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Key Features Flashcards

1
Q

In a patient presenting with abdominal pain, name the 4 diseases you should know how to manage pharmaco and non-pharmaco.

A

GERD
- P: antacids, H2-r antagonists, PPIs (4-8wks then deprescribe), prokinetics (metoclopramide, domperidone)
- NP: diet (trigger foods), weight loss, elevate head of bed

PUD:
- P: PPIs (2-12wks then deprescribe), antacids, H2-r antagonists
- NP: diet, smoking cessation, stress management

H.poylori
- triple = amox + clarithro + PPI
- quadruple tx = clarithromycine (tetracyclines) + bismuth salicylates + metronidazole + PPI

Ulcerative Colitis:
- P: 5-ASA (mesalamine), corticosteroids (prednisone), immunomodulators, monoclonal biological therapis (adalimumab), JAK inhibitors
- NP: exercise, stress management, regular FUs, diet as tolerated (not recommended to stop smoking)

Crohn’s:
- P: idem + abx (metronidazole, cipro) , ASA less effective vs UC, surgery more common
- NP: idem + smoking cessation

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2
Q

What are 2 life-threatening situations you should always recognize in a patient with abdominal pain?

Explain management

A

Ruptured abdominal aortic aneurysm or ruptured ectopic pregnancy.

Management:
1) Stabilize with IVF fluid rescusitation, type and screen, crossmatch, consider blood transfusions. ABC GMOVIE/ACLS if unstable.

2) Once stabilized, refer urgently for definitive management (vascular sx, obstetrics).

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3
Q

What should you always consider in a chronic or recurrent abdo pain?

A

Always consider cancer in a patient at risk:

bleeding, B sx, family hx, dont hesitate to ask for endoscopy.

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4
Q

Name the extra-GI manifestations of IBD.

A
  • Joints: Arthritis, ankylosing spondylitis.
  • Eyes: Uveitis, episcleritis.
  • Skin: Erythema nodosum, pyoderma gangrenosum.
  • Liver: Primary sclerosing cholangitis (PSC).
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5
Q

Which rythm should you promptly defibrillate?

A

V-Fib and pulseless or symptomatic ventricular tachycardia.

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6
Q

What are the reversible causes of arrhythmias and how do you recognize/manage them?

A

1) Hyperkalemia:
- peaked T waves, wide QRS
- stabilize ABC GMOVIE/ACLS
- calcium gluconate for myocardium stabilisation
- insuline with dextrose IV
- sodium bicarb
- nebulized salbutamol (IV if fails)
- epinephrine (5-20mcg IV q2-5min) PRN if requires vasopressor (cant get BP up)
- IV fluids (LR, not NS to avoid hyperchloremic acidosis) vs furosemide depending on volemia

2) Cocaine:
- BP +++, HR ++, sweaty
- diazepam for agitation/htn
- phentolamine for htn (avoid BBs)
- sodium bicarb for QRS widening
- look for emergencies (arrhythmias, seizures, dissection, ACS, arterial thromboembolism)

3) Digoxin toxicity:
- can cause many arrhythmias but mostly think SLOW AFIB
- brady + GI sx
- Digibind (atropine if not available)
- activated charcoal if <2hrs
- treat end-organ dysfct, hyperK+

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7
Q

How do you ensure adequate ventilation in ACLS?

A

Bag valve mask

(Do not confuse with non-rebreather mask. BVM is for PPV whereas NRM is when patient breaths spont. but needs high flow. NRM prevents exhaled air to mix with the oxygen in reservoir. Think for COPD/Asthma exacerbations.)

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8
Q

During rescuscitation which elements to you assess to decided when you should stop and why?

A

Assess following circumstances indicating you should stop:
- Asystole
- Long code time
- Poor prognosis
- Living wills

To avoid inappropriate resuscitation.

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9
Q

What should you discuss with patients that have serious medical problems or end-stage disease?

A
  • Code status (do you want us to let natural death occur or would you prefer to be resuscitated?)
  • End of life decisions (resuscitation, feeding tubes, levels of treatment)

Readdress issues periodically

[would also add antibiotics, ICU, etc.]

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10
Q

What resources can you use in pediatric resuscitation?

A

Broselow tape and patient’s weight.

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11
Q

In which patients should you inquire about allergy? and what should be your next step?

A

All patients
Document it

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12
Q

When a patient says he has an, what should you inquire about? What should you avoid misdiagnosing?

A

Clarify the manifestations of allergic reactions to diagnose true allergy

Avoid misdiagnosing a viral rash (onset of rash in 1-3 after viral syndrome/fever) or medication intolerance (side effects).

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13
Q

Explain allergy teaching.

A
  • Allergy to food/rx/insect stings
  • teach patients AND family
  • explain sx of anaphylaxis
  • explain self-administration of EpiPen
  • Advise to return for immediate reassessment and treatment if anaphylaxis sx or EpiPen used
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14
Q

When do you prescribe an EpiPen?

A

Every patient who has history of or is at risk of anaphylaxis

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15
Q

On top of an epipen, what should patients with any known drug allergy or previous major allergies get?

A

A MedicAlert bracelet.

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16
Q

When a patient has an anaphylactic :
- how do you recognize
- how do you manage acutely
- how should you monitor post stabilisation

A

1) Recognize:
- if min to hours post allergen exposure with BP drop, skin-mucosal involvement, resp sx +/- GI sx
- Exam: tachycardia/pnea, wheezing/stridor, angioedma/urticaria

2) Treat immediately and aggressively:[
- ABC GMOVIE (intubation if airway at risk of obstruction, oxygen)
- epinephrine 0.5mg IM q5min x 3 (adults) or 0.01mg/kg IM max 0.3mg (children)
- can also consider BBs, glucagon
- aggressive IVF
- salbutamol
- adjunctive (antihistamine H1 = diphenhydramine, H2=ranitidine)]

3) Monitor for delayed hypersensitivity reaction [biphasic reaction ad 72hrs] with:
- observation [4-6hrs before dc] [serum tryptase can help early recognition]
and treat with steroids

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17
Q

What is your next step with patients with anaphylaxis of unclear etiology?

A

Refer to allergist for clarification of the cause.

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18
Q

Name two actions you must take in the particular cases of children with anaphylaction reaction to FOOD?

A

1) Px an EpiPen for the house, car, school, daycare

2) Advise family to educate child, teachers and caretakers about signs/sx anaphylaxis and about when and how to use for EpiPen.

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19
Q

What 2 diagnosis should you think of in patients with unexplained recurrent respiratory symptoms?

A

Include allergy-related causes in your differential diagnosis:

1) Sick building syndrome
- sx linked to being in certain buildings (poor ventilation, chemical contaminants, or biological like mold)

2) Seasonal allergy
- sx vary per season
- tree pollen in spring, grass pollen in summer, weed pollen in fall.
- tx antihistamines H1 (diphenhynamine/benadryl) , nasal corticosteroids (fluticasone/flonase), decongestants (pseudo ephedrines)
- NP: keep windows closed, air filters, stay indoors.

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20
Q

In patients with anemia, what risks would make you consider prompt transfusion or volume replacement necessary?

A

In CHF/angina:
- lower threshold to give blood transfusion (HB<80-100, compared Hb<70-80)
- because less ability to compensate with their limited oxygen supply.

Volume status:
- consider volume replacement IVF if hypovolemic/shock (low BP, tachy)

In CHF think of the risk of TACO (transfusion associated circulatory overload):
- manifests as acute resp distress + pulmonary edema on CXR
- prevent with slow transfusion rate + diuretics + HYPERtensive

TRALI (transfusion related acute lung injury):
- immune rx between blood’s Ab and patient’s WBC
- idem as TACO (ARS+PE) but HYPOtensive/fever
- tx = supportive care with O2 and IVF
- prevent with donnor screening (avoid multiparous women)

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21
Q

In anemia what should you always order with your CBC?

A

1) MCV or smear test to classify micro/normo/macrocytic:
- Micro = TAILS (see picture)
- Normo = hemolysis HEADS (see picture), blood loss, chronic disease (CKD, chronic inflam, neo)
- Macro = B12/B9 deficiency, pregnancy, ETOH use disorder/liver disease, hypoT4, myelodysplasic

**Smear in IDA: microcytosis, hypochromia, anisocytosis, thrombocytosis, poikilocytosis (oval/pencil shaped)

2) In ALL patients, order iron profile:
- ferritin (low in IDA)
- serum iron level (low in IDA)
- total iron binding capacity (high in IDA)
- transferrin saturation (low in IDA)

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22
Q

When should you consider and look for anemia?

A

1) Wether sympatomatic or not:
- at risk of blood loss (anticoagulation, elederly taking NSAIDs)
- pts with hemolysis (mechanical valves!!)

2) New/worsening symptoms in :
- CHF
- angina

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23
Q

What should you consider first in macrocytic anemia? And what symptoms should you look to make a particular diagnosis?

A

1) Consider the possibility of vitamine B12 deficiency

2) Look for neurological symptoms (see picture) of B12 deficiency to diagnose pernicious anemia.
- pernicious anemia is more likely to manifest with neurologic symptoms than other causes of B12 deficiency

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24
Q

When should you consider looking for anemia during well-baby care assessment?

A

1) High risk populations (living in poverty)
2) High-risk patients:
- pale
- low iron diet
- poor weight gain

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25
Q

What should you do with a discovery of a SLIGHTLY low hemoglobin?

A

Do not assume that this is normal, look for other cause:

  • Hemoglobinopathies
  • Menorrhagia
  • Occult bleeding
  • Previously undiagnosed chronic disease
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26
Q

Name 4 elements you consider when choosing an antibiotic.

A

Make rational choices:
- Use 1st line therapies first
- Adjust to local resistance patterns
- Adjust to patient’s medical and drug history
- patient’s context

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27
Q

In a patient with purported antibiotic allergy, what other causes should you rule out before accepting the diagnosis?

A

1) intolerance to side effects
2) non-allergic rash

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28
Q

When should you order cultures BEFORE initiating treatment?

A

Usually no cultures for :
Uncomplicated cellulitis
Uncomplicated pneumonia
Uncomplicated UTI

Order a culture for the following reasons:
1) Assessing community resistance patterns
2) For patients with systemic symptoms [sepsis?]
3) For immunocompromised patients [more likely to have atypical pathogens]

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29
Q

When should you start empiric antibiotics even if you haven’t confirmed the diagnosis yet?

A

In urgent situations:
- meningitis
- septic shock
- febrile neutropenia

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30
Q

Anxiety disorder vs distress

A

Distress = fear, nervousness, worry

[acute, only one sphere, usually linked to a trigger and resolves when trigger resolved]

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31
Q

Name 3 symptoms of panic that would raise a flag and make you look for serious medical causes

Name those 2 serious medical causes.

A

Shortness of breath
Palpitations
Hyperventilation

Always include in ddx, mostly with patients with anxiety the following:
- pulmonary embolism
- myocardial infarction

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32
Q

Name 4 elements to assess when working up a patient with symptoms of anxiety BEFORE making the anxiety disorder diagnosis.

A

1) Exclude serious medical pathologies
2) Identify abuse, substance use, other co-morbid psychiatric conditions
3) Assess the risk of suicide
4) Discuss functional impact with the patient

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33
Q

Name 6 elements to anxiety management

A
  • Self-management techniques
  • Regular office follow-up
  • Community resources
  • Structured therapies (Cognitive Behavioral Therapy, psychotherapy)
  • Judicious use of pharmacotherapy [SSRIs, SNRIs, benzo PRN]
  • Referral to other health professionals with ongoing shared care
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34
Q

What should you never do in your management of anxiety?

A

Solely use medication

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35
Q

When managing anxiety, what should you teach your patient about concerning their habitus?

A

Discuss use of alcohol and substances as harmful self-medication

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36
Q

When should you include asthma in the differential diagnosis?

A

Pts of ALL ages with acute/chronic, recurrent respiratory symptoms.

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37
Q

What is your ddx in a child with acute respiratory distress?

A

Asthma [diffuse expiratory wheesing + atopy hx]

Bronchiolitis [<2yo, viral sx, think respiratory syncytial virus]

Croup [barking cough, low grade fever, inspiratory stridor worse when crying, hoarse voice/cry]

Foreign body aspiration [stridor if upper airway, unilateral wheezes/decreased breath sound, no fever]

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38
Q

With an asthmatic patient how do you objectively determine the severity of their condition?

A
  • History : pattern of medication use [day sx, night sx, use of relievers, impact on function]
  • Physical examination [pram score in ER]
  • Spirometry
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39
Q

Name 3 steps of your management of acute exacerbation of asthma

A

1) Trest with short acting beta agonists repeatedly + early corticosteroids (do not undertreat)

2) r/o comorbid disease : complications, CHF, COPD

3) Determine hospit vs d/c per:
- risk of recurrence/complications [pram score]
- parent’s expectations/resources

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40
Q

How would you manage chronic asthma?

A

1) Stepwise approache: [ICS+SABA, ICS/LABA + SABA +/- leukotriene, ICS/LAMA/LABA + SABA, consider monoclonal biologicals (anti-IL4, anti-IL5, anti-IgE)]

2) Include in the plan:
- self-monitoring
- self-adjustment of medication
- when to consult back
[basically Asthma Attack Plan]

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41
Q

Name 2 non-pharmacological interventions when asthmatic patient presents with ongoing or recurrent symptoms.

A

1) Assess severity [day/night sx, reliever use, impact function] + compliance with medications [review inhaler method, adherence]

2) Lifestyle changes recommendations:
- avoiding irritants/triggers
[pets, smoking, building with mold, burning wood, carpets, consider HEPA filter]

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42
Q

Name 7 underlying causes of atrial fibrillation.

A
  • Ischemic hear disease
  • Acute myocardial infarction
  • Congestive heart failure
  • Cardiomyopathy
  • Pulmonary embolus
  • Hyperthyroidism
  • Alcohol
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43
Q

What are the 2 steps to do immediately when a patient presents with afib?

A

1) look for hemodynamic instability
2) Intervene rapidly to stabilize

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44
Q

Outside of rhythm/rate control, what other medication could you consider starting when do you consider it?

A

Anti-coagulation (OACs)

  • per patient’s stroke risk (CHADS-65)
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45
Q

How do you give bad news?
- Ensure of 2 things BEFORE giving bad news
- Give bad news respecting 3 rules
- What should you do before involving family?
- What do you do AFTER giving bad news?

A

BEFORE:
- Ensure appropriate setting
- Ensure patient’s confidentiality

Give the news:
- empathetic/compassionate manner
- allowing enough time
- providing translation, as necessary

Involve family only after obtaining patient’s consent

AFTER:
- arrange definitive follow-up opportunitis to assess impact and understanding

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46
Q

In behavioural problems you should thoroughly assess medical and mental health conditions before offering a diagnosis.

Which condition should you particularly rule out in adolescents and young adults exhibiting behavioural problem?

Name 3 sources of information should you use with your patient’s consent to assess their behavioural problem.

A

Schizophrenia (do not just dismiss as a “phase”, “hormones”, “just adolescence”)

Family, workplace, school
(dont’s forget to explore patient’s own perspective)

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47
Q

While assessing the behavioural problems, there are 3 things you should do for your patient’s emotional wellbeing. What are they?

A

1) Evaluate the impact of the behaviour
2) Explore underlying emotional distress
3) Destigmatize embarrassing behaviour

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48
Q

In terms of behavioural problems:

What should you assess in terms of safety?

When treating ADD/ADHD, what should you offer on top of amphetamines?

A

1) Assess and address immediate risk for the patients and others [suicidal/homicidal]

2) Social skills training, time manage [mental health OT, parents training, explore school/community resources]

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49
Q

What should you do with a challenging relationship with a patient with behavioural problems?

A

maintain a continuous, therapeutic, and non-judgmental relationship with the patient and family

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50
Q

Name 4 diagnostic tools for managing breast lump

A

1) Fine needle aspiration
2) Imaging (breast US vs mammo)
3) Core biopsy
4) Referral

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51
Q

After proper referral of a woman with malignant breast lump, you should still be involved in care with proper follow up.

Name 3 elements to monitor/manage during follow ups.

A

1) Monitor + manage immediate/long-term complications of breast cancer.

2) Monitor for metastatic disease

3) Manage : make sure to provide a link to patient to community resources for adequate psychosocial support.

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52
Q

Name 3 cancer prevention advice you can give in opportunistic appointments, even when it is not the primary reason for the encounter.

A

Stop smoking
Reduced unprotected sexual intercourse
Prevent HPV infection

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53
Q

Name the different evidencce-based screening to detect cancer at an early stage.

A

1) Pap tests [25-69yo, q2-3years for cervical cancer]

2) Mammography [50-74yo q2year]

3) PSA [do not screen per CTFPHC, screen >=50 +15yrs life expectancy per Ca Urological Association]

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54
Q

Name 2 personal and social consequences of cancer you should inquire about.

A

Family issues, loss of job

+ patient ability to cope with the consequences

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55
Q

Name 2 side effects/complications of treatment you should actively inquire in cancer patients, that they might not volunteer.

A

1) Diarrhea
2) Feet paresthesias

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56
Q

Name 2 symptoms in a patient with a distant cancer history that should make you think of recurrence or metastatic disease in your ddx?

A

1) Shortness of breath
2) Neurological symptoms

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57
Q

How should you discuss prognosis with your cancer patients? (3)

A
  • Be realistic
  • Be honest
  • Say when you don’t know.
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58
Q

Nam 3 elements that should be part of your history with a patient presenting with undefined chest pain.

A
  • Determine risk factors
  • Pleuritic vs sharp pain
  • Pressure
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59
Q

In a patient with chest pain name 4 life-threatening conditions that would require timely treatment before the diagnosis is confirmed/while doing appropriate work-up.

A

1) Pulmonary embolism [anticoagulation]

2) Cardiac tamponade [pericardiocentesis]

3) Aortic dissection [BP control, IVF +/- blood transfusion per BP, sx vasc urgent consult]

4) Pneumothorax [tension –> needle thoracocentesis mid-clavicular line 2nd intercoastal space, then chest tube PRN]

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60
Q

Name 6 non-cardiopulmonary causes of chest pain.

A

Herpes zoster infection
Hiatal Hernia
Reflux
Esophageal spasm
Infections
Peptic ulcer disease

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61
Q

When investigating for pulmonary embolism list 2 things that are essential to your management?

A

1) dont r/o just because of a test with low sensitivity and specificity [d-dimers]

2) beging treatment immediately

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62
Q

Name 3 possible diagnoses categories for a patient with chronic disease presenting with acute symptoms

A

1) Complications of the chronic disease (diabetic ketoacidosis)

2) Acute exacerbations of the disease (asthma exacerbation, acute arthritis)

3) A new, unrelated condition

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63
Q

Explain how to treat appropriately a chronic disease.

A

1) Titrate medication to patient’s pain.
2) Take into account other treatments and conditions (watch for interactions)
3) Consider non-pharmacologic therapic and adjuvant therapies.

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64
Q

In patients with chronic disease, name 4 things you should actively inquire about:

A
  • Psychological impact of diagnosis and treatment
  • Functional impairment
  • Underlying depression or orisk of suicide
  • Underlying substance use
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65
Q

What diagnosis should you suspect with the following presentation:

  • Prolonged or recurrent cough
  • Dyspnea
  • Decreased exercise tolerance
  • Smoking history
A

COPD

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66
Q

How do you confirm a diagnosis of COPD?

A

Pulmonary function tests (FEV1)

[ FEV1/FVC <0.7 without or with limited reversibility of % predicted FEV1 post-bronchodilator]

[Severity per % predicted FEV1 post-broncho]

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67
Q

What vaccines should you offer to your COPD patients?

A

Influenza vaccination
Pneumococcal vaccination

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68
Q

Name 2 other health professionals you can refer COPD patients, to enhance QUALITY OF LIFE.

A

1) Respiratory technician
2) Pulmonary rehabilitation personnel

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69
Q

What medication can you offer your stable COPD patients?

A

Anticholinergics/bronchodilators
Steroids trial

[Low risk:
=<1 moderate (required abx and/or oral cortico) AECOPD in the last year
AND did not require admission/ED visit

High risk:
>= 2 moderate AECOPD in the last year
OR =<1 severe AECOPD requiring requiring hospitalisation/ED visit.]

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70
Q

In patients presenting with COPD exacerbations, name 4 co-morbidities you need to rule-out.

A

Myocardial infarction
CHF
Systemic infections
Anemia

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71
Q

What should you discuss with end-stage COPD patients, especially while they are stable?

A

Discuss, DOCUMENT, and periodically re-evaluate wishes about aggressive treatment interventions. [intubation]

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72
Q

What is the ONE lifestyle modification you need to encourage with patients diagnosed with COPD?

A

Smoking cessation

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73
Q

With chronic pain patients, you should establish and periodically review the underlying etiology. Why?

What particular comorbidities/complications of chronic pain should you look for?

A

1) Identify previously undisclosed abuse
2) Assess evolution of the underlying cause

Mental illness and addictions.

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74
Q

You receive a new patient already diagnosed with chronic pain by their previous doctor.

What are the 3 elements you need to establish when meeting the patient?

A

1) Establish an effective relationship
2) Verify the diagnosis
3) Clarify goals of treatment + plans for management

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75
Q

In terms of documentation for chronic pain patients:

What should you comprehensively document?

To whom should you make the treatment plan readily accessible?

A

Document: assessment, plan, goals, prescription details

Make it accessible to:
- patient,
- team members,
- emergency department,
- on-call doctors,
- pharmacy

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76
Q

What tool should you use when prescribing medications with abuse potential to a patient with chronic pain?

A

Written treatment contract with realising consequences (limiting prescribed quantities/carries)

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77
Q

What should you do if a patient breaches the contract?

A

Manage your own emotions

Address possible impact on your staff/team

Amend contract carefully (do not put patient into immediate withdrawal)

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78
Q

Teach patients about what could reduce potential efficacy of contraception. Name 4 factors.

A

1) Delayed initiation of method [not started within day1-5 of menstrual cycle or missed dose >24hrs] ***

2) Illness [vomiting, diarrhea>24hrs] ***

3) Medications [antiretrovirals, anticonvulsants, rifampin] ***

4) Specific lubricants [recommend water-based lubricants since oil-based can degrades condom/diaphragm or reduce spermicide effectiveness]

[*** In those cases use back up contraception (condom) after missed doses, delayed initiation (7days for estrogen/2days for progestin only) and during illness/rx + 7 or 2 days after if estrogen-contraction vs progestin-only contraception.]

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78
Q

You should discuss contraception with all patients but name 4 populations you should take extra care in advising about adequate contraception when opportunities arise.

A

1) Adolescents
2) Young Men
3) Postpartum women
4) Perimenopausal women

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79
Q

Name 2 psychosocial barriers to contraceptive methods.

A

Cost
Cultural concerns

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80
Q

What could you recommend to manage side effects of depo-provera?

A

Discuss adding estrogens.

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81
Q

When side effects of contraception occur, how can you counsel your patient?

A

[That they usually recedes after a complete trial of contraception so therefore] RECOMMEND AN APPROPRIATE LENGTH OF TRIAL [which is 12 weeks (3 cycles).]

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82
Q

Name 2 methods of emergency contraception or post-coital contraception.

A

1) Emergency contraceptive pills: [plan B (levonorgestrel), ulipristal, yuzpa method]

2) IUD [copper is the most effective emergency contraception]

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83
Q

In a patient with ACUTE cough, name the 2 serious causes you need to rule out.

A

Pulmonary embolism.

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84
Q

Name 5 causes of persistent/recurrent cough in pediatric patients.

A

GERD
Asthma
Rhinitis
Foreign Body
Pertussis

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85
Q

In persistent cough, name 2 serious causes to rule-out and name 3 non-pulmonary causes to consider.

A

r/o PE, cancer

consider GERD, CHF, rhinitis

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86
Q

What medication should consider for persistent and when can you consider medication as a cause?

A

ACEi

ONLY after ruling out other causes

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87
Q

What are the 6 elements essential to patient counselling?

A

1) Clear tx goals
2) Adequate time
3) Recognize limit of your own skills
4) Recognize your biases/beliefs can interfere
5) Risks of offering advices vs providing options [better to provide options –> shared decision + empower pt]
6) Be attentive to quality of therapeutic relationship and alliance

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88
Q

When a smoker presents with persistent cough, you should make the proper diagnosis. Name it.

A

Chronic bronchitis (COPD)

DO NOT just dx smoker’s cough

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89
Q

What should you do when a patient requests a referral for counselling/psychotherapy?

A

1) Clarify concerns

2) Give realistic info:
- expectations
- timing
- frequency
- costs
- duration
- homework
- starting/ending relationship if ineffective

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90
Q

When a patient faces a crisis your should identify personal and community resources. Name one example of each.

A

Personal: family, internal strength, friens

Community: counsellor

DO NOT CROSS BOUNDARIES (lending money, apts outside regular hours)

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91
Q

With a patient in crisis you should inquire about unhealthy coping methods. Name 4 (7).

A

Drugs
ETOH
Eating
Gambling
Violence
Sloth
Promiscuity

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92
Q

How should you deal with unanticipated medical crisis (seizure, shoulder dystocia)? Name 4 steps.

A

1) Stay calm + methodical
2) Assess env for resources (people, material)
3) Ask help
4) Timely action in context of situation:
- Resusc in waiting room [BCLS, ACLS if defib, call 911]
- resusc in ED [ACLS, more comprehensive answers on management, like IVF/intubation]

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93
Q

In patients with croup, identify 4 elements that indicates need for respiratory assistance.

A
  • Assess ABCs [A–> obstruction/stridor, B–> tachypnea/retractions, C–> cyanosis]
  • Fatigue
  • Somnolence
  • Paradoxical breathing
  • In drawing
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94
Q

Before attributing stridor to croup what other 3 conditions should you rule out first?

A

Anaphylaxis [angioedema, skin, BP drop]
Foreign Object (airway or esophagus)
Epiglottitis [drooling++]

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95
Q

Name 3 sx or signs to help differentiate upper vs lower respiratory disease.

A

Stridor [upper –> FB, anaphylaxis, croup, epiglottitis]

Wheezing [lower –> asthma/bronchiolitis, unilat in FB]

Whoop [upper –> whooping cough = pertussis bordella]

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96
Q

A patient presents with a clear history and physical exam of moderate croup. What imaging would you order?

A

None.

No routine xray in mild-moderate croup that is clear through history and physical exam [horse voice, fever, barking cough but stable, no resp distress/stridor and able to tolerate po]

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97
Q

For mild to moderate cases of croup, you should prefer supportive care treatment as it has a better risk/benefits ratio. True or false?

A

FALSE.

Do not under treat mild to moderate cases of croup!

Start with dexamethasone and add nebulized epinephrine over 15min if moderate/severe.

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98
Q

How can you reassure parents if their child is diagnose of croup?

A

1) Do not minimize their concerns or how sx can impact parents
[croup can be distress but is a self-limiting disease with proper management]

2) Educate on fluctuating course of disease
[barking cough, stridor are often worse at night/agitation]

3) Provide a plan to help parents anticipate recurrence of sx.
[RTC drooling, difficulty breathing, fever, resp distress, unable to talk. Counsel on humidified air.]

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99
Q

When should you consider starting anticoagulant therapy if tests are delayed?

A

In patients with high probability of thrombotic disease (extensive leg clot, suspected pulmonary embolism)

[extensive = risk PE or proximal or multisegmental thrombosis]

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100
Q

Name 2 investigations for DVT.

Consider their limitations, [mostly in context of high pretest probability.]

A

Compression Ultrasound (CUS)
D-Dimer

[Don’t rule out DVT because of negative d-dimers if your clincal suspicion is high

Don’t rule out DVT because CUS is negative if your supsicion is high –> d-dimers]

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101
Q

What are the main points of appropriate anticoagulation in the context of DVT?

A

1) Start quickly (immediately if high suspicion)

2) Watch for drug interactions and adjust dose [mostly for warfarin]

3) Stop warfarin when appropriate [risk of bleeding, trauma. tx = 3 months if provoked, lifelong if unprovoked]

4) Provide patient teaching [recognize bleeding like purpura/GI bleed, effect of diet on warfarine, need to monitor warfarine often]

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102
Q

You diagnose and treated a DVT with appropriate anticoagulation.

Name another management element and what it prevents.

A

Compression stockings to prevent/treat post-phlebitis syndrome.

In appropriate patient (careful PAD).

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103
Q

You should always assess for signs and symptoms of dehydration in acutely ill patient, but name one condition partiularly.

A

Debilitating pneumonia

[unofficial term to describe very severe pneumonia affecting functionality during/after infection]

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104
Q

What indicators should you use to assess the degree of dehydration?

When are those indicators particularly important to evaluate hydration status?

A

Vital signs

[N if mild, slightly tachycardic+pneic/lowBP if mod, very tachy/low BP if severe]

Elderly, very young, pregnant women [PIE]

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105
Q

When should you use po vs IV rehydratation?

A

It tolerate po use PO [oral rehydration solutions]

If not tolerating [or severe dehydration] : IVF.

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106
Q

What direct measure can you use to direct dehydration management?

A

Lab values

[Na, K, serum bicarbonate –> low in dehydrat, renal function –> AKI/hypovolemia]

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107
Q

Should dehydrated pregnant women be treated aggressively or not?

A

Yes they should as there are additional risks of dehydration in pregnancy. [preterm labour, fetal distress/demise]

108
Q

List nine appropriate interventions that should be included in management plan for patients with dementia.

A

Deal with medication issues
Behavioural disturbance Management
Safety issues
Caregiver issues
Comprehensive care plans, Advanced care planning
Driving safety –> report to appropriate authorities if you believe they should not be driving.
Placement

109
Q

What should you consider with patients with early-onset dementia?

A

Genetic testing.

110
Q

In a patient with depression, how would you assess if hospitalisation or close follow-up is more appropriate?

A

Severity of sx
Psychotic features
Suicide risk

111
Q

Name 4 populations more at risk of depression

A

Certain socioeconomic groups
Pts with substance abuse
Postpartum women
Chronic pain

112
Q

Name 4 elements of managing depression.

A

Medications
Psychotherapy
Supported self-management
Community resources
Set goals (incl. return to work)
Referrals

113
Q

You should always rule out a serious organic pathology with a patients presenting with sx of depression, but which 2 populations in particular should you be careful about?

A

elderly
addictions

114
Q

After diagnosing depression, look for other comorbid conditions, name 3.

A

Anxiety
Bipolar disorder
Personality disorder

115
Q

What should you consider if failure with appropriate treatment?

A

Consider other dx (bipolar, schizoaffective, organic disease)

116
Q

What presentation in the very young or elderly should make you consider the diagnosis of depression?

A

Behavioural changes

117
Q

When monitoring for medication effectiveness, what should you assess other than adherence?

A

Use of other substances as self-medication (help/naturopathic remedies, ETOH, cannabis)

118
Q

Name risk facotrs for diabetes

A

Gestational diabetes
Obese,
Certain ethnic groups
Strong family history

119
Q

With in an acutely ill diabetic patient, what should you think of investigating while diagnosing the underlying cause?

A

Diabetic ketoacidosis
Hyperglycemia [hyperosmolar hyperglycemic state]

120
Q

What should you question with a patient presenting with acute diarrhea?

A

Infectious contacts
Travel
Recent antibiotic/medication use
Common eating place for multiple people

121
Q

What conditions should you assess for in chronic/recurrent diarrhea?

A

Inflammatory bowel disease
Malabsorption syndromes
Compromised immune system

122
Q

Name 4 elements you should screen your eldelry patients for in context of screening for disability risks.

A

Falls
Cognitive Impairment
Immobilization
Decreased vision

123
Q

Name 3 population at risk of disability (social, emotional or physical).

Name 4 primary prevention strategies for those population.

A

Elderly
those who do manual labour
those with mental illness

Exercises
Braces
Counselling
Work modification

124
Q

Name all the spheres of function you should assess in disabled patients

A

Emotional
Physical
Social (including finances, employment, family)

125
Q

What a multifaceted approach should include to minimize disability and prevent further deterioration?

A

Orthotics
Lifestyle modification [exercise, diet, drugs/etoh cessation]
Time off work
Community support

126
Q

What should you think of when giving a short-term disability leave to your patient?

A

Time off is only part of the plan. [dont forget multifaceted approach with lifestyle modification community support and orthotics]

127
Q

Name 4 serious diseases to r/o in patients complaining of dizziness.

A

Arrhythmia
Myocardial infarction
Stroke
Multiple sclerosis

128
Q

What serious conditions should you exclude in hypotensive dizzy patients?

A

MI
Abdominal aortic aneurysm
Sepsis
Gastrointestinal bleeding

129
Q

What elements of history or exam in a patient with dizziness would warrant further investigation?

A
  • Central vertigo
  • Trauma
  • Suspicion severe underlying cause (anticoagulation)
130
Q

What opportunities can you take advantages of when screening for domestic violence?

A

Periodic annual exam,
Visits for anxiety/depression,
ER visits

131
Q

In a patient in a suspected or confirmed situation of domestic violence, what are your next 2 steps?

A

1) Assess level of risk and safety of children

2) Advise about the escalating nature of domestic violence.

132
Q

What should you counsel your patient living with domestic violence?

A

1) Cycle of domestic violence
2) Feelings associated (helplessness, guilt)
3) Impact on children

133
Q

Name and differentiate common conditions of dyspepsia.

A

GERD: worse after meals, burning RSCP.

Gastritis: epigastric pain, bloating, worse with NSAIDs/ETOH/spicy foods

PUD: similar gastritis, relieved by eating (duodenal). Endoscopy required to differentiate gastritis from PUD.

Cancer: progressive dyspepsia, constitutional sx, anemia/GI bleed, dysphagia (esophageal cancer), early satiety/anorexia, smoking, FMHx

134
Q

Name 3 worrisome features of dyspepsia.

A

Gi bleed
Weight loss
Dysphagia

135
Q

Name non-UTI related etiologies of dysuria

A

Prostatitis
Vaginitis
STI
Chemical irritation

136
Q

Name 4 populations at a higher risk for complicated UTI

A

Pregnancy
Children
Diabetes
Urolithiasis

137
Q

Name 3 underlying causes of recurrent dysuria.

A

Post-coital urinary tract infection
Atrophic vaginitis
Urinary retention

138
Q

When shouldn’t you wait for cultures before treating for UTI?

A

When it’s an uncomplicated urinary tract infection.

139
Q

What can you use to diagnose uncomplicated UTI?

A

HX + dipstick urinalysis

140
Q

What are the conditions of making the diagnosis of otitis media?

A

1) Good visualization of the eardrum (wax must be removed)

2) Sufficient changes : bulging or distorted light reflex. (not all red eardrums are OM)

141
Q

Name 4 conditions where earache could be a REFERRED pain.

A

Tooth abscess
Trigeminal Neuralgia
TMJ Dysfunction
Pharyngitis

142
Q

Name 3 serious causes of earache you should always consider.

A

Tumors
Temporal arteritis
Mastoiditis

143
Q

What are the 3 rules if you decided AGAINST prescribing antibiotics for OM?

A

1) Proper patient selection
2) Patient education most otitis are viral
3) Ensure good follow (48hrs)

144
Q

What should be included in your plan for earache?

A

Oral analgesics

145
Q

What should you consider in a child with fever and red eardrum?

A

Assess for other conditions than OM.

Do not assume that the ear is red because of fever.

146
Q

What should you test in children with recurrent ear infections?

A

Test for hearing loss (hearing assessment)

147
Q

When should you think of asking about body image and self-harm behaviours?

A

Ongoing psychological distress or unexplained physical sx

148
Q

You should use clinical encounters with female patients (child/adolescent/young adult) to assess for the risk of eating disorder. True or False.

A

False, you should do it irrespective of gender.

149
Q

What elements of history-taking should you ask for in a patient whose concerns about eating behaviour have been identified? Name 3.

A
  • Food: Eating patterns, relationship with food, body image, distress
  • Psych: Underlying mental health, alcohol, and substance use problems, including previous psychological trauma
  • Rx: Use of prescribed and over-the-counter medications, tobacco, caffeine, laxatives, and supplements
150
Q

In terms of safety assessment for patient with disordered eating behaviour what should you assess/determine?

A

Assess physiological/metabolical complications [creat, na, k, ca, mg, po4, EKG, Hb]

Determine if need for hospit or immediate intervention.

151
Q

The patient’s acceptance of eating behaviour diagnosis should not impede you to discuss to impact/potential consequence of diagnosis. True or False?

A

True

152
Q

Management of disordered eating:

A

Team: engage parents, partners, caregivers , inter- and intra-professional referral when necessary
Treat: CBT first (do not automatically assume tertiary care is needed)
Time: FU and monitor for impact on mood/anxiety, cognition, function, relationship

153
Q

Name 3 clinical presentations that should make you think of a complication of an eating disorder.

A

1) Arrhythmias without cardiac disease
2) Electrolyte imbalance without drug use or renal impairment
3) Amenorrhea without pregnancy

154
Q

Name 3 ways to avoid polypharmacy in the elderly.

A
  • monitoring side effects.
  • periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate).
  • monitoring for interactions.
155
Q

What modifiable risk factors can you screen for in the elderly to promote safety and prolong independence?

A

Hearing impairment

Vision impairment

156
Q

Name 4 over the counter medication you should inquire in the elderly.

A

herbal medicines, cough drops, over-the-counter drugs, vitamins

157
Q

Name 2 reasons to assess function stats of your elderly patient.

A

Anticipate and discuss the eventual need for changes in the living environment

Ensure social support is adequate

158
Q

Name 3 diseases that could present in atypical manner and should not be excluded without a thorough assessment.

A

pneumonia, appendicitis, depression

159
Q

Name possible etiologies for active/recent nosebleed.

A

1) Recent trauma [include nose-picking trauma]
2) Recent upper respiratory infection
3) Medications [nasal corticosteroids or drugs like cocaine]

[other causes: cancer, angiodysplasia, nasal/septal malformation, polyp, dry environment, rhinitis, chemical irritants]

160
Q

In context of epistaxis, when should you obtain lab work?

A

Unstable patient
Suspicion of bleeding diathesis
Use of anticoagulation

161
Q

Explain nosebleed aftercare

A

1) teach how to avoid subsequent nose bleed [pinch nasal alae x 10 min, x 3 times if unresolved come to ER]

2) When to return [unresolved epistaxis x 30 min, blood in the mouth, signs of toxic shock if packing, removing packing x 48hrs]

3) Humidification [avoid dry environment/chemical irritants]

[Also avoid picking/blowing nose next 24-48hrs]

162
Q

When should you ask about family issues?

A
  • periodically
  • at important life-cycle points (e.g., when children move out, after the birth of a baby)
  • when faced with problems not resolving in spite of appropriate therapeutic interventions (e.g. medication compliance, fibromyalgia, hypertension)
163
Q

What diagnosis should you always include in your ddx of fatigue?

A

Depression

164
Q

Always ask about what symptoms when assessing fatigue?

A

Constitutional

165
Q

What should you exclude as a reason for fatigue while doing your assessment?

A

If fatigue could be linked to medication adverse effects.

166
Q

How should you investigate 0-3 months old presenting with fatigue?

A

Investigate thoroughly:
- Blood cultures
- Urine culture
- Lumbar puncture
- (+/-) Chest xray

167
Q

How should you choose an antibiotic in a febrile patient requiring them?

A

Per local resistance patterns.

Never prescribe antibiotics if viral infx

168
Q

Name 3 investigations that should be part of your work-up in fever of unknown origin.

A

Blood cultures
Echocardiography
Bone scans

169
Q

What 2 life-threatening infectious causes should you consider in febrile patients?

A

Endocarditis
[Roth spots in retina, Janeway lesions, Osler nodes]

Meningitis
[meningismums kernig’s/brudzinski’s, AMS, photo/phonobia, h/a]

170
Q

Name 3 non-infx causes of hyperthermia

A

1) Heat stroke
2) Drug reaction
3) Malignant neuroleptic syndrom [dont confuse with malignant hyperthermia who is due to analgesis]

170
Q

What conditions causing fever would you treat before confirming diagnosis?

A

Febrile neutropenia [pip tazo IV + antifungal (fluconazole) + antiviral]

Septic shock [pip tazo]

Meningitis [see picture]

Heat stroke

Drug reaction
- sympathicomimetics (cocaine, ampethamines, theophylline)
- anticholinergics (TCAs, anti-histamines, levodopa, atropine, muscle relaxants)
- serotonin syndrome (SSRIs, SNRIs, MAOIs, lithium, valpropate)
- activated charcoal, benzo, phytostigmine for tropine/antichol.
- for cocaine supportive + correct hyperNa

Malignant neuroleptic syndrome
[RIGIDY, BRADYreflexia, catatonia. Antipsychotics, mostly HALDOL, but also olanzapine/risperidone/quetiapine/clozapine. Levodopa, metoclopramide, prochlorperazine]

171
Q

Before dealing with fractures in a patient with multiple injuries, how should you stabilize the patient? Name 2.

A

1) Assess airway, breathing and circulation
2) Life-threatening injuries

172
Q

In which population is there no correlation between absence/presence of fever and seriousness of a pathology?

A

Elderly

Don’t dismiss something serious because there was no fever

173
Q

Name 4 types of fractures who are prone to present with normal xrays.

A

1) Scaphoid fractures in wrist injury
2) Growth plate fractures (Saltzer 1)
3) Elbow fractures
4) Stress fractures

174
Q

Before excluding a fracture in the elderly with a normal x-ray but has an acute change in mobility (cant walk), what should you do?

A

CT scan or bone scan of affected joint.

175
Q

How do you provide analgesia to patients with suspected fracture?

A

1) Timely (before xrays)
2) Adequate (narcotic)

176
Q

Name ottawa ankle rules

A

1) Pain at posterior edge or tip of lateral malleola
2) Pain at posterior edge or tip of medial malleola
3) Unable to bear weight or walk more than 4 steps before AND in emergency room.

Foot: 3+ pain at base 5th metatarse + pain at navicular bone

177
Q

Name ottawa knee rules

A

1) AGE > 55
2) Isolated pain at the patella
3) Pain at head of fibula
4) Unable to do 90 degrees knee flexion
5) Unable to bear weight or walk more than 4 steps before AND in emergency room

178
Q

Name c spine rules

A
179
Q

Before doing extensive investigations for GI bleed, rule out 3 non-medical reasons that could pass as GI bleeding.

A

Beets
Pepto-bismol
Iron

180
Q

Name patients at greater risk of GI bleed

A

Previous GI bleed
ICU admission
NSAIDs
ETOH

Give cytoprotection

181
Q

What serious causes in GI bleeding do you have to think of?

A

Malignancy
IBD
Ulcer
Varices

182
Q

What should you not attribute GI bleed to unless you ruled out everything else?

A

Hemorroids
Oral anticoagulation

183
Q

How should you counsel a patient grieving?

A

Recognize grief reactions may vary per individual’s context and life experiences (life cycle, developmental stages, cultural&familial context).

184
Q

What should you inquire in a grieving patients?

A

Depression, suicidal ideation, self-medication and alcohol/substance abuse,

185
Q

Name different triggers causing grief reaction that are not necessarily obvious.

A

Grief of a pet
Loss of a job
Reactions to anniversary

186
Q

Name 4 serious pathologies that could present as a headache and the appropriate work-up for each.

A

Meningitis (lumbar puncture)
Tumour (CT head with contrast)
Temporal arteritis (biopsy, ESR)
Subarachnoid bleed (CT head without contrast)

187
Q

Give examples of chronic headaches and what to avoid in their treatment.

A

Tension headache
Migraine
Cluster
Narcotic-induced
Medication-induced

Avoid narcotic or barbiturate dependence.

188
Q

Assess functional impairment of CHF through New York Heart Association.

A

1) NYHA
2) Activities of daily living

189
Q

Identify possible triggers and comorbid conditions when managing an exacerbation of heart failure.

A

Triggers:
- Infections
- Ischemia
- Arrhythmia
- Diet
- Adherence [medication]

Comorbid condition: CKD

190
Q

Differentiate systolic vs diastolic heart failure as their treatment will be different.

A

1) Systolic = HFrEF (<40%)
- BB (metoprolol, carvedilol)
- MRA (spironolactone)
- SGLT21 (jardiance)
- Diuretics (furosemide)
- ARNI (sacubitril-valsartan)

2) Diastolic = HFpEF (>=50%)
- Improve hospit: Mostly SGLT2i + MRA
- Bp control: BB/CCBs, ACEi/ARBs
- Sx control: Diuretics PRN

191
Q

What medications can you prescribe to reduce mortality in hear failure and improve sx?

A
  • Diuretics
  • BBs
  • ACEi
  • Digoxin
192
Q

Name 2 things you should do with a patient with heart failure and progressively deteriorating clinical course.

A

1) Give a realistic prognosis to pt + family

2) Introduce palliative care principles when appropriate

193
Q

Name 4 causes of hepatitis symptoms/abnormal liver tests

A

New drugs
ETOH
Blood/body fluid exposure
Viral Hepatitis

194
Q

Explain HBV serologies

A
  • HBeAg (Hepatitis B e-antigen): Indicates high viral replication and infectivity.
  • Anti-HBe: Suggests recovery from active infection or lower infectivity in chronic cases.
195
Q

Explain HAV serologies

A
196
Q

Explain HCV serologies

A
197
Q

To whom can you offer post exposure prophylaxis?

A

HAV and HBV

None available for HCV.

198
Q

What are the 2 complications of hepatitis you should screen for?

A

1) Cirrhosis
2) Hepatocellular cancer

HCV are at greater risk of cirrhosis/cancer.

199
Q

Name 2 modifiable causes of hyperlipidemia.

A

Alcohol abuse
Thyroid disease

200
Q

When someone is diagnose with hyperlipidemia, what do you need to include in their management?

A

Appropriate lifestyle and dietary advice.

Periodically assess compliance with this advice.

201
Q

What are treatment targets when initiating statins?

A
  • In intermediate and high risk, consider optimizing statin treatment if :
    • LDL > 2.0
    • ApoB > 0.8
    • non-HDL > 2.6
202
Q

When should suspect secondary hypertension?

A

1) Young pts requiring multiple medication
2) Abdominal bruit
3) Hypokalemia in the absence of diuretics

Note: cushing and pheochromocytoma could also give hypokalemia

203
Q

Suggest lifestyle modifications for hypertension.

A

Weight loss,
Exercise,
Limit alcohol consumption,
Dietary changes

[stop smoking]

204
Q

What should you consider when choosing the correct anti-hypertensive therapy for your patient?

A

Age
Concomitant disorders
Other CVD risks

205
Q

What are the limits of all interpreters?

A

different agendas,
lack of medical knowledge,
something to hide

206
Q

What should you screen or in immigrants/newly arrived?

A
  • Vaccination status (+update)
  • Depression (higher risk/frequently isolate)
  • Inquire about past history of abuse or torture.
  • Resources for support (community, family)
207
Q

In immigrants with new or ongoing medication condition, what infectious disease should you consider in you ddx that they may have acquired before immigrating?

A

Malaria
Tuberculosis
Parasitic disease
[ascaris, schistosomiasis, strongyloides]

208
Q

Name 4 types of different alternative medicine you could inquire about with your immigrant patients.

A

‘‘Natural’’ or herbal medicines
Spiritual healers,
Medications from different countries,
Moxibustion

209
Q

Should you vaccinate a child even if they have a runny nose?

A

Yes

210
Q

Identify patients who will specially benefit from vaccination.

A

1) Immunosuppressed
2) Sickle Cell Anemia
3) Special risk for pneumonia of HAV/HBV
4) Children
5) Elderly

211
Q

If a patient presents with a suspected disease, but had proper vaccination, should you still suspect the disease?

A

Yes

Think of: pertussis, rubella, disease aquired while travelling

212
Q

Name 4 diagnosis that could present differently in children.

A

UTI
Pneumonia
Appendicitis
Depression

213
Q

In children, and mostly adolescents, take opportunity to ask about 4 things.

A
  • unverbalized problems (e.g., school performance)
  • social well-being (e.g., relationships, home, friends)
  • modifiable risk factors (e.g., exercise, diet)
  • risk behaviours (e.g., use of bike helmets and seatbelts).
214
Q

What kind of risk behaviours could you ask about to promote harm reduction.

A

Drug use
Sex
Smoking
Driving

215
Q

Name 4 situations where you should reassure adolscents of confidentiality and encourage them to talk about it with their caregiver too.

A

Bullying, pregnancy, depression/suicide, drug abuse

216
Q

Describe a situation where delaying antibiotics would be best

A

delayed treatment in otitis media with comorbid illness in acute bronchitis

[if comorbidity such as acute bronchitis, might likely be viral. Consider per age/severity of sx|

217
Q

When should you treat infection empirically?

A

In life threatening sepsis without culture report or confirmed diagnosis

Candida vaginitis post-antibiotic use

218
Q

Name 4 ill-defined clinical situations when you should look for infection as a possible cause.

A

Confusion in the elderly,
failure to thrive,
Unexplained pain [necrotizing fasciitis, abdominal pain in children with pneumonia]

219
Q

What should you do if a patient returns after a diagnosis of simple infection and is deteriorating and not responding to treatment?

A

Look for a more complex infection, don’t assume the infx is just slow to resolve.

220
Q

When treating infections with antibiotics, what other therapies can you use?

A

Aggressive fluid resuscitation in septic shock
Incision&drainage in abscess
Pain relief

221
Q

Before reassurance, what 3 things should you question when a patient consults you about difficulties becoming pregnant?

A

1) How long they have been trying
2) Menstrual history
3) Coital frequency and timing

Refer >35yo 6 months after trying and >40yo immediately

222
Q

Name 3 conditions you should investigate when evaluating female patients with fertility concerns and menstrual abnormalities. Name the investigation for each.

A

1) PCOS (luteal phase progesterone)
2) Thyroid disease (TSH)
3) Hyperprolactinemia (prolactin)

223
Q

What other sleep-related disorders should you distinguish insomnia from through history?

A

Sleep apnea
Periodic limb movements
Restless legs syndrome
Sleep walking
Sleep talking

224
Q

Name 2 thing that should be part of your assessment of sleep complaints.

A

1) Collateral hx from bed partner or parents

2) Contribution of drugs (px, OTC, recreational), caffeine, alcohol

225
Q

Name elements to teach for better sleep hygiene

A

1) Limiting caffeine
2) Limiting naps
3) Limiting screen time
4) Follow regular sleep schedule
5) Limit bedroom activities to sleep and sex

226
Q

Name clinical scenarios where ischemic heart disease could present atypically

A

Elderly
Women
Patients with diabetes

[New CP, >20min, at rest]

227
Q

Name 3 modifiable risk factors of ischemic heart disease.

A

Obesity
Smoking
Diabetes control

228
Q

When a patient presents with sx suggestive of heart disease what investigations should you do? And what should you do if they come back negative?

A

1) EKG [if normal, then send for stress test if tolerated, if does not tolerate stress test than vasodilation echocardiography]

2) Exercise stress test [if EKG N + can tolerate exercise]

3) Normal enzymes results

[if EKG abnormal:
Exercise Vasodilatation echocardiography

if LBBB or paced ventricular rhythm:
vasodilatation MIBI or coronary angiography (if high risk pretest, high risk features on other tests, persistent sx, hx ACS, life-threatening arrhythmias)]

229
Q

In a patient with stable ischemic heart disease, how should you manage changes in sx?

A

1) Adjust self-initiated medication: nitroglycerin

2) Appropriate physician contact : office visits, ED visits, phone calls (per severity/nature of sx)

230
Q

Name 5 elements to verify in FU care for ischemic heart disease that would help identify suboptimal control or complications.

A

1) Symptom control
2) Medication adherence
3) Impact on daily life
4) Lifestyle modification
5) Clinical screening. (sx and signs of complications)

231
Q

Name 5 ddx of acute coronary syndrome

A

1) Cardiogenic shock
2) Arrhythmia
3) Pulmonary Edema
4) Acute myocardial infarction
5) Unstable angina

232
Q

Name 2 serious pathology to rule out with a patient that presents with joint pain?

A

1) Sarcoma (x-ray if bones, MRI, bone scan, PET scan)
2) Septic arthritis (aspirate of synovial fluid for analysis and culture, xray, blood tests)

233
Q

In monoarthropathy, what cause should you rule out?

A

Infectious cause (STI –> N gonorrhoea)

234
Q

Do not forget to include visceral sources of pain in the ddx of joint pain, give 3 examples.

A

1) Angina
2) Slipped capital [femoral] epiphysis [eg hip pain] presenting as knee pain
3) Neuropathic pain

235
Q

Name 3 systemic conditions that could explain a presentation of joint pain

A

1) Granulomatosis with polyangiitis

2) Lupus

3) Ulcerative Colitis

236
Q

What complication should you look for when assessing a rheumatologic condition?

A

iritis

237
Q

Name 3 types of lacerations that are more complicated and would require special skills for repair.

A

1) 2nd vs 3rd degree perineal tear
2) Lip or eyelid laceration involving margins
3) Arterial lacerations

238
Q

What complications should you look for when managing a laceration?

A

Flexor tendon lacerations
Open Fractures
Bites to hands or face
Neurovascular injury
Foreign bodies

239
Q

Name 3 wounds at high risk of infection. What should you avoid doing?

A

Puncture wounds
Some bites
Some contaminated wounds.

Do not close them.

240
Q

What should you always verify with a patient that presents with a laceration?

A

Tetanus immunization status

241
Q

With a patient presenting with school problems, name 3 elements that should be part of you history

A

Mental health problems
Learning disability
Hearing [and vision impairment]

242
Q

Name 6 behaviours that could improve health to discuss with your patient.

A

1) Diet
2) Exercise
3) Alcohol use
4) Safer sex
5) Injury prevention (seatbelts and helmets)

243
Q

What should you explore concerning a patient’s context before giving them lifestyle advices&

A

Poverty

244
Q

Even when unconscious you can examine a patients for signs that could explain the LOC. Give 3 examples.

A

Ketone smell
Liver flap
Focal neurological signs

245
Q

What reversible conditions should you assess and urgently treat in an unconscious patients?

A

1) Shock
2) Hypoxia
3) Hypoglycemia/hyperglycemia
4) Narcotic overdose

246
Q

Name 2 conditions you should try to rule out with a LOC without clear diagnosis.

A

Transient arrhythmia
Seizure

247
Q

In terms of safety, what should you do for a patient that had a LOC?

A

Advise authorities regarding driving status

248
Q

Name 4 serious causes to rule-out in undefined acute low-back pain.

A

Cauda equina syndrome
Pyelonephritis
Ruptured abdominal aortic aneurysm
Cancer

249
Q

What should you advise a patient in the acute phase of low back pain?

A

1) Sx can evolve + FU
2) Majority gets better (positive prognosis)

250
Q

Name patients at higher risk of meningitis.

A

Immuno-compromised individuals
Alcoholism
Recent neurox/abdo sx
Head injury
Neonates
Aboriginal groups
Students living in residence

251
Q

What should be done in a timely manner if meningitis is suspected?

A

Lumbar punction + start IV antibiotic therapy if suspecting bacterial meningitis (before investigations are complete)

252
Q

Name symptoms of menopause

A

Hot flashes
Changes in libido
Vaginal dryness
Incontinence
Psychological changes

253
Q

What tests do you need to confirm menopause?

A

None, it is a clinical diagnosis.,

254
Q

Name 2 atypical symptoms in menopause that should warrant further investigation before diagnosing menopause.

A

Weight loss
Blood in stools

255
Q

Name contra-indications to HRT in menopause.

A

1) Hx PE/DVT or stroke/TIA
2) Coronary artery disease
3) Active liver disease (cancer, cirrhosis)
4) Past or active breast cancer
5) Unexplained vaginal bleeding/AUB

256
Q

Name alternative therapies for HRT in menopause when HRT is contra-indicated.

A

1) For vasomotor sx: SSRIs, SNRIs, gabapentin
2) Vaginal sx: lubricants (replens)
3) Osteoporosis: calcium and vitamin D
4) Lifestyle : weight bearing exercises, avoid trigger for hot flashes (alcohol, spicy foods, caffeine or hot environment.)

257
Q

What could you counsel in terms of preventative health measures for women in perimenopause/menopause?

A

Mammography (50-74yo)
Osteoporosis screening (>=65yo)

258
Q

Name 4 conditions that increases the risk of cognitive/functional impairment.

A

Dementia
Stroke
Severe mental illness
Head injury

259
Q

Name subtle changes in function that would warrant assessment of cognitive and functional abilities and refer for further assessment.

A

Family concerns
Medication errors
Repetitive questions
Decline in personal hygiene

260
Q

When should you think about assessing a patient’s decision-making ability?

A

Surgery/no surgery
Resuscitation status

261
Q

What are the 4 steps to take if a patient refuses to participate in capacity assessment&

A

1) Document their refusal.
2) Continue safe care accepted by pt.
3) Revisit assessment when possible.
4) Pursue the need for a substitute decision maker when necessary

262
Q

What are the 5 steps if involuntary treatment is indicated?

A

1) Initiate certification process
2) Collaborate with colleagues/family
3) Document and communicate per legal requirements
4) Help pt+family understand why it is important.
5) Clarify your role in the care of pt.

263
Q

What should you do with a patient presenting with multiple medical concerns?

A

Determine common ground.

264
Q

With patients with multiple complaints, name 3 underlying cause you should assess.

A

1) Depression
2) Anxiety
3) Abuse (physical, rx, or drug abuse)

265
Q

Name 4 ways you can re-address and re-evaluate management of patients with multiple medical problems.

A

1) Simply management (pharmaco or other)
2) Limit polypharmacy
3) Minimize possible drug interactions.
4) Update therapeutic choices (per new guidelines or pt’s situation)

266
Q

How can you set limits with patients with multiple medical problems.

A

Limit the duration and frequency of visits.

267
Q
A

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