General family medicine Flashcards
What are McIsaac’s criteria and when do you treat strep pharyngitis?
II. Criteria: Modified Centor (recommended) 1 Tonsillar exudate or erythema 2 Anterior cervical adenopathy 3 Cough absent 4 Fever present 5 Age Age 3 to 14 years: +1 point Age 15 to 45 years: 0 points Age over 45 years: -1 points II. Approach: Clinical Suspicion based on scoring above Strep Score 4 to 5 (or Strep Score 2 if patient unreliable) Treat with antibiotics Strep Score 2 to 3: Perform rapid antigen test Antigen test positive: Treat with antibiotics Antigen test negative: Throat Culture Strep Score 0 to 1 Provide Pharyngitis Symptomatic Treatment Tx of strep pharyngitis Amoxyl 250mg TID 7D
What are the criteria for the Pre-test probability for DVT?
Active cancer +1 Paralysis or imbilization +1 Recently bedridden > 3d or surgery within 4 wk +1 Localized tenderness in deep vein system +1 Entire leg swollen +1 Calf swelling >3cm asymptomatic side Pitting edema on affected side +1 Superficial (non-varicose) veins +1 Alternative dx more likely than DVT -2 0-1 DVT unlikely >/= 2 likely
What are the preventative measures for COPD?
Smoking cessation
Limit spread of spread of viral infections
Vaccines: influenza, pneumococcal vaccine
Rehab and nutrition programs
How do you diagnose acute bronchitis?
1) Acute onset of symptoms- cough, sputum production, chest discomfort but normal respiratory exam
2) Chest X-ray, sputum cultures only indicated for patients with evidence of consolodation
3) Green/yellow sputum production is indicative of inflammatory reaction, and does not necessarily imply bacterial infection
Antibiotics are not recomended in the management of acute bronchitis
What is the acute management of an open fracture?
1) ACB’s ATLS stuff
2) clean the wound of any large debris
3) Wash the wound but don’t scrub it
4) Draw a good picture of the wound, its size and location and Document neurovascular exam
5) Cover wound with wet sterile gauze
6) X-ray
7) start IV antibiotics
What are the important antibiotics for the Guistillo classification of open fractures?
1)Class 1- <1 cm–> IV cefazolin
2g IV q8h for 48h and then reasess
2)Class 2- 1-9cm–> IV cefazolin
3)
a) can easily be closed
b) requires a flab
c) neurovascular compromise
–> for grade 3 open fractures want to cover for
a) anaerobes–> clindamycin (150-450 mg q6), flagyl
b) gram negatives–> gentamycin
If it is a very dirty wound–> concerned about C.Perfringes–> Pen G
What is the most important classification of hip fractures?
1)Intra capsular (femoral head circulation is disrupted in these fractures IF FRACTURE IS DISPLACED–> AVN is a complication
a) subcapital
b) transcervical
2) extra capsular
a) intertrochanteric
b) sub-trochanteric
c) low basicervical (right at junction of neck and trochanteric line
What is the garden classification of femoral neck fractures? And how is this important?
The Garden Classification Helps in management of intertcapsular fractures
Garden 1- impacted into valgus
Garden 2- undisplaced
Garden 3- varus
Garden 4- neck displaced
Valgus or undisplaced (intracapsular undisplaced)–> in situ screw with 3 months protected weight bearing
Varus deformity (intracapsular displaced)–> hemiarthroplasty
What is the therapy for extra-capsular hip fractures?
a) intertrochanteric–> dynamic hip screw or short intermedullary device
b) subtrochanteric–> longer intermedullary device
c) low basicervical–> dynamic hip screw
What is the healing time and appropriate activity for fractures/sprains?
1) Hip fractures
2) ankle fractures- three months
- one month non-weight bearing crutches
- one month walking cast or airboot
- one month for physio
3) ankle sprain
- neutral ankle splinting/crutches+ non weight bearing x2 weeks
- walking cast or air boot x 4 weeks
- after 6 weeks physio prn
What are the three bones in the body that are most at risk for AVN and why?
The talus, scaphoid and femoral head due to their retrograde blood circulation
What is LARA and how is it used to describe a fracture?
Location- which bone, where in bone, intra-articular
Apposition of fracture fragments
Rotation
Angulation- distal relative to proximal fragment
-where is apex of deformity?
What are the general indications for an open reduction/ internal fixation in adult fracture care?
Non-union/ unstable fracture- floating limb or unstable
Open fracture
Neurovascular Compromise
Intra-articular displaced fractures by more than 2mm( b/ risk of post traumatic stiffness and arthritis)
Salter Harris III, IV, V
Poly-Trauma
examples of fractures considered to be unstable and requiring fixation:
1) displaced both bones of forearm
2) Holsteins ( distal third) shaft fracture of humerous
3) extra-articular wrist fractures- with comminution, poor bone
4) Spinal fractures with 2 or 3 columns affected
5) Displaced hip fractures
6) displaced tibial and femoral shaft fractures
How does mobility affect hip fracture patterns in the elderly?
1) people without hip joint osteoarthritis- good ROM= fracture femoral neck on way down to ground–> intra capsular fractures
2) people with hip joint osteoarthritis- bad ROM= fracture when hit ground-> extra capsular , inter-trochanteric or more distal fractures
What is the classification of hip fractures?
1)intertrochanteric
a) sub-capital femoral neck (most common)
b) Transcervical femoral neck
BY DEFINITION THERE IS DISRUPTION OF THE FEMORAL HEAD CIRUCULATION-> AVN AND NON-UNION ARE COMPLICATIONS
IF FEMORAL HEAD IN VALGUS AND THEREFORE NON DISPLACED–> SCREWS + PROTECTED WEIGHT BEARING X 3 MONTHS
IF FEMORAL HEAD IN VARUS THEREFORE DISPLACED–> HEMIARTHROPLASTY
2)extra-capsular
a) intertrochanteric-> TX IF DISPLACED GAMMA OR DYNAMIC HIP SCREW (DHS)
b) sub-trochanteric-> TX IF DISPLACED ARE DHS OR INTERMEDULLARY DEVICE
c) low basicervical -> TX IF DISPLACED ARE DHS
ALL EXTRACAPSULAR FRACTURES WILL HEAL AND HAVE EXCELLENT BLOOD SUPPLY
OPERATIVE TREATMENT SHOULD OCCUR WITHIN 48-72 HOURS
What is the classification of an ankle fracture?
1) count number of malleoli involved
a) medial
b) posterior
c) lateral
2) ankle mortise symmetric or assymetric
3) location of fibular fracture
OR
Weber A
Weber B
Weber C
What fracture do you need to rule out in a Weber C ankle fracture?
Maisonneuve fracture is combination of spiral fracture of the proximal fibula and ankle injury which could manifest by widening of the ankle joint due to distal tibiofibular syndesmosis and/or deltoid ligament disruption, or fracture of the medial malleolus.
What is the healing time for an ankle fracture?
Three months
- one month crutches
- one month walking cast or airboot
- one month physio
What is the treatment of a sprained ankle?
1) Neutral ankle splinting/ crutches/ non-weight bearing until swelling has decreased ~ 2 weeks
2) air cast or walking cast for subsequent 4 weeks
Total time to heal ~ 6 weeks
Avoid risky sports for 3 months
What other plantarflexors cross the ankle joint?
Flexor halicus longus
Flexor digitorum longus
What is the treatment for an achilles tendon rupture?
1) Partial tear- below knee splint/crutches->air cast->physio
2) complete tear-surgical management or wedge therapy-> physio
What are the factors that suggest instability of a wrist fracture?
Female
Age >65/ poor bone quality
Palmarly displaced/ angulated
High energy mechanism of injury
- initial displacement
- open injury
- intra-articular displacement
- lots of fragments
What are the classifications of wrist fractures?
1) Colles- extra articular, dorsally angulated/displaced metaphyseal fracture in adults
2) Smiths- extra articular, volarly angulated/displaced metaphyseal fracture in adults
3) Volar bartons fracture- intra articular fracture where volar lip of distal radius is displaced volarly
4) CHauffeur’s fracutre- intra-articular fracture of the radial styloid
5) Galeazzi- volarly angulated distal radius fracture with dorsal dislocation of distal ulna
6) Die punch fracture- intra-articular impaction fracture of lunate bone into distal radius
What are the principles of wrist fracture treatment?
1) Low energy- splint with f/u 7-10 days, replace splint with univalved cast
2) High energy-well aligned sgx in < 10 days
nod fully reduced sgx in < 24 hours
Open wound sgx < 6 hours
Cast no longer than 6 weeks, and avoid above elbow immobilization
What is the treatment for wrist injuries?
1)simple dorsally angulated (low energy)- closed reduction/ below elbow cast
+/- percutaneous pins
2) medium energy
a) extra articular with displacement- closed reduction +/- perc pins
b) scaphoid-> ORIF if > 2mm displacement, scaphoid flexed, high demand occupation
3) Higher energy : intra-articular- ORIF with plates
4) Highest energy
a) comminuted/ intra-articular- ORIF
b) carpal fracture/dislocations- ORIF
What is the diagnosis and treatment of a locked knee?
1) locked knee in young active adults- bucket handle tear of medial meniscus, normal knee x-ray
- Xray and refer to ortho for sgx tx within 2 weeks
2) middle aged- OA debris
- xray and refer to ortho for sgx tx within weeks or months
What is the treatment of a knee strain?
I- tenderness, no joint opening
II-abnormal opening with endpoint
III-joint opens- no endpoint
ALL OF THESE SHOULD HAVE A NORMAL X-ray
TX
grade I- supportive, no bracing
grade II, III- crutches, partial weight bearing, extension knee brace 2-3 weeks, physio and hinged knee brace 6-8 weeks
What is the most common injury in a knee strain?
MCL> LCL
Who needs an MRI in a suspected ACL blowout?
younger more active patients
grossly unstable knee such that early mobilization is impossible
block to knee extension (locked knee)
bony avulsion fracture
high performance athletes
What is the treatment of a torn ACL?
**ACL’s dont heal if in a splint, MCL’s do**
goals of treatment:
- early diagnosis
- splint until stable
- early protected ROM
SGX management needed if:
- grossly unstable knee
- block to motion ( locked knee)
- bony avulsion fracture
- high performance athlete
Who are the most common to have a quadriceps tendon rupture?
- body builders
- old men
what is the hallmark of a quadriceps or patellar tendon rupture?
What is the surgical management?
inability to extend knee against gravity
Treatment is surgical if can’t extend knee, should be operated on if < 2 weeks from injury
What are the two most common presentations of a knee dislocation?
Management?
high energy MVC and morbidly obese people with lax ligaments
MUST WATCH FOR COMMON POPLITEAL NERVE and for POPLITEAL VESSEL INJURY
MUST BE REDUCED WITHIN 6 HOURS
What is the management of patellar fractures?
1) Fracture displaced < 2mm and knee extension in place
- splint and physio
2) Fracture displaced > 2mm and knee extension not in place
- sgx management
What are the different fractures of the knee and the management?
1) Good bone
a) tibial plateua fractures–> all require sgx
- are typically intrarticular and compromise bone
- heal well particularly if lateral plateau
b) high energy distal femur fractures–>
2) Bad bone (old and OA)
a) typically metaphyseal, minimally displaced, Schatzker II, III
- many can be treated conservatively if < 5mm displacement
b) low energy distal femur fracture
- typically in people who have hip and knee replacements
what is the treatment for an acute uni-directional shoulder dislocation?
1) Document N/V exam
2) good x-rays in 2 planes to confirm diagnosis
3) reduction under sedation
4) Shoulder immobilizer worn 23 hours a day for first 2 weeks, then physio, gradual return to activity
What are the names and structure of damage to the humeral head with anterior shoulder dislocation?
Hill sacks lesion- posterolateral humeral head compression fracture
Bankart lesion-torn capsule and labrun
What is the classification and treatment of AC joint fractures?
Grade I-III–> shoulder immobilizer x 2 weeks, then physio
Grade IV to VI–> sgx consultation
What are the risks for potential non union of clavical fractures that suggest a sgx fixation is neccsary?
1) displacement > 150% shaft width
2) comminuted shaft fracture
3) sub-cutaneous bone fragments
4) dominant arm in labourers
What is the classification and treatment of proximal humerous fractures?
NEER CLASSIFICATION
There are 4 important fragments
1) anatomic humerous head fracutures
2) humeral shaft
3) greater tuberosity
4) lesser tuberosity
The greater the number of fragments, the greater chance of unstable, non-union, and AVN
Treatment is determined by the age, number of fractures
In middle aged people these fractures tend to be high energy and are usually displaced and require surgical fixation
In elderly people they are typically low energy, impacted (most common fractures happen at anatomic neck and metaphyseal junction)–> 90% can be treated conservatively
What is the conservative treatment for proximal humerous fractures?
- shoulder immobilizer
- 10-1 4 days re x-ray and refer for physio
- wean shoulder immobilizer over 3-4 weeks
- 3 months for fracutre healing
- expect stiffness
what are the physical findings of specific nerve injuries?
1) radial nerve- wrist drop
- can happen in humerous fractures
2)
What is the treatment for an uncomplicated midshaft closed humerous fracture?
If N/V intact and uncomplicated fracture
sugar tong splint, re-xray in 7-10 days with new splint
gravity and splint help fracture to heal
At 6 weeks custom orthotic made and pt wears 23 h/d for 6 weeks
What is the unhappy triad of elbow injuries?
1) raidal head fracture
2) coranoid process fracture
3) olecranon fracture
What are the three sections of the foot?
Forefoot- toes distally to metatarsal base
MIdfoot- metatarsal/cuniform joint to talonavicular and calcaneal
Hindfoot- talus and calcaneous and subtalar and ankle joint
What are the important midfoot fractures not to miss?
Jones fracture- fracture of the proximal 1/3 of the fifth metatarsal–> need to have surgery due to high non-union rate
very different than base of 5th metatarsal–> heal without surgery
What is a Lis Franc Injury?
mid foot fracture dislocation through base of metatarsals that can be isolated to first and second metatarsal or involve all five
These are unstable and require ORIF
What three bones in the body have a retrograde blood supply?
Scaphoid
Femoral head
Talus
What are the most common types of pelvic fractures?
A)low energy- most common
-stable, and patient can ambulate with a walker when able
B)High energy-
-major predictor of whether a pelvic fracture is stable is whether the posterior structures have been disrupted ( sacrum, SI joints, iliac bones)
classify unstable pelvic fractures into 3 groups
1) lateral compression
2) open book- unstable if >2cm widening of pubic symphysis
c) vertical shear- highest energy, always unstable,
- common injuries in vertical shear fractures are urethral injuries, venous bleeding, nerve injuries to sacral plexus or sciatic nerve
Where do you look for tenderness in tennis elbow?
lateral humeral epichondyle
What is the x-ray feature to look for to rule out a monteggia fracture?
centre of radial head should line up with capitellum of humerus
What is the cause of warts, and what is the best treatment?
Caused by HPV (usually HPV 1)
Risk factors include atopic dermatitis and other conditions that cause skin breakdown
Best treatment is Salicylic acid in combination with cryotherapy
Canthardrin/theophylline/salycilic acid is applied in office and then covered with bandage and then washed off 4 hours later–> causes huge blisters–> concern here is that theophyline is teratogenic
What are the options for treatment for strep throat?
Amoxicillin 20-40mg qd divided TID for 7 days
(max dose 500mg at once)
What are the elements of a good prenatal visit?
Should happen before 10 weeks ( ideally between 3- 8 weeks as this is a critical time for organogenisis)
Woman should be on folic acid PRECONCEPTION
0.4mg/d if low risk
4mg/d if high risk (previous history of NTD, on seizure medications)
1) history
2) Physical exam
3) Counselling
What are the physical exam findings suggestive of pregnancy?
Goodels sign-softening of cervix
Chadwicks sign-bluish discoloration of cervix due to venous engorgement
Engorgement of breasts
What are the times for the ultrasounds scans in pregnancy?
8-12 weeks- dating ultrasound
11-14 weeks- NTUS
18-20 weeks- fetal growth and anatomy
What is the schedule for prenatal testing?
What is the name of the RSV vaccine, and who is elligable to obtain it.
Palivizumab- a humanized monoclonal antibody against the RSV F glycoprotein
Indications for palivizumab
1) bronchopulmonary dsyplasia
2) Prematurity
- born at less than or equal to 28 weeks 6 days and are younger than 12 months of age at the start of RSV season
Who should not get palivizumab
infants born over the age of 29 weeks
Dosage
The dosage is one IM injection once per month for a maximum of five doses. FIrst dose is administered before RSV season begins (November)
What is the dosage of dexamethasone for group?
0.6 mg/kg po
What is the classification and staging of croup?
What is the dosage of IM toradol?
30mg IM
What are the dosages of medications important in Croup?
Dexamethasone- 0.6 mg/kg
Nebulized epinephrine- racemic 2.25% (0.5ml in 2.5ml NS)
or
L-epinephrine 1:1000 (5 ml)
Budesonide (if vomiting or too stressed to take oral medication) 2mg budesonide
What is travelers diarrhea?
Diarrhea that develops during or within 10 days of returning from travel to resource-limited countries or regions
Bacterial causes are more common in acute causes, the most common of these being enterotoxigenic ecoli
Rotavirus is the most common viral cause
Persistent travelers diarrhea can be caused by parasites, such as E.Histolitica, C.Parvum
What are the prophylactic strategies for travellers diarrhea.
1) Antibiotics- Rifamixin 200mg OD for time there (this is not absorbed)- for three days of therapy
2) Dukoral- cholera B subunit (not as good as antibiotics)
Asprin vs clopidegrel for secondary stroke prevention
Aspirin and clopidogrel both have similar efficacy for secondary stroke prevention (after the acute period)
aspirin has higher risk of gastric bleeding and upset
aspirin and clopidogrel combined have a higher risk of bleeding events than either apart
aspirin plus clopidogrel together did not reduce the risk of ischemic events
Aspirin is effective for secondary stroke prevention in patients with noncardioembolic transient ischemic attack (TIA) and ischemic stroke. However, clopidogrel treatment was better than aspirin as measured by a composite outcome of stroke, myocardial infarction (MI), or vascular death in the CAPRIE study [17], and the combination of aspirin-extended-release dipyridamole had greater benefit for secondary stroke risk reduction than aspirin alone in two clinical trials (ESPS-2 and ESPRIT
Given the available data, we suggest treatment with either clopidogrel 75 mg daily as monotherapy, or aspirin-extended-release dipyridamole 25 mg/200 mg twice a day, rather than aspirin alone. Some experts still prefer aspirin as the first-line agent, noting that the alternative antiplatelet regimens (clopidogrel or aspirin-extended-release dipyridamole) have an apparent modest advantage in benefit that is potentially offset by a disadvantage in cost.
USING the ABCD2 tool you can determine your risk for an acute ischemic event again, and
What are causes of an elevated QT interval >440ms?
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
Hypothermia
Myocardial ischemia
Post-cardiac arrest
Raised intracranial pressure
Congenital long QT syndrome
DRUGS
What are the diagnostic criteria for meniere’s disease?
What are the treatments/management?
1) Two spontaneous episodes of rotational vertigo lasting at least 20 minutes
2) audiometric confirmation of sensineureal hearing loss
3) tinitis and or perception of aural fullness
Treatment
a) trigger management- avoid caffiene and MSG
b) gravol, scopolamine
c) scopolamine (cerc)- reduces symptoms
d) systemic glucocorticoids do not help
e) referral to ENT is best for difinitive therapy
What is the best diagnostic test for BPV?
Dix-Hallpike maneuver (sensitivity 82%, specificity 71%)
Dix-Hallpike Positional Testing (see website for video and illustrations)
• the patient is rapidly moved from a sitting position to a supine position with the head hanging over the end of the table, turned to one side at 45° and neck extended 20° holding the position
for 20 s
• onset of vertigo and rotary nystagmus indicate a positive test for the dependent side
What is interstitial cystitis, and what is the treatment?
Interstitial cystitis is chronic urgency +/- pain without other reasonable causation
There are both ulcerative and non ulcerative forms with the non-ulcerative form being more common. The underlying pathophysiology is unknown
It is more common in females, with an association to fibromyalgia, severe allergies
Treatment
first line- patient empowerment (diet, lifestyle, stress management
second line- pentosan sodium, amitriptyline, cimetidine–> referral to urology is most important
What is recurrent or chonic cystitis?
>/= to 3 UTI’s in 12 months
Most common cause of cystitis are
Klebsiella
Ecoli
Enterococcus
Proteus mirabilis, pseudomonas
Staph.saprophyticus
What is the treatment for chlamydia and ghonorrhea?
Chlamydia
azithromycin 1g po X1
gonoccoal
cefixime 800mg po x1
Who should you send urethral swabs for N.gonarrhoeae?
1) Men who have sex with men
2) sexual assault
3) treatment failure
4) infection aquired abroad by patient or sexual contact
Who and when should you test by culture after completion of therapy?
1) regimen other than recomended used
2) antimicrobial resistance identified on culture
3) concern over false positive test
4) persistent signs
5) concomitant infection at non-genital site
6) disseminated gonococcal infection
7) uncertain compliance
What is the best therapy for restless leg syndrome?
Restless Leg syndrome= Willis-Ekbom disease (RLS/WED)
overwhelming urge to move the legs particularly at rest and at night that is relieved by moving legs
Commonly associated with sleep disturbance and with involuntary, jerking movements or the legs during sleep called periodic limb movements of sleep (PLMS)
PLMS can exist by itself or with RLS/WED, and both respond to pharmacological therapy well, with a broad scope of meds being used
1) Serum Ferritin- worse symptoms if less than 45-50- should replace iron if ferritin < 75
- use PO iron like palifer
Palifer (ferrous fumarate) 300 mg po 1-2 QHS
2) Targeted therapy should be given after this depending on symptoms
a) DOPAMINE AGONISTSpramimprexole 0.125mg 2-3 hours before bedtime
b) ALPHA-DELTA-2 CALCIUM CHANNEL LIGANDSgabapentin 100-300mg 2 hours before bedtime
Both of these drugs can be increased after a week of trying it a certain dose
What are important features to tell patients when taking iron?
Should take with Vitamin C or orange juice
Avoid taking with calcium or large amounts of dairy
Don’t take with cofee
What are the clinical features and treatment of scarlet fever
Scarlet fever is classified with
a) diffuse erythema that blanches with pressure and numerous small 1mm elevations causing sand paper skin. Rash usually starts in intertriginous areas (areas that rub together) and then move to the trunk
- usually accompanied with
1) circumoral pallor
2) strawberry tongue
the rash usually desquamates after it has moved to the trunk with sparing of the palms and soles
rash is most marked in skin folds
can display linear petechial character in the AC fossa and axillary folds—> Pastia’s lines
b)fever and pharyngitis
Diagnosis is made based on clinical picture and exposures as well as swab
Is caused by reaction to the pyrogenic exotoxin produced by Strep Pyogenes
Having this can predispose kids to rheumatic fever
Tx with same antibiotics as for strep pharyngitis–> Pen VK 250-500mg PO Q6-8h
***remember Strep Pyogenes is divided into group A, B, C with most common cause of pharyngitis is group A*****
What is the differential diagnosis of a scrotal mass
HIS BITS
H-hydrocele
I-infection
S-spermatocele
B-blood
I-
T-torsion
S-some veins (vericocele)
What physical exam finding is absent in testicular torsion?
Cremasteric reflex is absent
Prenh’s sign is negative- no change in pain with lifting the testicle, this is positive, or there is a relief of pain in epididymitis
Testicular torsion
- surgical emergency
- needs to be surgically corrected in 6 hours
- ultrasound with colour flow doppler
