Smell loss

Answer 368

Radiological imaging usually not required (unless diagnosis unclear) X-ray (3 views) diagnosis with air/fluid level or complete opacification CT scan if complication

Answer 369

Most are viral and resolve spontaneously within 10-14d Suspect bacterial if Deterioration of symptoms 5-7d after improvement (biphasic) Persistent symptoms without improvement >10-14d as per INESSS >7d without improvement (or >10d persisting symptoms) as per Canadian guidelines Treat bacterial if severe symptoms impacting function/sleep

Answer 370

Lack of response within 72h suggests treatment failure Referral to ENT if (and consider CT if long waiting time) Complications Persists >8w Recurrent rhinosinusutis >3 episodes per year

Answer 371

toxic, altered mental status Persistent fever (>38C) Periorbital erythema/swelling or decreased visual acuity Meningeal signs/severe headache or neuro signs

Answer 372

Recent viral URTI History of allergic/nonallergic/medication-induced rhinitis Concomitant conditions (pregnancy, immunodeficiency, migraine) Anatomic causes (deviated septum, enlarged tonsils, nasal polyp)

Answer 373

Prevention: Smoking cessation, hand hygiene Symptom management: Analgesics (acetaminophen, NSAIDs) Saline irrigation BID

Answer 374

Oral decongestants <10d (when worse congestion, eg. night) Topical decongestants <3d (risk of rebound congestion) Consider topical intranasal corticosteroids (eg. nasonex) in mild-moderate ARS (NNT 15) If no improvement after 72h, consider antibiotics Consider treatment for suspected acute bacterial rhinosinusitis (as above) with severe symptoms or mild-moderate not responsive to INCS after 72h (NNT 17, NNH 8) Amoxicillin 500mg PO q8h x 5-10 days Second-line (or first-line if suspect resistance, immunosuppressed, frontal/sphenoidal sinusitis due to higher rates of complications) Amoxicillin/Clavulanate 875/125mg PO BID x 7d Moxifloxacin 400mg PO daily x 5d Levofloxacin 500mg PO daily x 10d If non-severe penicillin allergy, consider cefuroxime 250 BID x7d or cefixime 400 daily x10d If anaphylaxis, consider clarithromycin, doxycycline or TMP-SMX

Answer 375

Oral glucocorticoids PLUS empiric oral antibiotics x 4w Prednisone 20mg PO BID x 5d, then 20mg daily x 5 days (total 10 days) Amoxicillin-clavulanate 875mg PO BID or Clindamycin 450 mg PO TID Topical glucocorticoid spray and intranasal saline irrigation or sprays

Answer 376

s regularly (every 24–38 days) for 4 to 8 days with blood loss of 5 to 80 ml

Answer 377

Heavy menstrual bleeding (most common AUB complaint) * Excessive blood loss that interferes with quality of life and daily function. * Can occur with other symptoms (e.g., menstrual pain). Prolonged menstrual bleeding * Menses lasts > 8 days. Frequent menstrual bleeding * Bleeding at intervals < 24 days apart. Irregular, non-menstrual bleeding * Intermenstrual—Bleeding (often light/short) between normal menstrual periods. * Post-coital—Bleeding after intercourse. * Premenstrual/postmenstrual spotting—Bleeding on a regular basis (≥ 1 days) before or after regular menses.

Answer 378

Polyps (cervical or endometrial) -Intermenstrual bleeding Ademonyosis -Endometrial glands and stroma present focally or globally in uterine musculature. Heavy or prolonged bleeding. Menstrual pain. Dense enlarged uterus. Leiomyoma (myoma or fibroids -Myomas or fibroids. Heavy or -prolonged bleeding. -Pelvic pain/pressure. -Enlarged uterus. Malignancy Malignancy of vagina, uterus, cervix. Variable bleeding patterns. Coagulopathy Inherited bleeding disorders, including von Willebrand disease. * Acquired coagulopathy. Heavy bleeding Ovarian dysfunction Polycystic ovary syndrome. * Thyroid diseases. * Ovarian follicle decline (perimenopause). Irregular bleeding. Heavy or prolonged bleeding. Endometrial -Pelvic inflammatory disease. * Endometritis. Iatrogenic Hormonal contraceptives. * Anticoagulants. * Antiepileptics. * Tricyclic and SSRI/SNRI antidepressants. * Antipsychotics. * Corticosteroid-related drugs. * Tamoxifen. * Herbs (ginseng, chasteberry, danshen, motherwort).* Not yet specified * Arteriovenous malformations. * Caesarean scar defects.

Answer 379

Ovulatory AUB is typically regular and often accompanied by premenstrual symptoms and painful periods. * Anovulatory AUB is common near menopause with irregular, heavy, and/or prolonged bleeding. * In a cohort of 804 women (42–52 years), anovulation occurred in 20% of cycles, mostly in the early perimenopause. Anovulation was associated with both shortened and prolonged cycle intervals and bleeding duration. Short-cycle intervals occurred more frequently in early perimenopause.14 Anovulatory cycles were less likely to be associated with heavy menstrual bleeding than were ovulatory cycles. Anovulatory AUB is more likely than ovulatory AUB to be associated with endometrial hyperplasia and cancer

Answer 380

bleeding, anemia sx, vaginal discharge, pelvic pain, galctorrhea, sexual and reproductive hx, systemic illness, presence of comorbidities, meds, family history

Answer 381

hypothyroidism hyperprolactinemia coagulation disorders PCOS adrenal or hypothalamic disorders

Answer 382

4 mm in follicular phase to 16 mm in luteal phase

Answer 383

Pap smear. * STI testing if there is a risk. * CBC for women with a history of heavy or prolonged bleeding . * Serum BHCG if there is a risk of pregnancy. * TSH—only if there are symptoms or findings that suggest thyroid disease [Low Evidence]. * Ferritin—there is no evidence that the addition of ferritin changes management if CBC is normal. Test only if there are symptoms of iron deficiency without anemia. * Coagulation tests—only for women with a history of heavy menstrual bleeding that began at menarche or a personal or family history of abnormal bleeding. · Endometrial biopsy (see Endometrial Biopsy section). other: blood type and screen if acute blood loss, consider prolactin if sx, vWF, fibrinogen, gono/chlam

Answer 384

Hormonal contraceptives. * Anticoagulants. * Antiepileptics. * Tricyclic and SSRI/SNRI antidepressants. * Antipsychotics. * Corticosteroid-related drugs. * Tamoxifen. * Herbs (ginseng, chasteberry, danshen, motherwort).*

Answer 385

when the history or examination suggests structural causes for bleeding, conservative management has failed, or there is a higher risk of malignancy. TVUS is considered a firstline imaging test for AUB because it has adequate test performance and is relatively noninvasive.3 TVUS can help diagnose endometrial polyps, adenomyosis, leiomyomas, uterine anomalies, and endometrial thickening associated with hyperplasia and malignancy (see Box 1)..3 In some cases (particularly the detection of intrauterine pathology such as submucosal fibroids or polyps), saline infusion sonohysterography and diagnostic hysteroscopy are preferred due to better test performance and can be used as second-line tests.

Answer 386

Are > 40 years of age. * Have high risk or findings suggesting malignancy -overall risk for endometrial cancer -risk of progression to cancer in women with hyperplasia (see risk factors) * Do not respond to medical treatment. * Have substantial intermenstrual bleeding (

Answer 387

1) previous Caesarean sections; 2) nulliparity; 3) structural issues (e.g., cervical stenosis, pelvic organ prolapse); or 4) anxiety with office procedures TVUS and/or gynecological referral may be offered in these cases.1

Answer 388

It has high specificity for endometrial cancer (almost 100%) but sensitivity is lower (~90%)

Answer 389

obesity, diabetes, nulliparity, history of polycystic ovary syndrome, and family history of hereditary non-polyposis colorectal cancer Lynch Syndrome 40-60% endometrial CA

Answer 390

* Atypical hyperplasia is associated with higher risk of progression to endometrial cancer. Up to 60% of patients will have co-existent endometrial cancer and ideally require definitive surgical management with hysterectomy and bilateral salpingo-oophorectomy. Medical management can be considered for patients wishing to preserve their fertility.26 * Hyperplasia without atypia has a much lower rate of progression (1–3%) and can be managed conservatively with progesterone or with watchful waiting, if the patient chooses, as spontaneous regression rates of over 75% have been reported.3,27,28 By comparison, progesterone treatment of any type appears to have higher regression rates (89–96%),28 although this data is derived from small observational studies. If watchful waiting is chosen, the SOGC recommends reassessment (with biopsy) every 3 to 6 months.26

Answer 391

Continuous oral or monthly injectable progestins or the LNG-IUS over a 6-month period. 9 Disease regression rates are the highest with the LNG-IUS (80–95%) and injectable progestins (> 90%) compared with about 70% for oral therapy.30 Endometrial biopsy (which can be performed with the IUD in place) should be performed every 3 to 6 months to monitor for disease progression and eventual resolution Obesity is associated with a lower rate of regression. * Persistent abnormal bleeding despite therapy, intolerance to therapy, inability to comply with surveillance, or failure of hyperplasia to regress after 6 to 12 months should prompt referral. * Following resolution of hyperplasia without atypia, the question of how often and how long to continue performing endometrial biopsies has not been directly addressed by research. The UK Royal College of Gynaecologists and Obstetricians guideline recommends performing endometrial biopsies every 6 months until 2 consecutive negative biopsies occur.28

Answer 392

Regular (cyclic) heavy menstrual bleeding: hormonal and non-hormonal treatments. * Irregular or prolonged bleeding: hormonal treatments, such as oral contraceptive pills or progestins, can help regulate cycles, but non-hormonal treatments can help to control any associated heavy bleeding. Note: Women with anemia should receive iron supplementation -Levonorgestrel Intrauterine Releasing System (LNG-IUS) (IUD) -> reduces ovarian and endometrial risk of cancer but does not increase risk of breast cancer e etonogestrel implant -reduces bleeding days but menstrual bleed can remain unpredictable -Combined Hormonal Contraception (CHC) -Oral Progestins: Treatment consists of medroxyprogesterone acetate, norethindrone, or micronized progesterone, -Injected Progestin 25. Depot medroxyprogesterone acetate (DMPA) is used to suppress ovulation and ovarian steroidogenesis, eventually leading to endometrial atrophy -Danazol 26. Danazol inhibits ovarian steroidogenesis and results in endometrial atrophy -Gonadotropin-Releasing Hormone (GnRH) Agonists 27. GnRH agonists (leuprolide, goserelin, nafarelin) stop ovarian steroidogenesis and lead to endometrial atrophy and amenorrhea within 3 to 4 weeks.3 However, long-term use leads to adverse effects associated with a hypoestrogenic state and should only be considered for women in whom other options are contraindicated Non-hormonal Medical Treatment -Nonsteroidal Anti-Inflammatory Steroids (NSAIDs) -Antifibrinolytics Tranexamic acid

Answer 393

y may be considered in women in whom 1) medical treatment has failed; 2) medical treatment is contraindicated or side effects are considered intolerable; 3) significant anemia is present; 4) uterine pathology (e.g., large uterine fibroids, endometrial hyperplasia with atypia, malignancy) is present; or 5) AUB has a severe impact on quality of life.3 Surgical options include hysteroscopic polypectomy, endometrial ablation, myomectomy, and hysterectomy. Uterine artery embolization is a radiological intervention that can be used to treat fibroids

Answer 394

Investigative tests show: * Malignancy, or atypical hyperplasia is present. * Hyperplasia without atypia, if this is the patient’s preference or the clinician is not comfortable managing. * No primary care practitioner is available to perform a required endometrial biopsy, or technical issues prevent the ability to perform a satisfactory biopsy. * AUB (including hyperplasia without atypia) fails to respond to medical treatment options or if GnRH agonists are being considered. * Patient wishes to explore surgical options (after being informed about or having trialled available medical treatments).

Answer 395

Serum positive 9d post-conception Urine positive 28d after LMP

Answer 396

Hypovolemia/Hemodynamic instability -blood type and screen, consider transfusion if necessary -if pregnant give rH immunoglobulin (winrho or rhogam ) Acute Non pregnant Conjugated equine estrogen 25mg IV q4-6h x24h Consider antiemetic due to side effects of nausea/vomiting Combined OCP TID x7d Medroxyprogesterone acetate 20mg TID x7d Tranexamic acid 1g PO/IV TID x5d Procedure (D&C, endometrial ablation, uterine artery embolization, hysterectomy) Treat underlying primary pathology Correct anemia (iron replacement) Rule out malignancy (if high risk)

Answer 397

implantation bleed abnormal prenancy (ectopic, molar) Abortion (threatened, inevitable, incomplete, complete, missed, septic) Non-Obstetrical (Uterine, Cervical Vaginal Pathology)

Answer 398

Vitals (r/o hemodynamic instability, fever) Abdominal exam (r/o surgical abdomen) Speculum Source of bleeding (Vagina/Cervical/Uterine) Cervical os (r/o cervical dilation) Bedside ultrasound (r/o free fluid, confirm IUP)

Answer 399

CBC Blood type Serial b-hCG Rising b-hCG >35% over 48h consistent with viable IUP (but ectopic may also display rising hCG) hCG <35% over 48h suggest ectopic or abnormal IUP Abdominal Ultrasound IUP if b-hCG >6000 IU/L Transvaginal Ultrasound Gestational sac and yolk sac at 5w gestation Cardiac activity at 6w gestation IUP if b-hCG >1500IU/L Absence of IUP does not always ectopic (eg. early multiple gestation)

Answer 400

-tranexemic acid1g IV over 10-20 mins -Misoprostol 800mcg SL/PO/PR/(avoid PV if excessive bleeding), then 400mcg q3h PRN -vasopressin injected on anterior lip of cervix

Answer 401

dilation and aspiration -prophylactic antibiotics Azithromycin 500mg PO x1 or Doxycycline 200mg PO x1

Answer 402

Bloody show (onset 72h prior to labor, PPROM) Placenta previa (20%) -Touching/covering internal os (low-lying is within 2cm) Placental abruption (30%) -Painful contractions, hypertonus tender uterus, vaginal bleeding may be concealed Uterine rupture (rare) -Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding Vasa previa (rare) -Suspect in painless bleeding with change in FHR

Answer 403

previous placenta previa, previous C/S, uterine surgery, advanced age, multiparity, smoking/cocaine, multiple gestation, in vitro

Answer 404

Prior abruption, thrombophilia, iron deficiency, PROM, Hypertension, Overdistended uterus, maternal age/parity, smoking/cocaine, abdominal trauma, c/s

Answer 405

Clinical diagnosis, not well diagnosed on ultrasound Kleihauer-Betke test (fetal cells in maternal blood)

Answer 406

Risk: Uterine scar, hyperstimulation (IOL), multiparity

Answer 407

Twins, placenta previa (consider TVUS screen at 32w), IVF

Answer 408

transvaginal color doppler ultrasound Apt test (positive = fetal blood, negative = maternal blood) - alkali denaturation test, also known as A or Apt test, is a medical test used to differentiate fetal or neonatal blood from maternal blood found in a newborn's stool or vomit, or from maternal vaginal blood Wright stain (nucleated RBC on smear)

Answer 409

Vitals (r/o hemodynamic instability) Abdominal exam (including uterine tone/activity) Bedside ultrasound (r/o placenta previa) Sterile speculum Avoid digital cervical exam until placenta previa ruled out by ultrasound (also if possible prior to speculum)

Answer 410

Type (Rh) and Crossmatch CBC Kleihauer-Betke if abruption Bedside clot test INR Fetal monitor bedside US management: Get help, oxygen, IVF (LOTS!), foley Massive transfusion protocol Follow Hb and Coag

Answer 411

Infectious vaginal discharge Bacterial vaginosis (most common cause of vaginal discharge 30%) Candida vulvovaginitis Trichomonas vaginalis (STI) Cervicitis (Gono/Chlam) Non-infectious vaginal discharge Physiologic Atrophic vaginitis (scant discharge) Foreign body Non-infectious vulvovaginal pruritus without discharge Irritant or allergic contact dermatitis (latex, soaps, perfumes) Lichen planus Lichen sclerosus Vulvar cancer Psoriasis Colovaginal fistula

Answer 412

Clinical (Amsel's), require 3 of 4 1-Adherent and homogenous vaginal discharge (smoothly coats vaginal walls) 2-Vaginal pH >4.5 3-Clue cells on saline wet mount 4-Positive whiff-amine test -Fishy amine odour (before or) after addition of 10% KOH Other Gram stain vagina smear with Nugent scoring system (gold standard) Commercial test DNA probe (eg. Affirm VP III) Note: Vaginal culture positive for G. vaginalis is not diagnostic due to low specificity (cultured in >50% of healthy asymptomatic women)

Answer 413

Oral: Metronidazole 500mg PO BID or Clindamycin 300mg PO BID x 7-14d -Preferred in pregnancy as they have been shown to reduce preterm birth Topical: Metronidazole gel 0.75% one applicator (5g) PV daily x 5d Longer courses if multiple recurrences Consider Metronidazole gel 0.75% one applicator (5g) PV daily x10d then two times per week for 3-6 months Alternatives: Vaginal metronidazole gel Oral or vaginal clindamycin cream

Answer 414

Malodorous, green/yellow frothy discharge, pruritus, dyspareunia, petechiae - strawberry cervix Motile trichomonads on wet mount microscopy, NAAT PCR vaginal swabs, culture

Answer 415

Metronidazole 2g PO x1 or Metronidazole 500mg PO BID x7d High-dose therapy may be needed for resistance Partner treatment enhances cure rates Abstain from intercourse until both patients treated and asymptomatic

Answer 416

Erythema, edema of vulvovaginal tissues with thick, white clumped vaginal discharge, pH<4.5 Budding yeast and pseudohyphae on wet mount microscopy (negative in 50%) Consider culture in negative microscopy or persistent/recurrent symptoms after treatment

Answer 417

Uncomplicated (Sporadic, infrequent ≤3/y, healthy, immunocompetent, nonpregannt) -Fluconazole 150mg PO x1 or topical intravaginal/suppository (clotrimazole, miconazole) -Topical antifungal azoles may require longer courses, but are first-line in pregnancy eg. Clotrimazole Combi Pak (Canesten 500mg vag tab/1% cream) or cream 10% x 1 Complicated -Fluconazole 150mg PO x3 doses 72h apart (day 1, 4, 7) -Consider maintenance with Fluconazole 150mg PO weekly x 6 months -Monitor for hepatotoxicity with long-term use and drug interactions Non-albicans species may not respond to fluconazole For C glabrata, consider vaginal boric acid capsules at compounding pharmacist (avoid in pregnancy) For C krusei, consider topical clotrimazole

Answer 418

Non-specific (most common) Causal factors Thin vaginal mucosa Moisture (tight clothing) Irritants (soap, bubble bath, prolonged contact with urine/feces) Bacterial: Group A beta-hemolytic strep H. influenzae E. coli Candida (unusual) Dermatologic: Lichen sclerosis Psoriasis Atopic dermatitis Foreign body:, usually toilet paper (recurrent symptoms or bloody discharge) Flush with sterile saline or refer to gyne for vaginoscopy Pinworms (nocturnal perineal pruritus) -Treat with mebendazole Systemic infection (varicella, measles, rubella, diphtheria, shigella) Rule out STIs and sexual abuse, especially in recurrent cases

Answer 419

Introital (not vaginal) swab if profuse discharge -Bacterial culture (GAS, Haemophilus influenzae, Gardnerella) -if positive bacterial culture, can treat with antibiotics Candida unusual, consider if immunosuppression

Answer 420

Treat underlying cause If non specific, Reassurance Hygiene (wipe front to back) Avoid causal factors (soaps, baby wipes, tight-fitting clothing, wet bathing suits, bubble bath, scented detergents) Warm soaks, gentle drying Sleep without underwear Gentle emollients and barrier creams

Answer 421

excessive or continuous vaginal bleeding: cesarean section regardless of gestational age. If bleeding subsides: expectant management if less than 36 weeks. -If at or greater than 36 weeks of gestation then cesarean delivery is recommended. Admission magnesium sulfate (before 32 weeks) for fetal neuroprotection and steroids for fetal lung maturity if indicated. Bedrest, reduced activity, and avoidance of intercourse are commonly mandated, though there is no clear benefit. If the vaginal bleeding subsides for more than 48 hours and the fetus is judged to be healthy, then inpatient monitoring is continued, or the patient may be discharged for outpatient management. Inpatient vs. outpatient management depends on the stability of the patient, the number of episodes of bleeding, proximity to the hospital, as well as compliance.

Answer 422

URTI post nasal drip COPD exacerbation asthma PNA, Sinusitis acute bronchitis

Answer 423

chronic bronchitis post nasal drip post nasal drip post infection cough (hyper responsiveness gerd foreign body primary or secondary tumor smoker's cough meds (ACEI, betablocker (asthma exacerbation)

Answer 424

PE pneumothorax cancer TB, HIV sarcoidosis pertussis

Answer 425

codeine, diphendydramine dextromethorphan chlophedianol guaifenestin for wet cough (expectorant) gabapentine can be tried for chronic cough

Answer 426

hemoptysis, dyspnes, weight loss, TB/HIV exposure, decrased SP)2, increased RR, exposure to toxins

Answer 427

FEV/FVC less than 0.8-0.9 and increace of FEV over 12 % or increase of PEF more than 20 % with bronchodilator

Answer 428

egophony, dullnes to percussion, decreased air entry, crackles

Answer 429

URTI pneumonia croup pertussis foreign object asthma gerd ro bacterial tracheitis, pe, ptx, cancer, TB, pertussis, foreign body, PNA

Answer 430

chronic bronchitis post nasal drip post infection cough GERD Bronchiectasis/Cystic fibrosis (wet productive cough, weight loss)

Answer 431

cough more than 3 weeks, more than 75 yo, clarithromycine, azithromycine, doxycycline

Answer 432

nasal corticosteroids allergen avoidance second generation antihistamines combination corticosteroids/antihistamine inhaler or cromolyn eye drops if non allergic rhiniris: -first generation antihistamine plus decongestiant (care in hypertension), glaucoma -sanal ipratropium bromide

Answer 433

Speech pathology treatment Neuromodulating medication Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w CT scan if suspect lung cancer, bronchiectasis or ILD Referral to specialty

Answer 434

Acceptable answers: Is she symptomatic when she is not sick? Can she identify triggers? Compliance: How often does she take her meds? Inhaler technique/Using a spacer? Co-morbidity: Does she have allergies? Co-morbidity: Does she have rash/eczema?

Answer 435

Daytime symptoms < 4 days/week No nighttime symptoms No limitation to physical activities Mild infrequent exacerbations No school absences No need for beta agonists FEV1 or PEF > than 90% of personal best PEF diurnal variation less10-15%

Answer 436

Parental history of asthma, Asthma diagnosed after age 3 Likely allergic rhinitis Persistence/recurrence of symptoms

Answer 437

Use of aerochamber if metered dose Education for child/parent Use of patient symptom diary Regular assessment of peak expiratory flow (PEF) Pulmonary function testing Allergy testing Environmental allergen/irritant control Written action plan

Answer 438

Leukotriene receptor antagonists Long acting beta agonists Increasing inhaled corticosteroid dose Medium-dose inhaled corticosteroid + long-acting beta agonist combination (recommend do not abbreviate)

Answer 439

typical clinical features: -wheeze, sob, chest thightness and cough -variable expiratory airflow limitation Reduced FEV1/FVC (<0.75-0.8 in adults and <0.9 for children) AND variable expiratory airflow limitation: Post-bronchodilator reversiblity increase in FEV1 >12% (minimum of 200mL in adults) Excessive variability in twice-daily (diurnal) PEF over 2 weeks (adults >10%, children >13% daily diurnal variability) Significant increase in lung function after 4 weeks of anti-inflammatory treatment (adults FEV1 >12% and >200mL increase from baseline) Positive exercise challenge test (adults decrease FEV1 >10% and >200mL or in children decrease FEV1>12% predicted or PEF >15%) Positive bronchial challenge test/methacholine (Fall FEV1≥20% or ≥15% with standard hyperventilation, hypertonic saline or mannitol challenge) Excessive variation in lung function between visits *less reliable (FEV1>12% and 200mL in adults)

Answer 440

exercise, laughter, allergens, cold air, viral infection, occupational hazards

Answer 441

GERD, post nasal drip, chronic sinusitis, ace inhibitor induced cough,eosinophilic bronchitis, CHF in elerly, COPD, TB, aids/HIV, parasitic or fungal lung disease

Answer 442

rhinitis, chronic rhinosinusitis, GERD, obesity, OSA, depression, anxiety

Answer 443

in the pst 4 weeks: -daytime sx less than twice per week -no night waking due to asthma -saba reliever needed no more than 2 x per week -no activity limitation due to asthma

Answer 444

-SABA over use -inadequate ICS -comorbidities like obesity, chronic rhinosinusitis, GERD, food allergy, anxiety, depression -smoking, vapijg, air pollution, allergen, major socioeconomic problems, lpw lung function, high blood eosinophils

Answer 445

at diagnosis, 3-6 months after starting tx and periodically q 1-2 years

Answer 446

GINA recommends adding an ICS-formeterol (eg. Symbicort) even in mild intermittent asthma in 12+ year old, as adding any ICS significantly reduces the risk of severe exacerbations ICS formoteral as needed (preferred) -ICS + LABA PRN (reliever) in 12+ years old Symbicort Turbuhaler or regular low dose ICS + as needed SABA -like Flovent HFA (fluticasone) 50, 125, 250mcg 1 inh BID -Pulmicort Turbuhaler (budesonide) 100, 200, 400mcg 1 inh BID -Ciclesonide (Alvesco) 400 mcg once daily DO not treat with SABA without ICS management: decrease allergens and modificable risk factors, comorbidities asthma information inhaler skills adherence written asthma action plan self monitoring of sx and or peak flow regular med review PFT for dx

Answer 447

ICS + LABA maintenance and PRN in 12+ years old Symbicort Turbuhaler (budesonide/formoterol) Refer for add-on treatment (LAMA Tiotropium, anti-IgE, anti-IL5, oral steroids, Bronchial thermoplasty, SC/SLIT) LTRA are less effective than ICS Consider if unable/unwilling to use ICS or in concomitant allergic rhinitis Singulair (Montelukast) 5, 10mg 1 tab PO PRN In <5yo, use MDI with spacer and face mask or nebulizer, and dose-adjust

Answer 448

If symptoms <2/month and no risk factors -Consider no controller If symptoms >2/month or risk factors -Consider Low-dose ICS If symptoms >2/week -Low-dose ICS Asthma most days or waking due to asthma ≥1/week -Medium/high-dose ICS or Low dose ICS/LABA Severely uncontrolled asthma or acute exacerbation -Short course oral corticosteroids AND High-dose ICS or Moderate-dose ICS/LABA

Answer 449

Ideally 1-3 months after starting treatment, and q3-12 months after Step-up vs. Step-down

Answer 450

difficult confirming dx occupational asthma uncontrolled asthma risk factors for asthma related death (ICU, anaphylaxis or confirmed food allergy)

Answer 451

Early intervention in worsening asthma is key Increase reliever frequency Increase usual controller Double ICS or Quadruple maintenance ICS/formoterol (max formoterol 72mcg/day) Severe exacerbation (PEF <60%) or not improving after 48h Oral corticosteroids and contact doctor Prednisolone 1mg/kg/day (40-50mg)/day

Answer 452

O2 target 93095% SABA MDI with spacer 4-8 puffs or 5 mg nebulizer q 20 min x 3 early oral corticosteroids ipratropium bromide (atrovent) consider MgSO4 2 g IV over 20 min transfer to acute care facility

Answer 453

Mild-moderate Talks in phrases, not agitated, Pulse 100-120, O2>90% Severe Talks in words, agitated, RR>30/min, Accessory muscle use, Pulse >120bpm, O2 <90%

Answer 454

Eliminate exacerbating factors Excessive bathing (without subsequent moisturization) Low humidity environment Overheating/hot water exposure Avoid potential allergens and irritants Exposure to solvents/detergents Avoid fragrant/perfumed topic agent Avoid coarse fiber clothing (wool/synthetic) Emotional stress/anxiety Xerosis (dry skin) Treat skin infections (S. aureus, herpes simplex) Sunscreen/protection Hydration/Emollients multiple times per day 💡 Occlusiveness of topical preparations (from most to least): ointments (use for dry lesions) > creams (use for wet lesions) > lotions (use for weeping/intertriginous lesions)

Answer 455

Prodromal flu-like illness: Fever >39C, sore throat, rhinorrhea, cough, aches Sudden onset tender/painful skin rash on face/limbs, 90% with involvement of mucous membranes (mouth, eyes, genital) Tender red/purple macules, diffuse erythema, targetoid lesions, bullae and/or vesicles (may have positive Nikolsky)

Answer 456

stop causative drug (Sulfas, Alloprurinol, Tetracyclines, anticonvultivants, NSAIds Treat infections (eg. Mycoplasma pneumoniae) Admission to ICU IV fluid resuscitation and wound management

Answer 457

Diffuse erythema, swelling, warmth, shiny, exquisite tenderness Late findings include crepitus, bullae, skin necrosis, loss of sensation

Answer 458

↑ WBC, ↑ CRP/ESR, ↑ CK, subcutaneous air on XR/CT/MRI

Answer 459

ICU admission plus aggressive surgical exploration and debridement and broad-spectrum antibiotics: e.g., Tazo/Clinda/Vanco IV

Answer 460

Can present with abnormal skin color pallor, mottling Petechial rash involving trunk, lower body, mucous membranes (oral and ocular), may have purpura, ecchymotic lesions

Answer 461

When in doubt, consult Poison Control for additional guidance Fluid Resuscitation for burns >15% BSA in children and >20% BSA in adults Modified Brooke/Parkland Formula 2-4mL x %BSA x kg Ringer's Lactate, 1/2 in first 8 hours, 1/2 in next 16 hours Wound management Keep moist Apply antibiotic ointment to non-adherent dressing (Adaptic) then apply to wound Pain control Ensure tetanus vaccine status up-to-date Follow-up at <72h, to re-assess burn to better characterize partial vs. full thickness Refer to burn center PRN

Answer 462

Diagnosis and treatment: full-thickness excisional biopsy with 0.5-2cm safety margin (according to Breslow thickness) Prognosis highly dependent on Breslow thickness, 5-year survival drops with depth > 1-2 mm

Answer 463

Treatment: Surgical excision + biopsy (e.g., punch biopsy, Mohs micrographic)

Answer 464

Treat local AK with cryotherapy (eg. two freeze thaw cycles of 5s) Treat widespread AK with fluorouracil 5% cream BID x 2-6 weeks

Answer 465

Refers to a group of life-threatening autoimmune blistering and erosive diseases affecting the skin and mucosa ( Complications include infection, fluid loss, electrolyte disturbances Types: Vulgaris (most common; 70% of all pemphigus), Foliaceus, IgA, Paraneoplastic

Answer 466

Systemic steroids (1-2mg/kg prednisone daily or 0.5-1mg/kg in combination with rituximab) Azathioprine or mycophenolate mofetil are often used to attempt to reduce steroids Consider adjunctive high potency topical steroid (e.g., clobetasol propionate) for larger erosions Cover erosions with antibiotic ointment or a bland emollient (eg, petroleum jelly) +/- non-adhesive wound dressings

Answer 467

granulomatosis with polyangiitis (wegener's) systemic lupus erythematosus dermatitis herpetiformis psoriasis kaposi's sarcoma in HIV

Answer 468

Treatment: Topical permethrin 5% cream applied to the whole body from the neck to the soles of the feet, including areas under the fingernails and toenails (plus scalp in infants & young children) and washed off after eight hours. Can be repeated 1 week later if necessary. Can manage pruritus with oral antihistamines or topical corticosteroids if severe All textiles, bedding, clothing should be washed and dried at hottest temperature Strongly consider prophylactic treatment for close contacts (even if asymptomatic as incubation period can be ~1 month) Watch for superficial bacterial infection and treat accordingly with oral antibiotics

Answer 469

Topical mupirocin 2% ointment (Bactroban) TID x 5 days Can consider topical fusidic acid (although some resistance)

Answer 470

Drug-induced acne Tropical acne - Extreme heat Acne aestivalis (Mallorca acne) - Sun exposure Rosacea - Late age onset, erythema, talengiectasia, papules, pustules, no comedones Periorificial dermatitis - Around mouth, nose or eyes sparing vermilion border Pseudo/Folliculitis, no comedones Keratosis pilaris - Follicular prominence and roughness (usually on arms, but may resemble acne on cheeks) Favre-Racouchot syndrome - Comedones on cheek due to sun damage

Answer 471

Comedonal Topical retinoids gel/cream (Tretinoin 0.025%, Adapalene 0.1%, Tazarotene 0.1%) Benzoyl peroxide (BPO) 2.5% or 5% gel or Azelaic acid (AA) 20% cream (possible better tolerability than BPO) Mild-moderate papulopustular Topical Retinoid + BPO or Topical Abx + BPO Adapalene 0.1% and BPO 2.5% (Tactupump) Clindamycin 1% and BPO 5% Treat with all three topicals (Retinoid, BPO, Abx) if no response x 3 months Combined OCP or systemic antibiotics High estrogen (ethinyl estradiol) concentration associated with decrease in inflammatory lesions Tetracycline (eg. doxycycline 100mg PO BID or daily x 3-4 months) Risk in pregnancy or <9yo (teeth discoloration/bone growth) Side effects: GI, photosensitivity Severe papulopustular Oral isotretinoin (pregnancy-prevention measures due to teratogenicity) 0.5-1mg/kg daily divided BID for 15-20 weeks or 0.5mg/kg daily divided BID for 1 month, then 1mg/kg/day divided BID, until a cumulative dose of 120-150 mg/kg Consider lower dose 20mg every alternate day or 0.25-0.4mg/kg/day for moderate Consider monitoring labs Fasting lipid and LFTs at 4 weeks and 8 weeks, and then stop if normal Other Oral zinc has been shown to have effect against inflammatory lesions Diet: Some evidence for low glycemic index diet, lack of evidence concerning dairy consumption Chemical peels have minimal evidence but are safe and inexpensive

Answer 472

fasting lipid LFTs

Answer 473

antibiotics benzoyl peroxides retinoids salicylates intralesional steroids

Answer 474

clindamycin/benzoyl peroxide erythromycin/benzoyl peroxide erythromycin/Vitamin A adapalene/benzoyl peroxide

Answer 475

minocycline, doxycycline, tetracycline, erythromycin, trimethoprim duration of therapy: 6-12 weeks

Answer 476

triglycerides white blood cell count and differential ALT/alanine aminotransferase

Answer 477

dry skin, dry mouth, dry mucous membranes (any one of these three) sun sensitivity teratogenicity/birth defects impaired night vision joint pain epistaxis cheilitis headaches psychosis abdominal pain/hepatitis pancreatitis initial exacerbation of acne low mood/suicidality

Answer 478

crohn's disease ulcerative colitis inflammatory arthritis (psoriatic arthritis) and spondyloarthropathy uveitis metabolic syndrome

Answer 479

Dovobet (Calcipotriol 50 mcg/g and betamethasone 0.5 mg/g) ointment apply once daily x 4 weeks High-potency topical corticosteroids (eg. Clobetasol 0.05% ointment) with ONE of the following: Vitamin D analogs (Calcitriol, Calcipotriol) Retinoids (Tazarotene 0.1% Gel) UVB phototherapy Alternatives Tar / Anthralin (15% LCD solution) Severe may need phototherapy, systemic therapy (methotrexate, retinoid), biologic immune modifying agents (infliximab) Psoriatic arthritis: NSAID, DMARD (MTX), biologics (TNF inhibitor) Facial/intriginous/genital psoriasis Low-potency Hydrocortisone 1% cream or ointment often sufficient Calcineurin inhibitors may be used (Tacrolimus 0.1% ointment, Pimecrolimus 1% cream)

Answer 480

Consider topical treatments above in different forms, eg. Clobetasol shampoo, betamethasone valerate foam or Dovobet gel.

Answer 481

Size/shape/texture: well vs. poorly demarcated, targetoid, verrucous, umbilicated Colour: erythematous, violaceous, hyper/hypopigmented, depigmented, jaundiced Arrangement: solitary, grouped, linear, reticular/mottled, dermatomal Lesion type (primary/secondary): Primary (< 1cm/>1cm) = macule/patch, papule/plaque, nodule/tumour, vesicle/bulla Secondary = lichenification, maceration, erosion/ulceration Distribution Always look at nails (e.g, pitting, oil spots), hair (e.g., scalp plaques, hair thinning), mucous membranes (e.g., white lacy patches, open sores), intertriginous areas

Answer 482

Previous episodes Previous treatment Contact/exposure/travel (e.g., infectious, new detergents/fabric softeners/lotions/deodorants, metal belt buckles/glasses, different humidity/climates) Medication/drugs (e.g., antibiotics [penicillin, sulfonamides], corticosteroids, NSAIDs, anti-epileptics) PMH/family history Associated symptoms (pain, pruritus, bleeding, exudate, blistering/ulcerations, fever, aches) Occupational history Impact on patient's life (function, sleep, mood, social life)

Answer 483

Erythemotelangiectatic (flushing/redness, telangiectasias) Papulopustular Phymatous (fibrotic skin thickening) Ocular (blepharitis, conjunctivitis)

Answer 484

Behavioural changes Avoid triggers Extreme temperature Sunlight Spicy food Alcohol Exercise Acute psychological stressor Medication Menopausal hot flashes frequen skin moisturization gentle skin cleansing sun protection

Answer 485

Unlike acne, no comedones in papulopustular rosacea Unlike systemic lupus, no cheilitis in erythematotelangiectic rosacea Perioral dermatitis Seborrheic dermatitis and rosacea may co-exist

Answer 486

First-line Metronidazole 0.75-1% gel or cream daily Note: There is no clinical difference between 0.75% and 1% metronidazole, but 0.75% may cost more Azelaic Acid (Finacea) 15% gel BID Ivermectin (Rosiver) 1% cream daily If Moderate-Severe Add oral antibiotics to topical above Doxycycline 50-100mg PO BID or 40mg modified-release daily or tetracycline or isoretinoin Taper after 2-3 months and maintain on topical laser and intense pulsed light or vascular laser

Answer 487

First-line Brimonidine (Onreltea) 0.33% gel Metronidazole 0.75-1% gel or cream daily Azelaic Acid (Finacea) 15% gel BID Second-line Alternative first-line or combination of first-line Intense pulsed light device or vascular laser

Answer 488

topical retinoid or PO doxycycline or PO tetracycline, irotretinoin severe: surgical/ electrosurgical /laser ablation

Answer 489

Precontemplation -not yet considering change or unwilling/unable to change -Increase awareness of risks in nonjudgmental manner (avoid resistance) Contemplation -sees possibility of change but is ambivalent or uncertain -Discuss pros/cons of quitting (understand ambivalence) Preparation -committed to changing, still considering what to do -Offer practical advice and anticipate diffiiculties -identify appropriate change strategies Action -taking steps towards change -primary task to help implement change strategies and eliminate relapses -Support, reward, prevent relapse -Review action plan maintenance -has achieved the goals and is working to maintain change -task: develop new skills for maintaining

Answer 490

Leading cause of preventable death (6.5-9y premature death) Financial gains (1ppy = $3650 per year) Somebody who smokes a pack a day will smoke through almost $1 million after forty years (if they had invested that money) Reduce risks of erectile dysfunction 8h - Carbon monoxide eliminated 24h - Risk of heart attack begins to drop 2w - Improved in lung function, walking easier 1mo - Decreased coughing, nasal congestion, shortness of breath 1y - Risk of coronary heart disease halved 5y - Risk of stroke same level as non-smokers 10y - Risk of mouth, throat and esophageal cancer halved, death rate from lung cancer also halved 15y - Risk of heart attacks similar to that of non-smokers

Answer 491

Tell family, friends, coworkers about quitting for support Remove tobacco products from environment Exercise program Alternative oral behaviours (gum, lozenges) Obstacles (withdrawal, weight gain, triggers) Support groups (eg. 1-800-QUIT-NOW) Combining counselling and smoking cessation medication is more effective than either alone Counselling by a variety or combination of delivery formats (self-help, individual, group, helpline, web-based) Multiple counselling sessions Practical counselling on problem solving skills or skill training Regular follow-up to assess response, provide support and modify treatment as necessary Peak withdrawal at 2-3d Highest relapse at 2-3w Refer patients/clients to relevant resources where appropriate

Answer 492

varenicline -Varenicline begin 1w before quit date 0.5mg/d x3d then 0.5mg BID x3d then 1mg BID >12 weeks (evidence up to 12 months) [OR 2.89] Nicotine -gum, patch, inhaler, lozenge bupropion nortriptyline

Answer 493

AE: Insomnia, headache, abnormal dreams, GI upset

Answer 494

AE: Insomnia, headache, dizziness, tachycardia, xerostomia, weight loss Avoid in seizure disorder, eating disorder, alcohol withdrawal

Answer 495

Typical: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis Atypical: Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella spp

Answer 496

No hospitalization within 14d of onset OR <4d prior to onset

Answer 497

Two symptoms (fever, rigors, cough change, pleuritic chest pain, SOB), AND auscultatory findings (localized crackles, bronchial breath sounds), AND X-ray opacity

Answer 498

chest XR (PA and lateral) Labs: CRP pro calcitoin leukocytosis if severe: -urine legionella/pneumococcal Ag sputum gram stain and culture (r/o MRSA, P aeruginosa) -legionella culture Nasopharyngeal swat viral PCR (influenza, coronavirus)

Answer 499

CURB-65: -confusion -BUN> 9 mmol/L urea -RR over 30 -systolic BP under 90 -age >65 PSI: Sex M (0 points) F (-10 points) Demographic factors Age (1 point for each year) Nursing home resident (10 points) Comorbid illnesses Neoplastic disease (30 points) Liver disease (20 points) Congestive heart failure (10 points) Cerebrovascular disease (10 points) Renal disease (10 points) Physical examination findings Altered mental status (20 points) Respiratory rate ≥30/minute (20 points) Systolic blood pressure <90 mmHg (20 points) Temperature <35 degrees C or ≥40 degrees C (15 points) Pulse ≥125/minute (10 points) Laboratory and radiographic findings Arterial pH <7.35 (30 points) Blood urea nitrogen ≥30 mg/dL (11 mmol/L) (20 points) Sodium <130 mEq/L (20 points) Glucose ≥250 mg/dL (14 mmol/L) (10 points) Hematocrit <30 percent (10 points) Partial pressure of arterial oxygen <60 mmHg or oxygen saturation <90% (10 points) Pleural effusion (10 points)

Answer 500

If no antibiotics in past three months Clarithromycin 500mg PO BID x7d or Azithromycin 500mg PO daily x1 day then 250mg PO daily x 4 days or Doxycycline 100mg PO BID x 7 days Promote less resistance to macrolides by using clarithromycin Amoxicillin 1g PO TID x7d (less emphasis on covering atypicals) Pediatrics - Amoxicillin 90 mg/kg/d PO divided TID x7-10d (consider atypical coverage in children ≥5 years old)

Answer 501

Amoxicillin OR amoxicilline/clavulanate with atypical coverage (Clarithromycin or Azithromycin or Doxycycline) Second-line (after failed 72-96h) -Levofloxacin 750mg PO daily x 5 days or Moxifloxacin 400mg PO daily x 7d

Answer 502

Cefotaxime 1-2g IV q8h or Ceftriaxone 1-2g IV q12-24h AND Levofloxacin or Moxifloxacin or Azithromycin Note: Ceftriaxone superior to Pip/Tazo (as 15% Strep pneumo resistant to Pip/Tazo in community-acquired pneumonia)

Answer 503

Risk factors: Elderly, immunosuppression, smoker, lung disease T>39ºC Neurological (Confusion/Weakness/Gen det) GI (diarrhea) Electrolytes (Hyponatremia. hypophosphatemia, renal/hepatic dysfunction, thrombocytopenia, leukococytosis) Hematuria Hotel, cruise ships, residence (water reservoir contamination)

Answer 504

Repeat CXR in 6w (r/o underlying disease) if >50yo or immunosuppressed, lung disease, alcohol, smoker, >5% weight loss in past month Extensive/necrotizing pneumonia

Answer 505

smoking cessation Hygiene (handwashing) Vaccination Influenza Pneumococcal >65yo or comorbidity Prevents invasive pneumococcal disease (bacteremia)

Answer 506

If non-anaphylactic penicillin allergy -Cefuroxime or Cefadroxil + atypical coverage (consider monitor in office 1-2h) -or cefprozil Anaphylactic penicillin allergy -Levofloxacin or Moxifloxacin as below

Answer 507

* Âge < 3 à 6 mois; * Enfant toxique ou léthargique; * Détresse respiratoire importante; * Besoin en oxygène; * Maladie cardiaque ou pulmonaire sousjacente; * Immunodéficience; * Pneumonie compliquée (épanchement, empyème, abcès, etc.); * Contexte épidémiologique d’un pathogène virulent/ multirésistant; * Déshydratation, incapacité de s’alimenter; * Vomissements; * Non-réponse à une antibiothérapie orale; * Faible participation parentale permettant d’assurer l’adhésion au traitement.

Answer 508

amoxicilline 90 mg /kg/TID x 7-10 days if usage of antibiotics in past 30 days; amoxicilline and clavulanate if suspicion of atypical PNA: clarythromycine or azithromycine

Answer 509

cefuroxime cefprozil if anaphylactic: clarithromycine azithromycine

Answer 510

Apparition soudaine de fièvre1 (≥ 38,5°C) OU de toux (sèche), ET d’au moins l’un des symptômes suivants: Mal de gorge Arthralgie Myalgie Prostration2 ou fatigue extrême Chez les adultes : Maux de tête Chez les enfants : Symptômes gastro-intestinaux (ex. : nausées, vomissements, diarrhée et douleurs abdominales) Chez les personnes âgées : Toux parfois tardive Fièvre gériatrique3 ou parfois absente

Answer 511

PEU SÉVÈRE Symptômes typiques parfois accompagnés de diarrhée et de vomissements MODÉRÉMENT SÉVÈRE Symptômes typiques ET signes ou symptômes plus sévères : Douleurs thoraciques Hypoxie légère Insuffisance cardiopulmonaire (ex. : hypotension artérielle) Atteinte légère du système nerveux central (ex. : confusion, altération de l’état mental) Déshydratation grave Exacerbation des maladies chroniques existantes SÉVÈRE Signes et symptômes associés aux conditions suivantes : Insuffisance respiratoire nécessitant une oxygénothérapie Anomalies du système nerveux central (ex. : encéphalite, encéphalopathie) Complications liées à une hypotension artérielle (ex. : choc, défaillance d’organe) Myocardite ou rhabdomyolyse Infection bactérienne secondaire invasive (ex. : fièvre élevée persistante et autres symptômes audelà de 3 jours)

Answer 512

2 yo and below 75 yo and above resident from elderly residence chronic disease (heart/lung/renal/hepatic/hamatologic, immunosuppressed, obesity) children with chronic ASA treatment pregnant women in T2-3 high risks of complications: Personnes immunosupprimées (ex. : receveurs d’une allogreffe ou d’une greffe d’organe solide récente, personnes sous chimiothérapie) Personnes avec pneumopathies sévères Personnes avec comorbidités multiples

Answer 513

Peu sévère Enfant âgé d’un an et plus1 avec un facteur de risque de complications de l’influenza (en plus de l’âge) Personne âgée de moins de 75 ans avec un facteur de risque de complications de l’influenza Personne qui vit sous le même toit qu’une personne à risque de complications de l’influenza ou qui prend soin d’elle à domicile Personne âgée de 75 ans et plus Personne à haut risque de complications de l’influenza >>Amorcer l’antiviral si les symptômes sont apparus depuis 48 heures ou moins si moderement ou severe: traiter même si les symptômes sont apparus depuis plus de 48 heures treat all regardless of severity if: Résident d’un centre d’hébergement et de soins de longue durée, d’une résidence pour aînés ou d’une ressource intermédiaire, qu’ils soient publics ou privés Personne hospitalisée avec influenza

Answer 514

Spirometry FEV1/FVC <0.70 post-bronchodilator Grade Mild = FEV1>80% predicted Moderate = 50-80% Severe = 30 to <50% Very Severe <30%

Answer 515

Smoking, air pollution, occupational exposures (dusts, chemical agents), genetic factors (alpha-1 antitrypsin), age and female, abnormal lung development, chronic bronchitis, childhood infections

Answer 516

WHO recommends all patients with COPD should be screened once, especially if high prevalence area Consider if early onset COPD, family history of AATD, <20py smoker, asthma poorly responsive to therapy Classic <45yo with panlobular basal emphysema

Answer 517

Smoking cessation, exercise Yearly influenza vaccine and pneumococcal vaccine (>65yo or risk) Pulmonary rehabilitation for exercise-limited patients or FEV1<50% Oxygen therapy for severe resting chronic hypoxemia (PaO2 <55mmHg, SaO2<88%) Non-invasive ventilation (CPAP) for OSA or chronic hypercapnia with history hospitalization Bronchoscopic and surgical treatments for advanced COPD

Answer 518

Lifestyle Stop smoking Exercise Vaccine Influenza Pneumococcal 23-valent Meds LA bronchodilators/anticholinergics Teach inhaler technique Action plan When to go to Emergency Department Refer Pulmonary Rehab Resp therapy/Respirology/Specialty clinic Smoking cessation group

Answer 519

Non-invasive ventilation for respiratory failure Mild SABA (eg. 4-8 puffs inhaled q20mins up to 4h then q1-4h PRN) +/- LAMA Moderate Antibiotics and corticosteroids (Pred 40mg PO daily x5d) indicated if increased sputum purulence with one of: sputum volume or dyspnea (or if requires ventilation) If simple COPDE, Amoxicillin 500mg TID x 7d, or clarithromycin 500 BID x 7d, or azithromycin, or cefuroxime, or doxycycline, or TMP-SMX If complicated (FEV1<50%, >3 COPDE/y, comorbidity, oxygen needs, chronic inhaled steroid, recent antibiotic use) Moxifloxacin 400mg PO daily x 5d, Levofloxacin 500mg PO daily x 7, or Clavulin if pseudomonas risk: ciprofloxacin Consider -Procalcitonin -Sputum cultures if recurrent or severe, r/o pseudomonas Severe: Magnesium sulfate 2g IV over 20 minutes may reduce hospitalizations (NNTB = 7) Hospitalization/ER visit

Answer 520

Bronchodilators Short-acting bronchodilator (beta-agonist and/or anticholinergic) SABA Salbutamol (Ventolin) 100 mcg/actuation 1 to 2 puffs inhaled PO q4h PRN, Levalbuterol SAMA (if not on long-acting anticholinergic) Ipratropium (Atrovent HDA) MDI 17mcg/actuation 2 inh QID, then additional actuations PRN Combination SAMA/SABA Ipratropium/Salbutamol (Combivent Respimat) 20/100mcg 2inh q4-6h PRN Long-acting LABA Indacaterol (Onbrez Breezhaler) 1 capsule (75mcg) inhaled once daily using Breezhaler inhalation device Olodaterol (Striverdi Respimat) 2.5mcg/actuation two inhalations once daily LAMA (anticholinergic- muscarinic) Tiotropium (Spiriva Respimat) 2.5mcg/actuation two inhalations once daily Umeclidinium (Incruse Ellipta) 1 inhalation (62.5mcg) once daily Combination if symptomatic ICS/LABA: Fluticasone furoate/vilanterol trifenalate (Breo Ellipta) 100/25 mcg/dose one inhalation once daily LAMA/LABA: Umeclidinium-vilanterol (Anoro Ellipta) 62.5mcg/25mcg one inhalation once daily Inhaled glucocorticoid if repeat exacerbations/symptoms despite combination long-acting bronchodilators Combination LABA and ICS Formoterol/budesonide (Symbicort Turbuhaler) 12/400mcg inhaled BID Salmeterol/fluticasone (Advair Diskus) 50/250mcg inhaled BID Vilanterol/fluticasone (Breo Ellipta) 1puff inhaled once daily

Answer 521

chronic cough and sputum for more than 3 months per yeat, more than 2 years

Answer 522

Asthma, CHF, GERD,TB, Bronchiolitis, alpha1 antitrypsin deficiency

Answer 523

skeletal muscle deconditioning, right heart failure, polycythemia, MDD

Answer 524

One or more somatic symptoms that are distressing or result in significant disruption of daily life. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: Disproportionate and persistent thoughts about the seriousness of one’s symptoms. Persistently high level of anxiety about health or symptoms. Excessive time and energy devoted to these symptoms or health concerns. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Answer 525

Preoccupation with having or acquiring a serious illness. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.

Answer 526

One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom or deficit is not better explained by another medical or mental disorder. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Answer 527

Rule out comorbid psychiatric disorders that require treatment (Anxiety, Depression) Schedule regular visits Acknowledging symptoms Focus on psychosocial and not just physical symptoms Assessing and treating diagnosable medical and psychiatric disorders Limiting tests and referrals Reassuring the patient that grave medical diseases have been ruled out (emphasize mind-body connection) Functional improvement the goal of treatment Pharmacotherapy (eg. Fluoxetine 20mg PO daily and titrate up, or Amitriptyline) Psychotherapy (CBT or Mindfulness-based therapy) Consult Psychiatry once to clarify diagnosis and reduce investigations

Answer 528

Impaired Control Had times when you ended up using X more, or longer, than you intended? More than once wanted or attempted to cut down or stop X but couldn’t? Spent a lot of time using/getting/recovering from X Craving: Wanted X so badly you couldn’t think of anything else? Social Impairment Obligations: Found that X—or being sick from X—often interfered with taking care of your home or family? Or caused job troubles? Or school problems? Interpersonal: Continued to use X even though it was causing trouble with your family or friends? Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to use X? Risky Use More than once gotten into situations while or after using X that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? Pharmacological indicators *Tolerance: Had to use X much more than you once did to get the effect you want? Or found that your usual number/amount had much less effect than before? *Withdrawal: Found that when the effects of X were wearing off, you had withdrawal symptoms (e.g., alcohol: trouble sleeping, shakiness, restlessness, nausea, sweating, racing heart, seizure? Or sensed things that were not there?)

Answer 529

Amount Frequency Duration of use Last use Signs of tolerance/withdrawal Affect on function Safety of patient and others Consider substance-specific screening tools (eg. AUDIT, CAGE)

Answer 530

Psychiatric disease, chronic disability, family or personal history of substance use disorder Associated symptoms, eg. Functional decline, confusion, delirium, syncope Associated medical problems, especially if not responding to appropriate intervention (alcohol in hypertriglyceridemia, inhalation drugs in asthmatic) Prescription medication that are commonly misused (opioids, sedatives, hypnotics, or anxiolytics, stimulants)

Answer 531

Do not share medication Do not receive medications from other sources Store medication in secure location (out of reach of children, adolescents) Ensure regular visits to healthcare provider, and regular urine samples for drug screens as requested Inform your healthcare provider of any changes to health, and if you would like to adjust your prescribed dose Avoid concurrent use of sedatives/depressants (eg. Alcohol, benzodiazepines)

Answer 532

Brief episode of neurological dysfunction without evidence of acute infarction, back to baseline <24h 3% risk of stroke in first 2 days after TIA, risk stratify with ABCD2 score >3 admission

Answer 533

Sudden onset focal neurological dysfunction from infarction or hemorrhage in the brain lasting >24h

Answer 534

Acute onset Hemiparesis / Motor weakness Neglect Amaurosis fugax Slurred speech Dysphagia Sensory deficits / Decreased reflexes Mental status change / Confusion / Inattention Impulsivity

Answer 535

smoking obesity Hypertension family history sedentary lifesty;e diabetes hyperlipidemia alcohol prior TIA/stroke

Answer 536

transient ischemic attack [TIA], brain tumour hypoglycemia subdural hematoma, subarachnoid bleed Recrudescence of old stroke from metabolic or infectious stress Todd’s paralysis after seizure Complex migraine Psych Mass/tumor CNS infections Bells palsy (central causes will spare the forehead) Subarachnoid hemorrhage (sudden onset severe headache, stiff neck, photophobia, diplopia) Subdural hematoma

Answer 537

Aphasia, right hemiparesis / right hemianopia

Answer 538

Left hemispatial neglect, left hemiparesis / hemianopia

Answer 539

Mental status changes / Confusion Diplopia Dysphagia Unilateral dysmetria/incoordination

Answer 540

ABC Vitals, serum glucose 12-lead EKG, cardiac monitor IV x 2 Oxygen >90% Determine onset of stroke symptoms (or last observed normal)

Answer 541

CBC INR PTT Creat lytes glucose Blood type and screen consoder troponine

Answer 542

Brain imaging (CT or MRI) with vascular imaging (CTA or MRA from aortic arch to vertex, or carotid doppler) >50% symptomatic (>60% asymptomatic) carotid stenosis should be offered carotid endarterectomy as soon as possible ECG and 24-hour cardiac monitoring + Holter (if no Afib on ECG and 24h monitor) TTE (or TEE if high suspicion) Thrombi, endocarditis, calcifications, tumour Patent foramen ovale (No clear evidence for PFO closure) Antiphospholipid Vasculitis

Answer 543

reverse anticoagulation monitor ICP consult neurosurgery

Answer 544

tPA if elligible IV thrombolysis alteplase control BP to target consider Eligibility for endovascular neurointerventional care ASA if no tPA

Answer 545

Age 18 years or older Clinical diagnosis of ischemic stroke causing neurological deficit Time of symptom onset <3-4.5 hours One study showed benefit up to 9 hours or on awakening

Answer 546

Active or history of intracranial hemorrhage <3 months neurosurgery, head trauma, stroke Uncontrolled hypertension >185/110 Known intracranial AV malformation, neoplasm, aneurysm Active internal bleeding Suspected endocarditis, suspected subarachnoid hemorrhage Bleeding disorder (Plat<100, heparin with elevated aPTT, INR>1.7, DOAC) Abnormal glucose <2.7mmol/L

Answer 547

<185/110 prior to treatment, and <180/105 for first 24h if thrombolytic therapy If no thrombolytic, only treat if >220/120 or other indication Consider Labetalol, Nicardipine, Clevidipine

Answer 548

National Institutes of Health Stroke Scale (NIHSS) >6 Vision, aphasia, neglect (VAN) assessment + Pronator drift x10s, only continue if positive (mild drift, severe weakness, or paralysis) Stroke vision Aphasia Neglect

Answer 549

Early mobilization (<24h post-stroke), NPO until Swallowing assessment Nutritional support Dedicated stroke unit Assess for functional impairment

Answer 550

Cardiac Depression Dementia Dysphagia Fatigue Ulcer Venous thromboembolus (25% early death post-stroke is from PE, consider prophylaxis) Pain Seizure (no evidence for prophylaxis)

Answer 551

High Risk of Stroke Recurrence -<48h of TIA or nondisabling stroke and transient, fluctuating and/or persistent unilateral weakness or speech disturbance -Immediate referral to ER with capacity for advanced stroke care (access to tPA) -CT or MRI and noninvasive vascular imaging (eg. CTA or MRA from arch to vertex) -ECG <48h without motor weakness or speech disturbance -Same-day assessment (ER or stroke prevention clinic) Increased risk: -48h-2w with symptoms of transient, fluctuating or persistent unilateral weakness or speech disturbance 24h clinical evaluation and investigation -48h-2w without motor weakness or speech disturbance 2w clinical evaluation and investigation ->2w of TIA or nondisabling ischemic stroke <1 month by neurologist

Answer 552

Antiplatelets -Clopidogrel (75mg daily) vs. aspirin/dipyridamole (25/200mg BID) vs. aspirin alone (delay 24h if given tPA) For minor stroke and TIA, consider dual antiplatelet for 10-21d Lifestyle: Smoking / Alcohol Obesity (Weight loss) Diet (avoid fat, sodium, sugar) Physical activity Atrial fibrillation (anticoagulate as per CHADS65) If ECG negative, can consider prolonged ECG monitoring (Holter) Lipids (Statin in all ischemic stroke/TIA) Screen and Treat: Diabetes (HbA1c) Blood pressure Hormone (Consider stopping hormone replacement therapy and OCP) OSA Review FAST (symptoms of stroke)

Answer 553

cardioembolic from a fib atheroemboli from athrosclerotic dz arterial dissection vasospasm vasculitis hypercoagulable state

Answer 554

Cardiovascular: ACS, pericarditis Aortic dissection, mesenteric ischemia, sickle cell crisis Pulmonary: Pneumonia, embolus Biliary: Cholecystitis, cholelithiasis, cholangitis Gastric: Esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction Colonic: Appendicitis, colitis, diverticulitis, IBD, bowel obstruction, peritonitis, celiac disease Hepatic: Hepatitis, abscess, mass Pancreatic: Pancreatitis, mass Renal: Cystitis, nephrolithiasis, pyelonephritis Splenic: Abscess Gynecologic: Ectopic pregnancy, ovarian mass, ovarian torsion, PID, fibroids, endometriosis, ovulatory pain, ruptured ovarian cyst Abdominal wall: Herpes zoster, muscle strain, hernia Metabolic: Uremia, DKA, porphyria, adrenal insufficiency, narcotic withdrawal, heavy metal poisoning Psych: IBS

Answer 555

Life-threatening Ectopic pregnancy Appendicitis Ruptured ovarian cyst Fertility-threatening PID Ovarian Torsion

Answer 556

Fever (after onset of vomiting or pain) Bilious vomiting Bloody diarrhea Absent bowel sounds Voluntary guarding Rigidity Rebound tenderness ** Do not forget testis **

Answer 557

Common: Colic, constipation, GERD, food protein allergy Urgent: Acute gastroenteritis, malrotation without volvulus, pyloric stenosis Emergent: Trauma (abuse), midgut volvulus, NEC, omphalitis, incarcerated hernia, intussusception

Answer 558

Common: UTI, constipation Urgent: Acute gastroenteritis, HSP, pneumonia, Meckel diverticulum Emergent: Trauma, appendicitis, asthma

Answer 559

Common: UTI, constipation, functional Urgent: Acute gastroenteritis, IBD, HSP, pneumonia Emergent: Trauma, appendicitis, gonadal torsion, DKA, asthma

Answer 560

Urgent: Gastroenteritis, IBD, pneumonia, hepatitis, pancreatitis, nephrolithiasis, PID Emergent: Trauma, appendicitis, gonadal torsion, ectopic pregnancy, DKA, asthma

Answer 561

Consider urinalysis, CBC, pregnancy test, ESR/CRP Consider ultrasound prior to proceeding with abdominal CT

Answer 562

MI, AAA, dissection, neoplasia, PID, peritonitis, cholangitis, abscess, pancreatitis, ectopic, SBO/strangulated hernia, perforation, appendicitis, PE, pneumonia, zoster, depression, DKA, drugs, anemia, UTI

Answer 563

Cardiac Acute Coronary Syndrome (ACS) Myocarditis Pericarditis -Pleuritic chest pain, decreased on leaning forward -Diffuse ST elevation, PR depression, pericardial friction rub -Treatment -Supportive, NSAIDs, steroids Pulmonary Pulmonary Embolism Tension pneumothorax (see trauma) Pneumonia COPDE Acute chest syndrome (sickle cell) Thoracic aortic dissection -Sudden, severe pain radiating to back Widened mediastinum on CXR, >20mmHg -difference in BP on left vs. right -Treatment -Decrease contractility and BP (target sBP <120)] -ABC, surgery/ICU GI Boerhaave's sydrome (esophageal rupture) -Treatment -NPO -IV Abx, IV PPI, Endoscopy/surgical repair GERD/PUD Chest wall Costochondritis MSK Herpes Zoster Psychogenic (Anxiety)

Answer 564

Age/sex: men 55 years or older, women 65 years or older Known clinical vascular disease (CAD, occlusive vascular disease, cerebrovascular disease) Pain worse with exercise Pain not elicited with palpation Patient assumes pain is of cardiac origin 0-1 points predicts a 1% CAD risk 0-2 points predicts a 3% CAD risk

Answer 565

Female Fat (Obesity), also recent weight loss Fertile (Estrogen), Pregnancy Forty (Elderly) Fair (Caucasians/Northern European but also Hispanic) Family history Liver transplant

Answer 566

Antibiotics Endoscopic Retrograde Cholangiopancreatography (ERCP) with stone removal/cholecystectomy

Answer 567

Abdominal Exam Murphy's sign Labs Leukocytosis (left shift) Bilirubin Alk Phos ALT Amylase Abnormal LFTs are not common in uncomplicated acute cholecystitis, as obstruction limited to gallbladder Ultrasonography Sonographic Murphy's sign Gallbladder wall thickening >4mm or edema (double wall sign) Pericholecystic fluid CT vs. MRCP if ultrasound unclear or if complications suspected

Answer 568

Surgery referral for symptomatic gallstones (biliary colic) Analgesia (NSAIDs, narcotic as second-line) Expectant management for asymptomatic gallstones (only 10-20% will become symptomatic within 5-20y) Surgery may be considered in asymptomatic gallstones in the following situations: Calcification of the gallbladder (porcelain gallbladder) because of high risk for gallbladder cancer Hemolytic anemia (e.g., sickle cell disease) Large gallstones (greater than 3 cm) because of high risk for gallbladder cancer Morbidly obese undergoing bariatric surgery because of high risk to becoming symptomatic during rapid weight loss Aboriginals because of high risk for gallbladder cancer Planning for a transplant

Answer 569

Lack of pain resolution, fever, peritonitis, abnormal labs

Answer 570

Calculous cholecystitis Acalculous cholecystitis - 10% (usually in critically ill patients)

Answer 571

Treatment No need for antibiotic prophylaxis in low risk Cholecystectomy Untreated, resolves within 7-10d but risk of complications (20% gallbladder gangrene, 2% perforation)

Answer 572

fever, jaundice, RUQ pain (risk of pancreatitis and acute cholangitis) + raynaud's pentad confusion and shock

Answer 573

DDx: IBD, ruptured cyst, abscess, ectopic pregnancy, testicular torsion

Answer 574

ABC Intravenous fluids NPO/ Bowel rest Consider antibiotics Consider prophylactic antibiotics (Cefoxitin/Cefotetan/Cefazolin PLUS Metronidazole) 60 mins prior to surgery If surgery delayed until next day, consider empiric antibiotics (Ertapenem, Pip-Tazo, Cefazolin/Ceftriaxone/Cipro/Levo PLUS Metronidazole) Surgical consult for appendectomy

Answer 575

Use of Aspirin and NSAIDs Older age Obesity Lack of exercise

Answer 576

CT abdomen with double contrast (PO and IV) Colonoscopy is contraindicated in acute diverticulitis but patients should have a colonoscopy in 4-6 weeks after resolution to assess extent of diverticular disease and to r/o colon cancer

Answer 577

Clear liquid and FU in 2-3 days Consider broad spectrum oral antibiotics against gram-negative rods and anareobic bacteria Septra DS 160/800mg po BID Ciprofloxacin 500-750mg po BID + Metronidazole 500mg po Q6H for 7-10 days

Answer 578

Hospital admission IVF IV antibiotics with PipTazo 3.375g IV Q6H or 4.5g IV Q8H until resolution of symptoms then transition to 10-14 days of oral antibiotics NPO CT abdomen

Answer 579

Abscess (CT guided percutaneous drainage) Bleeding Perforation Fistula Obstruction

Answer 580

Increase dietary fibers Smoking cessation Regular exercise Weight loss if BMI > 30

Answer 581

wheat rye barley

Answer 582

Classical Malabsorption (diarrhea, steatorrhea, weight loss, growth failure) Nonclassical Absent signs of malabsorption but intestinal/extraintestinal symptoms Subclinical (found on screening) Below clinical detection but abnormal serological test and villous atrophy Potential (latent) Abnormal antibody but normal intestinal mucosa - may develop intestinal lesion (requires monitoring)

Answer 583

1st degree relative celiac (5-20%) DM1 (3-10%) Consider serology screening q1-2y Down syndrome Turner syndrome Autoimmune thyroid disease Autoimmune liver disease Selective IgA deficiency

Answer 584

Malabsorption Abdominal pain/Bloating/Distension Chronic diarrhea/Constipation/IBS Weight loss/Fatigue Iron deficiency anemia Vit-D/Calcium - Dental enamel defects/Premature Osteoporosis B12/Folate - Neurological symptoms (Peripheral neuropathy, ataxia, seizures) Skin Dermatitis Herpetiformis ("Celiac of the skin" - pruritic papulovesicular rash on extensor) Recurrent aphthous stomatitis Infertility Abnormal LFTs Additional features in children Irritability Recurrent vomiting Delayed puberty Growth failure/Short stature

Answer 585

IgA tTG antibody (Sensitivity and Specificity 95%) False-negative -Age<2yo -Consider in <2yo, screen with both IgA tTG and IgG DGP Ab -Lab error -Reduction/elimination of gluten (may be negative within weeks of GFD) --Gluten-containing diet should be resumed before ordering test --Consider HLA-DQ2/DQ8 for patients on a GFD -Note: HLA present in almost all patients with Celiac (95% DQ2, 5% DQ8) -Selective IgA deficiency -Immunosuppressed (eg. steroids) -Seronegative Celiac disease (rare) - if high suspicion, consider referral for small intestinal biopsy or HLA testing Total IgA If <0.2g/L, consider testing IgG DGP antibodies Positive IgA tTG Ab requires endoscopic small intestinal biopsies to confirm -Do NOT start GFD prior to biopsy (as this will heal mucosa) -If GFD started, resume 3g gluten daily x 2-6w and referral to GI

Answer 586

In children can avoid biopsy with three criteria: Positive tTG Ab >10x ULN Positive endomysial Ab Positive HLA-DQ2 or HLA-DQ8

Answer 587

Strict Gluten-free diet (avoid wheat, barlet, rye - caution with oats) Referral to dietician Consider iron, folic acid, vitamin D and B12 testing Consider TSH and liver transaminase q1-2y

Answer 588

Nutritional deficiency (anemia) Osteoporosis Growth failure Autoimmune disorders (thyroid, liver) Malignancy (GI, LYMPHOMA)

Answer 589

IGETSMASHED" I - Idiopathic G - Gallstones E - Ethanol T - Tumors S - Scorpion bite M - Microbiology (TB, mumps, rubella, varicella, hepatitis, CMV, HIV) A - Autoimmune (SLE, polyarthritis nodosa, Crohn's) S - Surgery / trauma H - Hypertriglyceridemia (TG >11.3), hypercalcemia, hypothermia E - Emboli / ischemia D - Drugs (furosemide, estrogen, H2 blockers, valproate, antibiotics, ASA)

Answer 590

Early goal-directed fluid resuscitation Analgesia : hydromorphone, fentanyl, Nutritional support severe pancreatitis treatment: Intensive care unit (ICU) care Enteral nutrition preferred over parenteral nutrition Antibiotics for extrapancreatic infections and infected necrosis Necrosectomy (removal of necrotic tissue) for infected necrosis Endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis and concurrent acute cholangitis Drainage of pseudocysts

Answer 591

Crohn's Disease Any part of GI tract from the mouth to the rectum Transmural involvement Endoscopy: Skip lesions, cobblestoning, ulcerations, strictures Histology: Neutrophilic inflammation, noncaseating granulomas, Paneth cell metaplasia, and intestinal villi blunting Ulcerative Colitis Continuous lesions starting in rectum (generally only in colon) Mucosa and submucosal involvement only Endoscopy: Pseudopolyps, continuous areas of inflammation

Answer 592

Smoker in CD, but may be **protective for the development UC** Ashkenazi Jewish, White (compared to Black, Hispanic) Sedentary lifestyle, Obesity "Western" diet (processed, fried, sugar) Acute gastroenteritis, recent antibiotic use NSAID use Family history of IBD

Answer 593

Arthritis Peripheral arthritis Ankylosing Spondylitis (UC) Sacroileitis Dermatological Aphthous stomatitis Erythema nodosum Pyoderma gangrenosum Ocular Episcleritis and Scleritis (CD) Uveitis Primary sclerosing cholangitis (UC)

Answer 594

Infectious colitis Ischemic colitis Radiation-induced colitis Diverticulitis Appendicitis Colorectal malignancy (obstructing/perforating), lymphoma Celiac IBS

Answer 595

CBC BUN Creatinine Liver enzymes CRP and ESR Consider stool Cx and C. diff toxin PCR Consider fecal calprotectin if IBS vs. IBD Subsequent testing Iron profile Vitamin B12, Folate Albumin, prealbumin Vitamin D, calcium

Answer 596

Colonoscopy with ileoscopy and biopsy Capsule endoscopy (avoid in strictures) CT enterography MR enterography Small bowel follow-through Esophagogastroduodenoscopy recommended if upper GI symptoms, unexplained iron deficiency anemia, active Crohn's disease with normal colonoscopy

Answer 597

Smoking cessation Consider avoid NSAIDs (may exacerbate disease) Avoid pregnancy in women of childbearing age Conflicting data about OCP and IBD, may have small risk of association Ensure routine immunizations Tetanus and diphtheria, Polio, MMR, Varicella, Meningitis HPV Herpes zoster Influenza Pneumococcal Hepatitis A and B Prior to starting anti-TNF agents, obtain PPD testing and CXR (rule out TB), and update immunizations including Hep B Anxiety/depression Osteoporosis Screening/prevention if on chronic systemic steroids Colorectal Cancer Screening for colorectal cancer based on extent of disease Usually begin 8y after onset, q1-2 years (with random biopsies) Cervical Cancer Consider more frequent screening if on immunosuppressive therapy

Answer 598

Induction of Remission 5-ASA (sulfasalazine, mesalamine) Pentasa total 4g daily divided QID or BID If achieve remission, maintain dose or reduce to 3g daily Creat at 6w, 3mo, 6mo, 12mo, then yearly Glucorticoids (Topical Ileal release budesonide (Entocort EC), prednisone) Prednisone 40 mg PO x 1 week and then taper 5mg weekly for total duration of 8 weeks Maintenance 5-ASA (sulfasalazine, mesalamine) Immunomodulators (azathioprine and 6-mercaptopurine, methotrexate) Anti-TNF agents (infliximab, adalimumab) Consider Probiotics Lactobacillus GG and Escherichia coli Nissle 1917 Symptomatic Loperamide if no systemic (fever, tachycardia) Avoid opioids as may mask acute abdomen Consider avoid NSAIDs (limited data may worsen disease)

Answer 599

Breathlessness Fatigue Weight gain Peripheral edema Orthopnea (LR 2.2) Paroxysmal nocturnal dyspnea (LR 2.6) Confusion in elderly

Answer 600

Hypertension Ischemic heart disease (LR 3.1) Valvular heart disease Diabetes mellitus Alcohol, substance use Chemotherapy/radiation therapy Family history cardiomyopathy Smoking Hyperlipidemia

Answer 601

Bilateral lung crackles Elevated JVP (LR 5.1) Positive abdominal jugular reflex Peripheral edema (LR 2.3) Laterally isplaced apex S3 (LR 11), S4 or any heart murmur Low BP or HR>100 Note: In heart failure with narrow pulse pressure, think high output heart failure (eg. anemia, thyrotoxicosis)

Answer 602

HFrEF (reduced) LVEF <40% _________________________________ HFmrEF (mid-range) LVEF 40-49% Elevated natriuretic peptide Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction __________________ HFpEF (preserved) 💡 A preserved ejection fraction on a routine echocardiogram does not rule out the clinical syndrome of heart failure LVEF >50% Elevated natriuretic peptide Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction

Answer 603

I = No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath). II = Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath). III = Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. IV = Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Answer 604

CBC Ferritin Glucose Electrolytes Creat/eGFR TSH UA LFTs Lipids & A1c (risk factor management) Consider if diagnosis uncertain or if high suspicion Troponin → r/o ACS and prognosis NT-proBNP >125pg/mL → consider echocardiography HF unlikely if < 300; highly likely if > 900 (1800 if age >75) BNP>50 pg/mL → consider echocardiography HF unlikely if < 100; highly likely if >400

Answer 605

ECG -Afib, new T-wave change, Q waves, LVH, LBBB, HR>100, Lung ultrasound -B-profile bilaterally, pleural effusion CXR -Cardiomegaly, pulmonary venous redistribution, pulmonary edema, pleural effusion, Kerley B lines Echocardiography -Decreased LVEF -Increased LV diameter/LVH -Wall motion abnormalities, diastolic dysfunction -Increased RV size, RV dysfunction -Valve dysfunction -Elevated pulmonary arterial pressures (PAP)

Answer 606

Acute Management 💡 LMNOP (Lasix, Modify medications, Nitroglycerine, Oxygen, Position (upright) +/- Positive Pressure (BiPAP) Oxygen ≥ 90-92% NIPPV (BiPAP > CPAP) if SpO2 < 90% despite supportive O2 Position upright Hypotension (cardiogenic shock)→ Pressor (eg. Norepinephrine) to maintain MAP 65-80 Hypertension (SCAPE)→ High-dose nitroglycerin IV Nitroglycerine (NTG) SL 0.4mg x 3 q5 mins until IV nitroglycerine started (note SL nitro only 40% bioavailable) Nitroglycerine 100mcg/min IV infusion, increase by 20mcg/min every 10 mins until sBP decreases Then maintain until improvement in symptoms, then gradually reduce IV infusion until stop Alternatively may give intermittent nitroglycerin bolus 1-2mg IV q3-5 minutes Avoid in PDE5 inhibitors (e.g., sildenafil) or concomitant inferior STEMI (preload dependent) If suspect total body hypovolemia, no B-lines on lung ultrasound, hypoperfusion, Consider careful fluid bolus challenge (250mL isotonic crystalloid) If suspect total body hypervolemia (eg. B-lines on lung ultrasound, pedal edema, jugular vein distension, history of nonadherence to diuretics or missed hemodialysis) Note: Many patients may be euvolemic and have a maldistribution of fluids into the lungs Furosemide (Lasix) 20-80mg IV bolus (once stable) If taking regular furosemide at home, can give home PO dose as IV Consider the addition of acetazolamide 500mg IV daily to improve loop diuretic efficiency Monitor diuretic effect ~q6h while stabilizing Monitor daily weights and urine output, goals: urine output 3-5 L; 0.5-1.5 kg weight loss Increase/decrease diuretic by ~25-50% to meet above criteria If not responsive, consider adding metolazone 1.25-5mg one to seven times per week Consider consultations (e.g., cardiology, ICU) for advanced measures (e.g., intra-aortic balloon pumps, LVAD, ECMO, etc.)

Answer 607

💡 The classic “triple” therapy for HFrEF has recently expanded to “quadruple” therapy with the addition of SGLT2 Inhibitors in the updated CCS 2021 Guidelines. Quadruple Therapy for most patients with HFrEF (LVEF < 40% and symptoms) ACEi (or ARB if not tolerated) ACEi: Target Ramipril 10mg, Perindopril 8mg, or Lisinopril 20-35mg ARB: Target Candesartan 32mg BB (Careful initiating in NYHA III-IV) Target Bisoprolol 10mg or Metoprolol CR/XL 200mg MRA (Monitor potassium, creatinine) Target Spironolactone 50mg SGLT2 Inhibitor Target Empagliflozin 10-25mg or Dapagliflozin 10mg Convert from ACEi/ARB to ARNI if persistent/worsening symptoms despite adequate quadruple therapy (hospitalization and mortality benefit) Target Sacubitril/Valsartan 200mg BID (97mg:103mg) 💡 There is less evidence supporting the benefit of pharmacotherapy for patients with preserved EF (HFpEF). For patients with HFpEF consider SGLT2 and MRA as first-line therapies. Symptom Management Additional therapies should be considered for patients with HFrEF and persistent NYHA II-IV symptoms, despite optimization of quadruple therapy: Diuretic at lowest effective dose to maintain euvolemia Consider (with specialist involvement) Ivabradine if NSR and HR ≥ 70 bpm despite BB Vasodilators (e.g., hydralazine/Isosorbide dinitrate) if renal intolerance to ACEi/ARB/ARNI Digoxin (e.g., if poorly controlled AF despite BB) Device therapy (ICD, CRT) if LVEF ≤ 35% and NYHA I-IV (ambulatory)

Answer 608

>60yo Resting tremor, often unilateral, 4-6 Hz (cycles per second), pill-rolling, increased with stress, decreased with voluntary activity Muscle rigidity/cogwheeling (resistance to passive movement) Bradykinesia (slow movements) Postural instability, falls Shuffling gait, decreased arm swing, unsteady turning, difficulty stopping, stooped/flexed posture Mask-life facial expression, infrequent blinking Speech changes (hypophonia), micrographia Non-motor: Constipation, rapid eye movement (REM) sleep disorder, depression, olfaction impairment, personality changes

Answer 609

Improve quality of life and function Refer to neurology untreated within 6w Physical therapy Gait, balance, flexibility Occupational therapy Mobility, self-care, safety Speech therapy Vocal loudness, swallowing Parkinson Society of Canada / Support Groups Monitor for Depression, Dementia, Psychotic symptoms, Sleep disturbance, Autonomic dysfunction Psychosis Consider antipsychotics that have less antidopamine effects (Clozapine, Pimavanserin, Quetiapine) Postural hypotension Increase salt, head up, elastic stockings Midodrine or fludrocortisone

Answer 610

First-line: Levodopa/carbidopa (Dopamine precursor) Dopamine agonists - pramipexole (best early in disease) Anticholinergics - benztropine NMDA-receptor antagonist - amantadine MAOIs - selegiline COMT inhibitor - entacapone

Answer 611

Impulse control disorder (eg. compulsive gambling, hypersexuality, binge eating and obsessive shopping) Dyskinesia Somnolence Orthostatic hypotension/dizziness Nausea, Dyspepsia Psychotic symptoms and hallucinations

Answer 612

caustic acids and alkalis, alcohols, lithium, heavy metals

Answer 613

Dose: 1 to 2g/kg Multiple dosing q2-6h effective in phenobarbital, phenytoin, carbamazepine, salicylates, digitalis, theophylline and dapsone

Answer 614

Toxic foreign bodies (drugs packets), sustain release drugs, or toxic materials not bound by AC Contraindications: Mechanical obstruction, ileus, perforation

Answer 615

Indications: Highly toxic substances or large ingestions, substances not adsorbed by activated charcoal (lithium, iron, lead, methanol) and potential jeopardized airway (altered mental status) Contraindications: Ingestion of corrosives, hydrocarbons, depressed gag reflexes who are not intubated, clinically insignificant ingestions Complications: Aspiration, perforation of esophagus/bronchus

Answer 616

ABC, Oxygen (consider intubation), Mental status Vitals q5 mins Temperature, glucose IV access Cardiac monitor, EKG DON'T forget in Universal Antidotes in altered mental status: Dextrose, Oxygen, Naloxone (Narcan), Thiamine *CALL POISON CONTROL*

Answer 617

Labs CBC, electrolytes, glucose Hepatic and renal function High creatinine with normal BUN consider isopropyl alcohol or DKA Urinalysis Serum osmolarity VBG + lactate Quantitative drug serum levels: Acetaminophen, Salicylates, Ethanol Other: Digoxin, iron, lithium, theophylline, anticonvulsants, methanol, ethylene glycol Qualitative urine drug screen Pregnancy test Other EKG QRS, QTc CXR for aspiration, or medications (salicylates, narcotics, sedative-hypnotics) for pulmonary edema

Answer 618

Osmolar gap = Measured - (2 x [Na+] + [glucose] + [urea]) > 10 AGMA ([Na+] – [Cl−] – [HCO3−]>12)

Answer 619

Anticholinergic, sympathomimetic, hallucinogenic, drug withdrawal Treat with benzodiazepines and supportive care

Answer 620

Ethanol, sedative-hypnotic, opiates, cholinergic (parasympathomimetic), sympatholytics, toxic alcohol (methanol, ethylene glycol)

Answer 621

Toxic above 150mg/kg (7.5-10g for an adult)

Answer 622

0.5-24h: Asymptomatic (possible nausea, vomiting, diarrhea) 24-72h: RUQ pain (hepatic injury)

Answer 623

Initial and more importantly >4h Acetaminophen Level evaluate on Rumack-Matthew normogram ALT and INR (if ALT abnormal)

Answer 624

Activated Charcoal 50g within 2h (up to 4h) of ingestion unless contraindicated (unable to protect airway) N-acetylcysteine (NAC, Mucomyst) -If known time of ingestion, and above treatment line as per normogram -Time of ingestion not known or >24h, or chronic ingestion, treat if any acetaminophen concentration or abnormal AST/ALT -First dose, if serum level not available until >8h post-ingestion -Continue NAC if serum acetaminophen >10mcg/mL or elevated AST/ALT -ANY signs of liver injury (preferable to start NAC prior to elevated ALT)

Answer 625

Fatal above 10g in adults, 3g in children

Answer 626

Tinnitus, tachypnea, vertigo, vomiting, diarrhea Respiratory alkalosis initially, mixed, then metabolic acidosis

Answer 627

Serum salicylate levels >40mg/dL (2.9mmol/L) possible toxicity Measure q2h until decreasing, below 40mg/dL, asymptomatic and normal respiratory effort Blood gas

Answer 628

AVOID intubation (risk of neurotoxicity in acid pH from apnea) Consider multi-dose activated charcoal in enteric-coated (50g q4h) Alkalinization (serum and urine) with IV sodium bicarbonate (3 amps NaHCO3 in 1L D5W at maintenance rate x 2 ) Target urine pH >7.5 (repeat q1h) Monitor for hypokalemia Glucose especially if altered mental status Early nephrology for possible dialysis

Answer 629

Profound metabolic acidosis (HCO3<8mEq/L) and osmolal gap (>25mOsm), status epilepticus, shock, ischemic bowel Visual blurring, scotoma, blindness -> Methanol Flank pain, hematuria -> Ethylene glycol

Answer 630

Blood gas Electrolytes (anion gap), serum osmolality, ethanol (determine osmolal gap), calcium (ethylene-glycol associated hypoglycemia) Methanol, ethylene glycol and isopropranol Urinalysis (oxalate crystals)

Answer 631

Blood gas Electrolytes (anion gap), serum osmolality, ethanol (determine osmolal gap), calcium (ethylene-glycol associated hypoglycemia) Methanol, ethylene glycol and isopropranol Urinalysis (oxalate crystals)

Answer 632

Fomepazole (alcohol dehydrogenase inhibition) or ethanol Sodium bicarbonate Hemodialysis in severe toxicity

Answer 633

Rarely toxic, rule out coingestant Risk of propylene glycol poisoning if receiving large IV BZDs (used as a diluent)

Answer 634

Urine BZD identifies metabolites of 1,4-BZD (oxazepam), may not detect clonazepam, lorazepam, midazolam, alprazolam

Answer 635

Intubate if needed Consider avoid Flumazenil given risk of seizures in chronic benzodiazepine use Avoid GI decontamination (risk of aspiration) unless airway protected and coingestant treatable by charcoal

Answer 636

Airway NS IV bolus with atropine 1mg IV (up to 3 doses) Glucagon 5mg IV bolus (may be repeated) Calcium chloride (central venous access) Vasopressor (eg. epinephrine) IV high-dose insulin and glucose IV lipid emulsion

Answer 637

Respiratory depression Miotic pupils (coingestants may make pupils normal/large)

Answer 638

Naloxone (Narcan) titrated to RR>12 (not until normal LOC) Consider very small doses 0.04mg IV (or IO/IM/SC) q1min In cardiorespiratory arrest, no evidence of benefit, may consider 2mg IV (or IO/IM/SC) q1min If overshoot, manage withdrawal symptoms expectantly (not with opioids) If no effect after 5-10mg consider other diagnoses

Answer 639

Benztropine, diphenhydramine

Answer 640

Physostigmine salicylate (Antilirium)

Answer 641

Atropine, Pralidoxime

Answer 642

Digoxin immune Fab (Ovine, Digibind) Consider MgSO4 to stabilize if delay in digoxin antibodies

Answer 643

Deferoxamine (Desferal)

Answer 644

Sodium Bicarbonate 1-2mEq/kg

Answer 645

Keep items locked and out of reach/sight Keep in original containers (safety lids) Don’t take medications in view of children Don't refer to medicine as “candy”

Answer 646

Age, obesity, diabetes, family history

Answer 647

UTI, bladder stone, urinary retention, hydronephrosis, renal failure

Answer 648

BPH, UTI, urothelial cancer, BPH, prostate CA, urethral stricture, urethral diverticulum (women), medication, infection, trauma, neuro (spinal cord injury)

Answer 649

Lower Urinary Tract Symptoms (LUTS) Voiding - predominant in bladder outlet obstruction (BOO) secondary to BPH Hesitancy, Weak Stream, Intermittence, Straining Storage - r/o overactive bladder (OAB) Urgency, Frequency, Urgency Incontinence, Nocturia Postmicturition Dribbling, Incomplete Emptying

Answer 650

Urinalysis +/- culture (r/o infection) PSA PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)

Answer 651

Voiding/Frequency chart 2-3 days If urine output ≥3L Decreased intake, aim for urine output 1L If nocturnal urine output >33% nocturnal polyuria diagnosed Consider Desmopressin

Answer 652

Follow IPSS, DRE, PSA (if on 5-ARIs) as response to treatment Mild (Symptom score <8, or if not bothered by symptoms) Lifestyle and watchful waiting Fluid restriction particularly prior to bedtime Avoidance of alcohol, caffeine, spicy foods Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants) Timed or organized voiding (bladder retraining) Pelvic floor exercises Avoidance or treatment of constipation Phytotherapy/herbal medicine (Saw Palmetto) has very weak evidence, although minimal side effects

Answer 653

Moderate-Severe (SS≥8) For smaller prostates, Alpha-blockers alone (relax smooth muscle, onset 3-5 days) eg. Tamsulosin (Flomax) CR 0.4mg PO daily (avoid in sulfa allergy) Side effects: Orthostatic hypotension, retrograde ejaculation (ejaculation failure) For larger prostates (eg. DRE>25mL or PSA>1.5 ng/dL), combination therapy more effective with 5-alpha reductase inhibitors (onhibit conversion of testosterone to DHT, onset 4-6 months) eg. Dutasteride (Avodart) 0.5mg PO daily , or Finasteride (Proscar) Side effects: Decreased libido, erectile dysfunction After 6-9 months of combination therapy, consider stopping alpha blocker Consider addition of PDE-5 inhibitors for LUT symptoms, eg. Tadalafil (Cialis) 5mg PO daily Consider addition of anticholinergics (eg. Tolterodine, Oxybutynin, Mirabegron) especially if component of OAB (storage symptoms), caution if PVR >250mL

Answer 654

Failure of symptom control despite combination therapy, for possible Surgery (TURP) Complications: Hematuria, recurrent UTIs, urinary retention, renal failure Suspect prostate cancer (DRE/elevation in PSA) PSA<10 low risk (routine), PSA 10-20 (semiurgent referral), PSA>20 high risk (urgent) Upgrade urgency if DRE abnormal (firm or irregular)

Answer 655

Acute Bacterial Prostatitis Tender prostate Chronic Bacterial Prostatitis Intermittent UTIs with same bacteria Chronic Prostatitis / Chronic Pelvic Pain Syndrome Inflammatory Chronic Prostatitis Non-inflammatory Chronic Prostatitis Asymptomatic Inflammatory Prostatitis Leukocytosis

Answer 656

Fevers, chills, dysuria, pelvic or perineal pain, and cloudy urine, obstructive symptoms

Answer 657

Indwelling catheter, urogenital instrumentation, prostate biopsy, HIV/immunosuppression, STI risk factors, BPH

Answer 658

Enterobacteriaceae (typically Escherichia coli or Proteus species). STIs (Neisseria gonorrhoeae and Chlamydia trachomatis) in sexually active men, may have concurrent urethritis or epididymitis.

Answer 659

Urinalysis, urine culture and-sensitivity testing, gono/chlam urethral/rectal PCR and culture

Answer 660

Acute/Chronic Bacterial Septra DS 1 tab q12h x 6 weeks (or 12 weeks for chronic) or Ciprofloxacin 500mg PO q12h x 6 weeks (for both acute and chronic) Consider Urine culture at 7 days (if still positive, consider change in management) Rule out prostatic abscess in immunosuppressed or poor response to therapy

Answer 661

Target UPOINTS Urinary (storage/voiding symptoms) Tamsulosin 0.4mg PO daily (a-blocker), antimuscarinics Psychosocial CBT, counselling, antidepressants, anxiolytics Organ specific (prostate tenderness, hematospermia) Quercetin, pollen extract Infection (positive cultures in prostate sample, previous UTI) Fluoroquinolone x 6 weeks Neurologic / Pain Acetaminophen, NSAIDs Gabapentinoids, TCA, acupuncture Tenderness (pelvic floor spasm, trigger points) Physiotherapy (pelvic floor relaxation), exercise, heat therapy Sexual dysfunction PDE-5 inhibitors Refer to urologist if does not improve significantly with initial treatment

Answer 662

(dBP≥130mmHg) or emergency (severe elevation of BP in the setting of any below) → Immediate diagnosis management Emergency Cerebrovascular Hypertensive encephalopathy Intracranial hemorrhage Cardiac Acute aortic dissection Acute LV failure Acute coronary syndrome Renal Acute kidney injury Pre-eclampsia/eclampsia Catecholamine-associated HTN

Answer 663

AOBP over or equal to 135/85 non AOBP over 140/90

Answer 664

ABPM daytime mean over 135/85 24h mean over 130/80 home BP mean over 135/85

Answer 665

automated office blood presssure (AOBP)

Answer 666

2 readings before breakfast, 2 readings 2h after dinner, eliminate day 1 readings and average other 6 days (total 24 readings)

Answer 667

Cuff with appropriate bladder size (Bladder width 40% of arm circumference and length 80-100% of arm circumference) Nondominant arm, unless SBP difference >10mmHg (use higher value arm) Rest comfortably for 5 minutes in seated position, back support, arm supported at heart level No caffeine/tobacco 1h, no exercise 30mins preceding

Answer 668

Consider BP measured annually in children and adolescents ≥3 y of age. Diagnosis of HTN if a child or adolescent if auscultatory-confirmed BP readings ≥95th percentile at 3 different visits.

Answer 669

Cerebrovascular Stroke Dementia (Vascular) Hypertensive retinopathy Cardiac LV dysfunction LV hypertrophy CHF CAD (MI, angina, ACS) Renal (CKD, albuminuria) PAD (claudication)

Answer 670

Diabetes <130/80 All (including elderly and CKD) <140/90 High risk consider ≤120 SPRINT population ≥ 50yo CV disease CKD FRS ≥15% Age ≥75yo

Answer 671

Urinalysis (Grade D); Blood chemistry (potassium, sodium, and creatinine; Grade D); Fasting blood glucose and/or glycated hemoglobin (Grade D); Serum total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL), and non-HDL choles-terol, and triglycerides (Grade D); lipids may be drawn fasting or nonfasting (Grade C); and Standard 12-lead electrocardiography (Grade C).

Answer 672

Age ≥55yo Male Family Hx CAD (Age <55 in men, <65 in women) Sedentary lifestyle Poor dietary habits Abdominal obesity Dysglycemia Smoking Dyslipidemia Stress Nonadherence

Answer 673

Adjusting antihypertensive drug therapy q1-2 months Modify health behaviours q3-6 months

Answer 674

Exercise 30-60 mins of moderate-intensity dynamic exercise (walking, jogging, cycling, swimming) 4-7 days per week in addition to routine ADLs Weight loss (dietary education, physical activity, behaviour modification) -BMI 18.5-24.9 and waist circumference <102cm for men <88cm for women Alcohol consumption ≤2 drinks per day (Men <14/week, women <9) Diet Dietary Approaches to Stop Hypertension [DASH] Reduce saturated fat, cholesterol Emphasis on fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains, and protein from plant sources Sodium <2000mg (1 tsp salt) per day Potassium increase dietary intake to reduce BP (if no risk of hyperkalemia) Stress management (cognitive behaviour interventions with relaxation techniques) Smoking cessation Re-assess habits (steroids, licorice), meds (NSAIDs, OCP), OTC meds

Answer 675

renovascular hypertension endocrine hypertension Hyperaldosteronism Pheochromocytoma/paraganglioma

Answer 676

Rule out renovascular hypertension with imaging (eg. duplex ultrasound of renal arteries, MRA, CTA, captopril-radioisotope renal scan) if ≥2 of below Sudden onset, worsening HTN and age >55 or <30* Abdominal bruit* HTN resistant to ≥3 drugs* Serum creatinine ≥30% increase with ACE-I or ARB Atherosclerotic vascular disease (smoke/DLP) Recurrent pulmonary edema with hypertensive surges Consider r/o fibromuscular dysplasia with CTA/MRA if any of three above* or unexplained asymmetry of kidney sizes (>1.5cm), family history of FMD, or FMD in other territory _________________ Rule out endocrine hypertension Hyperaldosteronism (Plasma aldosterone and renin/renin activity) K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3) HTN resistant to ≥3 drugs Incidental adrenal adenoma ---------------- Pheochromocytoma/paraganglioma (24h urinary total metanephrines and catecholamines or 24h urine fractionated metanephrines, plasma free metanephrine/normetanephrines) Paroxysmal, unexplained, labile, severe (≥180/110) HTN refractory to usual therapy Symptoms of catecholamine excess (headache, palpitations, sweating, panic attacks, pallor) HTN triggered by BB, MAO-i, micturition, changes in abdominal pressure, surgery, anesthesia Incidental adrenal mass Hereditary (MEN2A/B, neurofibromatosis type 1, Von Hippel-Lindau)

Answer 677

No other indications Long-acting Thiazide diuretic (eg. Chlorthalidone, indapamide) BB (<60yo) ACE-i (nonblack) Long-acting CCB (eg. Amlodipine) ARB

Answer 678

ACE-i, ARB

Answer 679

ACE-i, ARB BB or CCB in stable angina

Answer 680

ACE-i (or ARB), BB

Answer 681

ACE-i (or ARB), BB Aldosterone antagonist (spironolactone) in recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV Monitor potassium

Answer 682

ACE-i, ARB, Long-acting CCB, Thiazide

Answer 683

ACE-i and thiazide combination

Answer 684

ACE-i (or ARB) if proteinuria, Diuretics as additional therapy

Answer 685

because of lower pretest probability, atypical symptom presentation, and greater prevalence of microvascular disease

Answer 686

A = A1C – Blood glucose control. The target is usually 7.0% or less. B = BP – Blood pressure control (less than 130/80 mmHg). C = Cholesterol – LDL-cholesterol less than 2.0 mmol/L. Your physician/nurse practitioner may advise you to start cholesterol-lowering medication. D = Drugs to protect your heart – These include blood pressure pills (ACE inhibitors or ARBs), cholesterol-lowering medication (“statins”), and, in people with existing cardiovascular disease, certain blood glucose lowering medications. These blood glucose-lowering medications can protect your heart even if your blood pressure and/or LDL-cholesterol are already at target. E = Exercise/Eating — Regular physical activity, which includes healthy eating, and achievement and maintenance of a healthy body weight. S = Stop smoking and manage stress.

Answer 687

Pooled estimates suggest that, for primary prevention of CVD events in people with diabetes, ASA results in no reduction of MI and stroke, but an important increase in gastrointestinal hemorrhage (61–64). Despite a plethora of data, there remains uncertainty about the use of ASA in the primary prevention of CVD events in persons with diabetes, and its routine use in primary CVD event prevention is not recommended. However, some people with multiple CV risk factors and evidence of vascular inflammation, as reflected by C-reactive protein levels, may cross the risk-benefit threshold in which the potential benefits justify the potential increase in hemorrhagic events.

Answer 688

Systemic - fever, weight loss, HTN, myalgias, scalp tenderness Neuro - confusion, decreased LOC, papilledema, visual field defect, CN asymmetry, extremity drift/weakness, reflex asymmetry, seizure Onset - Sudden Older - New onset or progressive >50yo Pattern change/progressive - Different or new Papilledema Postural aggravation Precipitated by valsalva (cough, sneeze) Secondary risk factors- HIV, malignancy, trauma, early morning/nocturnal

Answer 689

Primary: Migraine 4-72h (untreated) 2 of unilateral, pulsatile, moderate-severe pain, worse with or avoid routine physical activity 1 of nausea/vomiting, photo/phonophobia Tension 2 of Bilateral, non-pulsating (pressing), mild-moderate intensity, not worse with or avoid routine physical activity No N/V, no more than one of photo/phonophobia Cluster Severe unilateral orbital, supraorbital and/or temporal pain, 15-180mins (untreated) One symptom/sign ipsilateral (Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness, miosis, ptosis) Sense of restlessness or agitation If ≥15d/mo for ≥3mo Chronic migraine Chronic tension Medication overuse headache (usually present on wakening) ≥15d/mo simple analgesics (acetaminophen, aspirin, NSAID) ≥10d/mo ergotamine, triptan, opioids Hemicrania continua Strictly unilateral, persistent with exacerbations, cranial autonomic symptoms, restlessness, responsive to indomethacin New daily persistent headache Abrupt onset, daily, unremitting from onset (or within 3d of onset) typically in patients without history of headache

Answer 690

Infection: Meningitis, sinus, mastoid, dental Hypertension: Preeclampsia Systemic illness Carbon monoxide Extracranial: Eye disorder (refractory errors, glaucoma), Carotid dissection, TMJ

Answer 691

Vascular: Subarachnoid hemorrhage (thunderclap), Temporal arteritis, Venous Sinus Thrombosis, SDH (worsening over time), Cervical artery dissection (TIA/neuro deficit in young) Nonvascular: Increased/decreased (eg. CSF leak) ICP, Tumor, Chiari malformation (Valsalva)

Answer 692

Neuro exam, fundoscopy r/o increased ICP CT if red flags or risk of intracranial pathology Lumbar puncture if symptoms of secondary cause Valsalva/exercise, systemic illness (fever/rash/neck stiffness/meningismus), neuro sign (papilledema/seizure) Consider ESR/CRP if suspect temporal arteritis Consider CT/LP to rule out subarachnoid hemorrhage (SAH) Ottawa SAH Rule (100% sensitive, 15% specific - if negative helpful to rule out, excluded neuro deficits, brain tumors, chronic recurrent headache) Age≥40, Neck Pain/Stiffness, LOC, Onset during Exertion, Thunderclap, Limited Neck Flexion on exam CT (diagnosis 90% SAH within 24h) Lumbar Puncture (If negative CT) Elevated opening pressure, elevated RBC count that does not significantly diminish, Xanthochromia (hemoglobin degradation if blood in CSF >2h) If diagnosed SAH, proceed to angiography to rule out aneurysmal

Answer 693

Keep headache diary, record frequency, intensity, triggers, medication Lifestyle changes Reduce caffeine Regular aerobic exercise Avoid irregular/inadequate sleep or meals Avoid triggers Fluids Stress management Relaxation training CBT Pacing activity Biofeedback therapy Acupuncture Transcutaneous electrical nerve stimulation

Answer 694

Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg Second Line: Triptans (eg. Sumatriptan 100mg PO) Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans Contraindicated in CV diseases, pregnancy, ergots Consider Gepants (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)

Answer 695

Prophylaxis if 4+/month, or >12h, or increased in frequency or rebound (trial of at least 2 months needed, treat for 6-12 months then taper to reassess need) Betablocker (Propranolol, Metoprolol, Timolol), Antidepressants (Amitriptyline, Venlafaxine), Anticonvulsants (Valproate, Topiramate) Less evidence: Calcium channel blockers (Verapamil) Melatonin 3mg (as effective as amitriptyline in one RCT) Riboflavin (Vit B2) 400mg/d after three months

Answer 696

1L bolus NS, Prochlorperazine 10mg, Diphenhydramine 25mg , Ketorolac 30mg, Dexamethasone 10mg Maxeran (metoclopramide )

Answer 697

Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg Prophylactic: TCA (Amitriptyline, Nortriptyline)

Answer 698

100% oxygen 12L/min x 15 mins through non-rebreather mask Sumatriptan 6mg subcutaneous, Zolmitriptan 5mg intranasal Triptans contraindicated in Cardio/Cerebrovascular disorders Bridge with Corticosteroids (prednisone), Ergotamine, Occipital nerve block Prophylactic Verapamil 240-480mg/d or steroids Early specialist referral

Answer 699

Stop offending medication Can bridge with NSAID (naproxen) or prednisone

Answer 700

Indomethacin Specialist referral Consider MRI Brain

Answer 701

ergots, triptans, analgesics or codeine, opioids more than 10 adays a month or tylenol or NSAIDS more than 15 a month

Answer 702

Complete physical examination (including vision/hearing screen) >5yo - Urinalysis for protein, glucose (think diabetes), blood (think shistosomiasis) If abnormal, urine microscopy >11yo - CXR r/o TB >15yo or risk factor (eg. known infected mother, unprotected sex) HIV testing, Syphilis

Answer 703

Hep B (Africa, Asia, Eastern Europe and parts of South America) Vaccinate susceptible, refer chronic infection for treatment (and consider screen HCC as indicated) Hep C (specifically subSaharan Africa [10%]; eastern Europe, especially Uzbekistan and Tajikistan [27%]; Egypt [25%–50%]; Vietnam [10%]; and Pakistan [5-35%]) and exposure to contaminated blood, usually as nosocomial transmission through unscreened blood products, surgery or receipt of intramuscular injections) If positive, vaccinate Hep A/B, limit alcohol and refer for treatment TB PPD skin test (Sub-Saharan Africa, Asia, and Central and South America, and some in Eastern Europe) CXR to rule out active disease HIV (sub-Saharan Africa, Caribbean, Thailand) Post-test counselling and refer to HIV treatment program Intestinal parasites if from endemic area, compatible sign/symptoms of infection (asthma) or evidence of peripheral eosinophilia Strongyloides serology (consider in immigrants from Southeast Asia and Africa) If positive, treat with ivermectin (or albendazole) Shistosomiasis serology (Africa) If positive, treat with praziquantel DM2 >35yo South Asian, Latin American and African Iron-deficiency anemia with hemoglobin for women of reproductive age, and children 1-4yo Dental disease (ask all if any pain, and look for evidence of disease) Refer to dentist (and treat pain with NSAID)

Answer 704

Medical Interpreter (consider CanTalk - telephone interpreter) Document findings (scars) Medication review, including alternative/herbal remedies Infection Consider malaria, TB, hepatitis, HIV, parasitic disease in differential Chronic disease Age-appropriate screening Screening for immigrants as above (Hep B/C, TB, HIV, parasites, DM2, Iron-deficiency anemia, Dental) Consider other screening Sickle cell, Thalassemia Vision Mental Health Depression, PTSD Trauma (child neglect, genital mutilation, intimate partner violence, torture, abuse, war) Culture/tradition/religion/gender roles Women's health Contraception Cervical cancer screening HPV vaccine Vaccination Primary immunization schedule according to age (Tdap, MMRV, etc...) Consider Hepatitis A/B If positive for sickle cell or thalassemia -Consider pneumococcal, H influenzae, meningococcal

Answer 705

Adult BMI ≥25 Overweight ≥ 30 Obese class 1 ≥ 35 Obese class 2 ≥ 40 Obese class 3 Overestimated/underestimated depending on muscle:fat distribution eg. South Asian criteria for BMI ≥23 Overweight ≥25 Obese

Answer 706

Hypertension, diabetes, coronary artery disease, sleep apnea, osteoarthritis

Answer 707

Endocrine (hypothyroidism, Cushing's, PCOS) Medications (insulin, sulfonylureas, antipsychotics)

Answer 708

History and physical exam rule out secondary causes (Endocrine, OSA) Vitals (Blood pressure) Weight, height, waist circumference Impact personal and social life Rule out depression, eating disorder

Answer 709

HbA1c or fasting blood glucose Lipid profile Consider Thyroid (avoid repeating if confirmed normal)

Answer 710

Readiness to change Support Multidisciplinary approach Dietician Personal Trainer Psychology/Psychiatry (Cognitive behavioural therapy) Obesity specialist/Endocrinologist Lifestyle Diet May consider a weight los diet (reduction in dietary energy) High protein - Low fat diet Exercise 30 minutes daily of moderate intensity, increase to 60 minutes daily BMI ≥30 (Obesity class 2-3) after lifestyle/behavioural changes have failed Structured behavioural interventions (weight loss program)

Answer 711

Orlistat 120mg PO daily-TID Stop medication if weight loss <5% at 3 months No effect on mortality Adverse effects: Bloating, steatorrhea, fecal incontinence Lack of longterm safety data Supplement with multivitamin 2h before or after medication Consider GLP-1/SGLT2 for weight loss in diabetes (in addition to Metformin)

Answer 712

BMI ≥ 40 or ≥ 35 with comorbidity (OA, OSA), consider Bariatric Surgery Weight loss Reduce prevalence of chronic disease (eg. DM, HTN, DLP, MSK pain - RR decrease by 25%)

Answer 713

Normal - BMI < 85th percentile Overweight- BMI > 85th percentile Obese > 97th percentile Severe Obesity >99th percentile

Answer 714

Structured behavioural interventions Family-wide changes in diet and activity (family-oriented behaviour therapy) Avoid counterproductive interventions (e.g., berating or singling out the obese child) Encourage positive reinforcement Diet Family meals Healthy snacking Decreased sugar consumption (juices, drinks) Decrease portion size Increase vegetables Activity (WHO recommends 60 minutes moderate-vigorous daily) Focus on fun/recreational activity Limit screen time Limit motorized transport Limit time spent indoors Limit sitting (eg. stroller) Sleep

Answer 715

(r/o midline shift, hydrocephalus - enlarged ventricles, posterior fossa mass) Do CT head prior to LP if any of the following (prevent brain herniation): Age >60yo Immuncompromised (HIV, immunosuppressive therapy) CNS disease (mass lesion, stroke, or focal infection) Seizure (new onset within 1 week) Focal neurological deficit (excluding cranial nerve palsies) Papilledema Altered mental status (GCS<10) Unable to answer two consecutive questions or follow two consecutive commands

Answer 716

Neonates (0-1mo) = LEG Listeria monocytogenes E Coli Group B Strep (S agalactiae) >1mo = SHiN S Pneumonia H influenza N Meningitidis If >50yo or immunocompromised, alcoholism Listeria monocytogenes Viral (aseptic) Enterovirus HSV Lyme (Borrelia burgdorferi)

Answer 717

Age ≥65 years old, Neonates, Aboriginal groups, Students living in residence Immunocompromised (16%), Alcoholism, IVDU Infection Recent otitis or sinusitis (25%), mastoiditis Pneumonia (12%) Endocarditis Recent neurosurgery, Head trauma Recent travel to area with endemic meningococcal disease (eg. sub-Saharan Africa) recent abdominal surgery

Answer 718

Headache, fever, neck stiffness, and altered mental status (two of the following 95% sensitive) 99% have at least one classic feature - thus absence of all four findings above essentially excludes bacterial meningitis Nausea, vomiting Photophobia Seizure and focal neurologic deficits (especially in Listeria) Rhombencephalitis (manifested as ataxia, cranial nerve palsies, and/or nystagmus) Petechiae and palpable purpura (especially in N meningitidis) Arthritis (especially in N meningitidis)

Answer 719

Meningeal signs Neck stiffness (31% sensitive) Kernig's (9%) Inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees Brudzinski (11%) Spontaneous flexion of the hips during attempted passive flexion of the neck Jolt accentuation (97%) Accentuation of headache by horizontal rotation of the head at a frequency of two to three times per second Bulging fontanelle in children Neurological Papilledema, seizure, focal deficit Petechiae and palpable purpura

Answer 720

Droplet precautions (until 24h after antibiotics) Empiric Antibiotics (do not delay beyond 1h if possible) 0-1mo: Ampicillin + Cefotaxime (or Ampicillin + aminoglycoside) >1mo: Vancomycin + 3rd gen cephalosporin (Ceftriaxone 2g IV q12h or Cefotaxime 2g IV q4-6h) Vancomycin 15-20mg/kg IV q8-12h (pre 4th dose trough levels 15-20mcg/mL) + Ceftriaxone 2g IV q12h >50y: Add Ampicillin 2g IV q4h to cover Listeria monocytogenes Dexamethasone 10mg q6h x 4 days if suspect S. pneumoniae (reduce mortality), or H influenzae (reduce hearing loss) Best to administer prior or with initial antibiotic therapy Consider Rifampin instead of vancomycin if bacteria not sensitive to ceftriaxone, as vancomycin may not enter CSF as well after steroids decreased inflammation Consider Acyclovir if suspect HSV encephalitis (changes in personality, behaviour, cognition, AMS) Consider covering for P. aeruginosa in immunocompromised with Cefepime or Meropenem 2g IV q8h Consider covering for tuberculous and cryptococcal meningitis in immunocompromised

Answer 721

Consider delaying LP if unstable, signs of herniation, coagulopathy, overlying infection, If no concerns or negative CT head, proceed to lumbar puncture

Answer 722

CSF opening pressure (if done in left lateral decubitus) CSF leukocyte count, protein, glucose CSF culture (70-85% positive, antibiotics decreases yield by 10-20%) CSF Gram stain (60-90% positive with excellent specificity, yield decreases 20% if antibiotics) Gram-positive rods and coccobacilli (think L monocytogenes) add Ampicillin Gram-positive diplococci = pneumoccocal Gram-negative diplococci = meningococcal Small pleomorphic gram-negative coccobacilli = H influenzae CSF PCR (Meningococcal, Pneumococcal, Enteroviral, HSV, VZV) Consider CSF lactate and CRP to differentiate bacterial from aseptic (limited value if received antibiotic or CNS disease)

Answer 723

CBC Electrolytes (Mild hyponatremia) LFTs Coags VBG (AGMA) Blood cultures x2 (60% positive) before first dose of antibiotics if possible Consider If sexual history or substance use: serum RPR, CSF VDRL, serum HIV Ab and HIV PCR In children (to guide diagnosis): Serum CRP and pro-calcitonin Throat swab for meningococcal culture

Answer 724

Droplet precautions Chemoprophylaxis to close contacts and direct exposure to respiratory secretions Contact public health for post-exposure prophylaxis for close contacts (7d prior to symptom onset until 24h treatment) N meningititidis (>8h close contact or oral secretions) -Ciprofloxacin 500mg PO x1, Rifampin 600mg PO q12h x2d, Ceftriaxone 250mg IM x1 H influenzae (household with unvaccinated) -Rifampin Vaccination (H influenzae B, Pneumococcal, N Meningitidis) Pregnancy -Pen G to cover GBS as indicated -Avoid soft cheeses with unpasteurized milk, raw sprouts, melons, cold cuts, smoked seafood (Listeria monocytogenes)

Answer 725

Restriction of energy intake relative to requirements, leading to a significantly low body weight (BMI<18.5 or <5th percentile in children, or rate of weight loss) in the context of age, sex, developmental trajectory, and physical health. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Subtypes Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Answer 726

A. Recurrent episodes of binge eating, as characterized by both: Eating, within any 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances. A feeling that one cannot stop eating or control what or how much one is eating. B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise. C. The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months D. Self-evaluation is unjustifiability influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: Partial remission: After full criteria were previously met, some but not all of the criteria have been met for a sustained period of time. Full remission: After full criteria were previously met, none of the criteria have been met for a sustained period of time. Current severity1: Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Answer 727

An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements. Marked interference with psychosocial functioning. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

Answer 728

Does your weight/body shape cause you stress? Recent weight changes? Dieted in the last year? SCOFF Do you make yourself Sick (induce vomiting) because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? Have you recently lost more than One stone (14 lb {6.4 kg}) in a three-month period? Do you think you are too Fat, even though others say you are too thin? Would you say that Food dominates your life? ate/amount of weight loss Dietary intake (quantity, restriction) Compensatory behaviour (vomiting, laxatives, diuretics, exercise) Attitudes about weight / Body image Mood symptoms, suicidality Menstrual history Associated symptoms

Answer 729

Early puberty Poor or abnormal growth curves in children and adolescents Low or high body mass index, or weight fluctuations Weight concerns among normal weight individuals Activities and occupations that emphasize body, shape, and weight (e.g. ballet, gymnastics, modeling) Amenorrhea (primary or secondary) Type 1 diabetes Family history of ED

Answer 730

Exertional or chronic fatigue, weakness, dizziness, pre/syncope, hot flashes, cold intolerance, depression Cardio: Palpitations, CP, SOB, peripheral edema Dental: Tooth pain (decay/cavities), mucosal bleeding/trauma and parotid gland enlargement GI: Abdominal pain, early satiety, bloating, constipation Endo: Amenorrhea, decreased libido, infertility Derm: Hair loss, brittle nail and skin changes, poor healing

Answer 731

Vital Signs (eg. HR<60, BP<90/60, Temp<36) Orthostatic vitals (supine, standing) General Appearance Height/Weight and BMI; weight in kilograms divided by height in meters squared Hydration status HEENT Enlargement of parotid or submandibular salivary glands in BN Dental erosion due to frequent vomiting Cardiac, r/o murmur Skin Brittle hair and fingernails Lanugo hair Dry skin Pretibial edema Russell sign (callous on MCP from teeth abrasion during self-induced emesis) MSK Muscle strength Sit-up Squat Stand test (muscle weakness)

Answer 732

EKG Bradycardia, non-specific ST-T wave changes including ST segment depression, U waves in the presence of hypokalemia and hypomagnesemia CBC (hemoglobin, leukocytes, platelets) Serum electrolytes (Na, K, Glucose, Blood urea nitrogen, Creatinine, Calcium, Magnesium, Phosphate) TSH, T4, T3 Liver function tests (AST, ALT, bilirubin) Amylase/lipase Albumin, transferrin UA BhCG r/o pregnancy Consider celiac screen If underweight > 6 months Bone densitometry to assess for osteopenia and osteoporosis Abdominal ultrasound to assess maturity of ovaries and uterus FSH, LH, and estradiol levels in females Testosterone levels in males

Answer 733

Medical stabilization Assess outpatient vs. admission if needed for safety Assess and treat coexisting psychiatric conditions (MDE, anxiety, substance use) Nutritional rehabilitation with multidisciplinary approach Family-based treatment Individual Psychotherapy, FBT/CBT Psychiatry Dietician / nutritional rehab School Support groups / resources Target weight range in AN (90% of expected weight) Gradual weight gain in AN (1lb/week) Limit exercise Regular appointments with vitals, weight/BMI, and blood tests repeated Complications (tooth decay, amenorrhea, electrolyte) Disease activity (eating patterns, exercise, laxative)

Answer 734

SSRI / Fluoxetine at higher doses (60mg/d) in BN Multivitamins with iron and Vitamin D Consider Zinc 50mg PO daily (aids in weight gain) Treat acne (as patient re-experience puberty as they gain weight)

Answer 735

suicide risk, food refusal Vitals unstable Core temperature < 35.5°C or 95.5°F Heart rate < 40 beats per minute or severe bradycardia Blood pressure < 90/60 mm Hg or orthostatic hypotension ECG arrhythmia Electrolyte abnormalities Sodium < 127 mmol/l Potassium < 2.3 mmol/l Hypoglycaemia; blood glucose < 2.5 mmol/l Hypophosphataemia; phosphorous below normal on fasting Magnesium < 0.6 mmol/l (normal above 0.7 mmol/l) Rapid and progressive weight loss Acute medical complications of malnutrition Signs of inadequate cerebral perfusion (confusion, syncope, loss or decreased level of consciousness, organic brain syndrome, ophthalmoplegia, seizure, ataxia) Seizure Heart failure Pancreatitis Severe acrocyanosis Dehydration that does not reverse within 48 hrs Muscular weakness Comorbid psychiatric or medical (poorly controlled diabetes type 1) Pregnancy with an at risk foetus Inadequate weight gain, failure of outpatient treatment

Answer 736

suicide risk, food refusal Vitals unstable Core temperature < 35.5°C or 95.5°F Heart rate < 40 beats per minute or severe bradycardia Blood pressure < 90/60 mm Hg or orthostatic hypotension ECG arrhythmia Electrolyte abnormalities Sodium < 127 mmol/l Potassium < 2.3 mmol/l Hypoglycaemia; blood glucose < 2.5 mmol/l Hypophosphataemia; phosphorous below normal on fasting Magnesium < 0.6 mmol/l (normal above 0.7 mmol/l) Rapid and progressive weight loss Acute medical complications of malnutrition Signs of inadequate cerebral perfusion (confusion, syncope, loss or decreased level of consciousness, organic brain syndrome, ophthalmoplegia, seizure, ataxia) Seizure Heart failure Pancreatitis Severe acrocyanosis Dehydration that does not reverse within 48 hrs Muscular weakness Comorbid psychiatric or medical (poorly controlled diabetes type 1) Pregnancy with an at risk foetus Inadequate weight gain, failure of outpatient treatment

Answer 737

Metabolic changes during refeeding of a malnourished patient Risk of hypophosphatemia leading to heart failure, arrhythmia, respiratory failure Prevent with careful slow refeeding/monitoring and phosphate supplementation

Answer 738

Perimenopause Irregular periods and VMS until menopause Menopause >45yo and no period for 12 consecutive months and not using contraception If no uterus, diagnose based on symptoms Consider FSH <40-45yo If elevated FSH on 2 blood samples 4-6w apart and <40yo, diagnose premature ovarian insufficiency

Answer 739

Vasomotor symptoms (VMS) Hot flashes, sweats Genitourinary syndrome of menopause (GSM) - previously vulvovaginal atrophy Urinary frequency/urgency/incontinence, dysuria Vaginal dryness/burning/pruritus, post-coital bleeding, sexual dysfunction, dyspareunia Mood, irritability Sleep changes Joint and muscle pain

Answer 740

Healthy weight Diet (low sodium, low sugars - increase vegetables/fibers) Avoid VMS triggers (hot drinks, alcohol, caffeine) Exercise >150mins moderate-vigorous per week Routine Vitamin D +/- calcium STOP Smoking, alcohol Optimize sleep, relationship, mood Assess for HTN/DM/DLP

Answer 741

Hormone replacement therapy first-line if <60yo or <10y past menopause (can be continued beyond 65yo in cases where risk>benefit) Offer choice of preparations Estrogen-progesterone (EP) or tissue-selective estrogen complex (eg. Duavive) Transdermal Climara Pro (matrix patch) 45mcg Estradiol + 15mcg LNG once weekly Estalis 50mcg Estradiol + 140mcg NETA (or 250mcg NETA) twice weekly Oral FemHRT 2.5mcg EE + 0.5mg NETA once daily Premplus continuous 0.625mg CE + 2.5mg MPA (or 5mg MPA) once daily Premplus cycle 0.625mg CE + 10mg MPA 2 tabs once daily If post-hysterectomy (no need for endometrial protection), estrogen only If comorbidities (Diabetes mellitus, HTN, smoking, obesity, DLP/CVD risk, gallstones), Transdermal preparation recommended Consider off-label transdermal testosterone therapy for menopausal women with low sexual desire if HRT alone is not effective Consider tissue-selective estrogen complexes (eg. Duavive) for breast/endometrial safety Non-hormonal (Clonidine, Pregabalin, SSRI, SNRI) are second-line, if failed HRT or contraindicated

Answer 742

unexplained vaginal bleeding, pregnancy, history of breast cancer, coronary heart disease, a previous venous thromboembolic event or stroke, or active liver disease

Answer 743

Coronary heart disease (CHD) – 2.5 additional cases Invasive breast cancer – 3 additional cases Stroke – 2.5 additional cases Pulmonary embolism – 3 additional cases Colorectal cancer – 0.5 fewer cases Endometrial cancer – no difference Hip fracture – 1.5 fewer cases All-cause mortality – 5 fewer events

Answer 744

Water-based lubricants/moisturizer (equivalent to vaginal estrogen in a recent RCT) Vaginal estrogen (even if on systemic HRT) Estradiol 10mcg intravaginal tablet (Vagifem) daily x 2 weeks, then twice per week Estradiol 2mg intravaginal ring (Estring) in place for 90 days Estradiol 0.1mg/g cream (Estrace) 2-4g daily x 1-2w, then half dose 1-2 weeks, then maintenance dose of 1g 1-3x/week Conjugated estrogens 0.625mg/g cream (Premarin), dose 0.5-2g cream twice weekly (or cyclic 21 days on, 7 days off) CBT for mood and anxiety Limited evidence (efficacy and safety) for complementary and alternative medicine

Answer 745

CKD, Stroke, peripheral vascular disease, heart failure, valvular heart disease

Answer 746

Hb, full cholesterol panel, fasting glucose, HbA1c, creatinine, LFT, TSH, 12 lead EKG

Answer 747

adults over 30 yo with 2-3 angina criteria men over 40 or women over 60 with 1 of 3 anginal features men under 40 and women under 60 with only 1 of 3 anginal features with CV risk (abnormal baseline EKG, DB, smoking, DLP, HTN, chronic kidney disease)

Answer 748

treadmill exercise testing with 12 lead ECG and BP monitoring if cannot exercise: consider pharmalogical testing with vasodilator perfusion imaging or dobutamine echocardiography if LBBB or ventricular paced rhythm consider vasodilator perfusion imaging (with adenosine or persantine) in pts with very low pre test probability: cardiac CT angiography can be considered -avoid if arrythmia, significant renal dysfct or contreast media allx

Answer 749

Dull RSCP (discomfort, heaviness, aching, pressure; not changing in intensity with inspiration, cough or position change; with or without radiation into jaw, neck, shoulders, arms) Provoked by exertion or emotional stress (lying down, post-prandially) Relieved within <5 min by rest or Nitroglycerin. Non-classical symptoms might include: SOB(OE), N/V, diaphoresis, fatigue, dizziness Atypical chest pain in DM, women, patients without risk factors (eg. young) New CP Duration >20 min Occurrence at rest

Answer 750

Smoking DLP DM2 CKD HTN Obesity or Metabolic syndrome Physical Inactivity Diet Depression

Answer 751

Age Sex (male) Ethnicity (Hispanic, Native American, African American, Asian) Family history of premature CVD (1st degree relative, <55yo men, <65yo women)

Answer 752

All ≥30 years of age with ⅔ or more anginal features → noninvasive testing Men ≥ 40 and women ≥ 60 years of age with ⅓ anginal features → noninvasive testing

Answer 753

Men <40 or Women <60 + ⅓ symptoms → assess for other causes, non-invasive testing not recommended Consider non-invasive testing only if other risk factors (abnormal baseline ECG, diabetes, smoking, hyperlipidemia, hypertension, chronic kidney disease)

Answer 754

Indicated if High pretest probability of stable ischemic heart disease High-risk features on non-invasive testing Persistent symptoms or inadequate QOL despite optimal medical treatment History of ACS Life-threatening arrhythmias

Answer 755

Counselling Review treatment options Medication adherence for symptom relief and prevent disease progression Explanation of CV risk Treat any concurrent DM2 or DLP or HTN Lifestyle Smoking cessation Weight loss Diet (high intake of vegetables, whole grains, fresh fruit; reduce salt, saturated/trans fat) Physical activity (150 min/week of moderate or vigorous activity) Assess and manage stress/depression Red flags when to seek medical care Non-invasive testing as above within 2w Then referral to cardiologist/specialist within further 6w referral to a comprehensive cardiac rehab program

Answer 756

ASA 81mg (or Clopidogrel 75mg if ASA intolerance) High-intensity Statin (eg. Rosuvastin 20-40mg daily, Atorvastatin 80mg daily) ACEI (or ARB) if HTN, DM2, CKD, LVEF ≤ 40% b blocker Revascularization therapy (PCI or CABG) in patients who underwent coronary angiography

Answer 757

Nitroglycerin (short-acting) 0.4mg SL tab or spray q5 mins PRN, seek prompt medical attention if pain persists after 3 doses Beta-blockers especially if prior MI, HF, LVEF ≤ 40%, eg. Bisoprolol, target HR 55-60 bpm If cannot tolerate BB or symptomatic on monotherapy, start/combine Long-acting CCB (eg. Amlodipine or Diltiazem) Avoid non-dihydropyridine CCB in combination with BB if risk of AV block and excessive bradycardia Nitroglycerin transdermal patch 0.2mg/hour titrate up to 0.8mg/hour (remember to remove patch 12-14h, eg. apply 8AM-8PM)

Answer 758

Severity and progression of symptoms Impact on daily function and QOL NYHA Class I-IV Complications of CAD (arrhythmia, heart failure, ACS) Medication compliance Appropriate use of medication (Nitro SL prn) ECG if symptom change or annually Routine CBC, creat, FBG/HbA1c, lipids

Answer 759

Non-invasive testing as above within 2w Then referral to cardiologist/specialist within further 6w revascularization if indicated within 6 w

Answer 760

chronic stable angina with MI, or reduced LVEF or heart failure target HR 55-60 GIve bblocker or long acting CCB chronic stable angina in uncomplicated patients if not tolerated, add long acting nitrate

Answer 761

within 12-16 weeks

Answer 762

ABC vitals, exam ASA 160-325 mg to chew O2 for sat over 90% 12 lead EKG activate cardiac cath lab morphine for pain control nitroglycerin sublingual or spray IV access cardiac markers, CBC, coag studies, CXR

Answer 763

PCI goal of 90 minutes door to needle fibrinolysis goal of 30 min nitro heparin Acei statin consider: b blocker, clopidogrel, glycoprotein 2b/3a inh

Answer 764

consider early invasive strategy if: refractory ischemic chest pain recurrent or persistent ST deviation V tach hemodynamic instability signs of Heart failure start tx: nitro heparin Acei statin consider: b blocker, clopidogrel, glycoprotein 2b/3a inh

Answer 765

consider admisison for CP serial cardiac markers repeat EKG, telemetry consider non invasive dx test

Answer 766

Reflex (neurally-mediated) syncope Orthostatic syncope Cardiac arrhythmias Structural cardiopulmonary disease Pseudosyncope Seizure Sleep disturbances Accidental falls Psychiatric

Answer 767

EKG Orthostatic BP Sustained decrease in sBP ≥20 mmHg or dBP ≥10 mmHg within 3 min of assuming upright posture Labs (only if indicated) Consider CBC, BhCG, troponin Cardiac (if abnormal EKG or suspect cardiac) Consider echocardiogram if abnormal EKG or suspect structural abnormality Consider Holter 24-48h only if symptoms reoccur daily Consider carotid sinus massage if >40yo and no contraindications -Patient supine 5-10 seconds of massage to each carotid sinus (start with right) -Positive if asystolic or ventricular pause > 3s or decrease in sBP of 50 mm Hg -If negative, repeat with patient upright at approximately 60 to 70 degrees -Avoid in recent stroke/TIA <3mo or if carotid bruits Neurologic (only if suspect epilepsy, focal neuro deficit) -Consider EEG, CT head

Answer 768

Clinical history suggestive of arrhythmic syncope (e.g., syncope during exercise, palpitations, or without warning or prodrome) Comorbidities (e.g., severe anemia, electrolyte abnormalities) ECG suggestive of arrhythmic syncope (e.g., bifascicular block, sinus bradycardia < 40 beats per minute in absence of sinoatrial block or medication use, QRS preexcitation, abnormal QT interval, ST segment elevation leads V1- V3 [Brugada pattern], negative T wave in right precordial leads and epsilon wave [arrhythmogenic right ventricular dysplasia/cardiomyopathy]) Family history of sudden death Hypotension (sBP < 90 mm Hg) Older age Severe structural heart disease, congestive heart failure, or coronary artery disease

Answer 769

bifascicular block, sinus bradycardia < 40 beats per minute in absence of sinoatrial block or medication use, QRS preexcitation, abnormal QT interval, ST segment elevation leads V1- V3 [Brugada pattern], negative T wave in right precordial leads and epsilon wave [arrhythmogenic right ventricular dysplasia/cardiomyopathy

Answer 770

Age less than 50 years No history of cardiovascular disease Normal electrocardiographic findings Symptoms consistent with neurally mediated or orthostatic hypotension syncope Unremarkable cardiovascular findings

Answer 771

Age less than 50 years No history of cardiovascular disease Normal electrocardiographic findings Symptoms consistent with neurally mediated or orthostatic hypotension syncope Unremarkable cardiovascular findings

Answer 772

Education and reassurance Avoid triggers Lying down quickly with onset of presyncope Salt and water intake Removal of offending medications Counter-pressure manoeuvers (leg-crossing, limb/abdominal contractions, squatting), compression garments, and head-up tilt sleeping assess fitness to drive (can drive right away if single episode of typical vasovagal syncope, otherwise 1 month if recurrent)

Answer 773

Fludrocortisone 0.2mg PO daily or Midodrine 5-15mg PO TID (eg. q4h)

Answer 774

duration, trauma, preexisting conditions, drugs, toxins, medications and seizure activity

Answer 775

shock, hypoxia, hypoglycemia, hyperglycemia, and narcotic overdose)

Answer 776

arrythmia, VT, VF, AV block Ao stenosis, hypertrophic hypermyopathy, myxoma, PE CHF, cardiomyopthy vasovagal, orthostatic, acs, arrythmia, ao dissection, valvular disease HF, hypoglycemia meds: alpha blocker ,antihypertensives, b blockers, CCB, diuretics, antiepileptic, nitrates

Answer 777

cp, palpitations, dyspnea, HA, no warning or during exertion or supine without warning, p,hx cvd, fx hx sudden death

Answer 778

DB2: age over 40, over 30 yo with 15 y duration (type 1), microvasc disease AAA over 3 cm or previous surgery clinical atherosclerosis (MI, ACS, angina, over 10% stenoses, stroke, TIA, carotid disease, PADm claudication or ABI below 0.9) CKD (over 3 months, ACR ober 3, eGFR under 60)

Answer 779

FRS over 20% FRS 10% -19% with LDL over 3.5 or Non HDL over 4.3 or apoB over 1.2 -or men over 50 or women over 60 with additional RF: low HDL C, impaired fasting glucose, high waist circumference, smoker, HTN statin indicated conditions LDL over 5 (genetic dlp)

Answer 780

exercise 150 min per week (mod to vigourous) smoking cessation mediterranean diet

Answer 781

LDL-c under 2 or 50% reduction apoB under 0,8 g/L or non HDL C under 2.6 mmol/L

Answer 782

-target maximally tolerated dose of statin consider add on: -ezetimibe as 1st line -BAS as alternative -for statin indicated conditions: consider PCSK9

Answer 783

men and women over 40 yo women post menopausal until 75 yo regardless of age: clinical evidence of atherosclerosis AAA DB2 arterial HTN smoking stigmata of dlp (arcus cornea, xanthelasma, xanhoma) family hx of premature CVD family hx of DLP CKD obesity IBD HIV infx erectile dysfct COPD hypertensive dz of pregnancy automatically high risk if pre existing CVD

Answer 784

Framingham (2x risk if first degree relative F<65yo or M<55yo) Sex, Age, Total Chol, HDL, Smoker, sBP (or if treated) QRISK2 if CKD

Answer 785

screening; LDL-c, TC, HDL-C, TG, non HDL-C, glucose, eGFR optional: apoB, UCR eGFR, A1c, TSH

Answer 786

Rosuvastatin 2.5mg, 5-10mg, 20-40mg PO daily (Cheapest) Alternatives: Atorvastatin, Simvastatin, Lovastatin, Avoid Pravastatin in >65yo risk of cancer

Answer 787

Stop statin, follow CK until normal, consider restarting at lower dose / different statin / referral Consider baseline CK, ALT but generally NOT needed to be followed CK or ALT levels only if symptomatic or high risk of adverse events

Answer 788

Cholesterol target for reducing CVD NOT required (statins have been shown to reduce risk regardless of LDL) Monitoring lipid levels during therapy NOT required Note: CCS guidelines still recommend LDL targets despite no conclusive data for using targets LDL-C <2 mmol/L or >50% reduction Alternative target variables are apoB < 0.8 g/L or non-HDL-C < 2.6 mmol/L

Answer 789

fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach)

Answer 790

EKG: Many arrhythmias (eg. PVCs, ventricrular bigeminy/trigeminy, slow Afib, sinus brady, AV block, regularized AF, VT) Suspect in bradycardia and GI symptoms Consider activated charcoal if <2h, alert and protected airway Treat arrhythmia, end organ dysfunction or hyperkalemia with antidote digoxin-specific antibody (Fab) fragments (Digibind) If antidote not available, can use atropine 0.5mg IV for bradycardia

Answer 791

EKG: Tachycardia +/- ischemic changes ABC, vitals Airway management (avoid succinylcholine, consider rocuronium or other nondepolarizing agent) Manage hypothermia/hyperthermia Diazepam 5mg IV q3-5 mins for agitation (and hypertension) Phentolamine 1-5mg IV for hypertension Avoid beta-blockers Sodium bicarbonate 1-2mEq/kg IV push for QRS widening Look for emergencies (eg. arrythmias, seizures, ICH, ACS, dissection, arterial thromboembolism)

Answer 792

nspecter les lieux (sécurité du site), le patient Identifier l’arrêt cardiaque: état de conscience, vérifier pouls pendant max 10 sec (carotidien chez adulte) et respiration (agonale) en même temps Demander de l’aide, 911 (services préhospitaliers d’urgence ou équipe de réanimation) et DEA Massage (en l’absence de pouls) et DEA C: Compressions 100-120 par minute, entre 5-6 cm, relaxation thoracique après chaque compression 30 compressions pour 2 insufflations ou 3 x 200 compressions avec insufflateur passif d’O2 A: Voies respiratoires Ouvrir voies aériennes en basculant la tête avec soulèvement du menton OU subluxation mandibulaire Restriction de la mobilité cervicale manuelle Collier cervical par SMU B: Ventilation (1 insufflation par seconde) 2 x 1 sec en 10 sec max, entre 2 cycles Si advanced airway: q 6 secondes pendant les compressions Si IPO: faire 200 compressions avant Dès que DEA arrive: Vérifier si c’est un rythme défibrillable: choquer si oui RCR 2 min Revérifier avec DEA et choquer

Answer 793

Évaluer état de conscience, appeler 911, obtenir DEA et naloxone Vérifier si le pt respire ou non, ou respi agonale RCR 2min Naloxone 2 mg intranasale ou 0.4 mg IM q 4 min Répéter et utiliser DEA dès que c’est dispo

Answer 794

Donner de l’O2 Fixer le dispositif de surveillance ou le défibrillateur Défibrillation biphasique Choc 200 J (dire: Défibrillateur en charge! Je vais choquer à 3. Je suis prêt à choquer (s’assurer qu’il n’y a personne autour).) RCR en continue x 2 min Massage RCR en continue Ouvrir 2 grosses voies antécubitales Trouver les causes réversibles Ventilation q 6-8 secondes avec O2 maximale et envisager intubation, capnographie Épinéphrine 1 mg et finir cycle de 2 min. Choc 200 J Amiodarone 300 mg et cycle de 2 min. Choc 200 J Épinéphrine 1 mg et cycle de 2 min Choc 200 J Amiodarone 150 mg et cycle de 2 min Choc 200 J Épinéphrine 1 mg et cycle de 2 min Choc 200 J Lidocaïne 1.5 mg/ kg et cycle de 2 min Choc 200 J Épinéphrine 1 mg et cycle de 2 min Choc 200 J Lidocaïne 0.75 mg/ kg et cycle de 2 min

Answer 795

Donner de l’O2 Fixer le système de surveillance ou défibrillateur Rythme défibrillable: choc; si asystolie, AESP: RCR 2 min Massage RCR en continue Ouvrir 2 voies antécubitales et intra-osseux PRN Épinéphrine 1 mg q 3-5 min Envisager intubation, capnographie Défibriller après 2 min si défibrillable Trouver les causes et traiter les causes de DEM, AESP 6 H/6T

Answer 796

6 H: Hypothermie Viser 35 degré Acidose Bic IV Hypoglycémie Glucose IV Hypo ou hyperkaliémie Hypo: 1 perf de K Hyper: chlorure de calcium, hyperventilation, bic 1 meq/ kg, insuline et glucose IV Hypoxie: intuber Hypovolémie Crystalloïdes 6T: Pneumothorax sous tension, trachée déviée décompression immédiate à l'aiguille par l'insertion d'une aiguille de gros calibre (p. ex., 14 ou 16) dans le deuxième espace intercostal sur la ligne médio-claviculaire Vérifier DT 5e espace mid-axillaire Tamponnade Péricardiocentèse à l’aiguille Trauma ATLS Trouver le saignement Toxicologie DDR Thrombose cardiaque IDM Thrombolyse, coro Thrombose pulmonaire Thrombolyse ou embolectomie chirurgicale

Answer 797

Fio2 minimale pour sat ≥ 94% Envisager intubation et capnographie, ne pas hyperventiler Traiter/éviter hypotension (MAP<65mmHg, systolique <90mmHg) Bolus 1-2L LR IV, IO perfusion d’adrénaline IV 0.1-0.5 microgramme par kg par min OU perfusion dopamine IV 5-10 microgramme par Kg par min OU perfusion noradrénaline IV 0.1 à 0.5 microgramme par kg par min Traiter causes traitables ECG 12 dérivations: si IM STEMI: reperfusion coronarienne Gestion ciblée de la température (viser 32 à 26 C en 24 h) Soins intensifs

Answer 798

Déterminer et traiter la cause sous-jacente Garder les voies aériennes dégagées, O2, ventilation PRN Moniteur cardiaque pour déterminer le rythme, surveiller la pression artérielle et l’oxymétrie Si persistante avec hypotension, altération état d’éveil, signes d’un choc, inconfort thoracique ischémique, insuffisance cardiaque aiguë Sédation si possible: (ex) diazépam, fentanyl Cardioversion synchronisé ss sédation À complexe étroit synchronisé: 50-100 J À complexe étroit irréguliers: 120-200 J en biphasique ou 200 J en monophasique FA: 120-200 J TV 100J TSV, Flutter: 50-100J Dire défibrillateur charge!, appuyer sur charge Je vais choquer à 3!, je suis prête à choquer! Si tachy persiste, augmenter le niveau d’énergie et rechoquer Si tachycardie à complexes étroits réguliers, envisager adénosine 6 mg IV push suivi de rinçage avec du soluté physiologique Si pas de hypotension, altération état d’éveil, signes d’un choc, inconfort thoracique ischémique, insuffisance cardiaque aiguë: Accès IV et ECG à 12 dérivations Viser FC 220-âge Tachycardie avec pouls réguliers (>150 bpm) QRS fin SI pas de souffles carotidiens: Manoeuvres vagales par massage du sinus carotidien Vérifier si FC baisse Adénosine 6 mg IV push (suivi par rinçage soluté physiologique) Adénosine 12 mg-12 mg IV Métoprolol 5 mg IV en 5 min OU vérapamil 2.5 mg IV en 15 min OU Diltiazem 0.25 mg/ kg IV en 2 min OU amiodarone 450 mg IV en 30 min Tachycardie avec pouls irrégulier QRS fin (FA, extrasystoles, > 150 bpm) Accès IV et ECG à 12 dérivations Métoprolol 5 mg IV en 5 min OU Diltiazem 0.25 mg/ kg en 2 min

Answer 799

Déterminer et traiter la cause sous-jacente Garder les voies aériennes dégagées, O2, ventilation PRN Moniteur cardiaque pour déterminer le rythme, surveiller la pression artérielle et l’oxymétrie Si persistante avec hypotension, altération état d’éveil, signes d’un choc, inconfort thoracique ischémique, insuffisance cardiaque aiguë Cardioversion synchronisée ss sédation À complexe large synchronisé?: 100 J À complexe large irréguliers: Défibrillation non synchronisée 200 J Si pas de persistante avec hypotension, altération état d’éveil, signes d’un choc, inconfort thoracique ischémique, insuffisance cardiaque aiguë Accès IV et ECG à 12 dérivations si disponible Tachycardie avec pouls, régulier, QRS large (> 150 bpm, QRS 0.12 sec+) Adénosine 6mg IV push puis rinçage IV avec soluté physiologique-12 mg -12 mg Sinon: Amiodarone 150 mg en 10 min, répéter PRN. Puis perfusion d’entretien 1-4 mg par min OU Procaïnamide 20-50 mg/min IV, puis entretien de 1-4 mg par min OU sotalol 100 mg (1.5 mg/ kg) IV en 5 min (ATT pour torsade de pointe) Envisager de consulter un spécialiste SI Tachycardie avec pouls irrégulier QRS large (> 150 bpm) Défibrillation (idem FV/TV) car tachycardie pré-code Traiter la cause sous-jacente

Answer 800

Évaluer condition clinique Déterminer et tx cause ss-jacente (garder voies aériennes dégagées, oxygène, moniteur cardiaque, pression artérielle, oxymétrie, accès IV, ECG à 12 dérivations) Si bradyarythmie non persistante: Surveiller et observer Si bradyarythmie persistante causant hypoTA, altération marquée état conscience, signes choc, DRS, IC aigue… Atropine: Bolus de 0,5 mg, répéter toutes les 3 à 5 minutes, dose max 3 mg Après 20 min, on peut retenter atropine ad 3mg ** risque de ne pas être efficace pour Mobitz 2 et BAV 3 Atropine inefficace: Perfusion IV dopamine (2 à 20 microgram par kg par min) Perfusion IV adrénaline (2 à 10 microgram par min) Envisager consultation d’un spécialiste + stimulation transveineuse transcutanée (bloc AV mobitz 2, BAV 3)

Answer 801

Épinéphrine 0.3 mg adulte au tiers proximal cuisse en antéro-latéral q 5-15 min Sinon, Bolus IV de 0.05-0.1mg aux 5-15 min avec monitoring hémodynamique Perfusion si choc régractaire: 5-15 mcg/ min Si bronchospasme résistant à l’épinéphrine: b2-agoniste en nébul (2.5-5 mg dans 3 ml salin) Cesser les contacts, perfusions en cours, bannir le latex Caller le code précocément 100% O2 Regarder langue, lèvres, pharynx oral, faire parler le pt Intubation précoce si atteinte des VRS, éveillée à la fibre optique ou au vidéo laryngoscope avec légère sédation et anesthésie locale Décubitus dorsal avec membres inférieurs surélevés 2 grosses voies veineuses Accès intra-osseux PRN Monitoring cardio pulmonaire, prise TA fréquente Donner 2L LR sous pression si coeur sain Diphenhydramine (Benadryl) 25-50 mg IV ad 400 mg en 24h Méthyprednisolone 1-2 mg/ kg/ j Observer ad 4h après résolution des sx non cutanés

Answer 802

once q 6 secs

Answer 803

Serious (RED FLAGS) Cord Compression (Urinary/Fecal incontinence/retention, saddle anesthesia, motor weakness/numbness) Infectious - Discitis/epidural abscess/pyelonephritis (Fever, IV drug use, severe, recent surgery, recent infection, immunocomprised) Metastatic Cancer (Hx, weight loss, age>50, persist, night pain, pain at rest) Vertebral Fracture (Osteoporosis, steroid use, age, trauma) Ruptured AAA (pulsations) Spondyloarthritis (Improvement with exercise, pain at night (with improvement upon getting up/activity), insidious onset, age <40 years, no improvement at rest, inflamamtory arthritis, enthesitis, uveitis, psoriasis, family history) Radicular pain (leg pain, sensory loss, reduced reflex, myotomal weakness) Intervertebral disc herniation Neurogenic claudication (Bilateral buttock/thigh/leg pain, pseudoclaudication) Central spinal canal stenosis Non-specific (mechanical) Beyond lumbar spine Gyne Renal (kidney stones) GI Hip joint DISK MASS: Degenerative (DDD, OP) Infection (PID< UTI, osteomyelitis, prostatitis) Injury Spondyloarthropathy, prondylitis (ankylosing, rhuematoid, SLE) Kidney stone, infarction, infection Multiple myeloma Aneurysm Slipped disc, spinal stenosis Strain, Scoliosis, skin

Answer 804

Vitals (Temperature) Gait/Posture Heel-toe, Squat and Rise Spine Abnormalities ROM Schober's test (marks at 5cm below L5 and 10cm above, flexion should increase distance from 15 to >20cm) Vertebral Tenderness Waddell's Signs (Non-organic) Superficial or nonanatomic tenderness Simulation test Axial loading Rotation of shoulder/Pelvis in same plane Distraction Discrepency between sitting and supine straight leg raise Regional disturbances Cogwheel (give-way) weakness Nondermatomal sensory loss Overreaction Straight Leg Raise Motor/Sensory (Saddle anesthesia, sphincter tone) DF ankle, EHL Reflexes Joint above and below (eg. hip) FABER for SI joint

Answer 805

CBC, ESR (tumor, infection) SPEP (multiple myeloma) X-ray (fractures) X-ray or CT Sacroiliac joints (ankylosing spondylitis) HLA-B27 antigen (ankylosing spondylitis) MRI (cauda equina)

Answer 806

Superficial heat (moderate-quality evidence) Massage, acupuncture, or spinal manipulation (low-quality evidence) Maintain activity and re-assurance (95% improve in 6 weeks) Chronic low back pain: Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence) Tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence)

Answer 807

Topical NSAIDs NSAIDs (eg. ibuprofen 600mg PO QID) or skeletal muscle relaxants (eg. cyclobenzaprine 10mg PO TID) (moderate-quality evidence)

Answer 808

NSAIDs as first-line therapy Tramadol (50-100mg PO QID) or Duloxetine (30-60mg PO daily) as second-line therapy Opioids if failed above (weak recommendation, moderate-quality evidence) Keep opioids <90mg morphine equivalents if possible

Answer 809

vertebral fracture metastatic disease spinal infection axial spondyloarthritis cauda equina syndrome other ddx serious dz: -AAA, pyelonephritis, cancer

Answer 810

neuro deficit urinary retention, fecal incontinence, saddle anessthesia fever, IV drug use, immunossupressed fracture, trauma, OP tumor, x cancer, B sx inflammation, morning stiffness, improves with exercise

Answer 811

XR BMD, CBC, SPEP, ALP, TSH, Creatinine

Answer 812

Hearing/vision impairment CNS (head trauma, seizures) Metabolic (thyroid) Toxin (lead) Anemia Perinatal/Genetic

Answer 813

Child abuse/neglect Housing/food Substance use Life Stressors (eg. family/peer issues) Parental expectations/parenting style

Answer 814

Child abuse/neglect Housing/food Substance use Life Stressors (eg. family/peer issues) Parental expectations/parenting style psych: Mood disorder (eg. bipolar) Psychotic disorder ADHD Learning disorders Autism Spectrum Disorder M-CHAT screening If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?) Have you ever wondered if your child might be deaf? Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?) Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs) Oppositional Defiant Disorder Conduct Disorder

Answer 815

Head circumference (micro/macrocephaly, increase/decreased growth velocity) Weight and height (growth) Dysmorphic features (hypertelorism, micrognathia) Eyes (visual acuity, strabismus, cataracts) Ears (hearing acuity, effusion) Abdomen (organomegaly) Skin (Cafe-au-lait spots for neurofibromatosis) Neuro Tone, strength, deep tendon reflexes, primitive reflexes Midline defects, spina bifida

Answer 816

Parent management therapy (encourage parents to be more positive and less harsh) Peer support groups for family (Autism Society) Behavioral interventions (positive reinforcement, charts, checklists, reachable goals, set limits and clear consequences for misbehaviour) Time management (schedules) School-based interventions (accomodations) Social skills / psychotherapy Psychometric testing

Answer 817

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day). Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest). Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life) Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. Severity Level 1 "Requiring support" Level 2 "Requiring substantial support" Level 3 "Requiring very substantial support"

Answer 818

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. **Angry/Irritable Mood Often loses temper. Is often touchy or easily annoyed. Is often angry and resentful. ***Argumentative/Defiant Behavior Often argues with authority figures or, for children and adolescents, with adults. Often actively defies or refuses to comply with requests from authority figures or with rules. Often deliberately annoys others. Often blames others for his or her mistakes or misbehavior. ***Vindictiveness Has been spiteful or vindictive at least twice within the past 6 months. Impacts negatively on social, educational, occupational, or other important areas of functioning.

Answer 819

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals Often bullies, threatens, or intimidates others. Often initiates physical fights. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). Has been physically cruel to people. Has been physically cruel to animals. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). Has forced someone into sexual activity. Destruction of Property Has deliberately engaged in fire setting with the intention of causing serious damage. Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft Has broken into someone else’s house, building, or car. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others). Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules Often stays out at night despite parental prohibitions, beginning before age 13 years. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. Is often truant from school, beginning before age 13 years. Clinically significant impairment in social, academic, or occupational functioning. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Answer 820

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. Impulsivity or failure to plan ahead. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. Reckless disregard for safety of self or others. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. The individual is at least age 18 years. There is evidence of conduct disorder with onset before age 15 years. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Answer 821

psychothera[y -parent management training, individual therapy, family therapy and social skills training pre scholl: no evidence for stimulants, meds, focus on parent management therapy school aged children: if very disruptive, parenting skills training and training for child adolescents: decreased importance of parenting and incrased internal selft regulation strategies

Answer 822

male, low socioeconomic status, familial aggregation

Answer 823

insufficient monotherapy adjunts + crisis management + short term intervention ritalin, dexedrine to reduce aggression bupropion, prozav to deal with impulsiveness in ADHD + CD dilantin, tegretol, valproic acid, lithium to decrease aggression clonidine to decrease agression and impulsivity

Answer 824

1) social communication impairments 2) restricted repetitive patterns of behaviours and interests

Answer 825

fragile X, neuro cutaneous disorder, phenylketonuria, fetal alcohol syndrome, angelman syndrome, rett syndrome, smith lemli opitz syndrome

Answer 826

male, first degree relative, older parents (over 35), maternal obesity, DM, HTN, infection, close spacing of pregnancies, low birth wt, extreme prematurity

Answer 827

hearing test CBC, ferritin, TSH, thyroxine

Answer 828

refer to developmental peds, child psych or psychologist with expertise in ASD

Answer 829

any age: parental concerns, developmental regression, decreaed loss of social behaviour, communication 6-12 months: decreaed smiles, joyful expressions, limited eye contact, limited reciprocal sharing or sounds, smiles or facial expressions, decreased babbling/gestures/response to name 9-12 m: repetitive behaviours, unusual play 12-18 months :no single word, no compensatory gestures, no pretend play, no joint attention 15-24 m: diminished, atypical , or no spontaneous or meaningful 2word phrases

Answer 830

Irreconcilable breakdown of relationship Fraud, theft Threats, abuse to staff Give patient adequate notice to find another physician In QC, physician must have reasonable and just cause to end relationship Call CMPA for help

Answer 831

Irreconcilable breakdown of relationship Fraud, theft Threats, abuse to staff Give patient adequate notice to find another physician In QC, physician must have reasonable and just cause to end relationship Call CMPA for help

Answer 832

Not a lump Prominent rib Costochondral junction Firm margin at edge of breast Defect secondary to previous biopsy Lump Normal glandular tissue (upper/outer quadrant) Fibrocystic changes (25%) Nodular nondiscrete tender mass, changes with menses, cyclical or constant pain Cancer (10%) Infiltrating ductal (most common) Infiltrating lobular and inflammatory breast cancer often present with no discrete mass Gross Cyst Galactocele - milk retention cyst in breasfeeding women Fibroadenoma Fat necrosis Trauma, associated with ecchymosis

Answer 833

Female Age >70 (RR 18) Prior hx of breast CA BRCA1/2 (RR 3-7) Prior hx of biopsy (RR 1.7-3.7) 1st degree relative with breast CA (RR 2.6) Unopposed estrogen Bone density - High (RR 2.7-3.5) Nulliparity/Age at first birth* >30 (RR 1.9-3.5) Menarche<12 (RR 1.5) Menopause >55yo (RR 2) HRT* (RR 1.2) OCP* (RR 1.07-1.2) Alcohol* (RR 1.4) Radiation (Mantle radiation in Hodgkin's) Benign breast disease

Answer 834

Oophorectomy <35yo (RR 0.3) Postmenopause BMI* <22.9 (RR 0.63) Exercise* (RR 0.70) Parity* ≥5 (RR 0.71) Breastfeeding* ≥16mo (RR 0.73) Aspirin* ≥weekly for ≥6 mo (RR 0.79)

Answer 835

Change in breast mass (increase/decrease in size, change in symmetry) Changes with menstrual cycle (benign if prominent premenstrual and regress during follicular phase) Skin changes Nipple discharge New (acquired) nipple inversion Benign (ectasia) Central, symmetric, transverse slit with normal areola Malignant Asymmetrical, areola changes, flattened nipple, varied nipple position

Answer 836

Inspection with arms by side, raised above head, pressing on hips leaning forward Regional lymph nodes Cervical, supraclavicular/infraclavicular, axillary, mammary chain Skin changes Ecchymosis/erythema Peau d'orange Ulceration Dimpling/retraction Nipple/Areolar changes Discharge/crusting Inversion/retraction Breast Mass Obvious/Subtle Well-defined/Nondiscrete margins Density - Soft/Firm/Hard Mobile/Fixed to chest wall or skin Tender/Non-Tender

Answer 837

Feature of cancer (hard irregular fixed mass, palpable ipsilateral nodes, peau d'orange) -Mammography, U/S, core biopsy, breast surgeon referral Benign -Ultrasound or initial aspiration to differentiate between cystic vs. solids lesions

Answer 838

Clinical exam, Imaging, Non-excision biopsy (FNAC/Core) Any abnormal result requires surgical referral +/- further investigation 1st line imaging <35yo or Pregnancy/Lactation - Ultrasound* Mammography in all age groups if suspicious findings 35-50yo - Mammography + Ultrasound >50yo - Mammography

Answer 839

Women 50-74yo routine mammography q2-3y

Answer 840

Benefits: Reduces absolute risk of death from breast cancer by 0.13-0.22% Risks: False positive mammogram 20-25% Unnecessary breast surgery 0.5%

Answer 841

Personal Hx Breast CA ≤ 40 or Ovarian CA at any age Fam Hx Breast CA ≤ 50

Answer 842

Palpitations, tachycardia, angina, dyspnea Fatigue, weakness, dizziness, lightheadedness, reduced exercise capacity, presyncope Increased urination (due to the release of atrial natriuretic peptide) Right-sided heart failure (peripheral edema, weight gain, ascites) Embolic event

Answer 843

Cardiac Hypertension (1.4 x risk) Coronary heart disease (ischemia/MI) Valvular heart disease (including rheumatic heart disease) Heart failure Cardiomyopathy (hypertrophic, dilated, restrictive) Congenital heart disease (ASD) Venous thromboembolic disease (DVT/PE - likely due to right atrial strain from resistance/afterload) Myocarditis/Pericarditis Pulmonary COPD OSA Metabolic Hyperthyroidism (including subclinical hyperthyroidism) Obesity Diabetes (1.5 x risk) Metabolic syndrome (hypertension, obesity, diabetes, and dyslipidemia) Chronic Kidney disease Other Age Alcohol (heavy alcohol use in men - holiday heart syndrome), note: no evidence that caffeine can provoke arrhythmias Stroke/TIA Family history Inflammation/infection Medications: Beta-agonists (norepi, epi, dobutamine), theophylline, adenosine Surgery (highest in cardiac surgery)

Answer 844

New-onset Paroxysmal: Continuous AF episode longer than 30 seconds but terminates spontaneously or with intervention within 7 days of onset (episodes may recur) Persistent: Continuous AF sustained >7 days “Long-standing” persistent: ≥ 12 months Permanent: Joint decision by patient and clinician to cease further attempts to restore/maintain sinus rhythm

Answer 845

EKG (r/o MI, pre-excitation, conduction disturbances) Transthoracic Echocardiogram (structural/valvular heart disease, function, atrial enlargement) Transesophageal Echocardiogram (TEE) for LA thrombi to guide cardioversion Labs: CBC Serum Na, K, Calcium, Magnesium Serum Creatinine/eGFR TSH LFT A1C, Lipids (risk stratification, can be done as outpatient) INR (baseline) Other Holter monitoring/exercise testing to evaluate rate control CXR if pulmonary disease or heart failure suspected BNP or N-terminal pro-BNP may be elevated in paroxysmal and persistent AF in the absence of clinical heart failure (and decrease in sinus) Electrophysiological Study if AF due to SVT where ablation may be helpful to prevent/reduce recurrences of AF (suspect pre-excitation when delta wave on EKG) Troponin if suspect ischemia/infarction Sleep study if suspect obstructive sleep apnea

Answer 846

Always ABCs! Unstable if Hypotension or ACS or pulmonary edema (heart failure) Consider other causes of hypotension if HR<130 (MI, PE, sepsis, hypovolemia) Urgent Electrical DC cardioversion (AP pads, 200J synchronized) if hemodynamic instability (especially if >150) or if rate control not effective Consider procedural sedation, eg. Etomidate 0.1mg/kg (7-10mg) IV Immediate anticoagulation x 4 weeks Manage hypotension Fluids (care for pulmonary edema) Vasopressors

Answer 847

Treat underlying/reversible causes Review medications Avoid beta-adrenergic vasopressors (epi/norepi/dobutamine), consider using phenylephrine instead Optimize volume status Treat pain, anxiety, withdrawal Treat electrolyte abnormalities (potassium, magnesium) Consider empiric magnesium 2-4g IV if magnesium levels not available Treat hypoxemia or respiratory distress (CPAP/BiPAP/HFNC) r/o sepsis, PE, thyrotoxicosis, etc… r/o WPW or pre-excitation syndrome (bizarre QRS change in width beat to beat and HR >220) If WPW, do NOT start AV node slowing medications (Amiodarone, BB, CCB), consider only electrical cardioversion Rate vs. Rhythm control

Answer 848

Asymptomatic Chronic AF (eg. >1y diagnosed AF) Onset AF>48h and not anticoagulated (risk of thrombus)

Answer 849

LVEF≥40%: Beta-blockers Metoprolol IV 5mg q5mins x 3 PRN (max 15mg) Convert to PO with a 1:2.5 (IV:PO) ratio, start 30mins after effective IV rate control Esmolol IV ND-CCBs Diltiazem 15-25mg IV bolus (0.25mg/kg) x1, can repeat q15 mins once, then infusion at 2.5-15mg/h (consider reduce dose after target heart rate reached as diltiazem can accumulate) LVEF<40%: B-blockers Severe heart failure and longstanding AF: Digoxin 0.25mg IV x1 Borderline hemodynamic instability: Amiodarone

Answer 850

Highly symptomatic (especially if symptomatic despite adequate rate control) Risk of hemodynamic instability (heart failure, pulmonary hypertension, mitral stenosis) Newly diagnosed AF (within 1 year) Low risk (NVAF<12h with no recent stroke/TIA, or <48h with CHADS2<2) or if on OAC≥3w Atrial Flutter Associated with reduced CV deaths and rates of stroke

Answer 851

Electrical more effective (150J biphasic, or greater) -Ideal if unknown medical history -Consider paddles with force in obese patients -Consider preparation of atropine and pacing in the event of prolonged sinus pause -Consider second trained operator managing sedation and airway Pharmacological ideal on non-fasting patient and does not require procedural sedation -AVOID if hypotension, ischemic heart disease, heart failure, conduction system disease/significant structural heart disease, and Brugada syndrome.

Answer 852

Procainamide 1g (or 15-18 mg/kg) IV over 60 min Time to conversion 60 minutes, avoid in Brugada Amiodarone 150-300mg IV bolus then infusion at 1mg/min, can repeat bolus x1 OAC x 4w, then as per CHADS65

Answer 853

YES if highly symptomatic with acute medical illness/complex medical conditions, inability to achieve rate control, or require monitoring/testing not available as outpatient

Answer 854

Short-term OAC x 4 weeks after cardioversion Long-term OAC if CHADS65

Answer 855

persistent a fib

Answer 856

CHF: BB preferred+/- Digoxin CAD: BB preferred No CHF/CAD: CCB preferred if no compelling indication for BB, Digoxin or combo HTN or reactive airway disease: CCB

Answer 857

Beta-blockers as initial therapy in MI or LV systolic dysfunction: -Bisoprolol 2.5mg PO daily (target 10mg PO daily) -Preferred if LV dysfunction Metoprolol 12.5-25mg PO BID (target 100-200mg PO BID) -Preferred if CAD, HTN Carvedilol 6.25mg BID (target 25 mg BID) -Preferred if LV dysfunction ___________- Diltiazem extended release 120-360mg PO daily Verapamil extended release 180-480 mg PO daily or immediate release divided TID-QID Digoxin 0.0625-0.25mg PO daily (max trough 1.2mcg/mL) in selected older/sedentary individuals with HF and for those with inadequate response or contraindication to BB/CCB

Answer 858

Highly symptomatic (especially if symptomatic despite adequate rate control) Risk of hemodynamic instability (heart failure, pulmonary hypertension, mitral stenosis) Newly diagnosed AF (within 1 year) Low risk (NVAF<12h with no recent stroke/TIA, or <48h with CHADS2<2) or if on OAC≥3w Atrial Flutter Associated with reduced CV deaths and rates of stroke

Answer 859

Symptoms or extreme impairment QOL Recently diagnosed within 1 year Multiple recurrences Arrhythmia-induced cardiomyopathy. However long-term oral antiarrhythmic therapy when AF becomes permanent AVOID IF: advanced sinus or AV nodal disease unless PPM or ICD Intermittent antiarrhythmic "pill in pocket” if 1-2 episodes / year

Answer 860

Normal Systolic Function -Dronedarone 400mg PO BID (avoid in permanent AF or CHF) -Flecainide (50-75mg daily, max 150mg) or Propafenone (150mg daily, max 300mg) used with BB (eg. Metoprolol 25mg) or ND-CCB --Time to convert 2-6h -administer BB or ND-CCB ≥ 30mins before Class Ic antiarrhythmic (prevent risk of Atrial Flutter 1:1 AV conduction) -sotalol (40mg BID, max 160mg) -Amiodarone LV systolic dysfunction or CHF -Amiodarone: -loading: 400 mg PO twice daily x 1 week then 400 mg daily x 2 weeks, or 400 mg daily x 1 month -maintenance: 100-200mg daily CAD: -Amiodarone, Dronedarone, Sotalol Catheter Ablation -First line for symptomatic Atrial Flutter Consider if symptomatic despite antiarrhythmics, if rhythm control strategy remains desired Not an alternative to anticoagulation – still need anticoagulation after successful catheter ablation

Answer 861

(Congestive Heart Failure, Hypertension, Age 65, Diabetes, Stroke/Transient Ischemic Attack)

Answer 862

OAC alone if age >65, or stroke/TIA, or HTN or HF or Diabetes ASA alone if CHADS65=0, and arterial vascular disease (coronary, aortic, peripheral) with none of above

Answer 863

DOAC (apixaban, rivaroxaban, edoxaban, dabigatran) warfarin

Answer 864

DOAC preferred over warfarin in non-valvular AF (warfarin recommended in valvular AF, breastfeeding, liver failure, gastric bypass) -Careful in low eCrCl, measure CrCl regularly (6-12 months) and with acute illness

Answer 865

Apixaban 5mg PO BID (2.5mg PO BID if two of creat>133mcmol/L, age>80y, wt ≤60kg), avoid in CrCl<15) Rivaroxaban 20mg PO daily (15mg PO daily in CrCl 30-49, avoid in CrCl<30) Edoxaban 60mg PO daily (30mg PO daily in CrCl 30-49, weight ≤60kg, P-glycoprotein inhibitors) Edoxaban 15mg PO daily can be considered in elderly patients when standard oral anticoagulants are considered inappropriate (eg. bleeding risk) Dabigatran 150mg PO BID (110mg PO BID if age≥80y or >75y and high risk of bleed, avoid in CrCl<30)

Answer 866

Smoking cessation Weight control (under or overweight) Avoid alcohol/drugs Avoid consumption of undercooked meats and unpasteurized foods (risk of toxoplasmosis, CMV, listeria) Avoid mosquito (clothing, repellents) Optimizing natural fertility Intercourse timing Simple = 3x/week Fertile during 5 days prior to ovulation until ovulation (14 days prior to onset of menses) So take longest and shortest cycles (eg. 28-32 days) so ovulation on D14-18, so intercourse D9-18 q2-3d >10 days of abstinence can decrease sperm quality Avoid lubricants Reasonable time frame to conceive (85% pregnant in one year) Advise that risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age of both of mother and father Disease optimization (eg. glycemic control) Folic acid 0.4-1mg/d (high risk 5mg daily)

Answer 867

STI screen HbA1c Rubella and Varicella If lack of immunity, immunize and wait one month before conception Genetic screening based on family history Thalassemia (AR): CBC, Hb electrophoresis Mediterranean, South East Asian, Western Pacific Sickle Cell (AR) same as Thalassemia African, Caribbean CF (AR): CFTR gene DNA Mediterranean, Finnish, Caucasian, or FHx Tay Sachs (AR): Enzyme HEXA or DNA HEXA gene Ashkenazi Jewish* (Canavan disease, Familial Dysautonomia, ask for Fam Hx of Gaucher, CF, Bloom, Niemann-Pick), French Canadian, Cajun Fragile X (X-linked): FMR 1 gene DNA Fam Hx

Answer 868

Stop retinoids / Vitamin A >10,000 units/day (risk of malformations in T1) Stop ACE-i/ARB (risk of fetal kidney disease in T2/T3) Change to methyldopa, labetalol, calcium channel blocker (Nifedipine XL) Stop oral anti-hyperglycemic Consider metformin or glyburide Stop warfarin (risk of malformations in T1) Consider heparin/LMWH Avoid lithium (very low risk of Ebstein anomaly and malformations in T1) Avoid valproic acid/anticonvulsants (risk of malformations in T1) Avoid Sulpha drugs and Trimethoprim (anti-folate risk in T1, and kernicterus in T3) Avoid tetracycline (bone development, teeth staining) Avoid NSAIDs (cardiac defects, spontaneous abortion) Risks of untreated depression often outweigh risks of antidepressants Low risk of teratogenicity (some data suggests paroxetine may have small increase in congenital heart defects, other studies have not found this association) May be associated with a small reduction in gestational age at birth that is not clinically significant

Answer 869

Confirm pregnancy with urine or serum bhCG Accurate dates by LMP Confirm with T1 dating ultrasound Requisition for 20w morphology ultrasound

Answer 870

1 high risk factor: history of preeclampsia, multifetal gestation, chronic hypertension, DM1 or DM2, renal disease, autoimmune disease (SLE, antiphospholipid) 2 moderate risk factors: Nulliparity, Obesity (BMI≥30), family history of preeclampsia, age 35 years and older, sociodemographic risk factors (low socioeconomic status, etc), or personal history factors (fetus is small for gestational age, previous adverse pregnancy outcomes, etc)

Answer 871

Blood type and screen (Rh and Ab) CBC HIV Rubella Syphilis HepBsAg HepCAb UA, UCx Gono chlam Consider VZV, TSH (Target <2.5, then <3 for third trimester), ferritin, Hb electrophoresis, random glucose/HbA1c/fasting glucose

Answer 872

Serum Integrated Prenatal Screen (85% detection rate [DR], 4.4% false positive [FP], covered in Quebec) 9-13.6 (best 10-11.6) PAPP-A 15-20.6 (best 15.2-16) AFP, uE3, hCG, inhibin-A Integrated Prenatal Screen (87% DR, 1.9% FP) SIPS + Nuchal Translucency ultrasound (11-13.6w, best at 12-13.3w) Quad screen (77% DR, 5.2% FP) 15-20.6 (best 15.2-16) AFP, uE3, hCG, inhibin-A Cell-free Fetal DNA screen (99.9% DR, however confirm with amniocentesis as 33% FP) After 9w Chorionic villus sampling (amniocentesis to rule out false positive for mosaic karyotype) 10-12w Amniocentesis (if abnormal serum screen, anomalies on U/S or previously affected fetus) After 15w Risk <1/200 for loss of pregnancy

Answer 873

If Rh negative, schedule for Rh Ig (WinRho) 300mcg IM at 28w everytime there is a bleed

Answer 874

T1 US for dating 20 w morphology ultrasound

Answer 875

50g OGT, CBC, ferritin, repeat type and screen in RH neg repeat HIV, gono chlam, syphilis if high risk

Answer 876

35-36w - GBS vaginal and rectal swab (results valid for 5w)

Answer 877

amoxicillin 500 PO TID x 7 days Nitrofurantoin 100mg PO BID x 7 days (avoid at labour because of hemolytic anemia) TMP SMX 1 DS tab BID x 3 days (avoid in first trimester and near term) Amoxicillin-clavulanate 500 mg PO BID x 7 d consider repeat culture 1-2 weeks after tx

Answer 878

IV Pen G 5mill units + 2.5 units q4h (cefazolin if low risk, clinda if high risk and sensitive or vanco if not sensitive) Adequate intrapartum Abx is >4h of IV Abx

Answer 879

Treat if Previous infant with GBS GBS bacteriuria during current pregnancy Positive screen GBS unknown and one of: Preterm or ROM>18h or T>38C

Answer 880

If infant well, but inadequate Abx AND Preterm <37w OR ROM>18h → consider Blood culture, CBC If WBC <5, high risk of sepsis and consider Abx If symptomatic (apnea, fever, tachypnea, tachycardia, lethargy, poor feeding) → septic workup (CBC, cultures, CXR, lumbar puncture) and early treatment

Answer 881

Amniocentesis Cervical insuff/cerclage Prior conization/LEEP PPROM, preterm Vaginal bleed, Placental Abruption Polyhydramnios Multiple pregnancy Smoking STI, BV Low SES

Answer 882

No Digital Sterile speculum Look for fluid from cervix, cord Pooling in posterior fornix of vaginal vault Ferning on microscopic examination Liquid pH (>6) will turn nitrazine test blue (positive) Commericial tests (AmniSure, Actim PROM, ROM Plus) Consider collect fluid for lung maturity (fibronectin) Culture for STI and GBS Ultrasound for low AFI (Max vertical pocket <2cm or AFI ≤5 cm)

Answer 883

infection (fetal/maternal), umbilical cord prolapse, compression

Answer 884

Admit and regular vitals with daily BPP and WBC Term PROM Avoid Digital until labour/induction Consider antibiotics if indicated (no evidence in term PROM) IV Oxytocin for induction of labour in all term PROM Vaginal Prostaglandin higher chorio rates (but consider in unfavourable cervix) PO Misoprostol easier to administer If patient chooses expectant management >24h, need to evaluate for infection, avoid digital exams

Answer 885

Admit and regular vitals with daily BPP and WBC Preterm <37w (PPROM) Unclear if expectant vs IOL (preterm vs infectious risks) If <34w generally expectant, prophylaxis with antibiotics (prolongs latency) Glucocorticoids (betamethasone x2) <34w Magnesium sulphate for neuroprotection <32w

Answer 886

Ursodeoxycholic acid 15mg/kg/day Early delivery at 36w Follow LFTs up to 8w post-partum

Answer 887

under 32 w

Answer 888

Maternal Hypertension Polyhydramnios Retinopathy Hypoglycemia Pyelonephritis/UTI Fetal Macrosomia IUGR Hypoglycemia Polycythemia Fetal lung immaturity

Answer 889

Obesity Previous pregnancy with GDM or IGT Family history of DM

Answer 890

Screen at 24-28w with 50g OGTT, consider early HbA1c or fasting glucose if higher risk 1h 50g OGTT <7.8 mmol/L = normal 7.8-11.0 -> Indication for 2h 75g OGTT ≥ 11.1 GDM 2h 75g OGTT FPG ≥ 5.3 mmol/L 1h ≥ 10.6 mmol/L 2h ≥ 9.0 mmol/L

Answer 891

Dietary advice Pharmacotherapy (insulin, metformin, glyburide) Target A1C ≤6.5 (ideally ≤6.1) Blood glucose targets: Prepandial <5.3, 1h Postprandial <7.5 (or <7.8), 2h Postprandial <6.7mmol/L Serial ultrasound to monitor growth Induce by 40w gestation Blood sugars hourly during labour Follow-up with repeat 75g OGTT between 6 weeks and 6 months postpartum (risk of DM2)

Answer 892

≤6.5 (ideally ≤6.1

Answer 893

Blood glucose targets: Prepandial <5.3 1h Postprandial <7.5 (or <7.8), 2h Postprandial <6.7mmol/L

Answer 894

First stage - regular contractions + cervical change (dilation/effacement) Latent (days): Nulliparous up to 3-4cm dilation Parous up to 4-5cm Active Contractions leading to cervical change after above cervical change Second stage - Full dilation to delivery (active = pushing) Third stage - Delivery of baby to placenta Fourth stage - Placenta to one hour postpartum

Answer 895

First stage (active) 4h of <0.5cm/hr dilation or no cervical dilation>2h Obstructed (lack of dilation/descent) if evidence of strong contractions Second stage (active) >1h active pushing without descent

Answer 896

Power (50-60mm Hg above baseline by IUPC, >60 seconds) -oxytocin Passenger (fetal position, attitude, size, abnormalities) - reposition Passage (pelvic/soft tissue factors) - ensure bladder empty Psyche (pain/anxiety)

Answer 897

Prevent If epidural analgesia, augment ARM/oxytocin early Analgesia, hydration, rest Amniotomy Oxytocin augmentation, IUPC to assess contractions, Start at 1-2 mU/min increase q30mins to reach target 8-12mU/min (max at 20-30), or high-dose protocol start at 2-4mU/min Assisted vaginal Birth C-section

Answer 898

Antepartum: Suspected macrosomia (induction does not prevent risk), diabetes, GA>42w, multiparity, previous hx dystocia, previous macrosomia, weight gain, obesity Intrapartum: Prolonged labour, operative vaginal delivery, labour induction, epidural anesthesia

Answer 899

fetal: hypoxia, asphysia, fracture, brachial plexus palsy, death Brachial plexus injury most common at C5-6 (forearm flexor/supinator) → waiter’s tip = Erb-Duchenne, most recover C8-T1 = Klumpke (claw-hand) is rare Maternal: PPH, uterine rupture, 4th degree tears

Answer 900

Avoid the 4 P’s (Pull, push, panic, pivot head) Do ALARMER: Ask for help, Tell patient to STOP pushing until manoeuvre completed Lift legs in McRoberts Flatten head of bead and hyperflex legs Anterior Shoulder disimpaction (apply suprapubic pressure to the posterior anterior shoulder) If steady pressure not working, try rocking pressure Adduct anterior shoulder by applying pressure to posterior shoulder (Rubin) to push towards chest of baby Rotate posterior shoulder like screw (Wood’s) Manual removal posterior arm - Grab posterior hand and sweep across chest and deliver (can lead to fracture) Roll onto all fours - allows easier access for rotation and removal of posterior arm Episiotomy can facilitate above maneuvers but does not relieve dystocia

Answer 901

Fever (T (≥39°C or ≥38°C on two occasions 30mins apart) One of Baseline FHR >160/min for ≥10 mins (excluding periods of variability) Maternal WBC >15 in absence of corticosteroids (ideally showing left shift) Purulent fluid from cervical os visualized by speculum

Answer 902

Broad-spectrum antibiotics, eg. Ampicillin 2g IV 6h and Gentamicin 5mg/kg once daily Consider Clindamycin or Metronidazole to cover aneaerobes if undergoing surgery Prompt induction or augmentation of labor (cesarean only for standard obstetrical indications)

Answer 903

Normal FHR baseline 110-160, at least 2 accelerations (≥15bpm lasting ≥15s) in 40mins strip Moderate variability (5-25bpm)

Answer 904

Abnormal >160 for 10 mins or <110 for 10 mins, changing FHR baseline, decelerations Tachy: Reposition (alleviate cord compression), rule out fever/dehydration/drug/prematurity, IV fluids, maternal pulse/BP Brady: As above, check for cord prolapse Decelerations: As above, check amniotic fluid for meconium, oxygen if mother hypoxic or hypovolemic Early: gradual decrease, usually same time beginning, peak and ending Due to fetal head compression Late: gradual decrease, peak after contraction peak Uteroplacental insufficiency Variable: abrupt decrease (onset to nadir <30 seconds) Complicated : <70bpm for >60 seconds, loss of variability, biphasic, prolonged secondary acceleration, fetal tachy/brady Cord compression If unresponsive to resuscitation → consider continuous EFM, fetal scalp sampling, delivery Decreased variability Sleep <40 mins Meds (sedative, BB, MgSO4, steroids) Preterm <32w Fetal tachycardia Congenital Anomalies Uterine activity (frequency averaged over 30 mins, duration, intensity, resting tone) Normal uterine contractions = <5 in 10 minutes, lasting <90 seconds between 25-75 mmHg, resting tone <7-25mmHg

Answer 905

Stop/decrease oxytocin Change position (left/right lateral) Improve hydration with IV fluids Vaginal exam r/o cord Amnioinfusion if variable decelerations Reduce maternal anxiety Consider oxygen if needed

Answer 906

≥2 for most of the month (with one of the first three) Delusions (eg. perscution, passivity [thoughts/actions controlled by external force]) Hallucinations Disorganized Speech Grossly disorganized or catatonic behavior Negative symptoms (eg. avolition, diminished emotional expression) Marked dysfunction r/o schizoaffective, depression, bipolar Schizophrenia >6mo

Answer 907

Persecutory Grandiose Erotomanic (eg. movie star is in love with them) Somatic (eg. sinuses infested by worms) Delusions of reference (eg. dialogue on TV directed towards patient) Delusions of control (eg. thoughts/movements controlled by others)

Answer 908

Auditory (most common) Visual Tactile Olfactory Gustatory

Answer 909

Alogia/poverty of content – Very little information conveyed by speech Thought blocking – Suddenly losing train of thought, exhibited by abrupt interruption in speech Loosening of association Tangentiality – (circumstantiality if content eventually returns to original topic) Clanging or clang association – Using words in a sentence that are linked by rhyming or phonetic similarity (eg, “I fell down the well sell bell.”) Word salad – Real words are linked together incoherently, yielding nonsensical content Perseveration – Repeating words or ideas persistently, often even after interview topic has changed

Answer 910

Brief psychotic disorder >1d-1mo Schizophreniform >1mo - <6mo Schizophrenia >6mo Schizoaffective (major mood episode, and >2w of delusions/hallucination in absence of mood) Bipolar I with psychotic features Major depressive disorder with psychotic features Personality disorder (schizotypal, borderline) PTSD ADHD, CD, ODD Substance-induced psychotic disorder

Answer 911

Autoimmune (SLE, MS) Infection (HIV, Neurosyphilis, HSV encephalitis, Lyme, Prion disorders) Endocrine (Thyroid, parathyroid, adrenal) Metabolic (Wilson's disease, acute intermittent porphyria) Dementia Neurologic (trauma, lesion, seizure, stroke) B12 deficiency Malignancy Medication Delirium

Answer 912

Do you ever hear voices when you are alone? What do these voices say to you? Do you ever feel that people are talking about you behind your back? Or that they are out to get you? Do you ever think that people can pick up on or control what you are thinking?

Answer 913

CBC +/- blood culture Electrolytes LFT TSH Syphilis screen HIV UA +/- urine culture Urine drug screen B12 Consider Head CT/MRI Consider baseline EKG, lipids

Answer 914

Family intervention and CBT Housing, vocational, financial support, social worker Admission, day-time inpatient care Detoxification Agitation PRN Cocktail (LAB) - can mix all three in one syringe -Loxapine 25-50mg PO/IM q1-2h or Haldol 5mg IM q1-2h (max 4/24h) -Ativan 1-2mg PO/IM q1-2h -Benadryl 25-50mg PO/IM q1-2h atypical antipsychotic -Risperidone 1-6mg/day smallest risk for metabolic side effects -Clozapine for non-responders

Answer 915

Adverse: agranulocytosis, seizure, myocarditis, cardiomyopathy

Answer 916

Positive and negative symptoms Suicidal, homicidal ideation Function (social, home, ADLs) Psychosocial supports Medication adherence Medication side effects Signs/symptoms Function Suicidal/aggressive thoughts/behaviour Substance use BMI Labs: Fasting glucose/Lipids baseline, 3mo, then yearly

Answer 917

EPS, hyperprolactinemia, cardiometabolic risk (weight gain, diabetes, dyslipidermia), anticholinergic, antihistamine (sedation), antiadrenergic (orthostatic hypotension)

Answer 918

acute dystonia akathisia parkinsonism tardive dyskinesia

Answer 919

Consider antipsychotic dose reduction Consider switching to agent with less EPS Consider dystonia prophylaxis if treating with haloperidol or high risk

Answer 920

Acute Dystonia (hours-5days, involuntary contractions of major muscle groups) Severe - Benztropine 1-2mg IM/IV or Diphenhydramine 25mg IM Mild - Benztropine 1-2mg PO daily

Answer 921

Beta-blocker - Propranolol 10mg (to 40mg) PO BID Anticholinergic - Benztropine 1-2mg PO BID Benzodiazepine - Lorazepam 0.5mg PO BID

Answer 922

Anticholinergic - Benztropine 1-2mg PO BID Non-anticholinergic - Amantadine 100mg PO BID-TID

Answer 923

(years of treatment - lip smacking, facial grimace, jaw movements, choreiform movements of extremities/trunk) Switch to antipsychotic with low risk TD (quetiapine, clozapine) Benzodiazepine - Clonazepam Other - Botox injections, tetrabenazine, anticholinergic, deep brain stimulation

Answer 924

Altered mental status, rigidity, hyperthermia (>38-40C), dysautonomia (tachycardia, hypertension, tachypnea In the setting of neuroleptic use of dopamine withdrawal r/o infection (eg. meningitis) or drug-induced r/o serotonin syndrome (shivering, hyperreflexia, myoclonus, ataxia, GI symptoms)

Answer 925

Stop neuroleptic ICU - aggressive supportive therapy Treat hyperthermia Follow serum CK Consider benzodiazepines, dantrolene, bromocriptine, amantadine if no response to supportive care within 1-2d

Answer 926

Generalized: Tonic-clonic (grand mal), absence (petit mal), myoclonic Diffuse motor activity and LOC at onset Partial (focal, eg. one extremity) Complex = Consciousness affected Partial = No LOC Status epilepticus if >5-15mins or multiple seizures without full return to consciousness Pseudoseizure Diffuse motor activity (moving all extremities) with preservation of consciousness (eg. speaking) Eyes squeezed shut (most epileptic patients do not resist eyelid raising) Responsive noxious stimuli (nasal swab) Out-of-phase movement of limbs (usually limbs move synchronously) Unusual movmeents (pelvic thursting, side-to-side head movement)

Answer 927

Protect airway, oxygen, intubation if unable to terminate seizure IV access if possible Terminate seizure (prevent brain damage) First-line: Benzodiazepines Lorazepam 0.1mg/kg IV up to max 8mg IV, Midazolam 10mg IM Diazepam 10mg IV/rectal/ET q5 mins x 3 r/o hypoglycemia - Glucose 1-2 amps of D50W (25g-50g) IV (can be given empirically if no glucose test available) r/o hyponatremia - 150mL of 3% NaCl (with repeat bolus if persistent seizure) or 2 amps of NaCO3 (100mEq in 100mL) Anti-epileptic for ALL status epilepticus (seizure >5mins) If seizure persists, prepare for intubation Propofol 1.5mg/kg + Ketamine 2mg/kg + Rocuronium 0.6mg/kg (lower dose so that does't last to long) Then propofol infusion at 3-5mg/kg/hour (avoid propofol infusion syndrome, keep <5mg/kg/h) Prepare pressors PRN (norepinephrine) If severely hypotensive, consider Midazolam 0.2mg/kg loading dose with 0.1mg/kg/h infusion If seizure persists, consider re-bolus propofol and ketamine or high-dose ketamine 1-2mg/kg q5mins PRN (up to 10mg/kg cumulative dose) Consult neurology, ICU

Answer 928

Keppra 60mg/kg IV (up to 4500mg) over 10 minutes Preferred as safe, no contraindications, and minimal side effects (SIADH) Valproic acid 40mg/kg (up to 3000mg) over 10 minutes Fosphenytoin Phenobarbital (usually in alcohol withdrawal)

Answer 929

Keppra 60mg/kg IV (up to 4500mg) over 10 minutes Preferred as safe, no contraindications, and minimal side effects (SIADH) Valproic acid 40mg/kg (up to 3000mg) over 10 minutes Fosphenytoin Phenobarbital (usually in alcohol withdrawal)

Answer 930

TIA Eclampsia Syncope Migraine Cardiac disorders (Dysrhythmias, Long QT syndrome, HOCM) Sleep disorders (Narcolepsy) Movement disorder Acute dystonia Rigors Pseudoseizure

Answer 931

Stroke Metabolic / Electrolyte Hypo/hyperglycemia Hypo/hypernatremia Hypophophatemia Hypocalcemia Hyperammonemia/hepatic encephalopathy Uremia Hypoxia Hyperthermia Hypertension (encephalopathy, PRES, eclampsia) CNS trauma, tumor, bleed, stroke (ischemic>hemorrhagic), infection (meningitis, encephalitis, abscess) Drug intoxication (anticonvulsants, antidepressants, antipsychotics, isoniazid, opioids, theophylline, sympathomimetics) Drug withdrawal (alcohol, barbiturates, benzodiazepines) Low dilantin (in known epilepsy)

Answer 932

Known seizure Serum anticonvulsant levels First seizure Glucose Chem (Sodium, Creat, Calcium, Magnesium, Phos, Urea) Consider LFT, ammonia in cirrhosis B-hCG CBC Consider CK for rhabdo Consider anti-epileptic drug levels (for adherence) Consider toxicology (cocaine, methamphetamine) Head CT generally recommeneded unless obvious cause (non-adherence to anti-epileptic) In children, if <1yo and in those with cognitive or motor developmental delay, unexplained neurologic abnormalities, a history of focal seizures, or findings on electroencephalography (EEG) that are incompatible with benign partial epilepsy of childhood or primary generalized epilepsy EEG within 24-48h LP if immunosuppressed (r/o meningitis, encephalitis)

Answer 933

Do not need to start antiepileptic medication in first seizure Consider if risk factor (eg. abnormal EEG results or brain injury/lesion) If no risk factor, counsel on excellent prognosis, and can consider medication if second seizure episode occurs Consider as per patient's preference or work (eg. pilot) Anticonvulsants (valproic acid, phenytoin) are teratogenic, advise taking folic acid and be on lowest dose

Answer 934

Osteoporosis, hematologic (decreased WBC, pancytopenia), liver failure (phenytoin), GI symptoms, fatigue Antibiotics may interfere with anticonvulsant levels

Answer 935

Dangers of swimming, living alone, operating machinery, chewing gum, heights Seizure free x 1 year before driving

Answer 936

Hypertension Diabetes Age 60-75 with Cardiovascular disease Age 18+ First Nations, Inuit, Metis Other: Hereditary kidney disease, vasculitis, auto-immune (SLE)

Answer 937

eGFR and urine ACR (Albumin-to-Creatinine ratio) If eGFR <60, repeat test in 3 months (or sooner if suspect clinical concern for rapid decline) Adjust for black patients (eGFR multiplied by 1.21) If urine ACR ≥ 3 mg/mmol, repeat total of three times in next three months (at least 2 out of three should be elevated to diagnose) Acute illness/acute kidney injury (AKI) which may require more rapid evaluation Reversible causes (NSAIDs, contrast, BPH/urinary retention)

Answer 938

(NSAIDs, contrast, BPH/urinary retention)

Answer 939

Once CKD diagnosed, Urine R+M (urinalysis and microscopy), electrolytes Repeat eGFR and urine ACR q6 months ___ If eGFR<60 UA, CBC, HBsAg, HBcAb, HBsAb, PPD If UA 2+ blood/moderate or >10RBC/hpf, suspect autoimmune, anemia, or hypercalcemia Add C3, C4, ANA, ANCA, SPEP, Ig's, free light chains If history of stones, obstruction, frequent UTIs, family history PCKD, gross hematuria Renal ultrasound ____ Consult nephrology if eGFR<30 ACR>60 Progressive decline in eGFR Unable to achieve blood pressure targets Electrolytes abnormalities (potassium) RBC casts or hematuria >20RBC/hpf

Answer 940

Smoking cessation Healthy weight (nutrition, exercise) Diet modification if eGFR<60 (not on dialysis) Limit sodium (<2g/day or <5g salt/day), protein (0.8g/kg/day), phosphate (0.8g/day), calcium (1.5g/d), potassium (1.5g/d) Consider Vaccination Influenza annually Pneumococcal with repeat five years after

Answer 941

Manage hypertension (sBP<120 as per KDIGO 2021, or <130/80 for transplant and diabetic) -ACEI or ARB (Consider in non-hypertensive if Urine ACR >30mg/mmol) --Follow creatinine and potassium 2 weeks after starting --Stop if eGFR >25% drop from baseline Manage diabetes (A1c<7) Manage hyperlipidemia Statin if -≥50 years old -≥18 years old AND diabetes or CAD or CVA or 10 year Framingham risk >10% Renally dose medications Minimize further kidney injury -Avoid NSAIDs, Aminoglycosides, Lithium, contrast media Sick Day Medications list (to avoid if unable to maintain hydration) -SADMANS (Sulfonylureas, ACEI, Diuretics, Metformin, ARB, NSAIDs, SGLT2i)

Answer 942

volume overload hyperkalienia metabolic acidosis hyperphosphatemia hyperparathyroidism hypertension anemia decrease in EGFR

Answer 943

Restrict dietary sodium (eg. <2g/d) Diuretic therapy (usually daily loop diuretic, eg. furosemide 80mg)

Answer 944

Low-potassium diet (<1.5g/d) Avoid medications that raise serum potassium (NSAIDs)

Answer 945

Sodium Bicarbonate (NaHCO3) 1000 mg BID to maintain normal serum bicarbonate (>20-22mEq/L)

Answer 946

Restrict dietary phosphate (<0.8g/d) Phospate binders (eg. Sevelamer 800mg PO TID meals)

Answer 947

Treat hyperphosphatemia, vitamin D deficiency If >150-200pg/mL, consider calcitriol or vitamin D analog -Do not use calcitriol if serum phosphate or corrected serum total calcium is elevated -Adjust dose to maintain PTH <150pg/mL

Answer 948

Sodium restriction ACEi/ARB If edema, loop diuretic +/- thiazide diuretic If no edema, diuretic or CCB (consider non-DHP CCB in proteinuria) Resistent hypertension, consider spirinolactone

Answer 949

Work-up: CBC, retic, iron studies, ferritin, B12/folate, r/o GI loss Replete iron stores if TSAT ≤30% and Ferritin ≤500ng/mL -eg. Venofer 300 mg IV q 2 weeks x 3 doses If Hb<90 and iron replete or treated for iron deficiency consider Erythropoiesis-stimulating agents (ESA) -Aranesp 0.45 mcg/kg/week --Adverse: CVA, AVF clotting hypertension, cancer recurrence --Target Hb 100-115 Monitor Hb monthly until stable, Fe q3 months

Answer 950

Progression of disease Hypovolemia (vomiting, diarhea, excessive diuresis) UTI NSAID, medications Obstruction

Answer 951

Pericarditis/pleuritis Uremic encephalopathy/neuropathy (confusion, asterixis, myoclonus, wrist/footdrop, seizures) Uremic bleeding Fluid overload refractory to diuretics (CHF/LVH) Hypertension poorly responsive to medications Metabolic disturbances -Hyperkalemia -Hyponatremia -Hyper/hypocalcemia -Hyperphosphatemia -Metabolic acidosis Malnutrition Other Complications AKI Drug toxicity Infection Hypothyroidism

Answer 952

Encourage non-pharmacological Acetaminophen Topical capsaicin Hydromorphone, fentanyl, methadone, buprenorphine Gabapentin, Pregabalin TCA (amitriptyline, nortriptyline) Avoid NSAIDs, morphine, codeine, tramadol

Answer 953

Nociceptive pain is usually due to tissue injury. Causes of nociceptive pain common to patients with advanced CKD include (but are not limited to) osteoarthritis, renal osteodystrophy, dialysis-related amyloid arthropathy, and kidney or liver capsule distension from autosomal dominant polycystic kidney disease (ADPKD) -tx with acetaminophen, hydromorphone, fentanyl, methadone or buprenorphine Neuropathic pain arises from abnormal neural activity secondary to disease, injury, or dysfunction of the nervous system. Common examples of neuropathic pain among patients with advanced CKD include diabetic neuropathy, phantom limb pain, and carpel tunnel syndrome. -treat with acetaminophen, gabapentin or pregabalin

Answer 954

Immunizations (influenza, tetanus/diphteheria, pneumococal, herpes zoster) Habits (smoking, alcohol, substance, sexual) Nutrition (diet, appetite, weight loss, dentition,m swallowing) Bowel and Bladder (incontinence, constipation, diarrhea) Communication (vision, hearing) Pain Cancer screening ____ Cognition: MCI vs dementia vs. Delirium– MMSE / MOCA BPSD (Behavioural and Psychological Symptoms of Dementia)- SMART approach Safety – remove patient to safe environment Medical – perform an organic workup to treat reversible causes; reduce medication load Assess competency – decisions regarding personal care, finances, driving; protect assets Rest, nutrition, hydration ensured; address problems with pain, ambulation, vision, hearing, constipation Trial of medication – cholinesterase inhibitor/antipsychotic/antidepressant/ mood stabilizer Mood – Depression (MSIGECAPS) – PHQ-9 or geriatric depression scale Elder mistreatment/abuse -__ Function ADLs (dressing, eating, ambulating, toileting, transferring, hygiene/bath) IADLs (shopping, housework, accounting, food prep, telephone, transportation, taking meds) Fall risk (postural hypotension, vertigo) Vision Hearing Physical activity Mobility Driving _____-- Polypharmacy - Meds Non-prescription medication (herbal, OTC, vitamins) Consider efficacy/side effect profiles Convenient dosing/route Dispill / Blister pack Avoid treating side effect with another medication (medication cascade) Beer's Criteria STOPP/START criteria Social and Environmental Social activities, hobbies, interests Care support, POA Local resources Managing at home (financial, legal) Anticipate need for increased services Advance care planning (resuscitation)

Answer 955

Medical Visual/hearing impairment Polypharmacy Dizziness or orthostasis Incontinence Diabetes Depression Cognitive impairment/Dementia Vaccines Cancer, AAA screening Osteoporosis (Calcium, vitamin D, BMD) ___ Mobility Balance/gait impairment Muscle weakness Exercise level Environmental lighting Footwear ___ Habits Smoking Alcohol

Answer 956

Lack of symptoms (eg. fever), or may present with confusion/delirium Commonly missed diagnoses are cancer, pulmonary embolus, coronary disease, aneurysms, appendicitis Depression can present with somatic complaints (cognition, functional, sleep, energy)

Answer 957

resting Tremor (FYI: 4-6 Hz, pill rolling) muscle Rigidity (FYI: with cogwheeling) Akinesia/bradykinesia (slow movements, difficulty initiating movements) - (this answer changed from akathisia to akinesia, Feb 2021) Postural instability (FYI: late feature)

Answer 958

masked facies/stare/reduced blink rate hypophonia (quiet voice/speech) drooling seborrhea of face/scalp micrographia positive glabella tap reflex stooped, shuffling gait difficulty initiating gait dysarthria

Answer 959

Dementia Depression Essential tremor Huntington's disease Multiple system atrophy Progressive supranuclear palsy Wilson's disease Multiple sclerosis Primary cerebellar dysfunction EtOH withdrawal or toxicity Liver failure

Answer 960

Dementia Depression Essential tremor Huntington's disease Multiple system atrophy Progressive supranuclear palsy Wilson's disease Multiple sclerosis Primary cerebellar dysfunction EtOH withdrawal or toxicity Liver failure

Answer 961

Somnolence Dizziness/orthostatic hypotension Headache Dyskinesia/impairment in voluntary movement (FYI: this is the #1 side effect) Confusion Brief duration of action/need for frequent dosing Psychosis: Hallucinations/delusions Agitation Disinhibition/impulse control problems

Answer 962

Dopamine agonists FYI: bromocriptine, pramipexole COMT (catechole-o-methyl transferase) inhibitors FYI: Entacapone, tolcapone MAOIs (Monoamine oxidase inhibitors) FYI: Selegiline Anticholinergics FYI: Benztropine NMDA receptor antagonist FYI: Amantadine

Answer 963

deep brain stimulation

Answer 964

Nitrofurantoin 100mg PO BID x 5-7d fosfomycin tmpsmx Man/Complicated/Pyelonephritis: Ciprofloxacin 500mg PO BID x 7d Pediatrics: Amoxicillin 50 mg/kg/day PO ÷ TID x 5d afebrile, 10d febrile Complicated: Cefixime 16mg/kg first day, then 8mg/kg daily

Answer 965

Adult: Cefadroxil 1g PO daily (or BID) x 5-14d Pediatrics: Cephalexin 50-100mg/kg/d ÷ QID x 10-14d

Answer 966

Adult: Amoxicillin 500mg PO TID x 5-7d Pediatrics: Amoxicillin 90 mg/kg/day PO ÷ BID x 5d-10d (10d if <2yo or severe symptoms)

Answer 967

Ciprodex otic suspension 4 drops BID x 5d

Answer 968

Adult: Penicillin V 600mg PO BID x 10d Pediatrics: Amoxicillin 50 mg/kg PO daily (max 1g/day) x 10d

Answer 969

Adult: Clarithromycin 500mg PO BID x 7d (or Amoxicillin 1g PO TID x7d if do not need to cover atypicals) Pediatrics: Amoxicillin 90mg/kg/day (max 3g/day) ÷ TID x 7-10d

Answer 970

Adult: Amoxicillin 500mg PO TID x 5-10d Pediatrics: Amoxicillin 90mg/kg/day (max 2g/day) ÷ BID x 10-14d Second-line or if suspect resistance (S pneumo) Amox/Clav 40-80mg/kg/day ÷ BID (or 875/125 mg PO BID)

Answer 971

Metronidazole 500mg PO BID x 7d

Answer 972

First episode Acyclovir 400mg PO TID x 7-10d Recurrent Episode: Acyclovir 400mg PO TID x 5d (or 800mg PO TID x 2d)

Answer 973

Ceftriaxone 250mg IM or Cefixime 800mg PO x1 + Azithromycin 1g PO x1 or Doxycycline 100mg PO BID x 7d

Answer 974

Consider Cipro 500mg PO BID x 3 days or 750mg PO x1 Consider Azithromycin 1g PO x1 if travel to Asia (resistance to fluoroquinolones)

Answer 975

Vancomycin 125mg PO QID x 10-14d Pediatrics: 40mg/kg/d PO (max 2g/d) ÷ TID-QID x 10-14d

Answer 976

PPI PO BID + Amoxicillin 1g PO BID + Clarithromycin 500mg PO BID x14d (eg. HP-PAC) Second-line or if high resistance, add Metronidazole 500mg PO BID (CLAMET)

Answer 977

Stop antibiotic, and avoid further antibiotics until cleared Unlikely true IgE-mediated allergy IgE-independent reaction (eg. Red Man Syndrome with vancomycin) Delayed T-cell reaction (usually concomitant viral infection, eg EBV) Referral to Allergy for challenge testing

Answer 978

Unlikely true IgE-mediated allergy IgE-independent reaction (eg. Red Man Syndrome with vancomycin) Delayed T-cell reaction (usually concomitant viral infection, eg EBV) Rule out Serum Sickness (Type 3) - vasculitic rash, arthralgias, flu-like symptoms, fever DRESS (fever, rash, lymphadenopathy, blood count abnormality [eosinophilia, thrombocytopenia]) SJS/TEN (desquamation, positive Nikolsky's sign, mucosal-involvement)

Answer 979

vasculitic rash, arthralgias, flu-like symptoms, fever

Answer 980

(fever, rash, lymphadenopathy, blood count abnormality [eosinophilia, thrombocytopenia])

Answer 981

desquamation, positive Nikolsky's sign, mucosal-involvement

Answer 982

Denial, anger, disbelief, yearning, anxiety, sadness, helplessness, guilt, sleep and appetite changes, fatigue, and social withdrawal

Answer 983

Acknowledge the loss and the associated grief Actively listen to and explore patients' concerns, reinforce patients' strengths in coping with their illness Encourage external sources of support including family, friends, and faith communities, or support groups Consider psychotherapy if requests or in complicated grief

Answer 984

Loss of ≥5% weight over 6-12 months

Answer 985

Loss of ≥5% weight over 6-12 months

Answer 986

Malignancy GI (PUD, celiac, IBD) Psychiatric (depression, eating disorders) Endocrine (hyperthyroidism, diabetes, adrenal insufficiency) Infectious (HIV, viral hepatitis, tuberculosis, parasite) Chronic disease (heart failure, renal failure, autoimmune) Neuro (stroke, dementia) Medications/substances

Answer 987

CBC (Hb, WBC) Chem (Creat, Calcium) Glucose, A1C TSH LFT (Alk Phos), Albumin ESR/CRP, LDH UA FOBT CXR Consider PPD (TB), HIV, Hep C Abdominal ultrasound Age-appropriate cancer screening

Answer 988

Limited evidence for nutritional and pharmacological agents Treat underlying cause Consider Mirtazapine in Depression Watchful waiting 3-6 months Can consider exercise and nutritional supplements at meal times

Answer 989

lymphoma, carotid dissection myocardial infarction, pseudotumour cerebri Axial Neck Pain Syndromes: Cervical strain Cervical spondylosis Cervical discogenic pain Cervical facet syndrome Whiplash injury Cervical myofascial pain Diffuse skeletal hyperostosis Extremity pain/neurological deficit: Cervical spondylotic myelopathy Cervical radiculopathy Brachial plexus injury (eg. burner/stinger) Non-spinal: Thoracic outlet syndrome Herpes Zoster Diabetic neuropathy Other (Malignancy, vascular, cardiovascular -MI, carotid/basilar artery dissection, infection, visceral, referred, rheumatologic, neurologic)

Answer 990

Trauma Cancer or constitutional symptoms Infectious symptoms, Immunosuppression or IVDU (Epidural abscess, discitis) Neurological signs/symptoms (cord compression, demyelinating process) Severe ripping neck pain, unstable (carotid/vertebral dissection) Chest pain, SOB, diaphoresis (MI) History of rheumatoid arthritis (atlanto-axial disruption)

Answer 991

Neurological examination of upper limbs (strength, sensory, reflex) C1, C2 - Neck flexion C3 - Neck lateral flexion C4 - Shoulder elevation (Trapezius) C5 - Shoulder abduction/external rotation, bicep reflex C6 - Biceps/brachioradialis reflex C7 - Triceps reflex C8 - Finger abduction, grip T1 - Hand intrinsics

Answer 992

Consider NEXUS criteria (caution using criteria in <2yo, and>65yo) Neuro deficit (focal) Spinal (midline) tenderness Altered LOC Intoxication Distracting injury There is some data showing that you may consider clearing C-spine even in distracting injury Consider Canadian C-Spine Rule in alert, stable trauma patients (excluded known spine disease/surgery, non-trauma, GCS<15, age <16 years - consider NEXUS) -Can clear C-spine if no high risk factor: Age ≥ 65 years Extremity paresthesias Dangerous mechanism (Fall ≥3 ft/5 stairs, axial load to head [eg. diving], MVC >100km/h or rollover or ejection, motorized recreational vehicles, bicycle crash) -One low risk factor present AND able to actively rotate neck 45° left and right: Sitting position in the ED Ambulatory at any time Delayed (not immediate onset) neck pain No mid-line tenderness Simple rear-end motor vehicle collision

Answer 993

Penicilin cephalosporines carbapenems monobactam chloramphenicol lincosamides oxalidinome macrolides/ketolides tetracyclines aminoglycosides fluoroquinolones lipoglycopeptides (vancomycin) sulfonamides (TMP SMX)

Answer 994

Penicillin G (IV) Used in Strep pneumo, GAS, N meningitidis, Syphilis, Pasteurella multocida, Listeria monocytogenis, Actinomyces Israeli Pencillin V (oral) Strep throat from GAS Amino penicillins (Ampi, Amox) Broader gram -neg, covers enterococci Penicillinase-resistant penicillins IV (Methicillin, Naficillin, Oxacillin) Skin infections (not MRSA) Pencillinase-resistant penicillins Oral (Cloxacillin, Dicloxacillin) Skin infections (not MRSA) Antipseudomonal penicillins (Carbenicillin, Ticarcillin, Piperacillin) Anaerobic and pseudomonas coverage Combination with beta-lactamase inhibitors (Amoxi/Clav, Ticarcillin/Clav, Ampi/sulfabactam, Pip/Tazo) Broad coverage, including anaerobes, Timentin and Pip/Tazo cover pseudomonas Used for hospital-acquired pneumonias

Answer 995

Each generation has increasing spectrum against gram negatives but less against gram positives (except fourth) Note: MRSA and enterococci resistant to cephalopsporins First gen (eg. cephalexin, cefazolin, cefadroxil) Excellent gram-positive coverage Used as alternative to penicillin for staph/strep infection when penicillin allergy Used before surgery as prophylaxis Second gen (eg. cefuroxime, cefoxitin, cefotetan) Cefuroxime good coverage against strep pneumoniae and H influenza Used for CAP, sinusitis, otitis media Cefotetan, cefoxitin, cefmetazole have good anaerobic coverage (bacteroides fragilis) Used for intraabdominal infection, aspiration pneumonias, colorectal surgery prophylaxis Third gen (eg. ceftriaxone, ceftazidime, cefotaxime, cefixime) Ceftriaxone and cefotaxime excellent CSF penetration for meninigits Cefotaxime in neonates/children (ceftriaxone can interfere with bilirubin metabolism in neonates) Ceftriaxone for N gonorrhea (many resistant to penicillin and tetracycline) Ceftazidime, cefoperazone antipseudomonal Fourth gen (Cefepime) Added benefit against gram positives (and covers gram negatives like 3rd gen) and pseudomonas Pseudomonas (Pseudomonas coverage with Ceftazidime, Cefepime) Fifth gen (Ceftaroline) Only cephalosporin with activity against MRSA

Answer 996

Each generation has increasing spectrum against gram negatives but less against gram positives (except fourth) Note: MRSA and enterococci resistant to cephalopsporins First gen (eg. cephalexin, cefazolin, cefadroxil) Excellent gram-positive coverage Used as alternative to penicillin for staph/strep infection when penicillin allergy Used before surgery as prophylaxis Second gen (eg. cefuroxime, cefoxitin, cefotetan) Cefuroxime good coverage against strep pneumoniae and H influenza Used for CAP, sinusitis, otitis media Cefotetan, cefoxitin, cefmetazole have good anaerobic coverage (bacteroides fragilis) Used for intraabdominal infection, aspiration pneumonias, colorectal surgery prophylaxis Third gen (eg. ceftriaxone, ceftazidime, cefotaxime, cefixime) Ceftriaxone and cefotaxime excellent CSF penetration for meninigits Cefotaxime in neonates/children (ceftriaxone can interfere with bilirubin metabolism in neonates) Ceftriaxone for N gonorrhea (many resistant to penicillin and tetracycline) Ceftazidime, cefoperazone antipseudomonal Fourth gen (Cefepime) Added benefit against gram positives (and covers gram negatives like 3rd gen) and pseudomonas Pseudomonas (Pseudomonas coverage with Ceftazidime, Cefepime) Fifth gen (Ceftaroline) Only cephalosporin with activity against MRSA

Answer 997

Broad coverage (except MRSA) Ertapenem IV once a daily Drug of choice for severe diabetic foot infections (usually polymicobic) Ertapenem is only carbapenem that does NOT cover pseudomonas

Answer 998

Magic bullet for gram negative aerobic bacteria, including pseudomonas Used with gram positive antibiotics like Vancomycin and Clindamycin for broad-coverage

Answer 999

Anaerobic, gram positive and MRSA coverage Not useful against gram-negative Side effects pseudomembranous colitis (C-diff) Used with aminoglycoside (cover gram-neg) in wound infections of the abdomen Female genital tract infections Septic abortions Alternative to metronidazole for bacterial vaginosis Used with beta-lactam (penicillin) or vancomycin for toxic shock syndrome with GAS or staph aureus Aspiration pneumonia

Answer 1000

Gram-positive, MRSA, VRE Expensive Side effects Serotonin Syndrome (avoid if on antidepressants) Used with beta-lactam to cover hospital acquired pneumonia

Answer 1001

Erythromycin, Azithromycin, Clarithromycin, Telithromycin (Ketolide)

Answer 1002

Gram-positive, some gram-negative, atypicals (Legionella, Chlamydia pneumoniae, Mycoplasma) Use for outpatient community-acquired pneumonia Telithromycin efficacy against macrolide resistant Strep pneumo Black box warning for respiratory failure in myasthenia gravis

Answer 1003

Doxycycline

Answer 1004

Chlamydia trachomatis Mycoplasma pneumoniae (Walking pneumonia) Animal/Tick-borne Bruciella and Rickettsia Acne Side effects: Phototoxic dermatitis

Answer 1005

Gentamicin, Tobramycin, Amikacin (good against resistant), Neomycin (topical, as toxic)

Answer 1006

Break down cell walls, used with beta-lactams Aerobic gram-neg, Pseudomonas Side effects: CN8 toxicity (Hearing loss irreversible), renal toxicity, neuromuscular blockade

Answer 1007

Ciprofloxacine levofloxacine moxifloxacine

Answer 1008

Gram-negatives, best for Pseudomonas Enterobacteriacae except anaerobes (E coli, salmonella, shigella, Campylobacter) Complicated UTI, prostatitis, epididymitis Gram-neg intracellular (Legionella, Burcella, Salmonella, Mycobacterium)

Answer 1009

Expanded gram-positive Community acquired pneumonia, skin infections

Answer 1010

Strep pneumo and anaerobic (intraabdominal infections) Poor urinary concentration

Answer 1011

All Gram-posiitve (MRSA, enterococcus, indwelling IV catheter resistant staph epidermidis) Endocarditis (Strep/staph) in penicillin-allergic Red man syndrome (rapid infusion, treat with slow infusion and antihistamine) Daptomycin similar to vancomycin with some side effects: Monitor CPK levels (myopathy risk) Eosinophilic pneumonia (stop dapto and give steroids)

Answer 1012

Gram positive, gram negative, some protozoans (Pneumocystis carinii, Toxoplasma gondii, Isospora belli) Increases INR T (Resp Tree): Otitis media, sinusitis, bronchitis, pneumonia M (Mouth): Shigella, Salmonella, E coli P (Pee): UTI, prostatitis, urethritis S (AIDS): PCP prophylaxis

Answer 1013

Penicillins (Ticarcillin, Ticarcillin/Clav, Piperacillin, Pip/Tazo) Third gen cephalosporins (Ceftazidime) Fourth gen cephalosporins (Cefepime) Carbapenems (Imipenem, Meropenem, Doripenem) Aztreonam Ciprofloxacin Aminoglycosides (Amikacin, Gentamicin, Tobramycin) Polymixins

Answer 1014

Penicillins with beta-lactamase inhibitor (Amoxi/Clav, Ticarcillin/Clav, Ampi/subactam, Pip/Tazo) Second gen cephalosporins (Cefoxitin, Cefotetan, Cefmetazole) Carbapenems (Imipenem, Meropenem, Doripenem, Ertapenem) Chloramphenicol Clindamycin Metronidazole Moxifloxacine Tigecycline

Answer 1015

Fluoroquinolone (levofloxacin, moxifloxacin) Macrolide (erythromycin, azithromycin) Doxycycline

Answer 1016

Vancomycin Linezolin Daptomycin Quinupristin/dalfopristin Tigecycline Ceftaroline Clindamycin TMP/SMX Tetracycline (Doxycycline/Minocycline)

Answer 1017

Linezolid Daptomycin Tigecycline

Answer 1018

Oral vancomycin (or metronidazole)

Answer 1019

SPACE (Serratia, Pseudomonas, Acinetobacter, Citrobacter, and Enterobacter) infections (inducible β-lactamase AmpC Avoid Tazo as 30% treatment failure Use Cipro/Carbapenem

Answer 1020

If history of anaphylaxis reaction to one fluoroquinolone, avoid entire class For delayed on-set maculopapular nonpruritic rash, may consider graded challenge of another fluoroquinolone

Answer 1021

Avoid if bullous reaction or thrombocytopenia If Red Man Syndrome (flushing, pruritus, urticaria), premedicate with antihistamine (diphenhydramine) and acetaminophen, hold opiates if possible, and infuse slower (eg. half rate, or 1g over >100 mins)

Answer 1022

New/escalating back pain at rest, may progress to motor/sensory neurologic deficits MRI whole spine Treat with steroids, and consider surgery/radiotherapy

Answer 1023

Lung cancer, lymphoma Treat symptoms (SOB, pain, anxiety) Treat with steroids, radiotherapy, chemotherapy, stents

Answer 1024

Multiple myeloma, breast, NSCLC Symptomatic (weakness, confusion, coma) above corrected calcium >3mmol/L Treatment Stop calcium intake (supplements) IV hydration (eg. NS 200-300mL/h for urine output of 100-150mL/h) Severe if calcium>3.5mmol/L and symptomatic Consider calcitonin +/- zoledronic acid/pamidronate Consider denosumab in longterm control Consider glucocorticoids in lymphomas, sarcoid, granulomatous Consider calcimimetic and hemodialysis if renal failure or calcium >5mmol/L

Answer 1025

Percutaneous or surgical drainage of pericardial effusion

Answer 1026

Myalgia, dark urine, seizure, AKI Supportive care Hydration, follow potassium, creatinine, phosphate, calcium and uric acid Consider rasburicase for uric acid

Answer 1027

T>38, ANC<0.5 Empiric antibiotics and pan-culture

Answer 1028

No conception after 12 months of unprotected and frequent intercourse Primary (no previous pregnancy) Secondary (after previous conception) Always ask about pregnancy with other partners!

Answer 1029

>1 year of trying to conceive (85% will conceive after one year) >35yo at 6mo >40yo immediately Sooner if history of infertility, PID, pelvic surgery/CT/RT (in either partner), recurrent pregnancy loss, moderate-severe endometriosis

Answer 1030

Ovulatory dysfunction - 20% PCOS Premature ovarian failure Hypothalamic suppression (exercise, eating disorder, stress, hyperprolactinemia) Thyroid disease Advanced maternal age Turner syndrome Medications (contraceptives, corticosteroids, antidepressants, antipsychotics, chemotherapy) Uterine/tubal factors - 20% PID Prior ectopic pregnancies Endometriosis Adhesions Fibroids Asherman syndrome Cervical factors (eg. cervical stenosis) Peritoneal factors

Answer 1031

female: contraceptives, corticosteroids, antidepressants, antipsychotics, chemotherapy male: chemotherapy, steroids, spironolactone, phenytoin

Answer 1032

Testicular (sperm disorders - eg. azoospermia) Cryptorchidism Irradiation Varicocele Androgen insensitivity Klinefelter syndrome Infection (Mumps orchitis) Drugs (Marijuana, spirinolactone, ketoconazole, alcohol) Pre-Testicular Hypogonadotropic hypogonadism Hypothyroidism Hyperprolactinemia Pituitary tumor Drugs, alcohol, smoking Medications (chemotherapy, steroids, spironolactone, phenytoin) Post-Testicular Hypospadias Vas deferens obstruction Congenital absence of Vas deferens in Cystic Fibrosis Infection (prostatitis) Retrograde ejaculation Erectile dysfunction Iatrogenic (vasectomy)

Answer 1033

Prolactin, TSH, testosterone Ovarian reserve testing Day 3 FSH, LH, estradiol -Ovarian aging if FSH >14IU/L and high estradiol -Clomiphene challenge has poor predictive value Mid-Luteal Day 21 (or LMP -7d) progesterone -Progesterone >5ng/mL (15.9 nmol/L) r/o anovulatory -Consider repeating progesterone weekly if irregular until menses Consider Clomiphene citrate challenge test (CCCT) AMH (anti-mullerian hormone) DHEA r/o STI (HIV, Hep B, Hep C, G+C) Preconception Rubella, Varicella titres Pap Genetic testing if indicated/ caryotype if RPL, POIm suspicion x fragile or turner

Answer 1034

Hysterosalpingography Pelvic U/S (antral follicle count, r/o fibroids, cysts) Hysteroscopy Laparoscopy (endometriosis)

Answer 1035

Semen analysis: Count (>20mill), motility (>50%), volume (2-5mL), morphology (>30%), pH, WBC (<1mil/mL) 3-6 days abstinence Repeat if abnormal in one month

Answer 1036

Encourage weight loss if BMI >30 Stop smoking, drugs, alcohol regular unprotected vaginal intercourse home ovulation kits (LH peak 1-2 days before ovulation) Limit caffeine, alcohol, avoid tabacco (for both partners) Referral to fertility specialist Assisted reproductive technology (IVF, ICSI) Sperm/ovarian donation Consider adoption

Answer 1037

-folic acid 0,4 mg -subclinical hypothyroidism to treat -Consider Clomiphene Citrate 50mg PO daily x 5 days on day 3-5 -femara (letrozole 2.5 mg day 3 or 7 or cycle (or post withdrawal bled) -Counsel on risks of multiple pregnancy, hyperstimulation syndorme, thrombosis, ovarian cancer -If no pregnancy after 3-6 cycles, refer to specialist Referral to fertility specialist Ovulation induction Clomiphene citrate Metformin (PCOS) Gonadotropin Bromocriptine (to lower prolactin)

Answer 1038

Tuboplasty Lysis of adhesions

Answer 1039

Tuboplasty Lysis of adhesions

Answer 1040

combined factors: 40% male factors: 26-30 % ovulatory dysfunction 21-25% tubal factors 14-20 % other : cervical, peritoneal, uterine) 10-13 % unexplaned 25-28%

Answer 1041

1) hypothalamic (low FSH, LH, low estradiol) -low BMI, amenorrhea, athletes, ED, pituitary tumors, prolactinoma) 2) hypothalamic ituitary ovarian axis: -Normal FSH LH, normal Estradiol -oligomenorrha and other signs of hormonal imbalance 3) hypogonadic - ovarian insufficiency (high FSH LH, low estradiol) -amenorrhea, signs of estrogen deficiency -hot flashes, vaginal dryness, POI, post chemo

Answer 1042

TSH under 2.5

Answer 1043

neural tuve defects, congenital heart and urinary tract defects, oral facial clefts, limb reduction anaomalies

Answer 1044

(0.4֪-1.0 mg) If a woman with obesity has had a previous fetus or child with a folate-sensitive fetal anomaly other than a neural tube defect, she should take a folic acid supplement containing the recommended dosage for women at increased risk (4e5 mg) (conditional, low) 1 to 4-5 mg /d if: -previous pregnancy iwth neural tube defect or women with a previous fetus or neonate with another folic acidesensitive congenital anomaly, such as: ! congenital heart defects ! oral facial clefts ! limb-reduction defects ! urinary-tract defects -neural tube defect in mother, -first relative with neural tube defect -pre-gestationl diabetes, GI pathologies, surgical bypass -use of methotrexate, phenytoin, carbamazepine, valproate, sulfasalazine -alcohol use disorder -hx non compliance iwth oral med 1 mg if moderate risk -from pre-conception to 12 weeks gestation and switching to the standard low-dose regimen of 0.4 mg of folic acid daily after 12 weeks

Answer 1045

2 separate periods of supplementation: from pre-conception to 12 weeks gestation (see below), and from 12 weeks gestation until completion of breastfeeding, when the folic acid supplementation dosage reverts to the low-dosage regimen (strong, high

Answer 1046

2-3 months before conception, throughout the pregnancy, and for 4e6 weeks postpartum or as long as breastfeeding continues

Answer 1047

2-3 months before conception, throughout the pregnancy, and for 4e6 weeks postpartum or as long as breastfeeding continues

Answer 1048

biceps C6 tricep C7 brachioradialis C5-6 hyperreflexia: check upper motoneuron signs and check lower extremity plantar reflexes

Answer 1049

irrigation of wound reduction splint tetanus booster IV antibiotics Cefazolin (ancef) 1st line

Answer 1050

Snuffbox tenderness * Ulnar deviation If no snuffbox tenderness but still high index of suspicion? * Splint and repeat X-ray in 10-14 days * OR CT/MRI/bone scan and cast q2 weeks until clinically healed * Fracture clinic

Answer 1051

Risk of non-union and avascular necrosis * Highest risk in the proximal 1/3 of the scaphoid

Answer 1052

* Thumb spica splint

Answer 1053

* Posterior sail sign * When in doubt, compare with X-ray of opposite elbow High risk of neurovascular injury

Answer 1054

supracondylar fracture

Answer 1055

brachial artery Most commonly injured nerve? * Anterior interosseous nerve (extension) * Ulnar nerve (flexion)

Answer 1056

Non-circumferential sugartong and gutter splint * Sling 1-3 weeks * Orthopedic follow-up

Answer 1057

compartment syndrome

Answer 1058

neuro exam: -axillary nerve, radial and ulnar nerves

Answer 1059

Bony Bankart lesion (anterior glenoid rim #) * Hill-Sachs deformity (cortical depression in the posteriolateral head of the humerus) * Avulsion of greater tuberosity CT/MRI for bony Bankart

Answer 1060

anterior 95%

Answer 1061

* Cunningham (gentle downward traction while massaging) * Stimson (prone with affected arm hanging down) * Milch (longitudinal traction and external rotation) * Traction – countertraction Analgesia (conscious sedation vs. intra-articular lidocaine)

Answer 1062

Repeat neuro exam * Repeat X-ray * Sling immobilization 1-3 weeks, ortho follow-up, and physiotherapy

Answer 1063

hemarthrosis

Answer 1064

age 55 or older isolated tenderness to patella tenderness to head of fibula connot flex 90 degrees unable to bear weight both immediately and in the ER for 4 steps

Answer 1065

segond fracture tibial spine fracture

Answer 1066

tensor bandage, crutches reassess in 2 weeks ortho FU physiotherapy

Answer 1067

ABCs, vitals, glucose * Mental status exam. Confused? Agitated? * CT head? CT C-spine? * ECG * Labs (eg. CK, creatinine) * Imaging

Answer 1068

* Hip injury may present as knee pain, especially in the elderly * Findings suspicious for hip #: * New inability to weight bear * Hip pain on axial loading of leg * Inability to straight leg raise

Answer 1069

CT/MRI of the left hip

Answer 1070

Admission * Orthopedics consult (need for ORIF depends on baseline function and operative risk) Analgesia (acetaminophen, opioids) * Consider fascia iliaca block

Answer 1071

Pelvic fracture Consider pelvic binder/tourniquet

Answer 1072

Vascular compromise Open fracture Neuro compromise (Cauda equina syndrome) or potential neuro compromise (unstable C-spine fracture) Compartment syndrome Hip dislocation Osteomyelitis / Septic arthritis Unstable Pelvic fracture

Answer 1073

1- Same = Transverse through growth plate 2 - Above = Through metaphysis 3 - Low = Through epiphysis 4 - Through = Both metaphysis/epiphysis 5 - Ram = Crush injury

Answer 1074

Orientation (eg. Transverse, oblique, comminuted, intra-articular) Alignment (displacement, distracted angulation, translation, rotation)

Answer 1075

Scaphoid fractures (see below) Distal radius, femur neck fracture, radial head fracture, supracondylar fracture, growth plate fracture in children

Answer 1076

Open fracture (irrigate/clean/debride wound) Displaced / Non-union Intraarticular (Salter-Harris 3,4,5) Polytrauma / Comminuted Spiral/Oblique (Easily to be displaced)

Answer 1077

Local nerve block, hematoma block, procedural sedation Three-way slab splint if significant swelling or cast (ensure joint immoblized) Post-reduction X-ray Antibiotics and Tetanus as needed

Answer 1078

Arterial injury / Avascular necrosis Nerve injury Compartment syndrome Thromboembolic disease / Fat embolism Infection / Open fracture Fracture blisters Non-acute Osteomyelitis Nonunion / Malunion Osteoarthritis / Post-traumatic arthritis Complex Regional Pain Syndrome

Answer 1079

Radial deviation of wrist (scaphoid compressed between radius and second metacarpal) Scaphoid compression test (axial loading/telescope thumb into wrist, to compress scaphoid between radius and first metacarpal) Ulnar deviation with Snuffbox tenderness (use pinky to be more precise) Wrist extension and tenderness on volar-side scaphoid tubercle (only will be positive in proximal injuries) Watson's Test (extend wrist and then radial/ulnar deviate while pushing on volar-side of scaphoid looking for pain/click) Rule out scapholunate dissociation (ligament injury that should be treated like scaphoid fracture)

Answer 1080

Widened space (>3mm) between scaphoid and lunate = Scapholunate dissociation

Answer 1081

pain over distal ulna after FOOsh injury Piano Key sign (ballot ulnar styloid) Crepitus in pronation/supination Ulnar fovea sign (point tenderness over ulnar capsule)

Answer 1082

AP wrist Widening distal ulna/radius >2mm Lateral wrist Dorsal displacement (in most DRUJ dislocations) Reduce and above-elbow splint in forearm supination

Answer 1083

Posterior back slab, non weight-bearing Follow-up orthopedics

Answer 1084

Suspect in fall from height (Calcaneus, ankle, pelvic, spinal) Harris view X-ray - look for Bohler's Angle <20% Consider Ortho

Answer 1085

Consider CT angiogram in suspected knee dislocations (3+ ligament laxity

Answer 1086

quadriceps tear -immobilize (zimmer splint) and ortho FU

Answer 1087

pelvic apophyseal avulsion fracture Management Non-weight-bearing (crutches) then weaning as tolerated

Answer 1088

Percussion test (stethoscope on pubic symphysis and percuss on patella each side) Groind tenderness Inability to SLR Painful hip movement Pain on axial loading

Answer 1089

bone tenderness at posterior edge or tip of lateral malleolus (6 cm) or medial mallolus, or base of 5ft metatarsal or navicular bone inability to bear with immediately and in er department

Answer 1090

over 65 yo dangerous mechanism paresthesias in extremities able to actively rotate neck low risk factors to assess ROM: -simple rearend MVC stitting position in ED ambulatory at any time delayed onset of neck pain absence of midline C spine tenderness dangerous mechanism -fall from elevation more than 3 feet or 5 stairs axial load to head (ex diving) mvc high speed (over 100km/h), rollover, ejection motorized recreational vehicles bicycle collision

Answer 1091

Anaphylaxis or other serious reaction (eg. Guillain-Barre syndrome) upon administration of previous dose of a particular vaccine Anaphylactic reaction or other serious reaction to a component of a vaccine (eg. egg, gelatin, latex, neomycin, thimerosal) Pregnant or immunocompromised/suppressed, active TB should not receive LIVE vaccines (BCG, Zostavax, LAIV, MMRV, rotavirus, Smallpox Typhoid [oral], Yellow fever) Consider delaying inactivated vaccines 1-3 months after immunosuppressive therapy

Answer 1092

BCG, Zostavax, LAIV, MMRV, rotavirus, Smallpox Typhoid [oral], Yellow fever

Answer 1093

Severe asthma Medically attended wheezing in the 7 days prior to vaccination

Answer 1094

Uncorrected congenital malformation of GI tract Previous intussusception

Answer 1095

Neomycin/gelatin allergy

Answer 1096

yes except; GI illness for rotavirus (if does not affect dose scheduling age limit), oral cholera, and traveller's diarrhea vaccine Significant nasal congestion that will impede delivery of live-attenuated influenza vaccine

Answer 1097

Limb swelling, febrile seizure, hypotonic-hyporesponsive episode, inconsolable crying, oculo-respiratory syndrome (except influenza contraindicated)

Answer 1098

In infancy Before pregnancy Before traveling When new to the country if not previously immunized

Answer 1099

Most common side effects are mild fever and sore extremity. Serious reactions (death, encephalopathy) are so rare that their incidence cannot be calculated.

Answer 1100

The original paper in the Lancet publishing this association was recently withdrawn and there have been no definitive cases to support this claim. This was originally associated with a preservative agent called thimerosal. The only vaccines in Canada that are given to children and contain thimerosal are the multidose influenza vaccine and Hepatitis B. Both these vaccinations are available in formulations that do not contain thimerosal (ex. Vaxigrip for children and pregnant mothers). The only true contraindication to thimerosal is anaphylaxis.

Answer 1101

No vaccine is entirely effective. If a vaccine-preventable disease outbreak does occur, some vaccinated individuals will contract the disease. However the proportion of unvaccinated individuals who contract the disease will be much higher than the proportion of vaccinated individuals.

Answer 1102

Certainly some vaccine-preventable diseases are rarely, if ever, seen in Canada and herd immunity for unvaccinated individuals does occur. However, unvaccinated individuals may still be exposed in their lifetime given the immigrant population that may not have been vaccinated or if the unvaccinated chooses to travel later in life.

Answer 1103

To protect yourself from common (HiB, Influenza, Varicella) or serious (Tetanus, Hepatitis, Meningococcemia) preventable infectious diseases. To protect individuals in society who are unable to receive vaccinations (newborns, immunocompromised, elderly)

Answer 1104

Premature infants should receive immunizations at the same time (chronological age) as term infants, ie. do not delay vaccinations - in Quebec first vaccines at 2 months old

Answer 1105

Pneumococcal (most common infection in asplenia) Meningococcal Haemophilus Influenza Type B Influenza Hep A and B if repeated transfusions

Answer 1106

Hepatitis A and B Influenza +/- Pneumococal

Answer 1107

≥65yo, <65 with specific risk factors

Answer 1108

≥60yo (consider 50-59yo), immunosuppressed Live attenuated (Zostavax) vs. Non-live recombinant adjuvanted (Shingrix) -1 dose vs. 2 doses (2 months apart) -Herpes Zoster relative risk reduction 51% (NNT 59) vs. 97% (NNT 37) -Post-herpetic neuralgia RR reduction 67% (NNT 364) vs. 89% Adults ≥50yo who are known VZV seronegative should be given univalent varicella vaccine rather than herpes zoster

Answer 1109

9-26yo and ≥27yo who are at ongoing risk PIQ recommends vaccinating women 9-45yo, men 9-26yo even if previous HPV exposure

Answer 1110

Primary series for unimmunized, and booster every 10y (Note: In Quebec, current guideline is for one single booster after 50yo) Earlier if non-clean/minor wound (if fully vaccinated >5y, if not fully vaccinated needs complete series with Ig)

Answer 1111

Pre- or post-exposure if high-risk, consider call local public health for risk assessment

Answer 1112

Once in adulthood (Tdap), as early as possible if close contact with young infants One dose during each pregnancy ideally between 26-32 weeks gestation

Answer 1113

Annually for all, focus on high risk (6mo-5yo, ≥65yo, chronic disease, pregnancy/postpartum, healthcare worker, frequent contact with above) Not recommended in <6 months old as effectiveness not proven Children <9yo are recommended to get 2 doses one month apart for their first influenza vaccine

Answer 1114

Risk or anyone who wants protection from hep B

Answer 1115

Up to 24yo not immunized, or risk

Answer 1116

For susceptible adults born in or after 1970 or risk of exposure (traveller, healthcare worker, student, military)

Answer 1117

If susceptible or seronegative (2 doses)

Answer 1118

legal status judged by a legal professional Situation-specific (care for self, sign out AMA, stand trial, sign a POA, change a will, financial decisions) May be competent to make care decisions but not financial decisions

Answer 1119

Must be voluntary (without duress/coercion) Patient must have the mental capacity to consent Understands nature of proposed options, anticipated effect of options, and consequences of refusing Patient must be properly informed Diagnosis, proposed investigation/treatments, chance of success, alternatives, consequences of refusing

Answer 1120

advance care directive (living will) Substitute decision maker If not assigned, by hierarchy: Guardian appointed by the court Power of Attorney for personal care Representative appointed by Consent and Capacity Board Spouse, common-law spouse or partner Child (if >16yo) or parent (custodial) Parent with right of access only (non-custodial parents) Brother or sister Any other relative Office of the Public Guardian and Trustee

Answer 1121

dementia, stroke, severe mental illness, head injury

Answer 1122

Wound irrigation Foreign body removal, necrotic tissue debridement Tetanus vaccine as needed (minor clean wound >10y, otherwise >5y + Ig if not fully vaccinated) priamry vs secondary closure

Answer 1123

up to 18h (Facial wounds up to 24-72h if no risk factors for infection)

Answer 1124

Extends through dermis, careful approximation (eg. vermillion border), tension Simple interrupted standard Vertical mattress if tension and edges fall or fold into wound Horizontal mattress for eversion in areas of high tension

Answer 1125

Clean with antiseptic around wound (but not inside wound to avoid impaired wound healing) Local anesthetic 25-30G needle with lidocaine 1% with epi between dermis and subcutaneous tissue Avoid dose exceeding: Lidocaine without epi 5mg/kg (max 300mg = 30mL lidocaine 1%, 15mL lidocaine 2%) Lido with epi 7 mg/kg (max 500mg = 50mL lido 1% with epi) Irrigate wound vigorously (60mL syringe with splash guard) Drape wound + sterile gloves Explore wound (look for vessels, nerves, tendons, structure) Suture (ensure depth greater than width, entering and exiting wound at 90 degrees) 6-0 for face, 3-0 for thick skin (back, scalp, palms, soles), 4-0 for rest

Answer 1126

5 days (face), 7-10 days (scalp, arms), 10-14 days (trunk, legs, hands, feet), 14-21 days (palms, soles, high tension)

Answer 1127

<5cm, low tension, elderly fragile skin

Answer 1128

Noncosmetic region, long linear >5cm (faster closure)

Answer 1129

Concern about wound infection, risk factors of proper wound healing (eg. immunocompromised, peripheral artery disease) Animal bites (especially if noncosmetic area) Consider prophylactic Amoxicillin/clavulanate (Clavulin) 25-45 mg/kg divided q12h (max dose 875/125) mg every 12 hours x5d (unless dog bite not on hand) Consider post-exposure rabies vaccine and immunoglobulin within 24h if high risk (call public health, send animal to laboratory if available) Consider HIV/Hep B/C in human bites Deep puncture wounds when irrigation not effective Actively bleeding (first hemostasis to prevent hematoma) Superficial wounds (epidermis)

Answer 1130

Arthritis: Pain on ROM, decreased ROM, swelling, erythema Soft tissue: ROM preserved, tendernes over bursae, tendons, or ligaments

Answer 1131

Trauma -Hemarthrosis is associated with intraarticular fractures, dislocations, ligamentous injury Infection (Septic arthritis) -Gonoccocal can present as purulent arthritis or a triad of tenosynovitis, vesiculopustular skin lesions, and polyarthralgias -Non gonococcal bacterial infections should be suspected in IVDU, immunocompromised, prosthetic joint Other: Mycobacterial, fungal, Lyme Crystal-induced arthritis Gout (monosodium urate crystal) Pseudogout (CPPD) Osteoarthritis Systemic -Seronegative spondyloarthritis (suspect in enthesitis, dactylitis, conjunctivitis/uveitis, psoriasis) -Reactive arthritis -Psoriatic arthritis -Inflammatory bowel disease-associated arthritis Sarcoid periarthritis Rheumatoid arthritis Myelodysplastic and leukemic disorders Mechanical derangement Neoplasm

Answer 1132

Hot/swollen joints Constitutional symptoms (high-grade fever, weight loss, malaise) Morning stiffness >30 minutes Night pain Weakness Neurological (burning pain, numbness, or paresthesia)

Answer 1133

Skin changes (Psoriasis, Malar rash, Erythema nodosum)

Answer 1134

Imaging (XR, US, CT, MRI) Consider avoiding imaging in absence of trauma or focal bone pain Joint aspiration Gross appearance Crystal analysis White cell count and differential <2,000/mm3 usually non-inflammatory >20,000 suspect septic arthritis Gram stain and Culture Consider Labs CBC LFT ESR/CRP ANA, RF, Anti-CCP (HLA)-B27 Coags (in hemarthrosis)

Answer 1135

Noninfective Alcohol NAFLD/NASH Drug-induced (Acetaminophen, INH, tetracyclines, antiepileptics/phenytoin) Autoimmune Infective Hepatitis B/C/D (Blood/body fluid/sexual) Hepatitis A/E (Fecal/oral, usually self-limited)

Answer 1136

Medication history (OTC, herbal and dietary supplements) Alcohol consumption IVDU / Needle stick exposures Tattoos or body piercings High-risk sexual contact Blood transfusion prior to 1992 Travel to areas endemic for hepatitis Prior hepatobiliary disease (including gallstones) Prior inflammatory bowel disease (autoimmune) History of diabetes, skin pigmentation, cardiac disease, arthritis, hypogonadism (hemochromatosis) History of blood disorders (hemolysis) Family history of inherited liver disorders

Answer 1137

Light-colored stools, pruritus, dark urine (bilirubinuria) Acute pain in RUQ, ascites (hematologic diseases, may have hepatic vein thrombosis) Fever/weight loss/night sweats (acute viral hepatitis of any etiology)

Answer 1138

Jaundice Malnutrition Temporal and proximal muscle wasting Hormonal Spider nevi, caput medusa, palmar erythema, gynecomastia, testicular atrophy Hepatomegaly, splenomegaly Decompensated Cirrhosis Ascites, peripheral edema Neuro Hepatic encephalopathy Asterixis Alcohol abuse Dupuytren’s contracture, parotid enlargement, testicular atrophy

Answer 1139

Past or current infection

Answer 1140

past or current infection

Answer 1141

Infection (if persists >6 months = chronic infection)

Answer 1142

Immunity due to infection or immunization

Answer 1143

Past or current infection (IgG usually persists for life)

Answer 1144

High infectivity (viral replication)

Answer 1145

Appears with recovery from acute infection In chronic infection, the presence of Anti-HBe suggests low infectivity

Answer 1146

False positive result/lab error (most common) Positive Anti-HBe infers prior HBV exposure, and unlikely false positive "Window phase" - resolving acute infection before the appearance of anti-HBs "Remote resolved HBV infection" - undetectable anti-HBs due to a decline in antibody titre over time "Occult HBV", chronic infection with undetectable HBsAg (rare)

Answer 1147

If negative Booster (or complete series) and follow-up HBsAb after 1-2 months if responds with immunity If no response to booster to ensure not occult HBV, consider repeat viral load q3-6 months until undetectable x 2-3 Test co-infection HIV/HCV See below (Positive Hepatitis) if chronic carrier

Answer 1148

HbsAg, anti-HBs, anti HBc total Review HBV immunization history, previous testing Consider screen if high-risk (eg. exposures, travel, family history, abnormal liver tests) Screen all pregnancy, HIV/HCV, immunocompromised (or planned therapy)

Answer 1149

IVDU, needle-stick injury, hemodialysis, pregnancy Canadian Taskforce does not recommend people born in Canada between 1950-1975 be screened

Answer 1150

Abstain from alcohol Vaccination against Hep A/B Screen pregnancy Mothers with high HBV viral loads should be given antiviral therapy to further reduce the risk of infection in the newborn Follow-up infants (HBV vaccine and HBIG within 12h after birth, with repeat vaccine at 1 and 6 months)

Answer 1151

antiviral therapy infants HBV vaccine and HBIG within 12h after birth repeat vaccine at 1 and 6 months

Answer 1152

Clean wounds, avoid any further blood/body fluid exchange until cleared Vaccinate Hep A/B as indicated Screen all contacts and offer PEP as indicated

Answer 1153

Hygiene practices: Handwash, avoid tap water, raw foods, heating foods >85°C

Answer 1154

close personal contacts, child care contacts, food handlers (not warranted in a single case of Hep A in school or hospital) For healthy individuals aged 12 months to 40 years HAV Vaccine (Havrix 1mL IM x1) For individuals ≥41 years or <12 months, immunocompromised, chronic liver disease, allergic to the vaccine Hepatitis A immune globulin 0.02 mL/kg IM x1 The combination vaccine TWINRIX should not be used for postexposure prophylaxis

Answer 1155

PEP not required if either source or exposed has either Recorded previous (at any time) anti-HBs ≥10 IU/L History of recovery from HBV infection Hep B vaccine (0, 1-2, and 4-6 months) if source HBsAg-positive or HBV-unknown Within 24 hours of exposure, and complete three-dose series (zero, one, six months) if not vaccinated HBIG 0.06 mL/kg IM x1 if source HBsAg-positive or high risk (e.g., IVDU, MSM) As soon as possible, within 7 days of percutaneous exposure or within 14 days of sexual exposure Repeat dose at 28-30 days after exposure in non-responders to Hepatitis B vaccine or in patients who refuse vaccination If PEP given, do anti-HBc and HBsAg after 6 months to assess for HBV transmission

Answer 1156

No PEP recommended Close observation for those who had percutaneous or high-risk sexual exposure (unless source negative HCV RNA) If source HCV RNA positive, repeat HCV RNA at 4w, and HCV RNA + HCV Ab at 3 and 6 months If source HCV RNA unknown, repeat HCV Ab six months after exposure Delay treatment for six months minimum to monitor for spontaneous clearance of HCV RNA

Answer 1157

Inform health care providers (dentist, nurse, other physicians) and other providers eg. (acupuncturist, tattoo artist) of infection Do not donate blood/semen/tissues Safely dispose of blood (hygiene products, floss, bandages, needles) Cover cuts/sores Do not share personal hygiene materials and sharp instruments (razors, nail clippers, toothbrushes, glucometers) Ensure all partner/household members/drug use partners are tested and immunized if susceptible (Hep B vaccine free for susceptible contacts) Condom-use until partners test immune Avoid medication or alternative therapies (herbals) that may affect or be affected by liver Go to ER if black stools or vomiting blood

Answer 1158

Bilirubin (total and direct), albumin, INR (PT), creatinine ALT, AST, ALP CBC Test co-infection HIV status, Hep B/C Assess infectiousness - HBV DNA, HbeAg

Answer 1159

Management focus on relief of symptoms, monitoring, prevention of complications and transmission Does not require antiviral treatment for acute Hep B as most (95%) will clear Refer if deteriorating liver failure (INR, bilirubin, platelet, encephalopathy)

Answer 1160

If confirmed chronic carrier HIV/HCV (if not done already) HBeAg Repeat labs ALT q6 months HBV DNA (viral load) q1 year Ultrasound (+/- AFP) q6-12 months for HCC Cirrhosis HIV/HCV co-infection African descent>20yo Men>40yo, Women>50yo Family history of hepatoma Referral to specialist (treatment with interferon injections or oral nucleoside/nucleotide analogues) Usually if elevated ALT or HBV DNA >2000 IU/mL

Answer 1161

Cirrhosis HIV/HCV co-infection African descent>20yo Men>40yo, Women>50yo Family history of hepatoma

Answer 1162

Gown, gloves, face shield mask Oxygen, monitor, BP cycle NPO Two large IVs NG + Elective endotracheal intubation if ongoing hematemesis, altered mental status, or risk of aspiration Fluid resuscitation Type and Screen or Cross-match if risk Blood transfusions to maintain Hb >70g/L (consider >90g/L if massive bleeding or comorbid eg. CAD) Avoid overtransfusing patients in variceal bleeding - can worsen bleeding Consider platelets, plasma if receiving massive RBC transfusions In patients with variceal bleeding OR undifferentiated bleeding in cirrhosis, Prophylactic antibiotics (Ceftriaxone 1g IV daily x 7d) as 50% risk of infections when hospitalized for UGIB (UTI, SBP, pneumonia, bacteremia) PPI - Reduces rebleeding in high-risk ulcers treated with endoscopic therapy Omeprazole 40mg IV BID or Pantoloc 40mg IV BID Pantoloc 80mg bolus and 8mg/h drip has not been shown to be superior Prokinetic - Promotes gastric emptying, shown to reduce second endoscopy Consider Erythromycin 3mg/kg or 250mg IV over 30 mins (30 mins-90mins prior to endoscopy) Somatostatin (and analogs) in suspected variceal bleeding, however may have a role in nonvariceal bleeding in settings where endoscopy is unavailable Octreotide 50mcg IV bolus then 50mcg/hour Balance risks and benefits of anticoagulant and antiplatelet agents reversal Warfarin → Vitamin K Heparin → Protamine, Fresh frozen plasma Dabigatran → Praxbind (Idarucizumab) Balloon tamponade for uncontrollable hemorrhage, intubation necessary prior GI consultation for early endoscopy vs. interventional radiologist (angiography) Can risk stratify (AIMS65, or Glasgow-Blatchford Score 0-1 denotes "low-risk" safe for discharge)

Answer 1163

previous GI bleed, intensive care unit admission, nonsteroidal anti-inflammatory drugs, alcohol

Answer 1164

CBC (Hb, platelets), Chem (BUN, creat), Liver enzymes (AST, ALT), Coag (INR), Albumin EKG, Troponin if risk of MI (older, hx of CAD, chest pain or dyspnea)

Answer 1165

Bleed Peptic ulcer Esophagogastric varices AV malformations Tumor Esophageal (Mallory-Weiss) tear Esophagitis/Gastritis Not bleed Beet Iron Pepto-Bismol

Answer 1166

Diverticulosis - most common Angiodysplasia Colitis Inflammatory bowel disease Infectious Neoplastic Anorectal (hemorrhoids, anal fissures, rectal ulcers)

Answer 1167

Urine and Serum B-hCG STI screen HIV : (0-6w-12w-24w) Syphilis EIA or RPR Gonorrhea and chlamydia PCR HBsAg, HepBsAb Optional Wet mount/culture for trichomoniasis vaginalis HCV (consider in high risk, IVDU)

Answer 1168

Pregnancy prophylaxis : -ullipristal -plan B - Yuzpe (estrogen + progesterone) -copper IUD Prevention of STI: -cefixime 400mg x 1 for gono -azithro 1g Ix 1 for chlam or doxy 100mg po BID x 7 d -metronidazole if positive for trichomoniasis -tx for syphilis -hep B (HBIG, 3 doses of hep B vaccines 0-1-6m) -HIV prophylaxis

Answer 1169

urethral, endocervical or rectal : ceftriaxone 250 mg IM x 1 or Cefixime 800mg PO x1 AND azithromycin 2g PO x 1 if pharyngeal infection : Ceftriaxone 250 mg, IM, en dose unique if oral exposition for partne

Answer 1170

Doxycycline 100mg PO BID x7d or Azithromycin 1g PO x1 Doxycycline PO preferred for rectal chlamydia Azithromycin PO preferred in pregnancy

Answer 1171

Primary, secondary, and early latent syphilis: Pen G 2.4 million units IM x1

Answer 1172

Metronidazole 2g PO x1 Treat partner Bacterial STI or trichomonas should abstain from unprotected sex until 7d after treatment of both partners complete

Answer 1173

Initial (within 72h or ongoing new lesions/pain): Acyclovir 400mg PO TID, Famciclovir 500mg PO TID , Valacyclovir 1000mg PO BID x 7-10d If severe odynophagia, consider IV acyclovir Recurrent episodic: Famciclovir 1500mg PO x 1 dose or Valacyclovir 2g PO BID x 1 day Chronic: Acyclovir 400mg PO BID or Valacyclovir 500mg PO daily

Answer 1174

Initial (within 72h or ongoing new lesions/pain): Acyclovir 400mg PO TID, Famciclovir 250mg PO TID , Valacyclovir 1000mg PO BID x 7-10d Recurrent episodic: Acyclovir 800mg PO TID x2d, Famciclovir 1000mg PO BID x 1 day, Valacyclovir 500mg PO BID x3d Chronic suppressive: Valacyclovir 500-1000mg PO daily

Answer 1175

Imiquimod 5% cream qHS 3/week x 15w, wash off after 6-10h Podofilox 0.5% solution BID x3d then none x4d, repeat PRN x4 Cryotherapy

Answer 1176

Gentamicine6 240 mg IM (en deux injections de 3 ml) ET Azithromycine3 2 g PO en dose unique

Answer 1177

Un test de contrôle n’est pas recommandé dans les cas d’infection à C. trachomatis, sauf dans les situations suivantes: Persistance ou apparition de signes ou symptômes Grossesse Problème anticipé d’adhésion au traitement Utilisation d’un schéma thérapeutique autre que ceux recommandés Infection rectale à C. trachomatis traitée avec azithromycine Infection à C. trachomatis de génotype L1-3 (LGV TAAN effectué le plus tôt possible à partir de 3 semaines après la fin du traitement

Answer 1178

Un test de contrôle est recommandé dans tous les cas d’infection gonococcique, en particulier dans les situations suivantes: Persistance ou apparition de signes ou symptômes Grossesse Problème anticipé d’adhésion au traitement Utilisation d’un schéma thérapeutique autre que ceux recommandés Infection pharyngée (même si traitée avec ceftriaxone) Utilisation du schéma thérapeutique combinant la gentamicine et l’azithromycine dans le cadre d’un antécédent de réaction allergique Résistance démontrée ou sensibilité réduite1 à l’un des antibiotiques utilisés Partenaire d’une personne chez qui une résistance ou une sensibilité réduite1 à l’un des antibiotiques utilisés a été démontrée

Answer 1179

En cas d’infection pharyngée2 : TAAN3 et culture effectués le plus tôt possible à partir de 2 semaines après la fin du traitement OU culture4 effectuée le plus tôt possible à partir de 3 jours et jusqu’à 2 semaines après la fin du traitement. En cas d’infection autre que pharyngée2 : TAAN effectué le plus tôt possible à partir de 2 semaines après la fin du traitement5 . Si la personne présente des symptômes au moment de la visite de contrôle, procéder également à un prélèvement pour culture. Une culture effectuée le plus tôt possible à partir de 3 jours et jusqu’à 2 semaines après la fin du traitement est également envisageable.

Answer 1180

Partenaires à joindre s'ils ont eu un contact sexuel avec la personne atteinte: dans les 60 jours précédant les premiers symptômes ou le prélèvement; OU pendant que la personne avait des symptômes; OU avant la fin du traitement à doses multiples ou moins de 7 jours après un traitement à dose unique. Il peut être justifié, dans certaines situations, de rechercher des partenaires sur une plus longue période. L’intervention devrait inclure: une évaluation clinique comprenant l’identification des facteurs de risque d’ITSS; un dépistage de l’infection à laquelle la personne a été exposée et des autres ITSS selon les facteurs de risque décelés, consulter l’outil ITSS à rechercher selon les facteurs de risque décelés; en l’absence de signes et de symptômes, un traitement épidémiologique sans attendre les résultats du dépistage: algorithme décisionnel; en présence de signes ou de symptômes: une approche syndromique; le soutien auprès de cette personne dans sa démarche visant la notification et le traitement de ses partenaires si les résultats des analyses microbiologiques sont positifs. Pour plus d’informations, consulter les outils Personne exposée à une ITSS : que faire? et Soutenir la personne atteinte d'une ITSS pour qu'elle avise ses partenaires : quatre étapes. Traitement accéléré du partenaire (TAP) : Il est préférable de faire l’évaluation de la condition de santé du partenaire sexuel avant l’activité de prescription afin qu'il reçoive les meilleurs soins préventifs. Dans certaines circonstances, le traitement accéléré du partenaire (TAP) peut être utilisé après une analyse judicieuse des avantages et des inconvénients. Le TAP demeure une mesure d'exception. Pour plus d'informations, consulter l'aide-mémoire pour les cliniciens et l'aide-mémoire pour les pharmaciens

Answer 1181

(Truvada plus raltegravir 400mg PO BID x 28d) if known HIV (or high-risk, eg. sex worker, MSM, IVDU)

Answer 1182

HBsAg, HBsAb, HBcAb Post-exposure baseline serologies (ensure HBsAb immune) Vaccinate Immunoglobulin if contact known HepBsAg positive Repeat serology 2 months after vaccine series

Answer 1183

Post-exposure baseline HCV Ab HCV RNA 3w after exposure (or HCV Ab 6 months after exposure)

Answer 1184

1w - Gonorrhea 2w - Chlamydia 12w - Syphilis, HIV, HBsAg /HCV Ab

Answer 1185

Ampicillin (100-200mg/kg/d IV divided q6h) + Cefotaxime 50mg/kg IV q8h or Gentamycin 2.5mg/kg IV q8h or Tobramycin 6mg/kg IV q24h with dose adjustments

Answer 1186

Cefotaxime 50mg/kg IV q8h

Answer 1187

Non-meningitic: Ceftriaxone 50mg/kg/day IV divided q12-24h Meningitis: Ceftriaxone 100mg/kg/day IV divided q12-24h Add ampicillin for Listeria or enterococcus concern Add vancomycin for MRSA if concern Consider empiric antivirals (acyclovir), especially if suspect HSV meningitis

Answer 1188

WBC, platelet, AST, ALT, CRP, ESR, Urinalysis for pyuria, consider viral testing for alternative diagnoses

Answer 1189

Fever ≥ 5 days (if any of the 4 below criteria present at any time during illness, diagnose on day 4 of illness) Conjunctivitis (bilateral nonexudative) Rash (polymorphic) Adenopathy (Cervical lymph node >1.5cm) Strawberry tongue (oral mucous membranes changes, also injected/fissured lips, injected pharynx) Hands and feet edema (acute)/desquamation (convalescent)

Answer 1190

Abdominal X-ray r/o occult constipation Lab if suspected or failed intervention with laxatives TSH Celiac Electrolytes and calcium Blood lead level Urine culture (if enuresis)

Answer 1191

Renal-Bladder Ultrasound if child <2yo with first febrile UTI within 2w of acute illness Recurrent UTIs Pyelonephritis (Complicated) Family/personal history of urologic/renal abnormalities VCUG if Hydronephrosis on ultrasound that suggests high grade (4-5) VUR, in addition consult urology or nephrology <2yo with second febrile UTI

Answer 1192

Ampicillin 50 mg/kg/dose IV q6h + Gentamicin 7.5 mg/kg IV/IM once daily Cefixime 8mg/kg PO daily (max 400mg/d) TMP/SMX 6-12mg/kg/day divided q12h (max 320mg TMP daily), avoid in newborns Amox/Clav 7:1 suspension, 45mg/kg/day of Amox divided q8h (max 3g Amox daily) Alternatives Amoxicillin 50 mg/kg/day divided q8h (max 3g daily) Cephalexin 50 mg/kg/day divided q6h (max 500mg/dose)

Answer 1193

ASA and Ivig

Answer 1194

What I would do Why I would do it How I would do it When I would do it Where I would do it eg. “Inhaled oxygen stat in a resuscitation room to treat the patient’s respiratory distress”

Answer 1195

biguanide, sulfonylurea, DPP4i (-gliptin), GLP1r-agonist (-tide), SGLT2i (-flozin), meglitinide, alpha-glucosidase-i, thiazolidinediones, insulin

Answer 1196

BB, CCB, ACE-i, ARB, thiazide, aldosterone antagonist

Answer 1197

SSRI, SNRI, NDRI (buproprion), TCA, TeCA (tetracyclic - Mirtazapine), MAOI (Selegiline used in Parkinsons)

Answer 1198

NRTI (tenofovir/emtricitabine), Combination (Truvada), Integrase inhibitor (Raltegravir), NNRTI , Protease inhibitor

Answer 1199

NSAIDs, acetaminophen, triptan

Answer 1200

beta blocker tricyclics (amytriptyline) Valproate SNRI: venlafaxine

Answer 1201

anticholinergics: benztropine levodopa dopamine agonisst MAOB inhibitor (rasagiline, slegiline) NMDA-receptor antagonist COMT inhibitor

Answer 1202

myalgia, nausea, diarrhea, insomnia

Answer 1203

dyspepsia, N/v/D, GI bleed, CV risk (MI, stroke)

Answer 1204

dry cough, angioedema, HA, fatigue, hyperK, elevated creat

Answer 1205

fatigue, nausea, diarrhea

Answer 1206

fatigue, diziness, nausea, palpitations, vertigo, flushing

Answer 1207

Headache, nausea, sexual dysfunction, somnolence/insomnia

Answer 1208

Irregular/breakthrough bleeding, headache, nausea, breast tenderness

Answer 1209

N/V/Constipation, urinary retention, dizziness, sedation, pruritus, resp depression, confusion

Answer 1210

A = Assess airway and if compromised begin by attempting secure it with chin lift or jaw thrust if necessary B = Assess breathing, and begin to assist with bag and mask if necessary C = Assess pulse, and start high-quality CPR if not palpable G = Measure plasma glucose M = Get monitors: pacing pads, cardiac monitor, BP monitor, SpO2 monitor O = 100% non rebreather mask with O2 set to flush V = Assess vital signs (6!) I = Place large bore IVs x2 (14-16G) E = EKG stat

Answer 1211

Safety: ABCs assessed and addressed? Vital signs stable? Admission to hospital? Stop driving? Next visit: Regular f/u Offer: Labs, imaging, investigations Prevention: Diet, weight loss, exercise, safe sex, helmets, vaccines, screening for associated conditions Quit: Smoking, EtOH, drugs, stress, offending medications Refer: Specialists, clinics, allied healthcare professionals, multidisciplinary teams Report to: Health authority for outbreaks, driving authority if unsafe to drive (eg. seizure) Start: Non-pharmacologic and pharmacologic interventions Teach: Counsel, refer to online resources, patient handouts; instructions to return sooner if Sx persist or worsen

Answer 1212

HIV Pregnancy Pain Danger to self or others (Suicide) Abuse Vaccines Eating disorders

Answer 1213

10-15mg/kg PO q4-6h

Answer 1214

4-10mg/kg PO q6-8h in>6mo

Answer 1215

Child (duration usually 5-10d) Strep pharyngitis: 50mg/kg/day PO daily UTI: 50mg/kg/day PO div TID AOM/sinusitis: 90mg/kg PO div BID Pneumonia: 90mg/kg PO div TID

Answer 1216

Pneumonia 1g PO TID x7d

Answer 1217

: Cefixime 800mg PO x1 + Azithromycin 1g PO x1 ("fix az" soon as possible)

Answer 1218

PPI (eg. Lansoprazole 30mg PO) BID Amoxicillin 1g PO BID Clarithromycin 500mg PO BID

Answer 1219

Nicotine replacement, Champix 0.5mg/d x2d then BID , Zyban 150mg/d x3d then BID

Answer 1220

Epinephrine 1, Amiodarone 300/150, Atropine 0.5, Adenosine 6/12 push with rapid NS flush

Answer 1221

Child: 0.01mg/kg IM Adults: Epinephrine 0.5mg IM

Answer 1222

1mg (1000mcg) PO daily, or IM/deep SC weekly x one month then monthly

Answer 1223

Lifestyle, wet alarm DDAVP 0.2mg PO qHS (up to 0.6mg)

Brainscape's Knowledge GenomeTM

general Flashcards

Brainscape's Knowledge Genome^TM