ITE 2020 Flashcards
1
Q
Institutional influenza outbreak definition:
A
two lab-confirmed cases within 72 hours on the same unit
2
Q
Influenza treatment/chemoprophylaxis for institutional outbreak?
A
Treat anyone with symptoms.
Chemoprophylaxis for all asymptomatic patients on the same unit.
3
Q
PID clinical diagnosis:
A
At-risk female.
Lower abdominal or pelvic pain.
Cervical motion, uterine, or adnexal tenderness.
Saline micro: mucopurulent discharge or WBCs.
Fever/leukocytosis/CRP not sensitive or specific.
Don’t wait for NAAT+
4
Q
Gender dysphoria, F -> M treatment?
A
Testosterone.
Clomiphene increases T but only with functioning testicle, doesn’t work here.
Spironolactone blocks androgen receptors ie decreases male features.
5
Q
Cervical cancer screening guideline:
A
PAP age 21 regardless of sexual activity q 3 years
HPV co-test age 30 q 5 years until age 65
May discontinue if last two tests negative and tested within previous 5 years
6
Q
Risk associated with long-term PPI
A
Pneumonia (gastric overgrowth by G- bacteria)
Also fractures.
7
Q
Indication for long-term PPI
A
Barrett’s esophagus
8
Q
Symptoms of hypocalcemia
A
Trousseau sign: Spasmodic contraction of muscles caused by pressure on the controlling nerves
9
Q
Symptom of hypercalcemia
A
Hyperreflexia
10
Q
Treatment of chronic insomnia
A
Cognitive-behavioral therapy (CBT-I)
Brief behavioral therapy (BBT-I)
Stimulus control (sleep hygiene) + sleep restriction Reduce time in bed, later bed time
No naps
Get out of bed after 30 min without falling asleep OR
after awake for 30 min
11
Q
Symptoms, causes, treatments of SVC syndrome
A
facial swelling, progressive dyspnea with exertion
in this case was caused by non-Hodgkin’s lymphoma, but can also be from lung cancer, indwelling catheters, lymph nodes, or metastatic tumors
Treat with hospitalization and stabilization, then IV CS, chemo, radiation, sometimes intravascular stent
12
Q
Hyperviscosity syndrome cause and treatment?
A
Oncologic emergency from leukemia, multiple myeloma, and Waldenstrom’s macroglobulinemia.
Treat with chemo and plasmapheresis
13
Q
Description and causes of stridor, and what do do about it:
A
high-pitched whistling / crowing sound on inspiration
caused by obstruction of larynx or trachea
ie foreign body, vocal chord edema, neoplasm, abscess
send for ED evaluation
14
Q
Stepwise treatment of acne:
A
- Topical retinoids (adapalene, benzoyl peroxide) 8-12 weeks
- Add topical antibiotics ie clindamycin gel for up to 12 weeks
Do not use antibiotics alone or for maintenance due to resistance.
15
Q
Symptoms and treatment of acute simple cystitis:
A
Brief history, dysuria, frequency/urgency
No fever/chills/back pain/discharge
OK to treat empirically, no UA or UCx needed
16
Q
Most common complication of HIT?
A
Thrombosis
Most commonly DVT/PE, then arterial thromboses, CVA, MI
Occurs concurrently or shortly after thrombocytopenia
17
Q
When to worry about HIT?
A
7-10 days after exposure to unfractionated heparin, especially after cardiac surgery
18
Q
How to score HIT risk?
A
4T system:
acuity of Thrombocytopenia
Timing of onset
Thrombosis
alternate causes of Thrombocytopenia
19
Q
How to manage HIT?
A
discontinue heparin
initiate full-dose anticoag with argatroban, danaparoid, fondaparinux, or bivalirudin
20
Q
What is the leading cause of injury-related morbidity and mortality among older adults in the US?
USPSTF recommended intervention?
A
Falls
Moderately certain that exercise interventions provide moderate net benefit in fall prevention for community-dwelling adults >65 who are at increased risk for falls (B recommendation)
Moderately certain that calcium and vit D supplementation has no clear benefit in preventing falls.
Insufficient evidence for supportive footwear or psychological intervention ie CBT for fall prevention
21
Q
Treatment for hoarseness of voice?
A
less than 2 weeks -> voice rest, 3-4 months high-dose PPI (SOR C)
greater than 2 weeks without apparent benign cause -> direct or indirect laryngoscopy (SOR C)
22
Q
NYHA functional classification of heart failure
A
Class I - no symptoms, no limitation of physical activity
Class II - mild symptoms with normal physical activity
Class III - significant limitations of activity, including symptoms with less than normal activities
Class IV - symptoms at rest, unable to carry on activity without discomfort
23
Q
Tibial stress fracture, presentation and workup
A
Localized pain/swelling at midpoint of shin
Worsened with running
Get a plain film XR, easily available and low cost
Most sensitive if symptoms >3 weeks
If XR normal and symptoms persist -> MRI
24
Q
Presentation and treatment of Bartholin gland abscess?
A
3x3cm tender fluctuant mass on labia minora
-> Marsupialization (0% recurrence at 6 months)
Local anesthesia is fine (SOR A)
If >5cm, send to Gyn
25
Which fish have high mercury content?
Larger ocean fish ie shark and swordfish
can cause neuro problems in children and pregnant / nursing women
Low mercury: Catfish, crawfish, shrimp, lobster, flounder, haddock, salmon, trout
26
Clinical dx of croup, and what to do about it?
What if patient fails to respond as expected to initial treatment?
child with low-grade fever, runny nose, hoarseness, inspiratory stridor, barking cough. No drooling or muffled voice.
No further testing for mild cases.
CBC only indicated if bacterial cause is suspected, ie bacterial tracheitis/epiglottitis/retropharyngeal or peritonsillar abscess.
If failure to respond to initial treatment -> viral culture and rapid antigen testing.
If drooling and muffled voice? Neck radiograph, possible epiglottitis.
27
Crohn's Disease presentation and red flags
vs celiac, pancreatitis, IBS, or UC?
Crohn's
- diarrhea, abd pain, rectal bleeding, fever, weight loss, fatigue.
- Red Flags: perianal lesions, first degree family history of inflammatory bowel disease, weight loss 5% of usual weight, abd pain >3 months, nocturnal diarrhea, fever, no pain 30-45 after eating, no rectal urgency
No rectal bleeding in celiac disease
No improved pain with eating in pancreatitis
No fever/rectal bleeding/anemia/fistula in IBS
No perianal lesions in UC
28
Treatment of migraine if pregnant? What to avoid in pregnancy? What if not pregnant?
Only metoclopramide and acetaminophen for abortive migraine during pregnancy (SOR B)
```
Avoid dihydroergotamine (oxytocic, risk of IUGR)
Avoid NSAIDs especially in 1st and 3rd trimesters
Avoid opiates, only moderately useful anyway
Avoid triptans in 2nd and 3rd trimesters (risk of uterine atony, bleeding during delivery, preterm birth)
```
DA antagonist antiemetics are 2nd line if not pregnant, first line triptans.
29
Duration of action for U-100 insulin products?
```
Degludec (Tresiba)
Glargine (Lantus)
Isophane NPH (Humulin N)
Lispro (Humalog)
Regular (Humulin R)
```
```
Degludec (Tresiba) - Ultralong (42 hrs)
Glargine (Lantus) - Long (11-24 hrs)
Isophane NPH (Humulin N) - Intermediate (12-16 hrs)
Regular (Humulin R) - Short (5-8 hrs)
Lispro (Humalog) - Rapid (3-6.5 hrs)
```
30
ADL vs Instrumental activities
ADL
- eating, bathing, dressing, transferring, toileting
Instrumental
- telephone, housework, meal prep, taking meds, managing finances
31
Effects of anorexia on hypothalamic-pituitary axis?
```
Loss of bone mineral density
Low T
Hypoglycemia (not all that common)
Amenorrhea / infertility
TSH / T4 normal or low
```
32
Asthma exacerbation treatment in children
1. inhaled short-acting bronchodilators
2. inhaled CS
3. IV magnesium sulfate
Mag reduces hospital admission by 68%
IV CS as effective as oral CS
Omalizumab prevents exacerbations, not used in management of exacerbations
33
Scoliosis management based on Cobb angle
Increased risk when Cobb angle >29 degrees
| -> referral to spine specialist
34
Symptoms of cerumen impaction, also how to and not to remove cerumen in nursing home residents
Symptoms = pain, tinnitus, hearing loss, itching.
Remove when symptomatic, also if patient is unable to communicate symptoms.
Remove by irrigation with warm water, cerumenolytic agent ie carbamide peroxide, or manual removal if patient is cooperative.
Do not use cold water, olive oil, ear candle, or cotton tipped swabs.
35
Signs, symptoms, etiology, and treatment of herpetic whitlow
Burning, pain, redness of fingertip.
Erythema of the palmar tip of finger with opaque fluid-filled vesicles. Soft, tender digital pulp.
Viral infection of distal finger, herpes simplex.
Self-limited. Treat with pain management and keep covered to prevent transmission.
36
Initial evaluation of stress incontinence? Why not the alternative?
Cough stress test with 200-300cc of urine or full bladder sensation to detect urine leakage.
Excellent sensitivity compared to urodynamic testing.
37
What is the number needed to treat?
What is absolute risk reduction?
What is relative risk reduction?
NNT = 1/absolute risk reduction (ARR)
ARR = difference in risk or outcome rates between treatment and control groups.
Relative risk reduction = how much risk is reduced in treatment vs control groups.
38
Extrapulmonary manifestations of sarcoidosis to monitor?
Ocular, 20-50% of patients, screen for asymptomatic inflammation of the eye (anterior uveitis and keratoconjunctivitis)
Bone density screening if treated with CS.
Cardiopulmonary, echo or CT chest if symptomatic.
39
When to evaluate delay in puberty?
Signs of Turner Syndrome?
F >13yo lacking breast development
Turner = XO
- delayed puberty, amenorrhea, elevated FHS (hypogonadism)
40
What to test for in precocious puberty, and how?
Cushing syndrome
Corticotropin stimulation testing
41
What does irreversible pulmonary obstruction look like on PFT?
FEV1 <80% of predicted, and FEV1/FVC ration <0.70
42
What is the FIB-4 index?
Advanced liver fibrosis:
Low albumin and
FIB-4 = (age x AST) / (plt x ALT^1/2)
Score <1.45 has a negative predictive value of 90%
Good for avoiding biopsy, should be evaluated with transient elastography to confirm cirrhosis.
43
What is Goodpasture Syndrome?
Vasculitis classically involving lungs and kidneys, causes a restrictive PFT.
44
Which medications cause false + on drug screening?
Amphetamines:
- Bupropion (Wellbutrin)
- labetalol
- ranitidine
- trazodone
Opioids - levofloxacin
Cannabinoids - PPI
Benzodiazepines - sertraline
45
Should I do additional annual screening on a lady with history of breast cancer?
No, unless they are at high risk for recurrence ie BRCA+, then MRI
46
Should I give O2 to a patient with MI?
Evidence does not support supplemental O2 unless O2 sat drops below 90% or are in respiratory distress.
47
Feeding tube for advanced dementia?
No, alter food texture or offer small portions, high calorie supplements may promote weight gain, but non improve function or survival.
Tube feeding increases risks associated with placement, chemical/physical restraints, tube blockages and dislodgements = increased ED visits and no clear benefits.
48
What are the benefits of exercise?
Does it substantially increase weight loss?
Exercise improves insulin and glycemic control in diabetes, improves blood pressure, reduces CVD risks, and maintains weight loss.
Only moderately beneficial for promoting weight loss, including when added to diet.
49
When and how to treat for fracture risk?
```
Osteoporosis = T-score of -2.5 or less
Osteopenia = T-score -1 to -2.5 and probability of hip fracture at least 3% on FRAX
```
First line bisphosphonates for 5 yearss.
50
What is legacy prescribing?
Failing to discontinue medications beyond their usual effective or recommended period.
Leads to inappropriate polypharmacy.
51
Symptoms and risk factors for PE?
How to confirm diagnosis?
Acute onset of pleuritic chest pain associated with travel, swollen leg, smoking.
CT angio
52
Red flags / best way to confirm MI?
MI: diaphoresis, N/V, radiating pain.
Elevated troponins
53
When to suspect TB?
How to confirm TB?
Hemoptysis, fever, night sweats, weight loss, often associated with travel or contacts from high-risk areas
Acid-fast bacilli on Gram stain
54
What to do if urine drug test is incongruent with medication regimen?
Which benzos will or won't show by immunoassay?
Which opiates will show by immunoassay?
Immunoassays can have false positive or negative results, and unexpected results require confirmatory testing for verification.
Example: benzo immunoassay detects metabolite nordiazepam only
From
- diazepam
- oxazepam
- temazepam
Not From
- alprazolam
- lorazepam
- clonazepam
Only nonsynthetic opioids show up
- morphine
- codeine
55
When to use warfarin (Coumadin) rather than direct oral anticoagulant?
Valvular Afib with moderate-severe mitral stenosis or a mechanical valve.
DOAC options are at least not inferior to warfarin for preventing strokes and other embolic events, with a lower risk of bleeding in most cases.
56
What are social determinants of health?
- socioeconomic status
- education
- employment
- social support networks
- neighborhood characteristics
Key drivers of health inequities, greater impact on population health than health care, behavior, or biologic factors
57
What are the six domains of health care quality?
1. Effectiveness - providing health care services likely to benefit while avoiding those not likely to benefit
2. Efficiency - avoiding waste
3. Safety - avoiding harm
4. Timeliness - avoiding unnecessary waiting and harmful delays
5. Equity - care that does not vary regardless of gender, ethnicity, geographic location, SES
6. Patient-centered care - respecting individual patient values
58
Ottawa ankle and foot rules
nearly 100% sensitive, 30-40% specific
Ankle radiographs if
- pain in malleolar zone, plus
- bony tenderness over distal 6cm of posterior lateral or medial malleolus, or
- inability to bear weight for 4 steps immediately after injury and at time of exam
Foot radiographs if
- pain in the mid-foot zone, plus
- bony tenderness at base of fifth metatarsal or navicular bone, or
- inability to bear weight for 4 steps immediately after injury and at time of exam
59
Most common causes of SBO?
How to confirm diagnosis?
How to treat?
```
Intestinal adhesions, 60-75%
Neoplasms, 13-20%
Herniation, 2-15%
Volvulus, <5%
Constipation, rare
```
Evaluate with CT abd/pelvis, rule out ischemia
Initial management:
- NGT decompression, IV fluid resuscitation
- Surgical consult
- Immediate surgery if unstable, closed-loop obstruction (volvulus), intestinal ischemia, or perf.
- most resolve with conservative management, surgery if not resolved within 3-5 days
60
When to treat primary hyperparathyroidism surgically?
PTH overproduction -> calcium loss
Surgery if
- serum calcium >1mg/dL above normal range
- skeletal problems (previous vertebral fracture or bone density >2.5 SD below peak mean at hip, lumbar spine, or distal radius)
- renal problems (eGFR <60, 24hr urine calcium >400mg/day, or nephrolithiasis/calcinosis on imaging),
- or age <50.
61
Auscultatory findings of:
Aortic regurgitation
Aortic stenosis
Mitral valve regurgitation
Acute pericarditis
Aortic regurgitation
- "blowing" decrescendo diastolic murmur along tract from aortic valve (upper right sternal border) to lower left sternal border (loudest)
- best heard sitting, leaning forward, holding breath in expiration
- S3 gallop may present in decompensation due to L ventricular dilation
Aortic stenosis
- mid to long crescendo-decrescendo systolic murmur
- loudest right upper sternal border
- often radiates to carotids
Mitral valve regurgitation
- harsh holosystolic murmur at lower left sternal border radiating to axilla
Acute pericarditis
- pericardial friction rub
62
Lyme disease
vs
Ehrlichiosis
Rocky Mountain Spotted Fever
Fever, chills, joint and muscle pains, headache, rash. Vermont / New England.
Headache and fever, no rash
63
Oral iron prep in non-dialysis-dependent CKD?
Iron for CKD on chronic hemodialysis?
Ferric citrate (Auryxia)
IV iron prep ie iron dextran work in both groups
64
Describe:
Benign Essential Tremor
Parkinsonian Tremor
Cerebellar Tremor
What to worry about in young person with tremor?
Postural symmetric tremor in hands and wrists, tx B-blocker
Resting tremor, tx DA agent
Postural intention tremor, MRI brain for eval
Young? Wilson's, check copper levels with ceruloplasmin and urinary copper excretion testing.
65
What do Medicare parts A, B, and D cover?
A - hospital based & hospice (no premium)
B - provider visits & outpatient services (premium)
D - drug coverage
66
Ottawa Knee Rule
Radiograph if any are present:
- age 55 or greater
- isolated tenderness of the patella
- tenderness of head of fibula
- inability to flex knee to 90 degrees
- inability to bear weight for four steps both immediately after the injury and at time of evaluation
67
Daily palpitations suspicious for cardiac etiology?
What if symptoms occur less frequently?
What if symptoms are exertional?
What if there is history of cardiac disease or worrisome signs/symptoms of dyspnea, crackles, lower extremity edema, or increased JVP?
24-hour Holter.
30-day event monitor.
Exercise stress test if symptoms are exertional.
TEE if worrisome signs/symptoms/history for structural heart disease.
68
How does adult ADHD present differently than children?
How is adult ADHD diagnosed? Treated? Risks?
Inattention persists to adulthood.
Hyperactivity often presents as talkativeness, irritability, and restlessness.
Screen for coexisting psychiatric disorders.
Symptoms onset before age 12
Tx behavioral strategies / stimulants (monitor BP/HR)
69
What is the most common chronic inflammatory condition in older adults?
What condition is associated with it, and why?
PMR = most common chronic inflammatory condition in older adults.
Giant cell arteritis (Temporal arteritis). Both are chronic inflammatory diseases.
70
Routine follow-up blood tests for colorectal cancer survivors?
carcinoembryonic antigen (CEA) levels only
71
What is the most effective measure to prevent diabetes in a pre-diabetic patient?
Long-term lifestyle intervention programs
ie National Diabetes Prevention Program
approx 30% reduction in progression to type II
Goals
- lose 7% total body wweight
- 150 min moderate-intensity exercise
Metformin also works, but not as effective (18%)
72
Most common food allergens?
Is skin testing a good way to find out?
Oral challenge?
IgE response most common from:
- cow's milk
- eggs
- soy
- fish
- shellfish
- tree nuts
- wheat
- peanuts
Skin testing has limited positive predictive value, but may help if patient has an immediate reaction.
Negative test with oral challenge has good negative predictive value, but should be performed in an allergist's office in case of anaphylaxis.
73
What is at increased risk for smoking in pregnancy?
What evidence-based benefit is there with tobacco cessation in pregnancy?
What risks are unchanged by tobacco cessation?
Smoking increases the risk for fetal growth restriction.
USPSTF: tobacco cessation increases infant birth weight, decreases risk for preterm delivery.
No evidence for decreased risk for C section, pre-E, or need for epidural.
74
Pulmonary aspergillosis
vs
Coccidioides immitis
Histoplasma
TB
Pneumocystis jiroveci
1. Ranges from invasive cavity-forming disease in the critically ill and profoundly immunosuppressed, to allergic bronchopulmonary disease.
Allergic bronchopulmonary aspergillosis
- low/ish O2 sat
- interstitial thickening / bronchiectasis on CXR
- eosinophilia
Get Aspergillus IgE titers, treat with antifungals
2. C immitis present in desert regions of US, causes muscle / joint pains.
3. Histoplasma endemic to Mississippi and Ohio River valleys of midwest and south US, also causes muscle / joint pains
4. TB less common in US
5. P jiroveci -> pneumonia, uncommon outside overt immunosuppression
75
de Quervain's tenosynovitis
- what is it?
- signs/symptoms?
- Dx?
inflammatory changes in the extensor pollicis brevis and abductor pollicis longis / tendon sheaths.
Pain at radial wrist / base of thumb. Finkelstein test (thumb in fist, pain with ulnar deviation)
Repetitive use injury.
76
Dx first carpometacarpal joint arthritis?
Pain with axial compression of carpometacarpal joint.
77
Sign/symptom of carpal tunnel syndrome?
Compression of median nerve at the wrist -> numbness, tingling, pain in hand, worse at night or after use of hand. 1st, 2nd, 3rd, and half of 4th fingers.
78
Deep tenderness at anatomic snuffbox?
Scaphoid fracture, usually history of falling on outstretched hand.
79
Ulnar nerve entrapment?
ulnar arm pain / numbness in 4th and 5th fingers.
80
13 y/o F, normal breast development but no menarche. What age to evaluate for primary amenorrhea?
Define delayed puberty.
15 y/o
- menarche usually 2.5 years after onset of breast development, avg age 12.5 (normal 9-15)
Delayed Puberty
- absence of breast development by age 13
81
What meds can help clear kidney stone?
What meds increase risk for kidney stones? Why?
What meds decrease risk? Why?
alpha blockers ie tamsulosin (Flomax)
Loop diuretics ie furosemide (Lasix) increase calcium excretion.
Calcium sparing diuretics (HCTZ) increase serum calcium and decrease excretion in to urine -> decreases risk but does not hasten stone passage
Lithium also causes hypercalcemia, btw
82
What antihypertensive regimen has been demonstrated to reduce both fatal and nonfatal cardiovascular events in patients with diabetes and HTN?
ACEi + CCB
Most diabetics should be on combination including CCB, ACEi or ARB, or TZD (SOR A)
83
How to treat frostbite?
Immersion foot (Trench foot)?
Decrease risk of amputation with grade 3, 4, or deep frostbite?
Rewarming, ibuprofen
Amitriptyline
tPA
84
Signs / diagnosis of Graves?
vs. central hypothyroid?
vs. Iodine deficiency?
Hyperthyroid
+ anti-thyrotropin-receptor Ab (thyroid-stimulating immunoglobulin) is virtually diagnostic.
Central: low TSH and low T3/4
Iodine def -> goiter and hypothyroid
85
Hallmark findings of adhesive capsulitis
Increasing shoulder pain difficult to localize + decreased ROM due to contraction of glenohumeral capsule
86
How to diagnose COPD?
FEV1/FVC consistent with obstruction not significantly reversible with bronchodilator.
Reversibility = improvement over 12%
87
Which labs highly suggest alcoholic liver disease?
Acute viral hepatitis?
Non-alcoholic fatty liver disease?
elevated transaminases with AST:ALT >2
AST and ALT levels >25x upper limit
elevated transaminases with AST:ALT <1
88
What med causes gynecomastia?
Spironolactone, is antiandrogenic, discontinuation resolves gynecomastia typically within 3 months
89
Conservative management of vertebral fracture? If that fails?
Scheduled acetaminophen and topical lidocaine patch.
If that fails, procedural intervention ie vertebroplasty or kyphoplasty
90
Who to screen for HIV?
Chlamydia and gonorrhea?
Syphilis?
everyone aged 13 - 64 at least once.
women under age 25 and those at risk ie new or multiple partners, or a partner with STI
MSM annually, but not WSW
91
Condition associated with non-atopic asthma?
nasal polyps
also aspergillosis, but IgE will be elevated
92
What is the glycemic control target for diabetes in pregnancy?
What is the best way to achieve target control?
Risks of uncontrolled diabetes?
Tight, A1c <6.5%
Insulin is best, requirements will increase through week 9, then decline through week 16, and rise again through week 37, then may again decline.
Exquisite sensitivity to insulin after placental delivery, no longer requiring insulin if not previously insulin dependent
Risks: pre-E, congenital defects, preterm delivery, macrosomia, stillbirth
93
How have these cancer rates/mortality changed over time?
```
Cervical
Breast
Hodgkin's Lymphoma
Lung
Prostate
```
Cervical - declined in both incidence (rate of diagnosis) and mortality (rate of deat)
Breast - increased incidence (more mammo screening), decreased mortality (increased testing, improved treatments?)
Hodgkin's - stable incidence, declining mortality (better treatment)
Lung - increased then decreased incidence and mortality since the 1970s, mirrored rise and fall of cigarette smoking
Prostate - steep rise in incidence with increased PSA testing in the 90s, but incidence and mortality are declining
94
Who should be screened for TB with the interferon-gamma release assay (IGRA)?
5 y/o or older who are likely infected with TB, low - intermediate risk of progression, and either history of bacille Calmette-Guerin (BCG) vaccination or unlikely to return for tuberculin skin test (TST) read. (SOR B)
95
Which symptoms of depression on PHQ2?
Depressed mood and anhedonia ->
Further eval for symptoms such as
- energy
- appetite change
- sleep disturbance
- psychomotor
- suicidality
96
Who to screen for celiac disease, and how?
first degree relatives of known celiac
Screen with serum total IgA and IgA tTG Ab, f/u with small bowel bx
97
who to screen for AAA?
male age >65 with any tobacco history
98
What meds cause hypercalcemia?
Lithium
| thiazide diuretics
99
Resistant / Secondary HTN definition?
What lab abnormality can be used to suggest renovascular hypertension?
Pheochromocytoma?
Cushing syndrome?
OSA?
Persistent uncontrolled HTN despite three adequate antihypertensives, including a diuretic.
Rise in Cr after adding ACEi -> MR angio for confirmation
Pheo -> plasma free metanephrines
Low-dose dexamethasone suppression test
Polysomnography
100
Review the GOLD classification
Group A
- short or long acting bronchodilator
Group B
- single LAMA or LABA
Group C
- LAMA
- or LAMA + ICS for persistent exacerbations
Group D
- LAMA
- or ICS + LABA
101
How to diagnose and treat BPPV?
Dix-Hallpike (B recommendation)
Canalith repositioning procedure (Epley, A recommendation)
102
Anal fissure treatment
fiber, sitz bath, topical nifedipine, diltiazem, or nitro
-> Botox injection
103
Cardinal symptoms of aortic stenosis?
Why is this relevant?
1. Angina
2. Dyspnea
3. Pre/Syncope
Natural history changes dramatically, risk for death increases from <1%/year to 2%/year, ie 75% of patients die within 3 years without valve replacement.
104
What is hidradenitis suppurativa?
Risk factors?
Associated with?
How to treat?
Acne inversa, chronic folliculitis of intertriginous areas -> scarring and affecting quality of life.
Age 18-39 y/o, more often F and AA
Risk = FH, smoking, obesity.
Associated with Crohn's, DM
Treat with topicals, ie clindamycin, to oral abx and biologics
105
Which thyroid nodules to biopsy?
Which to thyroid uptake scan?
Nodules 1cm or greater that or solid or have suspicious features -> FNA biopsy
If TSH is low, thyroid scan to look for toxic nodule
106
ACC/AHA recommended first line HTN agents?
TZDs
CCBs
ACEi or ARB
chlorthalidone > amlodipine and ACEi to prevent heart failure, but they increase uric acid and risk gout attacks
107
Who should be prescribed naloxone?
How does it work?
>50MME daily in case of overdose
Opioid antagonist, displaces opioids from receptors and reverses effects.
Other related meds:
Clonidine - treats opioid withdrawal
Methadone - full opioid agonist, treats opioid use disorder or chronic pain.
Naltrexone - opioid antagonist requiring administration from trained staff
108
Types of hallucinations:
Parkinson's (Lewy Body)
Schizophrenia
Sleep disorders
```
Parkinson's = visual only
Schizophrenia = visual + auditory
Sleep = hypnagogic and hypnopompic
```
109
How to treat fracture of scaphoid:
Displaced
Nondisplaced
Middle / Proximal
surgical fixation
short arm thumb spica cast 4-6 weeks
long arm thumb spica cast 6 weeks -> short arm
110
Head lice treatment?
Permethrin 1% shampoo (Nix)
111
USPSTF breast cancer screening recommendation?
Biennial screening mammo women aged 50-75 (B recommendation)
Can be considered in women 40-49 with discussion or risks vs benefits (C recommendation)
112
Benefits of hydroxyurea in sickle cell disease?
Who should get it?
fewer severe vaso-occlusive pain crises per year, decreased need for blood transfusions, also only med that prevents acute chest syndrome (NNT = 6 to prevent one episode ACS over 21 month period)
Traditionally recommended for patients with 3 or more severe pain crises per year or those with daily pain negatively affecting quality of life. Now recommended for all sickle cell anemia patients >9 months of age (SOR B)
113
When to use backup contraception?
Not needed if starting a copper IUD (ParaGard).
OCP requires backup for the first week if started today, until next menstrual cycle if it will be started then.
Hormonal implant (Nexplanon) requires backup if placed >5 days from start of LMP, and if levonorgestrel IUD (Mirena) is placed >7 days from start of last LMP
114
H. pylori, how to document clearance of infection?
Urea breath test 1 month after abx
115
SLE clinical and lab findings?
```
Lab findings to help confirm:
RA?
Autoimmune hepatitis?
Systemic sclerosis?
Seronegative spondyloarthropathies (psoriatic arthritis)?
```
symmetric polyarthritis, thrombocytopenia, +ANA, and pleural effusion
+ANA sensitive but not specific
low compliment levels help to confirm
RA = anticyclic citrullinated peptide antibodies
AH = Anti-smooth muscle antibodies (also causes elevated ANA)
SS = Anti-centromere antibodies
Seroneg Spondylo = HLA-B27
116
How does carpal tunnel syndrome produce symptoms?
What are the symptoms?
Distribution of symptoms?
Pressure on median nerve.
Paresthesia, numbness, pain -> motor weakness
Thumb, index and long finger, radial half of ring finger.
Motor: thumb adduction
117
What can cause morning stiffness of fingers?
Inflammatory arthritis
118
What can cause numbness to the dorsum of the hand?
de Quervain's tenosynovitis
119
Symptoms of cubital tunnel syndrome?
Numbness/tingling along ulnar border of forearm, hand, and ring + little finger.
120
What med can treat both opiate and alcohol abuse?
Naltrexone
121
What meds are for alcohol use disorder?
Acamprosate and disulfram.
122
Who gets antibiotic prophylaxis before dental work?
Any patient with history of valve repair or replacement with prosthetic material.
Valvular disease DOES NOT get prophylaxis
123
Risk factors for trigger finger?
Most cost-effective treatment?
Trauma, overuse, DM, carpal tunnel syndrome.
More common in women than men.
Treatment = CS injection
Mild cases -> NSAID, splint
124
What is procalcitonin useful for?
Biomarker for the presence of severe bacterial infections, ie pneumonia, sepsis.
Helps to assess need and duration of abx.
125
What does 17-hydroxyprogesterone level test for?
17-hydroxyprogesterone deficiency -> congenital adrenal hyperplasia, presents in childhood, part of newborn screening
Can be acquired in adulthood -> adrenal insufficiency (Addison's disease), however low 17-hydroxyprogesterone will not confirm.
126
What are the symptoms and causes of Addison's disease?
Adrenal insufficiency:
- fatigue
- lightheadedness
- weight loss
- hypotension
- vitiligo
- hyponatremia and hyperkalemia
Can be autoimmune, idiopathic, or secondary to cancer (lymphoma) or infections (TB)
127
What does erythema ab igne look like?
What are some predisposing conditions?
Reticular brown hyperpigmented skin changes at site of exposure to heat.
Exposure to excess heat and humidity.
128
What does Henoch-Schonlein purpura look like?
leukocytoclastic vasculitis -> palpable purpuric lesions on lower extremities and buttocks usually sparing the trunk, preceeded by streptococcal or viral URI
129
What does idiopathic guttate hypomelanosis look like?
2-5mm white spots with sharply demarcated borders on sun-exposed areas of arms / legs
130
What does tinea versicolor look like?
Fungal infection with white/pink/brown circular macules commonly on upper trunk.
131
What to do if hep C screen (anti-HCV Ab) is positive?
Qualitative HCV RNA test
Quantitative HCV RNA and genotype prior to treatment
Assess degree of fibrosis for urgency of treatment with percutaneous liver biopsy
132
Four principles of medical ethics:
1. Respect for Autonomy
- involve patients in health care decisions commensurate to capacity to understand and make decisions
2. Beneficence
3. Nonmaleficence
- do no harm
4. Justice
- "injustice" when a person who is entitled to a benefit is denied without good reason, or imposed some undue burden
133
Post bariatric surgery diet recommendations:
Avoid fluid 15 min before and after meals
Avoid carbonated beverages
Three small protein-rich meals and one/two snacks
Do not increase whole grains / fibrous veggies
134
What is the STOP-Bang questionnaire?
Tool to help ID patients with sleep apnea
```
Snoring
Tiredness
Observed apnea
high blood Pressure
BMI >35
age >50
neck circumference >40cm
gender = male
```
yes = 1, no = 0
135
How to formally diagnose conduct disorder?
3/12 symptoms within 12 months:
```
examples:
aggression toward people or animals
deceitfulness
theft
destruction of property
serious violation of rules
```
136
Which antibiotic can increase INR in a patient on chronic warfarin therapy? Decrease?
TMP/SMX (Bactrim) increases
| Rifampin decreases
137
Which rash is coral-red under Wood's lamp?
Erythrasma from Corynebacterium minutissimum -> erythromycin gel, topical clindamycin, Whitfield ointment, antibiotic soaps
138
Which mechanism is highly specific for achalasia?
incomplete LES relaxation
- loss of ganglion cells in esophageal wall 0> loss of normal esophageal peristalsis, failure of relaxation fo LES
139
What causes burning over the inferomedial aspect of the calcaneus?
medial calcaneal nerve entrapment
140
What causes pain with resisted flexion of the great toe?
flexor hallucis longus tenosynovitis
141
What causes paresthesia in the plantar aspect of the foot?
tarsal tunnel syndrome
142
What causes swelling and pain in the retrocalcaneal region?
retrocalcaneal bursitis
143
The risk for what is increases with anticholinergic and sedative use?
dementia, especially when combined with OTC meds like chlorpheniramine
144
At what age to screen for amblyopia?
3-5 y/o
one of the most common causes of vision abnormalities in children
early detection/treatment can help prevent vision loss
145
Symptoms of thyrotoxicosis?
Thyroid Storm:
- fever, CNS dysfunction, GI or liver dysfunction, cardiovascular (tachycardia or heart failure)
- Dx with Burch-Wartofsky Point Scale
- admit to ICU
146
What to use for first recurrence of C. diff previously treated with vanc?
Fidaxomicin (Dificid) 200mg bid x10 days
147
Conservative management for minimally displaced toe fractures?
When to use a pneumatic brace?
When to use a posterior splint then transition to a walking cast?
Buddy taping and rigid-sole shoe.
Pneumatic brace for nondisplaced tuberosity avulsion fractures.
Metatarsal shaft fractures.
148
Hypertension definition and goal for children?
BP >95%ile, goal <90%ile to age 13, then <130/80
149
Treatment of female pattern hair loss?
Topical minoxidil 5% foam indefinitely
150
What to add for patients with PAD to improve walking distance? What is the preferred antihypertensive, based on which trial?
Cilostazol (PDEi with antiplatelet and vasodilatory properties) increases maximal walking distance by 25%
ACEi based on the HOPE trial
151
Which viruses cause hand-foot-mouth disease? What is the treatment?
enterovirus 71 or coxsackie virus A16
symptomatic treatment of pain and oral hydration, no abx or labs
152
What are the stages of change model?
```
Precontemplation
Contemplation
Preparation
Action
Maintenance
```
153
What lab findings do we see with anemia of chronic disease (inflammation)?
primarily a disorder of iron distribution in response to systemic inflammation
biases hematopoiesis toward myeloid cell production rather than erythropoiesis, shortens erythrocyte lifespan
normocytic, normochromic
iron restriction without systemic iron deficiency
154
Which diets have the best overall evidence for primary prevention of CVD? Is it ok to skip breakfast?
DASH and Mediterranean
Skipping breakfast may increase risk of CVD
155
Which test to investigate ovarian incidentaloma?
Normal, no follow up for a simple cyst 5cm of less in premenopausal women or 3cm or less in postmenopausal women
Pelvic US for simple-appearing cysts incompletely characterized by initial imaging and are >5cm premenopausal or >3cm postmenopausal
156
Which problem causes anterior shoulder pain with resisted supination of the hand with elbow flexed to 90 degrees?
Active or passive cross adduction of the arm at the shoulder?
Shooting pain to the thumb with axial compression of the head with neck flexed to R shoulder?
Resisted extension of the elbow with shoulder in neutral position?
Yergason test: Bicipital tendinitis (pain with abduction and external rotation of arm, tenderness of bicipital groove)
AC arthritis
Spurling test: Cervical radiculopathy
Triceps
157
Clinical characteristics of episcleritis?
Conjunctivitis?
Iritis?
Keratitis?
Self-limited, idiopathic, mild discomfort and focal hyperemia.
Clear discharge in viral cases, mucopurulent in bacterial cases.
Significant pain, poorly reactive pupil, diminished vision, photophobia.
Decreased visual acuity, photophobia, severe pain, abnormal fluorescein stain showing corneal ulceration.
158
Developmental milestones for 1 month old:
- looks at faces
- responds to voices
- moves extremities equally
- lifts head
159
Developmental milestones for 2 month old:
- vocalizes
- smiles
- follows to midline
- responds to sounds
160
Developmental milestones for 4 month old:
- holds up head at 90 degrees (tummy time)
- laughs
- follows past midline
- no persistent fist clenching
161
Developmental milestones for 6 month old:
- No head lag
- bears weight on legs
- rolls over
- turns toward voice
- transfers hand to hand
162
Developmental milestones for 9 month old
- sits without support
- stands holding on
- cruises
- imitates speech / single syllables
- thumb and finger grasp
- dada, mama
- peek-a-boo
163
Developmental milestones for 1 year old
- stands independently
- walks with help
- babbles
- specific dada mama
- responds to "no"
- pincer grasp
- waves bye bye
- bangs 2 blocks together
164
Developmental milestones for 18 month old:
- walks backwards
- knows 1 body part
- drinks from cup
- imitates household chores
- speaks 3-6 words
scribbles
- stacks two blocks
- understands simple commands
165
Developmental milestones for 2 year old:
- kicks ball
- takes off clothes
- speaks 2 words together
- speaks 50 words
- understands 2 part commands
- uses own name
- stacks 4 blocks
- knows 6 body parts
166
Developmental milestones for 3 year old:
- washes hands
- draws vertical line
- understands "tired" and "hungry"
- names 4 pictures
- throws ball
- pedals tricycle
- asks "why?"
167
Developmental milestones for 4 year old:
- dresses self
- plays games
- speech understandable
- names 4 colors
- knows first and last name
- up and down stairs alternating feet
- balances on each foot for 2 seconds
- draws a circle
168
How to treat human bite?
Irrigation + amoxicillin/clavulanate (Augmentin), f/u 24 hrs
169
How to treat cough in children?
Nasal saline irrigation, menthol rub, and honey (12 months or older)
170
Who should be screened for vitamin D deficiency?
Only patient with decreased kidney function, skeletal disease, or hypercalcemia.
171
Describe
```
Pearly papules
Angiokeratomas
Genital warts
Lichen nitidus
Squamous cell carcinoma
```
- benign, normal variant dome-shaped, skin-colored 1-4mm papules in a ring-like distribution around the corona of glans
- red or blue papules well circumscribed 1-6mm
- soft, rased masses, pearly and smooth or rough, cauliflower-like appearance not confined to penile corona
- discrete, hypopigmented 1mm papules not confined to corona, also can occur on upper extremities / abdomen
- edophytic (ulcerated) or exophytic (thickened skin or wart-like growths -> large, irregularly shaped, fungating mass)
172
How to stratify for risk in the outpatient setting?
CRB-65 rule:
confusion
respiratory rate
blood pressure
65 years of age
1 point for each:
- new onset confusion
- RR >30/min
- BP <90 sys or <60 dia
- age 65 or older
```
0 = low risk, manage outpatient
1-2 = moderate risk -> hospitilization
3-4 = high risk -> ICU
```
