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LMCC II > LMCC II > Flashcards

LMCC II Flashcards

1
Q

Pregnancy Hx

A 
-Previous pregnancies:
GPA 
Mode of delivery
Sex
weight
length of labour
complications
-Hx present pregnancy
GA, EDC
Bleeding, N/V
-Past medical history
(DM, thyroid, htn, coagulopathy)
-Past gene hx
-Medications
Prescription and no
-Family hx
genetic disease, birth defects, multiple gestations
-Social
Smoking, ETOH, drugs
Domestic violence (50% begin in pregnancy)
Social support, employment/finances, hx abuse, is mother prepared to raise a child
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2
Q

Gestational Age

A

weeks from the first day of last menstrual period

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3
Q

Estimated date conception (date when will give birth)

A

LMP + 7 days - 3 months

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4
Q

MSIGECAPS

A
  • Mood (depressed)
  • sleep (increased, decreased, early morning awakening)
  • Interest
  • Guilt/ worthlessness
  • Energy
  • concentration/ difficulty making decisions
  • appetite/weight
  • psychomotor activity
  • suicidal ideation
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5
Q

MDD

A
  • Requires 5 of MSIGECAPS over 2 week period

- 1/5 must be loss of interest or depressed mood

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6
Q

Health tips while pregnant

A
  • abstinence from eton, smoking, drugs
  • use of meds only after consulting MD
  • healthy eating
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7
Q

Abortion age limits

A
  • Latest in Canada is at 20 weeks

- preferably earlier at 16 weeks

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8
Q

Abortion medical options

A

<12 weeks: 12 weeks: prostaglandins (intra or extra amniotic) OR misoprostol

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9
Q

Surgical abortions

A

16 weeks: dilatation and evacuation, early induction of labour

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10
Q

Complications of abortion

A
  • pain + discomfort commonly
  • hemorrhage
  • perforation of uterus
  • laceration of cervix
  • risk of infection/endometritis
  • retained products of conceptions
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11
Q

Risk factors for breast cancer

A 
Age over 50
Sex f over m
Estrogen exposure
Post menopausal
In utero exposure to des
Hrt
Early menarche
Nulliparity
Pregnancy at older age
Personal history of breast cancer
Family history
Genetics: brca
Lifestyle; etoh, smoking, 
Exposure to chest radiation
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12
Q

preconception counselling supplementation

A

Folic acid within 8-12 weeks of conception (0.4-1 mg daily, 5 mg if previous NTD, anti-epileptic meds, DM or BMI > 35) and continue for T1
Iron supplementation
Prenatal vitamins
Ensure adequate calcium/ Vit D

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13
Q

preconception counselling: risk modification

A
  • lifestyle: balanced nutrition and physical fitness

- infection screening: toxo, rubella, CMV, hepatitis B, VDRL, Pap smear, gon/chlam, HIV, TB, varicella

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14
Q

Investigation first pregnancy visit

A

CBC,blood group and type, Rh antibodies
Infectious screening
Urine C and S, screen proteinuria
Pelvic exam; Pap smear, chlam/gono, bacterial vaginosis

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15
Q

Air travel when pregnant

A

Allowed into second trimmest, discouraged after 36 weeks

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16
Q

Exercise during pregnancy absolute contraindications

A
  • ruptured membranes
  • pre-term labour
  • hypertensive disorders of pregnancy
  • incompetent cervix
  • IUGR
  • multiple gestation (>3)
  • placenta previa >28 weeks
  • persistent 2/3 trimester bleeding
  • uncontrolled T1DM, thyroid disease
  • other serious cardiovascular, respiratory or systemic disorder
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17
Q

Pre-natal visit: asess at every visit

A
  • fetal movements
  • uterine bleeding
  • leaking
  • cramping

P/E
-BP
-weight gain
-fundal height
Investigations
-urinanalysis for glucosuria, ketones, proteinuria
-fetal heart tones starting at 12 weeks using doppler

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18
Q

Symphysis pubic height

A

12 weeks: uteirne fundus at pubic symphysis
20 weeks: fundus at umbilicus, SFH should be within 2 cm of GA btw 20-36 weeks
37 weeks: fundus at sternum

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19
Q

Fetal movements

A

First noticed at 18-20 weeks

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20
Q

Prenatal screening: high risk population screening test

A
  • Thalassemia (mediterranean, south east asian)
  • Sickle cell (african, caribbean)
  • Cystic fibrosis
  • Tay Sachs
  • Fragile X syndrome
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21
Q

T2DM in pregnancy fact sheet

A
  • 2-4% pregnancies complicated by diabetes

- diagnosed 24-28 weeks

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22
Q

Treatment for pregnancy induced DM

A
  • lifestyle modifications
  • insulin (OHG controversial)
  • tight glycemic control: post-prandial blood glucose
  • 1 hr post prandial <5.3,
  • monitor 24 hour urine protein and creat clearance, retinal exam, hga1c
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23
Q

T2DM and labour

A
  • monitor glucose q1hr
  • pt should be on insulin and dextrose drip
  • 3.5-6.5
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24
Q

Risk factors for gestational diabetes

A
  • age >25
  • obesity
  • ethnicity (aboriginal, hispanic, asian, african)
  • Fhx of DM
  • previous hx GDM
  • previous child with birthweight > 4 kg
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25
Q

GDM and long term prognosis

A

-50% risk of developing DM in next 20 yrs

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26
Q

Complications of DM

A
  • Obstetric: htn/PET, polyhydramnios, pre-term, stillbirth
  • Fetal: macrosomia OR IUGR, RDS (hyperglycemia interferes with surfactant synthesis), congenital abnormalities
  • Mom: hypoglycemia, DKA
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27
Q

Defn pre-eclampsia, criteria for diagnosis

A
  • Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, and
  • Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein:creatinine ratio ≥0.3, or
  • Signs of end-organ dysfunction (platelet count 1.1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration)
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28
Q

PET investigations

A

MAHA picture (CBC, D-dimer, fibrinogen, blood smear, hap to, bill)
LFT
Creat
Thrombocytopenia < 100

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29
Q

Labour management PET

A

-hourly ins and outs
-urine dip q12
-hourly Neuro vitals
-continuous FHR monitoring
-anticonvulsant therapy: mag sulfate
-anti-hypertensive therapy:
hydralazine 5-10 mg IV bolus over 5 mins q 15-30 mins
labetolol 20-50 mg IV q 10 mins
2nd line: nifedipine 10-20 mg PO q 20-60 mins
ACEi contraindicated

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30
Q

Post partum management PET

A
  • early admission (36 weeks)
  • mag sulfate (continue mg sulfate in first 12-24 hours post partum: seizure risk increased)
  • IV hydralazine
  • 2nd line: labetolol
  • 3rd line: nifedipine
  • vitals q 1h
  • most return normotensive in 2 weeks
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31
Q

PET symptoms P/E

A
  • persistent headache
  • sudden weight gain over 1-2 days/edema
  • RUQ pain
  • Persistent and/or severe headache
  • Visual abnormalities (scotomata, photophobia, blurred vision, or temporary blindness)
  • Nausea, vomiting
  • Dyspnea
  • decreased urination
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32
Q

Eclampsia defn

A

PET + CNS involvement (decreased LOC and seizures)

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33
Q

HELLP syndrome

A

variant of PET

  • hemolysis
  • elevated LFT
  • low platelets
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34
Q

4 types of pregnancy-related hypertensive disorders

A
  • preeclampsia/eclampsia/hellp
  • Chronic/pre-existing htn
  • pre-eclampsia superimposed upon chronic/pre-existing htn
  • gestational hypertension
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35
Q

chronic pre-existing htn

A
  • > 140/90

- pre-dates pregnancy OR present before 20 weeks and persists longer than 12 weeks post partum

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36
Q

pre-eclampsia superimposed upon chronic preexisting htn

A
  • new onset proteinuria or other end organ dysfunction after 20 weeks
  • if had proteinuria + htn before pregnancy then defined by worsening or resistant htn in last half pregnancy or development os S and S of severe spectrum of disease
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37
Q

Gestational htn

A

-htn without proteinuria or signs of PET that develops > 20 weeks and should resolve within 12 weeks post partum

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38
Q

Prevalence PET

A

7.5% pregnancies worlwide
more prevalent in first pregnancies
Late onset (>34 weeks) more common than early onset <34 weeks
10-15% of direct maternal deaths are associated with PET/clampsia

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39
Q

PET increased maternal risk for

A
  • progession to eclampsia=> seizures
  • stroke (hemorrhagic)
  • pulmonary edema
  • AKI
  • hepatic failure or rupture
  • DIC (bleeding problems)
  • placental abruption
  • maternal and fetal death (rarely)
  • fetal risks: prematurity, IUGR, hypoxia
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40
Q

Risk factors for PET

A
  • hx PET
  • first pregnancy
  • fam hx PET
  • pre-existing medical conditions including DM, htn, antiphospholipid antibodies, high BMI, CKD
  • twin pregnancies
  • advanced maternal age
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41
Q

PET increases fetal risk of

A
  • malnutrition
  • hypoxia
  • IUGR
  • prematurity
  • death
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42
Q

treatment PET

A
  • delivery is curative!
  • no use of antihypertensives unless BP >150/100 or symptomatic
  • admit hospital 36 weeks for monitoring; may need to admit earlier with steroids and earlier delivery
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43
Q

Management of pregnancy induced hypertension (severe)

A
  • control BP with IV labetolol or hydrazine (target BP <160/110)
  • prevent seizures with mg so4
  • delivery by induction or C section when stable with prophylaxis 24 hours post partum
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44
Q

Eclampsia

A 
ABC + supplemental O2
Mg SO4 g over 20 mins then drip
-If seizures occur use IV diazepam
-control BP with labetolol/hydralazine
-initiate delivery when mother stable
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45
Q

PE on EKG

A

S1Q3T3
Deep S in lead I
Q wave lead III
T wave lead III

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46
Q

Hampton hump

A

Peripheral wedge shaped opacity

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47
Q

Westermark sign

A

Focus of oligemia; secondary to proximal pulmonary artery dilatation and peripheral vasoconstriction (hypoxic)

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48
Q

Life threatening causes of CP

A 
MI
Tamponade
Tension pneumothorax
Aortic dissection
PE
Esophageal rupture
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49
Q

Nasal prong L translated into FiO2

A 
2L=> 26%
3L=> 30%
4L=> 35%
6L=> 40%
40% considered maximum inspired oxygen obtainable without high flow mask such as ventimask
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50
Q 
DTaP-IPV
Diptheria
Tetanus
acellular Pertussis
Inactivated Polio vaccine
A

2, 4, 6 months
18 months
DTap at 14-16 yrs
Tetanus and diptheria q 10 yrs

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51
Q

MMR

A

12, 18 months

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52
Q

Pneumo-C

pneumococcal 7 valent conjugated vaccine

A

2, 4, 6, 15

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53
Q

Men-C

Meningococcal C conjugate vaccine

A

2, 4, 6, OR 12

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54
Q

Var

A

15 months

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55
Q

Hep B

A

0, 1, 6 months

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56
Q

Vaccines at 2, 4, 6

A

DTaP-IPV + 18 + teens + adult
Men-C (6 or 12)
Pneu-C + 15 months
HiB + 18

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57
Q

Hib

A

2, 4, 6, 18

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58
Q

Live vaccines

A

MMR
Varicella
**can give to pts with CD4 > 200

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59
Q

Contraindications to all vaccines

A

moderate to severe illness +/- fever (common URTI fine)

allergy to vaccine component (yeast or gelatin?)

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60
Q

MMR contraindications

A
  • allergy egg or neomycin
  • pregnancy
  • immunocompromised (except healthy HIV positive children)
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61
Q

Varicella contraindications

A
  • Pregnancy or planning to get pregnant within 3 months

- anaphylaxis

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62
Q

HPV

A

between age 9-26 at 0, 2, 6 months

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63
Q

Contraindications to pertussis component

A

Hx of progression neuro disorder or epilepsy

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64
Q

Somatoform disorder (diseases)

A 
Conversion 
Somatization
Pain disorder
Hypochondriasis
Body dysmorphic disorder
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65
Q

Malingering

A

Intentional production of false or grossly exaggerated physical or psych symptoms motivated by external reward (missing work)

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66
Q

Factitious disorder

A

intention production or feigning of physical or psych signs or symptoms to assume the sick role where external incentives are absent

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67
Q

Conversion disorder

A

symptoms affecting voluntary motor or sensory function that mimic neuro disorder
-symptoms preceded by stress or conflict
(blindness, inability to speak, numbness)

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68
Q

Somatization disorder

A

recurrent multiple clinically significant complaints which result in pt seeking txt or having impaired functioning

  • 4 pain sx to four different sites
  • 2 GI sx (not including pain)
  • 1 sexual
  • 1 pseudo-neural
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69
Q

Pain disorder

A

pain as primary symptom

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70
Q

Hypochondriasis

A
  • preoccupation with fear of having serious disease based on misinterpretation of bodily signs or symptoms
  • belief is not delusional
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71
Q

Body dysmorphic disorder

A

preoccupation with imagined defect in appearance or excess concern around slight anomaly; usually related to face

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72
Q

Treatment of somatoform disorders

A
  • brief frequent visits
  • focus psychological not physical symptoms
  • minimize medical investigations
  • minimize psychotropic drugs; anxiolytics in short term only, antidepressants for depressive symptoms
  • attend to transference and countertransference
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73
Q

Joints of ankle

A

Tibio-talar: dorsi and plantar flex
Subtalar: talar-calcenal joint
Transverse tarsal: forefoot

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74
Q

Talar drawer sign

A

laxity indicates anterior talo-fibular ligament rupture

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75
Q

talar tilt

A

transverse tarsal joint; laxity indicates tear in medial or lateral tendons (calcaneo-fibular or deltoid)

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76
Q

Treatment of sprains

A 
RICE:
Rest
Ice
Compression 
Elevation
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77
Q

Grading ankle sprain

A

1: stretched ligament fiber
2: partial tear with pain and swelling
3: complete ligament separation

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78
Q

CAGE questionnaire

A

Cut back
people Annoyed
Guilty
Eye-opener

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79
Q

HEEADSS

A 
Home
-where, with who, relations with family, recent moves, ever run away?
Education
-attending school? grades? failures? suspensions? future plans, goals
Eating
-habits, hx AN, obesity
Activities
-extracuricular, sports, work
-best friends
-social clubs
-car
-gangs
Drugs
-types/amount
-with friends or alone
Sexuality
-dating, types experiences
-contraception, pregnancies, STD
-sexual abuse
Suicide
-self harm thoughts
-prior attempts
-depression
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80
Q

Special test for appendicitis

A

Psoas sign
Obturator sign
Rosving’s

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81
Q

Obturator sign (appendicitis)

A

hips and knees flexed
hold ankle and knee
internal rotation
-to identify a pelvic appendix

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82
Q

Psoas sign

A

raise leg against resistance

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83
Q

Rosving’s sign

A

palpate LLQ which produces RLQ pain

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84
Q

Approach to neonatal jaundice

A

Conjugated vs Unconjugated
Hemolysis vs no hemolysis
If hemolysis; Coombs + or negative

Conjugated Hyperbilli is ALWAYS PATHOLOGICAL

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85
Q

Causes of conjugated hyperbilli

A

Hepatic;

  • infectious (TORCH)
  • metabolic (lipid storage, galactosemia, hypothyroid)
  • drugs
  • TPN

Post hepatic

  • biliary atresia
  • choledochal cysts
  • sepsis
  • UTI

Work-up
U/S +/- HIDA scan
ALWAYS PATHOLOGIC

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86
Q

Causes unconjugated hyperbilli

A

Hemolysis

Coombs +

  • ABO incompatibility
  • SLE
  • drug induced
  • idiopathic

Coombs-
RBC defects: G6PD, hemoglobinopathy, hereditary spherocytosis, HUS

No hemolysis

  • physiologic jaundice of newborn
  • breast milk jaundice
  • breast feeding jaundice
  • Gilbert/crigler-najjar
  • hypothyroid
  • pyloric stenosis
  • sepsis
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87
Q

Physiologic jaundice of newborn

A
  • occurs at day 2-3 NEVER ON DAY 1
  • resolves by 1 week (but could last a bit longer if premature)
  • diagnosis of exclusion
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88
Q

Breast milk jaundice

A
  • 5-7 days into breast feeding, peaks at 3 weeks
  • mild unconj hyperbilli
  • considered normal
  • substances in breast milk increase enterohepatic circulation
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89
Q

Breast feeding jaundice

A
  • failure to breast feed
  • caused by decreased intake with excessive weight and fluid loss
  • nutritional inadequacy causes increases EHC of bill
  • change to formula, frequent feeding
  • *take good breast feeding history
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90
Q

Txt of hyperbillirubinemia

A

If unconjugated

  • phototherapy
  • exchange RBC
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91
Q

W/U of hyperbilli

A
  • LFT
  • neonatal and maternal blood type
  • Coombs
  • Blood smear
  • CBC+ retics
  • septic w/u +/- CSF
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92
Q

Acute billirubin encephalopathy

A

acute rise in bill in CNS
lethargy, decreased feeding, hypotonic, high pitched cry

Kernicterus is the chronic sequelae of acute bill encephalopathy

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93
Q

Differential for microscopic hematuria in adults

A 
CA
Stones
Infection
GN
BPH
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94
Q

Psych history

A 
Past psychiatric hx
-suicide attempts
-hospitalizations
-pharmacology/ECT
Past medical/surgical hx (head trauma, seizures)
Family psychiatric hx
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95
Q

Mental status exam: ASEPTIC

A

A: Appearance
-dress, posture, stated age, psychomotor agitation/depressionm attentive, eye contact
S: Speech
-rate (pressured or slow), rhythm, volume, tone, articulation
E: Emotions
-Mood (how do you feel?)
-Affect (how do they seem; range of expression, flattened affect)
P: Perception
-illusions (misperception of real stimulus)
-hallucination: perception in absence of stimulus
-derealization, depersonalization
T: thought process and content
-coherent, tangential, loose association
-content: suicidality/homicidality, obsessions, delusions
I: insight and judgement
-Judgement: dr’s own of patient
C: Cognition
-MMSE, intellect

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96
Q

Bacterial vaginosis

A
  • grayish/white fishy discharge
  • clue cells
  • +whiff test (also sometimes positive in trichomonas)
  • NOT sexually transmitted
  • can cause PID
  • Treat with metronidazole or clinda (Amox in pregnancy)
  • High pH (>5)
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97
Q

Trichomonas

A

-motile trichomonads on microscopy
-STI
yellow/green frothy discharge
-Motile flagellated organisms on microscopy
-treat partner
-can cause PID
-treat with flagyl
->pH (>5)

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98
Q

Yeast infection

A
  • cottage cheese d/c
  • erythematous/pruritic
  • high pH R/O yeast infection
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99
Q

Chlamydia

A
  • Asymptomatic in 80% of women
  • Muco-purulent endocervical discharge/urinary sx/pelvic pain/post coital bleeding
  • Test with cervical culture/PCR/urine test
  • Reportable disease
  • Treat with doxy X 7 days OR azithro X 1 (safe in pregnancy)
  • In pregnancy=> re-test for cleared infection 3-4 weeks after txt
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100
Q

Gonorrhea

A
  • Can infect cervix, oropharynx (sore throat), anorectal area
  • Txt: ceftriaxone IM or cefixime OR cipro
  • if pregnant: use cephalosporins (avoid quinolones)
  • treat co-infection with chlam
  • Re-test in pregnancy
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101
Q

HSV of vulva

A

classically HSV-1 above belt
HSV-2 below belt
-presents 2-21 days following contact
-prodromal sx: burning, tingling, pruritus
-multiple painful shallow ulcerations with vesicles appear 7-10 days after initial infection
-lesions are infectious
-treat first episode of acyclovir 7-10 days, second episode for 3-5 days
-can use suppressive therapy if 6-8 recurrences/year
-C-section if active genital lesion
-suppression therapy for pregnant women with first episode or hx HSV from 36 weeks on

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102
Q

Grading muscle strength

A

0-no contraction
1-visible muscle twitch but no movement of joint
2-weak contraction insufficient to overcome gravity
3-weak contraction able to overcome gravity with no additional resistance
4-weak contraction able to overcome some resistance but not full resistance
5-normal able to overcome full resistance

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103
Q

Reflex grading

A 
0-no reflex
1-trace reflex
2-normal reflex
3-very brisk
4-clonus
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104
Q

Hoffman reflex

A

Upper motor Babinski

Flick index finger downwards and watch for reflex flexion of thumb

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105
Q

C4 dermatome

A

below mandible to clavicle (neck anterior and posterior)

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106
Q

C5 dermatome

A

Strip on medial arm not including hand

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107
Q

C6 dermatome

A

Strip on external arm (lateral to C5) including thumb

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108
Q

C7 dermatome

A

Strip on outer arm including index and middle finger

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109
Q

C8 dermatome

A

trip on lateral arm including elbow and ring and pinky fingers

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110
Q

muscles innervated T1

A

Hand intrinsics

Adduction of fingers
Adduction/abduction of thumb (involves T1 and C8)

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111
Q

Muscles innervated by C5

A

Deltoids
Biceps

Weakness

  • shoulder abduction
  • elbow flexion
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112
Q

Muscles innervated C6

A

Biceps
Wrist extensors

Weakness

  • flexion
  • wrist extension
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113
Q

Muscles innervated C7

A

Triceps
Wrist flexors
Finger extension

Weakness

  • triceps
  • wrist flexion
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114
Q

Muscles innervated C8

A

Finger intrinsics
Thumb ad/abduction (C8/T1)

Weakness hand grip
Thumb abd/adduction

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115
Q

Median nerve sensory innervation

A

Palmar aspect: thumb, indexm, middle and medial half of ring

Dorsal aspect: distal half of index, middle fingers and medial half of distal ring

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116
Q

Radial nerve sensory innervation

A

Dorsal aspect of hand including thumb and proximal 1/2 index and middle

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117
Q

Ulnar nerve sensory innervation

A

Palmar aspect: hypothenar eminence, pinky and distal half of ring finger
Dorsal aspect: proximal half/lateral half middle finger, wring finger and pinky

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118
Q

Motor innervation median nerve

A

thenar muscle

flex at metacarpophalangeal joints of index and middle finger

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119
Q

motor innervation of ulnar nerve

A

flexion/adduction wrist
flexion fingers
intrinsic muscles of fingers

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120
Q

Damaging ulnar nerve

A

commonly occurs with medial epicondyle fracture

Classic sign: can flex wrist but is accompanied by abduction, cannot abduct fingers, cannot grip pager

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121
Q

Tinel’s sign

A

tap on palmar surface of wrist + if elicits shooting parasthesias in median nerve distn

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122
Q

Phalen’s sign

A

maximally flex both wrists but pushing the dorsi of hands together for 30-60 sec+ if elicits median nerve distribution numbness/paresthesias

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123
Q

Exam for pt with new petecchiae

A 
Skin, nails for nutritional status
Stigmata liver disease
Liver/spleen size/tenderness
Lymphadenopathy
Lungs for effusions
Thyroid exam (high association with ITP)

NO RECTAL EXAM GIVEN RISK OF BLEEDING

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124
Q

Blood tests Thrombocytopenia

A 
R/O plt clumping
CBC, coags, LFT
Blood smear
Hemolytic w/u
R/O infection (HIV, Hep)
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125
Q

TXT of BPH

A

Proscar (finasteride) (5 alpha reductase blocker)
Flomax (alpha blocker)
Referral to urology for TURP

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126
Q

When should an LP be performed in the setting of a febrile seizure

A
  • if meningeal signs on exam
  • if vaccination status of strep pneumo of Hib uncertain
  • if on antibiotics since can mask signs and symptoms of meningitis
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127
Q

Defn Febrile seizure

A
  • age 6 months -18 months (typically btw 12-18)
  • convulsions associated with T >38
  • no CNS infection/inflammation, no metabolic cause
  • no hx of afebrile seizures
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128
Q

Simple febrile seizures

A
  • last less than 15 minutes
  • have no focal features
  • occur once in a 24-hour period.
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129
Q

Complex febrile seizures

A
  • last >30 mins
  • focal neuro symptoms
  • occur >1 in 24 hours
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130
Q

Prognosis febrile seizure

A
  • 2/3 never have another febrile seizures
  • 1/3 will have further febrile seizures
  • 3% will go on to have seizures without fever
  • 2% develop lifelong epilepsy
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131
Q

W/U febrile seizures

A
  • Chem 7/CBGM
  • CBC
  • Cultures
  • imaging with CT/EEG indicated only in specific situations
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132
Q

Txt febrile seizures

A
  • treat seizure lasting > 5 mins with lorazepam (0.05-0.1 mg/kg)
  • Tylenol
  • use of anti epileptics for complex seizures should be individualized
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133
Q

Dysphagia solids vs liquids

A

Solids indicate mechanical obstruction

Liquids indicate neuromuscular dysfunction (often occurs swallowing either liquids or solids)

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134
Q

Approach to esophageal dysphagia

A

Solids

  • mechanical obstruction
  • intermittent: esophageal ring
  • Progressive: if chronic heartburn indicates peptic sricture, if B sx malignant

Liquids/Solids

  • suggests motor dysfunction
  • Intermittent: DES
  • Progressive: scleroderma, achalasia
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135
Q

W/U esophageal dysphagia

A 
Barium swallow (diagnose stricture or achalasia)
Manometry if concern re achalasia
Endoscopy
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136
Q

Secondary causes of Htn

A 
Primary renal disease
Vascular
-Renovascular disease (RAS)
-Coarctation aorta
Endo
-Renin/Aldo
-Hypercortisolism
-Pheochromocytoma
-Hyperthyroidism
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137
Q

Test coarctation aorta

A

BP UE>LE

brachial-femoral delay

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138
Q

Diagnosis of HTN

A

1) First visit:
- take three readings, discard first and average 2/3
- If BP >140/90: schedule visit two within 1 month

2) 2nd Visit
- If BP >180/110 diagnose HTN
- If BP > 140/90 AND evidence of macro vascular target organ damage, DM, CKD diagnose HTN

Diagnose HTN if
-BP >160/100 averaged across first three visits
OR
-BP>140/90 averaged across five visits

ABPM

  • if mean awake SBP >135, DBP >85
  • mean 24 hours SBP >130/80

Home BP measurement
- >135/85 average

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139
Q

Htn urgency

A

BP >180/110 often with mild headache
No signs of acute end organ damage
-reduction of BP gradually over hours to days
-can use Acei, Lasix, clonidine acc uptodate
-rapid BP lowering not recommended in pts with known aortic or intracranial aneurysm (BP lowering over course of hours); arguably pts high risk for stroke or MI also

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140
Q

Diagnosis HTN on ABPM

A

awake BP >135/85
OR
mean 24 hour BP >130/80

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141
Q

Examples of target organ damage in HTN

A
  • CVA
  • Vascular dementia
  • htn retinopathy
  • LV dysfunction/hypertrophy
  • CAD/angina/CHF
  • renal disease/albuminuria
  • PAD/claudication
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142
Q

Hx of extra-intestinal manifestations of IBD

A
  • iritis/uveitis
  • arthritis
  • mouth ulcers
  • anal ulcers
  • skin lesions
  • kidney stones
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143
Q

HTN emergency

A 
BP >180/110 with evidence of end organ damage;
Cerebrovascular
-Htn encephalopathy, ICH/SAH
Cardiac
-acute aortic dissection/LV failure/MI/after CABG
Renal
-Acute GN, post kidney transplant, MAHA
Eclampsia
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144
Q

Arcus senilis

A

evidence of familial hypercholesterolemia in the eyes

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145
Q

Guidelines to ECHO pts with a symptomatic heart murmurs

A
  • diastolic murmur
  • continuous
  • late systolic murmur
  • murmurs associated with ejection clicks
  • murmurs that radiate to the neck or back
  • grade 3 or louder mid peaking systolic murmurs
  • Other indications (class IIa): associated with abnormal physical findings, associated with abnormal ECG or CXR
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146
Q

Qualifying heart murmurs

A

Intensity (grade I-VI)
Pitch (high or low, rumbling, blowing, musical)
Configuration (shape; cresc/decresc)
Location
Timing (midsystolic, holosystolic, early or late systolic, continuous)

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147
Q

Grading murmur

A

I: faint, heard with difficulty
II: faint
III: moderate
IV: associated with palpable thrill
V: loud but cannot be heard without stethoscope
VI: loud and can be heard without stethescope

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148
Q

Timing of systolic murmurs

A

Midsystolic: begins after S1 and ends before S2 (both S1S2 audible)
Holosystolic: obscures both S1S2
Early systolic: obscures S1, audible S2
Late systolic: starts after S1, obscures S2

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149
Q

Timing of diastolic murmurs

A 
Early diastolic: begins with A2/P2 and extends into diastole for variable duration
Mid diastolic: starts after S2 terminates before S1
Late diastolic (presystolic) starts well after S2 and extends to S1
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150
Q

Continuous murmur

A

begins in systole and continues through diastole without interruption, encompassing S2

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151
Q

Mid systolic murmurs, causes

A

Most often benign
-Flow murmurs: increased flow rate across normal semilunar valve (thyrotoxicosis, pregnancy, anemia) or aortic valve sclerosis
-ASD with left to right shunting
Benign if NOT associated with other cardiac signs

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152
Q

Diff’ll holosystolic murmur

A

MR
TR
VSD

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153
Q

MR

A 
Holosystolic 
best heard in left lateral decubitus with bell stethoscope 
Blowing/high pitch
Apex
Radiate to axilla/scapula
Increases with manoeuvres that increase LV volume ex leg raising or when after load increases (squatting, handgrip)
Decreases with valsalva or with standing
little respiratory variation
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154
Q

TR

A

Holosystolic
Diaphragm
Left lower sternal border
Murmur increases with increased venous return; inspiration, leg raising
Decreases with standing (decreasing venous return)
c-v wave JVP, pulsatile, increase with inspiration due to increased in venous return (Kussmaul)

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155
Q

VSD

A

holosystolic
loud, can be associated with thrill
LL sternal border

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156
Q

Late systolic murmur

A

MVP
TVP
Ischemic MR

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157
Q

MVP

A
  • late systolic
  • diaphragm
  • apex
  • -usually preceded by single or multiple clicks
  • murmur increases with increasing preload (squatting, elevation legs, hand grip)
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158
Q

early diastolic murmur

A

AR

Pulmonic regurgitation

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159
Q

Mid diastolic murmur

A

MS

TS

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160
Q

Inspiration as it portends to right and left sided venous return

A

Increases right sided and decrease left sided venous return
Increases right sided murmurs (TR, PR)
Decreases murmur of MVP

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161
Q

Abrupt standing as it portends to heart murmurs

A

Decreases venous return to heart
Decrease intensity AS
Decrease MR/TR
Increases HCM

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162
Q

Squatting as it portends to heart murmurs

A

Increase venous return (preload) with increased after load

  • Increases MR (after load)
  • Increases VSD
  • decreases HCM (after load increases effective orifice size of outflow tract)
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163
Q

HCM

A

crescendo-decrescendo murmur
apex and LLSB
radiate axilla and base, usually not to neck
Increases by increasing obstruction; squatting to standing, valsalva
Decreases by attenuation of obstruction; handgrip, passive elevation of legs

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164
Q

Valsalva

A

Decreases venous return to both right and left ventricle

  • Decreases AS, MR and TR
  • increases HCM (decrease LVOT with decrease venous return)
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165
Q

hand grip

A

increase SVR, increase LV volume
Most useful to differentiate AS v MR
AS: decrease
MR: increase

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166
Q

AS

A
  • systolic
  • RUSB
  • harsh
  • crescendo/decrescendo
  • radiates carotids/clavicle
  • musical radiation to apex (gallaverdin)
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167
Q

OPQRST hx

A 
Onset
Progression/provoking
Quality
Radiation
Severity
Timing
Relieving/exacerbating
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168
Q

Hx of spinal stenosis

A

Pain worse with activity, resolves with rest

Pain worse lying down

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169
Q

Lower extremity dermatomes

A 
L2-L1
Upper thigh 
Inner lower leg
L3: Inner thighs over medial knee
L4: Medial to calf
L5: dorsal foot (plantar foot)
S1: outer foot
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170
Q

Low back pain history

A
  • OPQRST
  • Neuro sx: weakness, parasthesias
  • bladder/bowel incontinence
  • B symptoms
  • Infectious sx
  • trauma
  • arthralgias, skin lesions
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171
Q

LBP exam

A

Observation:

  • Gait, toe walk (S1), heel walk (L4L5 weakness)
  • observe back for scoliosis, kyphosis

Palpate: spinuous processes, paraspinals, deeper into facet joint areas

  • PSIS: transition lumbar to S1 joint
  • sacroiliac joint

Passive ROM:

  • forward bending/extension
  • lateral flexion
  • straight leg raise

Motor

  • Hip flexors (flex/ex/int/ext rotation)
  • Knees
  • Ankle

Neuro

  • reflexes
  • sensory (test dermatomes)
  • Babinski
  • Ankle clonus
  • saddle anasthesia
  • rectal tone

Vascular
Peripheral pulses

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172
Q

Quads

A

L234

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173
Q

Hamstrings

A

L4L5S1S2

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174
Q

plantar flexion: Anterior tibili

A

L4L5

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175
Q

Toe extension

A

extensor hallucis longus

L5

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176
Q

Ankle eversion

A

S1

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177
Q

Indications for early imaging of LBP

A
  • neuro findings
  • constitutional symptoms
  • hx traumatic onset
  • Hx malignancy
  • Age >50
  • Osteoperosis (increased risk of compression fracture, W>M)
  • Infection risk: steroids, IVDU
178
Q

Diff’ll LBP

A
  • Degenerative (90%); mechanical, spinal stenosis, peripheral nerve compression (herniated disk)
  • Trauma
  • Inflammatory (ank spond)
  • Infectious (epidural abscess, osteo, discitis)
  • CA
  • Referred (AAA, pyelo, stones, pancreas)
179
Q

Red flags back pain

A 
BACKPAIN
Bowel/bladder dysfunction
Anasthesias (saddle)
Constitutional sx
K for chronic disease
Pain > 1 month and/or at night
AGE > 50
IVDU
Neuromotor deficits

Others;

  • unexplained decr weight
  • CORT use
  • Osteoperosis
  • Prior surgery
  • cumulative trauma
180
Q

Back surface anatomy

A

PSIS (posterior, superior iliac spine) corresponds L4L5

Of NOTE: cord ends at L1; below is caudal equine

181
Q

Benign causes LBP

A

Irritation paraspinal muscles, ligaments or vertebral body articulations
Characterized by no radiation, worse with activity, improving with rest

182
Q

Sciatica

A

Typically L5-S1
-burning/electric shock starts in LB travelling down buttocks and along back of legs, radiates below knees
Causes: irritation of nerve root as it exits spinal column due to compromised neuroforamina (bony osteophyte) OR herniated disc

183
Q

Spinal stenosis

A

Pain starts in LB and radiates down buttocks bilaterally continuing along backs of both legs
-sx usually worse with walking, relieved when patient bends forward (neurogenic claudication)
Pain quickly resolves when stops walking unlike PAD takes longer to resolve
-Normal peripheral pulses

184
Q

Walking on toes mediated by

A

S1 root

185
Q

L5 radiculopathy sx

A

Radiation from buttock to lateral calf
Numbness medial dorsum of foot (including web of great toe)
-weakness ankle dorsiflexion

186
Q

S1 radiculopathy Sx

A

Radiation posteriorly down leg to heel (lateral)
Lateral foot numbness
Ankle plantar flexion weakness
Decreased ankle jerk

187
Q

Ankylosing spondylitis history

A
  • AM Stiffness that improves during day
  • recurrent and nocturnal back pain
  • Associated: weight loss, fever, fatigue, anemia
  • ask joint pains (typically large joints)
  • uveitis (occurs in 1.3 of cases)
  • Family hx
188
Q

Pain on flexion of back indicates

A

discogenic pain

189
Q

Pain on extension of back indicates

A

facet joint pain

190
Q

When to suspect malingering with LBP

A

pt claims to be unable to bend from standing position but able to extend knees from sitting position

191
Q

kernig sign

A
  • pt supine, flex hip with knee flexed
  • while hip flexed try to extend knee
  • positive if resistance to knee extension or back pain
  • if bilaterally + more suggestive meningeal irritation
192
Q

Brudzinski sign

A

Pt supine
Lift head off examining table
Positive if pt flexes hip and/or knees

193
Q

Developmental milestones

2 months

A
  • smiles
  • coos
  • recognizes parents
  • track
  • when prone can extend arms forward +/- hold head up
194
Q

Developmental milestones

4 months

A
  • laughs
  • rolls over
  • responds to voice
  • reaches and grabs stuff and puts in mouth
195
Q

Developmental milestones

6 months

A
  • tripod sit
  • babbles
  • stranger anxiety/object permanence
  • ulnar grasp
196
Q

Developmental milestones

9 months

A
  • Pulls to stand, crawls
  • mama/dada
  • finger-thumb grasp
  • peek-a-boo
197
Q

Developmental milestones

12 months

A
  • walks
  • pincer grasp
  • 2 words
198
Q

Developmental milestones

15 months

A
  • walks without support
  • draws line
  • jargon
199
Q

Developmental milestones

-18 months

A
  • climbs steps
  • follows simple commands (sit down)
  • drinks from cup, eats with spoon
200
Q

Developmental milestones

24 months

A
  • 2 word sentences

- understands 2 step commands

201
Q

Developmental red flags

A 
Gross motor: not walking at 18 months
Fine motor: handedness at < 10 months
Speech < 3 words at 18 months
Social: not smiling at 3 months
Cognitive: no peak a boo at 9 months
202
Q

Birth weight

A

Loss up to 10% in first 7 days normal

Neonate should regain all of birth weight by day 10

203
Q

Hip flexors

A

L2 largely

204
Q

Amenorrhea, types

A

Primary

Secondary; most common

205
Q

Primary amenorrhea defn

A

Absence of menses AND secondary sexual characteristics by age 14
OR
absence of menses by age 16 if sex characteristics present

206
Q

Secondary amenorrhea definition

A

Absence of menses for >3 cycles (or >6 months) after menarche

  • more common
  • most common case: pregnancy
207
Q

Oligomenorrhea

A

vaginal bleeding is irregular and light at intervals > 35 days
PCOS common cause

208
Q

GTPAL

A 
gravita (#pregnancies)
Term
Pre-term
Abortions
Living
209
Q

Primary amenorrhea history

A
  • pregnancy history
  • developmental history (secondary sexual characteristics)
  • family hx: age menarche of mother, family history of delayed puberty or absent puberty
  • Cushingoid features (striae, puffiness), ACTH excess (change skin colour); may indicate possible 21 hydoxylase deficiency
210
Q

Secondary amenorrhea history

A

Gyne hx

  • GTPA, type abortions
  • menses history
  • family hx early menopause
  • sexual hx ?pregnancy
  • sx of menopause: hot flashes, night sweats, decreased libido, vaginal dryness) for premature ovarian failure
  • signs virilization (hair growth, voice changes)

Endo hx

  • signs of prolactinoma: galactorrhea, visual changes (loss peripheral vision), chronic headache
  • Thyroid dysfunction (T, mood, GI, skin/hair changes)
  • hypothalamic amenorrhea (exercise, weight loss, fasting, stress)

GI hx
-Celiacs (bloating, dyspepsia, diarrhea)-association btw celiacs and amenorrhea

211
Q

Differential for secondary amenorrhea

A

Gyne

  • PREGNANCY
  • Premature ovarian failure
  • PCOS
  • menopause
  • hypothalamic amenorrhea (stress, exercise)
  • uterine or vaginal defect (structural; atrophy…)

Endo

  • Thyroid
  • Prolactinoma
  • other tumours
212
Q

Oligomenorrhea, differential (similar to secondary amenorrhea)

A

Thyroid

PCOS

213
Q

PCOS diagnosis

A

2/3

  • oligmenorrhea/irregular menses for 6 months
  • clinical or lab evidence of hyperandrogenism
  • PCOS on U/S

W/U

  • LH>FSH
  • high DHEA, testosterone, androstenedione
  • decr sex hormone binding globulin

Txt

  • Lifestyle (lose weight)
  • OCP
  • metformin
  • clominphene citrate to induce ovulation
  • 5 alpha reductase to reduce hirsutism
214
Q

Exam amenorrhea

A

GA

  • BMI
  • Skin; darkening, cushingoid, easy bruising (CAH)
  • galactorrhea; if suspect do visual fields
  • parotid hyperplasia, eroded dental enamel (bulimia)
  • eval for tanner staging, turner sydrome (neck web, wide spaced nipples, low hairline)

Gyne

  • vaginal atrophy, dryness (estrogen deficiency)
  • careful genital exam (primary amenorrhea)
215
Q

W/U for amenorrhea-labs

A
  • hcg
  • FSH (central or gonadal)
  • LH
  • TSH
  • Total testosterone (secreted by gonads) if suspect virilization
  • 17 hydroxyprogesterone to R/O classic 21 hydroxylase deficiency
  • DHEA-to R/O adrenal source of androgens (androgens produced in adrenals)
216
Q

W/U amenorrhea-imagine

A

-transvaginal U/S to image ovaries (R/O PCOS, absence of usual uterine stripe in ashermans syndrome), normal anatomy (R/O structural esp in primary amenorrhea))

217
Q

Primary amenorrhea plan

A 
get FSH and refer!
50% from chromosomal abnormalities
25% functional hypothalamic ameorrhea vs tumor
20% anatomic abnormalities
PCOS (more rare)
**will need specialists
218
Q

Secondary amenorrhea trial of progesterone challenge (this may be in the real of specialists aka refer to gyny)

A
  • If get a withdrawal bleed considered positive test
  • indicates have enough estrogen on board to thicken endometrium
  • Diff’ll: anovulation
  • if no bleeding may be inadequatee estrogen or excessive androgens
  • Diff’ll: ovarian dysfunction, premature ovarian failure, PCOS, hypothalamic dysfunction
219
Q

If find premature ovarian failure

A

High FSH/LH, normal testosterone/androgens

  • <40
  • screen for autoimmune adrenal insufficiency (anti-adrenal antibody, anti-21 hydroxylase antibody), R/O hypothyroid
  • discuss need for HRT, adequate cal/vit D, protection bone density loss
  • continue HRT until natural age of menopause (50) to avoid risk of increased CV and CA complications
220
Q

Diagnostic criteria for premenstrual syndrome

A

-at least 1 of following during 5 days preceding menses during last 3 cycles
-affective sx: depression, angry burst, irritability, anxiety, confusion, social withdrawal
-physical: breast tenderness, abdo bloating, HA, peripheral edema
-sx must be relieved within 4 days of onset of menses
-not due to eton/drugs/rx
sx result in dysfunction
-must occur through 2 cycles of recording
R/O hypothyroidism, depression
Ask to keep symptom diary to better diagnose

221
Q

Abnormal LFTs overview

A 
Infectious hx (RF for hepatitis)
Habits (IVDU/etoh)
Drugs (including OTC, *tylenol)
Nash (HTN/DM)
Fam Hx (Wilson's, hemochromatosis, Gilbert, HBV vertical transmission)
Hemolysis
Gallstones (jaundice)
Developmental history
222
Q

Liver disease P/E

A

Hands: palmar erythema, deputryan’s contracture, Terry’s nailes
Face: temporal muscle wasting, telangiectasias, scleral icterus
Abdomen: caput medusae, liver space, liver edge, splenomegaly, ascites, hemorrhoids

223
Q

W/U liver dysfunction

A 
Hepatitis IGM (only in acute jaundice)
HBV (surface ag-active infection, surface ab-immunization or past exposure, core ab-previous exposure with cleared virus)
HCV ab
Iron profile + ferritin
Ceruloplasmin level
ANA, anti-sm antibodies
U/S R/O thrombosis and ischemia
Hemolysis work up
224
Q

Protective factors for breast cancer

A

Brast feeding

Physical activity

225
Q

Red flag for familial breast cancer

A

Breast cancer in young women
Multiple relatives with breast or ovarian
Bilateral breast cancers
Family hx of male cancers

226
Q

Breast exam

A 
Seated
-observe
-raise both arms upwards
-arms on waist with contraction of pecs
-cervical and axillary node exam
Supine
-use pads of first three fingers
-imagine wheel with spokes radiating from nipple
-feel all quadrants, including towards axilla
-feel around nipple
-squeeze nipple for discharge
227
Q

If breast mass found on exam

A

Women under 30: send for ultrasound
Women over 30: mammogram even if recently had a normal study
10-20% clinically palpable masses will be missed on mammography
If large palpable mass can refer directly to surgeon for biopsy

228
Q

Triad asthma

A

Asthma
Allergic rhinitis;
-
Atopic dermatitis; hx rash (infancy; red, scaly itchy crusted lesions on extensor surfaces, cheeks or scalp)
(child; rash less exudative, lichenification on lexical surfaces like antecubital and popliteal fossa)
(adults: lichenified skin and excoriated papules on hands and feet)

229
Q

Asthma triggers

A 
URTI
Pets
Smoker/smoke in house
cold weather?
(helps in assessment of whether asthma on differential)
230
Q

Asthma symptom control

A
  • how many days of week do they have sx/use PRN puffer (< 4 ok)
  • how many times/week SOB/cough (90% of best value and that varies by <15% adequate
231
Q

Diagnosis asthma on PFT

A

FEV1/FVC (actual ratio, not predicted)
<0.7 means obstruction
FEV1 percent predicted indicates severity of asthma

232
Q

Post-nasal drip (cause of childhood dry cough)

A

if allergic rhinitis prescribe intra-nasal topica glucocorticoid spray (budenoside, mometasone) especially if suspect asthma/known asthmatic as will worsen symptoms +/- referral to ENT

233
Q

Treatment of atopic dermatitis

A

steroid cream +/- referral to derm

234
Q

Treatment asthma general principles

A

Pyramid approach
Controllers and relievers
Action plan (written document telling them how often to monitor, how to maintain good control (avoidance triggers, med regularly) and when to seek help (If taking a lot of Ventolin)

235
Q

Pyramid treatment asthma

A

SABA PRN
ICS + SABA PRN
LABA + ICS + SABA PRN
then could add leukotriene receptor antagonist (montelukast) then eventually oral glucocorticoids

236
Q

Psychosis differential

A
  • Schizophreniform disorders
  • Affective disorders
  • Personality disorders
  • general medical condition (hypercalcemia, delirium, glucocorticoids)
  • intoxication
237
Q

Schizophreniform disorders

A
  • schizophrenia
  • schizoaffective disorder
  • delusional disorder
238
Q

Schizophrenia diagnostic criteria

A

> 2 of following OR only 1 if sx is a first rank (voices minting running commentary OR two voices talking to each other)

  • delusions
  • hallucinations
  • disorganized speech
  • negative symptoms

Marked decline in functioning
At least 1 month
Not schizoaffective OR affective disorder
Not general medical condition

239
Q

Schizoaffective disorder

A
  • Meets criteria for schizophrenia BUT concurrent affective episode (mania/MDE/mixed)
  • In same period del/hall last at least 2 weeks in absence of mood symptoms
  • affective sx present for substantial portion of whole episode
  • Not due to into or GMC
240
Q

Psych hx

A

Age
Occupation
Social structure/support
Living situation

PMHx

  • psych
  • past suicide attempts
  • hospitaliaiton
  • treatments
  • legal

Habits
-substance abuse

Fam Hx

  • psych problems or psychosis
  • family structure, relationships

Meds

241
Q

gynaecological causes of pelvic pain

A 
Acute
-Adnexal
Mittelschmerz, ruptured ovarian cyst, ruptured ectopic pregnancy, ovarian/tubal torsion
-Uterine
Fibroids
-Infectious
Acute PID, endometritis

Chronic

  • Chronic PID
  • Endometriosis
  • Adenomyosis
  • adhesions
  • ovarian cyst
  • Fibroids (rare)
242
Q

Vaginal bleeding (Gyne) history

A 
Age
Obs hx (GPA, pregnancy complications)
Menstrual history (date started menstruating, frequency, quality, pain, date last menstrual bleeding, episodes similar bleeding)
Gyne hx (pelvic infections)
OCP history (barrier method, IUD, tampon, foreign bodies)

PMHx

  • bleeding diathesis
  • endocrine dysfunction (PCOS, thyroid)
  • surgery (C/S)

Meds

  • hormones
  • anticoagulants
  • chemo
  • steroids

Fam Hx

  • bleeding disease
  • vaginal bleeding

Habits

  • sexually active, contraception, possibility of pregnancy
  • inter menstrual bleeding
  • Menorrheagia
  • Dyspareunia
  • infectious
243
Q

Quantifying vaginal bleeding

A 
# tamponds changed/24 hours
-if changing q3 hours=> heavy bleeding

Passing clots
-clot >1cm associated with 80 ml blood loss

80cc normal for period loss

244
Q

Reproductive age vaginal bleeding diff’ll

A
  • structural (uterine fibroids, endometrial polyps, adenomyosis)
  • Anovulation (PCOS, thyroid, hyperPRL)
  • Disorders of hemostasis
  • Neoplasia
  • Drugs (HRT, progestin only contraceptives)
  • Infection (endometritits, PID)
245
Q

Dysfunctional uterine bleeding

A

Irregular uterine bleeding that occurs in absence of recognizable pelvic pathology, general medical diseases or pregnancy
Disruption in normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
Bleeding may be heavy/light/prolonged/frequent/random
Diagnosis of exclusion
Common cause is anovulation (weight changes, eating disorder, stress

246
Q

Consequences of PID

A

Hydrosalpinx (damage fallopian tubes)
Chronic pelvic pain (30%)
infertility
ectopic pregnancy

247
Q

Causes of pelvic pain in pregnancy

A

Spontaneous abortion

Ruptured ectopic

248
Q

Risk factors for spontaneous abortion

A

Increasing maternal age
Previous spontaneous abortion (risk of miscarriage in future pregnancy 43% after >3 consecutive miscarriages)
Maternal smoking

249
Q

Classic presentation spontaneous abortion

A

Amenorrhea
Vaginal bleeding
Pelvic pain

250
Q

Pelvic exam for spontaneous abortion

A 
source of bleeding is uterus
Volume bleeding
Uterine size
products of conception at cervic/in vagina
open cervix
***R/O ectopic
251
Q

Ruptured ectopic classic symptoms

A

6-8 weeks after last normal menses

abdo pain/amenorrhea/vaginal bleeding

252
Q

normal pregnancy discomforts

A

Breast tenderness
frequent urination
nausea

253
Q

bhcg and pregnancy

A

doubles Q48 hours
Failure of bhcg to rise consistent with failed pregnancy (arrested pregnancy, tubal abortion, spontaneous resolving ectopic, complete or incomplete abortion)

254
Q

bhcg must be what to visualize gestational sac by TV U/S

A

1500-2000

Can be seen as early as GA 5 weeks

255
Q

Post menopausal bleeding

A

Endometrial atrophy
Endometrial carcinoma
Meds (HRT)

256
Q

When NOT to perform a vaginal exam

A

women in 3rd trimester of pregnancy: risk of causing separation of placental previa

257
Q

Rhogam; when to give, dose

A

Give to pts with any bleeding during pregnancy (miscarriage, ectopic, blunt abdo trauma, antepartum bleeding, fetal death) who are RH- to prevent RhD alloimmunization
-300 mcg

258
Q

W/U bleeding pregnant patient

A

CBC (hg, plt)
Blood type + X match, Rh status
R/O coagulopathy: Coags, D-Dimer, Fibrinogen, blood smear

259
Q

Fast facts uterine bleeding

A

Estrogen-progestin contraceptives: unschedulled bleeding
Progestin-only: irregular uterine beleding or amenorrhea
Copper IUD: increases menstrual flow
Ask about Trauma
Dysmenorrhea, dyspareunia, or infertility suggest endometriosis
Change in bowel/bladder dysfnx suggests mass effect
Galactorrhea, heat or cold intolerance, hirsutism or hot flashes suggests endocrinologic issue
Recent illness, stress, excessive exercise or possible eating disorder suggests hypothalamic dysfunction
Endometrial polyps, endometritis or PID may present with heavy or prolong menses but intermenstrual bleeding most common

260
Q

Risk factors for endometrial cancer

A 
Increasing age
Tamoxifen therapy
Early menarche
Late menopause
Nulliparity
PCOS
Obesity
DM
Estrogen secreting tumor
Family history
261
Q

Irregular bleeding suggests

A

ovulatory dysfunction
Often extremes of reproductive age
PCOS
Endocrine disorder (thyroid, hyper prolactinoma)

262
Q

Intermenstrual bleeding

A

Endometrial polyps
Contraception
Endometrial hyperplasia/CA
Endometritis or PID

263
Q

Heavy menstrual bleeding

A

Uterine leiomyas
Adenomyosis
Related to CSection
Bleeding disorder

264
Q

VBAC counselling on risks

A
  • Avoid induction of labour
  • In-hospital birth so uterine rupture can be managed expectantly and quickly
  • having more than 1 C/S increases risk
  • having one VBAC increases chances of safe delivery
265
Q

Risks of VBAC

A

-uterine rupture (0.5-1%)
-risks of uterine rupture increases with: classical incision,
2+ C/S, single layer closure,
induction of labor,
use PG,
short inter pregnancy interval,
infx at prior C/S

266
Q

Tox history

A

How much
***WHEN
WHAT
Suicidal intention (will need psych consult after)

267
Q

Universal toxidrome antidote

A 
TONG
Thiamine
Oxygen
Naloxone
Glucose
268
Q

Things to not forget in overdose pts

A 
R/O hypoxia
R/O hypoglycemia
Consider Cspine trauma
Consider meningitis
R/O brain bleed (pupils, DTR)
269
Q

Anticholinergic toxidrome

A 
Hot at a hare
Blind as a bat
Dry as a bone
Red as a beet
Mad as a hatter
Hyperthermic
Dilated pupils
No sweat
Flushing
Confusion
Urinary retention
Ileus
tachycardia
270
Q

Anticholinergic OD substances

A

TCA
Antipsychotics
Antiparkinsonian

271
Q

Cholinergic toxidrome

A 
Lacrimation
Salivation
Sweating
Urination
Diarrhea
Bradycardia
272
Q

Cholinergic OD substances

A

organophosphate insecticides

Sarin nerve gas

273
Q

Serotonin syndrome signs and symptoms

cognitive, neuromuscular, autonomic

A

Cognitive:

  • confusion
  • agitation
  • reduced LOC
  • seizures

Neuromuscular

  • myoclonus/clonus
  • hyperreflexia
  • tremors
  • muscle rigidity

Autonomic

  • Hyperthermia
  • htn
  • tachycardia
  • diaphoresis
  • shivering
274
Q

neuroleptic malignant syndrome signs and symptoms

A

Cognitive
-AMS; delirium progressing to lethargy, stupor, coma

Neuromuscular

  • tremor
  • rigidity
  • shuffling gait

Autonomic

  • labile BP
  • hyperthermia
  • tachycardia
275
Q

Malignant hyperthermia

A

appears after general anasthesia with inhaled anesthetic OR Succinylcholine

276
Q

Serotonin syndrome drug causes

A

SSRI
TCA
MAOIs

277
Q

NMS causes

A

Antipsychotics (typical and atypical)

Withdrawal from parkinsonian meds (dopamine agonists; withdrawal results in acute depletion of dopamine)

278
Q

Blood tests in NMS

A

Muscle damage and necrosis

  • CK
  • LDH
  • AST
  • ALT

Cell necrosis

  • hyperkalemia
  • hyperphosphatemia
  • hyperuricemia
  • hypocalcemia
  • myoglobulinuria can lead to renal failure
279
Q

Txt NMS

A 
supportive
cooling blankets
Antipyretics
Aggressive fluid resuscitation
Alkalinization of urine can help ARF and enhance excretion myoglobulinuria
280
Q

Tylenol toxicity

A

clinically silent within first 24 hours then evidence of hepatic toxicity

281
Q

ASA toxicity

A 
Hyperventilation (deep, rapid)
Hyperthermia
Tinnitis
AMS
ABG; metabolic acidosis with respiratory alkalosisexamp
282
Q

Acute toxidrome labs

A 
pregnanc test 
EKG
Chem 7
ABG + Lactate
Tox screen
serum osmolality
CK
Ketone
CT head
283
Q

Management Anticholinergic toxidrome

A 
Cardiac monitor (arrhythmias!)
Activated charcoal 
Call poison control
Benzos to control agitation
If asymptomatic monitor for at least 6 hours
284
Q

Cholinergic poisoning management

A

Intubate pt early (death by resp failure if you don’t)
If skink ontact, remove clothes and irrigate
DO NOT GIVE CHARCOAL
Benzos
Poison control
Atropine 2 mg IV double dose q5 mins until resp status improves

285
Q

Tylenol toxicity treatment

A

Normogram (*time of ingestion crucial)
activated charcoal if within 4 hours
NAC
Prophylax with anti-nausea meds

286
Q

ASA toxicity treatment

A

do not intubate unless hypo ventilate (hyperventilation is protective; apneic periods increases ASA toxicity)
IVF
Bicarb
Glucose (ASA selectively decreases cerebral glucose concentration, so give it even if glucose is normal)

287
Q

Acute dystonic reaction Txt

A

Benzaprine 2 mg PO/IV daily

288
Q

Contraindications for fibrinolysis

A
  • suspected aortic dissection
  • Stroke >3 hours or < 3 months ago
  • Hx ICH/mass
  • Hypertensive emergency
  • Surgery within 2-4 weeks
  • Unstable (shock, pulmonary edema, required CPR)
289
Q

ACS initial management

A 
ABC
IV access
Cardiac monitor
VS
CBGM
EKG
MONA (ASA 325 mg chewed stat unless allergy)
R/O phosphodiesterase inhibitor (viagra) prior to Nitro
-Atorvastatin 80
-MT 25 PO BID unless in heart failure
290
Q

STEMI cath vs fibrinolysis

A

PCI preferred
IF cannot do PCI, pain < 12 hours and no contraindications to fibronolysis=> LYSE
If lyse, can still use ASA/plavix/heparin

291
Q

TIMI score

A

4 points hx

  • age >65
  • 3 cardiac risk factors (Htn, DLP, smoking, DM, dam hx MI < 65)
  • known high grade stenosis (>50%)
  • on ASA

3 points ACS diagnosis

  • ST change admission EKG
  • CP (>2 episodes in last 24 hours)
  • Trops

TIMI 3-4 indicates increased chance of bad outcome with medical management alone

292
Q

ATLS approach

A 
ABCDE
Airway
Breathing
Circulation
Disability (GCS + pupils)
Exposure and environmental control
293
Q

Trauma general guidelines

A 
Universal precautions gloves and gown
Vitals + cardiac monitor
ABCDE
primary and secondary survey
AMPLE hx
Transfer pt to trauma centre when stabilized
294
Q

Airway assessment trauma

A

Look incr WOB, cyanosis, secretions
Assess difficulty of airway (teeth, deformities, edema)
Trachea midline
Feel subcutaneous emphysema

295
Q

Doses of intubation agents

A 
Etomidate 0.3 mg/kg IV push
Propofol 1-1.5 mg/kg
Ketamine 1-1.5 mg/kg
Fentanyl 50-100 mcg
Succinylcholine 1-1.5 mg/kg
296
Q

GCS components

A 
Eye opening (4)
Verbal response (5)
Motor response (6)
Total score out of 15
297
Q

GCS eye opening

A

spontaneous 4
To speech 3
To pain 2
No response 1

298
Q

GCS verbal response

A 
oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
299
Q

GCS motor response

A 
Obeys commands 6
Moves to localized pain 5
Flexion withdrawal from pain 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response 1
300
Q

Basilar skull fracture

A

occurs most commonly through temporal bone
Increased risk of ICH
Battle sign (retroauricular and mastoid ecchymosis)
Periorbital ecchymosis (Raccoon eye)
CSF rhinorrhea or otorrhea
Hemotympanum

301
Q

Disability (as part of ATLS)

A

GCS + pupils

302
Q

Exposure and Environment (as part of ATLS)

A 
Remove clothes
Cover with warm dry blankets to prevent hypothermia
Log Roll
Palpate C Spine
R/O CSpine injury
Pelvic exam
-DRE
-R/O blood at meatus
-R/O high-riding/non palpable prostate
-check anal sphincter tone
-Foley catheter if no contraindications
303
Q

Get CT C spine if any of five are present

A
  • Neuro deficits, focal
  • spine tenderness, midline
  • AMS
  • intoxication
  • distracting injury
304
Q

Radiology for trauma

A 
CXR; lungs + ETT placement
Spine: entire C spine (C7-T1)
Pelvic XR (R/O pelvic fracture)
Abdo XR R/O free air
Any other areas including joints above and below
305
Q

Contraindications to NGT in trauma

A

Basal skull fracture

Esophageal stricture or bleeding diathesis

306
Q

4:2:1 rule

A

4 cc/kg/hr for first 10 kg
2 cc/kg/hr for next 10 kg
1 cc/kg/hr for subsequent kg

307
Q

intussuseption

A 
Air contrast barium enema diagnostic and therapeutic (do if high clinical suspicion)
U/S
Most common cause 
Colicky abdo pain
bloody mucus
Currant jelly stools
vomitting
308
Q

Pyloric stenosis

A

In first 3 weeks of life
Palpable olive shaped epigastric mass
Visible gastric peristaltic wave
Diagnosed by ultrasound

Non biliary vomitus
Hypochloremic hypokalemic metabolic alkalosis

309
Q

Fever in <1 month yr old

A

Blood Cx
Urine Cx
CSF cx (LP!)

310
Q

If 30 days to 3 months w/u for fever

A

Blood cx, urine cx but only LP if looks toxic

311
Q

Txt Meningitis

A

3 months

Strep pneumo, Neisseria, Hib; Ceftriaxone + vanco +/- Ampi for Listeria if over 50

312
Q

Fever <1 month

A

Ampi + cefotaxime
OR
Ampi + gent

313
Q

Red flags for pediatric diarrhea

A 
<6 months
Fever
Blood in stool
High vol diarrhea
OR
clinical signs of diarrhea
Change in MS
Recent antibiotic use (C Diff)
314
Q

Chronic diarrhea without FTT diff’ll

A 
Lactose intolerance
Osmotic diarrhea (fructose intolerance, fruit juice diarrhea)
Cow's milk intolerance
315
Q

Chronic diarrhea with FTT diff’ll

A 
Celiacs (>3 months)
IBD (>3 yrs)
Pancreatic insufficiency (Cystic fibrosis)
Milk protein allergy
Laxative abuse
316
Q

Acute diarrhea diff’ll

A

Infectious (viral/bacterial)
R/O surgical problems
-appendicitis
-intussussuption (<1 yr)

317
Q

Diagnosis lactose intolerance

A 
>6 yrs: hydrogen breath test
ellimination diet (use soy based infant formula)
318
Q

General w/u diarrhea

A 
Stool O/P
Fat content
C Diff
Anti-TTG, IgA
Sweat test
Lactose breath test
\+/- upper GI series, small bowel follow-up/endoscopy (usually for chronic diarrhea)
319
Q

When to use antibiotics in acute diarrhea (in immunocompetent pts)

A

Severe illness
Persistent diarrhea with specific pathogen isolated on cx

Do NOT use even if bloody stool and fever
Most can be managed as outpatients in normal vitals and little danger of dehydration

320
Q

Toddler’s diarrhea txt

A

benign self limiting osmotic diarrhea due to malabsorption of disaccharides
Four Fs:
-adequate fiber
-normal fluid intake
-forty % dietary fat
-no fruit juice
Dx of exclusion if no evidence weight loss/electrolyte probe

321
Q

FTT defn

A

-weight <80% expected weight for heigh and age

322
Q

Peds hx

A

PMHX

  • pregnancy hx
  • APGAR scores
  • milestones
  • growth curve
  • med condition

Fam Hx

  • short stature
  • genetic diseases

Social

  • parents/siblings
  • stressors/coping
323
Q

Adult vaccines

A

Strep pneumo >65 q 5 yrs if many med comorbidities
Zoster vaccine >65 (pay)
Influenza Q winter >65, all pregnant women

324
Q

C5 radiculopathy

A

Motor: weakness shoulder abduction

Reflex
Bicep

Sensory
lateral shoulder
lateral neck
scapula

325
Q

Axillary nerve damage

A

C5C6 root

326
Q

C6 Root encompasses which peripheral nerves

A

Musculocutaneous (C5C6)
Radial C5

Musculocutaneous nerve C5, C6
-innervates biceps; responsible elbow flexion

Radial nerve C6

  • innervates brachioradialis: elbow flexion
  • innervates extensor carpi radialis longus: wrist extension
327
Q

Median nerve

  • nerve root
  • motor innervation
  • sensory innervation
A

Nerve root: C7-8, T1

Motor:
weakness intrinsics of hands + thumb
Wrist extension

Sensory:
-Palmar surface:
Index finger
Middle finger
radial 1/2 ring finger
-Dorsal surface
DIP index, middle and radial half ring
328
Q

C8 radiculopathy

A

Motor:
Intrinsics of hand
Abd/add thumb

Reflex
Finger jerk

Sensory:
-ulnar forearm +ring/pinky
(spares upper arm)

329
Q

Ulnar nerve

A

C8T1

330
Q

Radiculopathy vs Neuropathy

A

Radiculopathy

  • painful
  • parasthesia
  • sensory loss mild or absent

Neuropathy

  • NOT painful
  • parasthesias not as common
  • sensory loss in patch area
331
Q

Causes of radiculopathy

A

Disc herniation
Meningioma
L

332
Q

Red flags neck pain

A
  • neck pain associated with H/A, shoulder or hip girdle pain or visual symptoms in older pts (PMR vs GCA)
  • Fever/chills
  • weight loss
  • immunosuppression
  • Hx CA
  • IVDU
333
Q

Diagnosis of cervical strain

A

Nonspecific diagnosis to describe injury to cervical paraspinal muscles, ligaments and spasm of neck and back muscles

neck and trapezius pain
No neuro symptoms
<6 weeks duration

334
Q

cervical spondylosis

A

***most common cause of acute and chronic neck pain

  • includes soft tissue, disk and degenerative bony lesions
  • changes in facet joints and laminal arches
  • can identify on plain radiograph (disk space narrowing, osteophytes)
335
Q

Diff’ll for neck pain

A

Neck strain
Spondylosis
Discogenic nerve entrapment
Whiplash syndrome

336
Q

Presentations of cervical spondylotic myelopathy

A
  • pain in neck, subscapular, shoulder radiates to arm
  • lhermitte’s sign: electric shock like sensation in neck radiating down spine into arms, produced by forward flexion of neck (could indicate myelopathy (herniation) OR MS)
  • numbness/parasthesias in arms
  • weakness
337
Q

Non-spinal causes of neck pain

A
  • inflammatory arthritis (ank spond)
  • infections; meningitis, pharyngeal abscess, herpes zoster
  • CA
  • CV; thoracic outlet obstruction, vertebral/carotid artery dissection, ACS
  • diabetic neuropathy
338
Q

CN II

A

Visual acuity
Pupils
Visual fields
Fundoscopy

339
Q

Oculomotor nerves

A 
CN III
-levator palpebrae superioris
-Medial rectus
-superior rectus
-inferior rectus: extorsion, elevates eye while in adducted position
-inferior oblique
CN IV (trochlear)
--superior oblique: intorsion, depresses eye while in adducted position
CN VI (abducens)
-lateral rectus
340
Q

Trigeminal nerve CN V

A
  • Sensory V1-V3, afferent limb corneal reflex

- Motor: temporalis, masseter, petygoids, jaw jerk reflex

341
Q

Facial nerve CN VII

A

Sensorimotor: muscles of facial expression, hyperacussis (stapedius), corneal reflex (efferent)
Visceral sensory: taste anterior 2/3
Visceral motor: salivary and lacrimal glands

342
Q

Vestibulococchlear CN VIII

A

Whiper baseball into ears and ask to repeat
Rinne
Weber

343
Q

Rinne

A

Tuning fork against mastoid bone then in front of external ear
Normal: continue to hear in front of ear indicating intact conductive hearing
Abnormal: don’t hear it in front of ear indicating problem with conductive hearing loss

Air conduction = sensorineural hearing loss
Bone conduction = conduction hearing loss

344
Q

Weber

A
  • Tuning fork in middle of head
  • A normal result is when the sound is the same in both ears
  • If the sound is louder in one ear, it is indicative of conductive hearing loss (CHL) in that ear or sensorineural hearing loss (SNHL) in the opposite ear.
  • if sensorineural hearing loss is preserved (i.e. bone conduction is preserved), then only conduction hearing

-The reverse is also true. If the sound is quieter in one ear, it is indicative of SNHL in that ear or CHL in the opposite ear.

If bone conduction is intact on both sides (therefore no SNHL), the patient will report a louder sound in the ear with CHL. This is because the ear with the CHL is only receiving input from the bone conduction and no air conduction, and the sound is perceived as louder in that ear.
If air conduction is intact on both sides (therefore no CHL), the patient will report a quieter sound in the ear with the SNHL. This is because the ear with the SNHL is not receiving input from the bone conduction, and the sound is perceived as louder in the normal ear.

Air conduction = sensorineural hearing loss
Bone conduction = conduction hearing loss

345
Q

Glossopharyngeal (CN IX)

Vagus CN X

A

Palatal elevation
gag reflex
vocal cord function
swallowing

346
Q

Hypoglossal CN XII

A

tongue muscle

Tongue deviates to side of the lesion

347
Q

Accessory (CN XI)

A

Sternocleidomastoid: left SCM turns head right

Trapezius

348
Q

C7 nerve root encompasses which peripheral nerves

A

Radial nerve

Posterior interosseos

349
Q

Radial nerve innervates which muscle

A

Triceps: Elbow extension

350
Q

Posterior interosseus innervates which muscle

A

Extensor digitorum communis: finger extension

351
Q

C8T1 nerve root encompasses which peripheral nerve

A

Median

Ulnar

352
Q

Median nerve innervates which muscle

A

Flexor pollicis longus: thumb flexion
**look for thenar wasting
Abductor policis brevis: thumb abduction
Opponens pollicis: opposition

353
Q

Ulnar nerve innervates which muscle

A

First dorsal interosseus: finger abduction

***wasting in first dorsal webbed space

354
Q

L2L3L4 nerve roots innervate which peripheral nerve

A
  • Femoral nerve

- Obturator nerve

355
Q

Femoral nerve responsible for what muscle movement

A

-Iliopsoas: hip flexion

Quadriceps: Knee extension (L3L4)

356
Q

Obturator nerve responsible for what muscle movement

A

-Adductor muscles: hip adduction

357
Q

L3L4 nerve roots innervate which peripheral nerve

A
  • femoral (L3L4)

- Deep peroneal (L4)

358
Q

Deep peroneal nerve responsible what muscle movement

A

L4

-Tibialis anterior: Dorsiflexion

359
Q

L5 nerve root innervates which nerves

A

Sciatic (L5S1)
Tibial
Superficial peroneal
Deep peroneal

360
Q

Sciatic nerve responsible what muscle movement

A

Gluteus maximus: hip extension (L5)

Hamstring muscles: knee flexion (S1)

361
Q

Tibial nerve responsible what muscle movement

A

Tibialis posterior: ankle inversion (L5)

Plantarflexion (gastroc and soleus), S1

362
Q

Superfical peroneal responsible what muscle movement

A

Peroneal muscles: ankle eversion

363
Q

Deep perineal responsible what muscle movement

A

big toe extension

364
Q

S1 nerve root innervates which peripheral nerve

A

Sciatic

Tibial

365
Q

Sciatic nerve responsible what muscle movement

A

Hamstring: Knee flexion

Gluteus maximus : hip extension

366
Q

Cauda Equina symptoms

A 
Bowel or bladder dysfunction (overflow incontinence typically present)
saddle anasthesia
areflexia
bilat sciatica
leg weakness

Most commonly caused by tumor or massive midline disk herniation

367
Q

Physical exam for sciatica

A

Straight leg raise
Crossed straight leg raise
Seated straight leg test
(seated, knees flexed 90, leg is slowly raised extending knee; positive if symptoms distal to knee OR if symptoms abolished with knee flexion)

368
Q

Diff’ll back pain

A

-Lumbar strain
-Degenerative = spondylosis
-osteoperosis
-Disc herniation (radiculopathy)
-Spondylolisthesis
-Spinal stenosis
-Trauma/fractures
-Congenital diseases (kyphosis, lordosis, scoliosis)
-Malignant (MM, leuk/lymp, mets)
-Infectious (abscess, osteomyelitis)
-Inflammatory (ank spond, psoriatic spondylitis, IBD)
-Referred pain
(pelvic organs: prostatitis, endometriosis, chronic PID), renal pain (nephrolithiasis, pyelo), AAA, GI (pancreatitis, chole, perf ulcer)

369
Q

Common disc herniations

A

L5S1 > L4L5

370
Q

Spinal stenosis symptoms

A

Back pain
transient parasthesias (tingling) in legs
Ambulation induced pain localized to calf and distal lower extremity, resolving with rest (sitting or spine flexion)=neurogenic claudication
**differentiate from vascular claudication by presence of good pulses)

371
Q

Social aspects of back pain

A
  • disability compensation?

- screening for depression

372
Q

Key points for history back pain

A
  • R/O red flags

- Asess social factors (compensation, depression)

373
Q

P/E back pain

A

Inspection:
-back, posture

ROM
-flex/ex

Palpate
-spinuous process, soft tissue

Motor
-strength legs

Sensory
-legs

Vascular
-pulses

DRE/sphincter tone

374
Q

L4L5 radiculopathy

A

need to find

375
Q

Pheochromocytoma should be suspected in pts with…

A

Paroxysmal htn
self-limited episodes of nonexertional palpitations, diaphoresis, headache, tremor or pallor
-Htn triggered by beta blockers, MAOI
-pts with adrenal incidentalomas, MEN, NF, vHL
-W/U: urine metanephrines and abdo MRI

376
Q

Suspect hyperaldosteronism if

A
  • Spontaneously Hypokalemia
  • diuretic induced hypoK
  • resistant htn (>3 drugs)
  • concomitant incidentaloma
  • W/U: AM renin and aldosterone levels
377
Q

W/U for pt presenting with htn

A

CBC (wbc infx, hg chronic disease)
CHEM 7 (glucose DM, K, Creat)
EKG (R/O end organ damage)
Lipid profile (metabolic syndrome)

378
Q

Medication that can increase BP

A 
NSAIDS
CORT/anabolic steroids
Vasoconstricting/sympathomimetic decongestants
Calcineuron inhibitors (cyclosporin, tacrolimus)
EPO
Antidepressants: MAOI, SSRI, SNRI
Drugs (cocains, ETOH)
Salt
379
Q

Dysphagia PMHx

A 
DM
Autoimmune
-sjogren
Neuromuscular
-PD
-MG
-Muscular dystrophy
-MS
Malignancy
Surgery
380
Q

Dysphagia

A

Difficulty swallowing, sensation food getting stuck after swallowing

381
Q

Odynophagia

A

Pain on swallowing

382
Q

Key questions for dysphagia

A
  • Difficulty in initiating swallow (odynophagia) vs food getting stuck
  • Associated sx: choking, coughing, nasal regurgitation, change voice pitch
  • Solids, liquids, both
  • Intermittent vs progressive
  • Hx heartburn
  • Change in eating habits/diet
383
Q

Diff’ll dysphagia

A

Neuromuscular

  • DES
  • Scleroderma
  • Achalasia

Mechanical

  • carcinoma
  • stricture/heartburn
  • lower esophageal ring
384
Q

Odynophagia diff’ll

A

Neuromuscular

  • CVA
  • MG
  • muscular dystrophy
  • Polymyositis

Mechanical

  • tumors
  • Zenker’s diverticulum
  • peritonsillar abscess/pharyngitis

Functional
-Xerostomia (dry mouth)

385
Q

Progressive dysphagia solids + liquids

A

Scleroderma (if reflux symptoms)

Achalasia

386
Q

Bird’s beak on Ba swallow

A

Achalasia: failure of lower LES to relax (hiccups)=> obstruction distal esophagus
Need endoscopy to R/O malignancy
Motility studies for definitive diagnosis

387
Q

Corkscrew on Ba swallow

A

Diffuse esophageal spasm

388
Q

Progressive dysphagia solids

A

CA (Adeno vs SCC)
if >50, wt loss

Peptic stricture
(heartburn)

389
Q

Intermittent dysphagia solids

A

Lower esophageal ring

Eosinophilic esphagitis

390
Q

Intermittent dysphagia solids and liquids

A

DES (chest pain)

391
Q

GERD S and S

A

Non-esophageal

  • Chronic cough
  • wheezing
  • aspiration pneumonia
  • sore throat
  • Hoarseness
  • dental erosions

Esophageal

  • heartburn
  • acid reflux
  • chest pain
  • dysphagia
  • odynophagia (rare)
392
Q

Lifestyle modifications GERD

A
  • weight loss
  • decreased spicy food/coffee
  • avoid eating before bed
  • Stop smoking/drinking
393
Q

Diagnostic criteria for delirium (and qs to ask on hx)

A

-Disturbed consciousness (distractibility, inattention)
-Change in cognition
(memory deficits, language disturbance, disorientation, perceptual disturbance ex hall)
-acute onset with fluctuating course
-concomitant GMC (infx, ingestion/intox, metabolic endocrine/etc)

394
Q

Dementia diagnostic criteria

A

Memory impairment +

  • aphasia
  • agnosia
  • apraxia
  • disturbed executive function

Sign decline from previous level functioning
-R/O GMC, depression/pseudodementia

395
Q

Lab W/U delirium

A 
CBC
CHEM 10
LFT
TSH
Folate/B12
Tox screen
U/A
Blood cx
\+/- LP (may need CT head before)
CXR
CT head
396
Q

Medications for dementia

A

Cholinesterase inhibitors
-indicated for mild-mod AD
Memantine (GABA antagonist)
-mild symptomatic improvement severe dementia
Antidepressants may be useful
Antipsychotics to control sx (black box warning)

397
Q

Acute urinary retention diff’ll

A

Infex/Inflammation

  • Cystitis
  • prostatitis

Structural

  • BPH
  • constipation
  • Tumors (bladder, pelvic mass)
  • urethral strictures
  • prolapse
  • stones

Neuro

  • DM with peripheral neuropathy
  • MS/Parkinsons
  • Cauda equina

Meds

  • anticholinergic
  • post op (opioids)
398
Q

W/U acute urinary retention

A 
-Chem 7
CBC
U/A
Cytology
PSA

Imaging: renal U/S R/O hydronephrosis
PVR
+/- CT abdo/pelvis

399
Q

When to refer to urologist for acute urinary retention

A
  • pelvic radiation or surgery
  • pelvic pain
  • severe incontinence
  • severe LUTS
  • recurrent uro infx
  • neuro disease
  • abnormal prostate exam
  • hematuria
  • elevated PSA
400
Q

Febrile seizure hx

A 
NO CNS infx
No systemic metabolic abnormality
No hx previous afebrile seizures
No development delay
Normal head circumference
No neuro abnormalities
Normal vaccinations
401
Q

Cause of febrile fever

A

Convulsion associated T>38
Recent infx (viral or bact)
Recent immunization esp MMR, DTP

402
Q

Polymyalgia rheumatica Dx

A
  • Age > 50
  • F>M
  • pain > 1 month in 2/3 areas: neck, shoulders, pelvic girdle
  • High index suspicion for development temporal arteritis (1/4 pts, examine temporal artery and retinal fundus)
  • High ESR/CRP
  • responds well low dose pred
403
Q

Fibromyalgia

A

Pain 11/18 trigger points
lasting at least 3 months in all four quadrants of body
Suggest conservative therapy with physical activity, stress reduction, sleep improvement
Low dose TCA OR pregabalin

404
Q

Manic episode

A 
DIG FAST
Distractibility
Insomnia
Grandiosity
Flight of ideas
Activity/agitation (increased goal directed activity, sexual)
Speech
Thoughtlessness (buying sprees, sexual indiscretions)
405
Q

Infantile colic

A
  • Unexplained irritability and crying >3 hours/day and > 3 days/week for > 3 weeks in otherwise healthy well fed baby
  • 10% infants
  • etiology: lag in normal peristalsis, lack self soothing mechanisms
  • baby may be crying due to gas pains, too hot/cold, overstimulated, need to suck or be held
  • 10 days to 3 months of age;peaks 6-8 weeks
  • child may cry and pull legs up and passes gas after feeding
  • Management: parental relief and reassurance, hold baby, music, check diaper, car ride
  • meds don’t work
  • in small percentage of cases elimination cow’s milk from mother’s diet useful
  • try casein hydroxylates formula
406
Q

Schizophreniform disorder

A
  • Same symptoms as schizophrenia but:
  • duration>1 month < 6 months
  • level of functioning may not be affected
  • onset may be more rapid than schizophrenia (which can be months)
  • prognosis overall better than Sz
407
Q

Risk factors for child abuse

A

First time mother
Young Mom
Difficult child
Lack of social/family support

408
Q

CAP treatment

A

Healthy ppl, no antibiotics in previous 3 months
-Clarithromycin (biaxin) 500-1000 mg PO x 7 days
OR
-Azithromycin
(7 days)

Presence comorbidities or antibiotics past 3 months

  • Levaquin 500 DIE 7-14 days OE 750 x 5 days
  • Moxi 400 mg DIE X 10 days

OR

-Amoxicillin or Amox-clav
AND
Clarithro/azithro

409
Q

Investigations for ALL pts with HTN

A
  • CBC
  • electrolytes (including creat, K, Ca)
  • Fasting glucose
  • Lipid profile
  • 12 lead ECG
  • U/A
410
Q

Older lady with urinary incontinence;

history

A

Stress vs Urge incontinence

Stress;
-pelvic prolapse/surgery
-vaginal delivery
-hypoestrogenic state
-age
-smoking
Txt: 
-kegel
-local estrogen vaginal therapy
-vaginal pessary

Urge

  • urine loss associated with sudden urge to void “OAB”
  • R/O neuro causes (MS, DM, slipped disc)
  • frequency/urgency/nocturia/leakage
  • txt
  • lifestyle: caffeine, smoking cessation, regular coding schedules
  • Kegel
  • Meds: anticholinergics, TCA
  • **multichannel urodynamics gold standard but most cases can be diagnosed on history alone
  • **typical investigations: UA, Cx
411
Q

ASCUS on Pap smear

A

if < 30, no HPV testing available

  • repeat cytology in 6 months
  • if Negative: repeat 6 months with routine testing
  • if ASCUS again => colposcopy

If > 30
HPV-DNA testing
-if Negative; routine testing
-If positive: colposcopy

412
Q

Anything above ASCUS

  • ASC-H (atypical squamous cell cannot exclude HSIL)
  • LSIL (low grade sq intraepithelial lesions)
  • HSIL (high grade sq intraepithelial lesions)
A

LSIL=CINI
-observe with regular cytology Q 6 months
Colposcopy if 2X positive

Other lesions:
Go straight to colposcopy

413
Q

Cervical spine XR views

A

-lateral (most important)
-Antero-posterior view
-Odontoid peg view (open mouth view)
+/- Swimmer’s view if don’t see T1

414
Q

Cervical spine XR Lateral view; high points

A

-all vertebrae visible from T1-C1
-aligment; anterior line, posterior line, spinolaminar line
-trace cortical outline of all bones to check for fractures
-disc spaces (should be equal height)
-prevertebral hematoma
-

415
Q

Cervical spine XR AP view; high points

A
  • Aligment; lateral edges of Cspine are aligned
  • fractures less well seen on this view than lateral
  • spacing of spinuous processes (should be even)
  • surgical emphysema
  • pneumothorax
416
Q

Cervical spine XR Odontoid/peg view high points

A
  • need to see C1C2

- distance between peg (odontoid) and lateral edge of C1 should be equal

417
Q

Canadian CT head rules

A

Ct head required in pts with minor head injury if any one of findings present:
-GCS < 15 at 2 hours after injury
-suspected open or depressed skull fracture
-signs of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea, Battle sign)
-vomitting > 2 episodes
Age > 65

Medium risk for brain injury on CT

  • amnesia before impact > 30 min
  • dangerous mechanism (pedestrian, occupant ejected, fall from elevation)
418
Q

Ottawa ankle rules for ankle XR

A

Ankle XR required if there is pain in malleolar zone and any of the following

  • bone tenderness at posterior tip of medial OR lateral malleolus
  • inability bear weight both immediately AND in ED
419
Q

Ottawa ankle rules for foot XR

A

Pain in midfoot zone and any of these findings

  • bone tenderness at base of 5th metatarsal OR navicular
  • inability to bear weight both immediately after AND in ED
420
Q

L234 radiculopathy

A

Sensory: anterior thigh and course medially over lower leg with pain
Reflex: patellar
Motor: weakness hip ADduction, flexion and knee extension

421
Q

L5 radiculopathy

A

MOST COMMON
Sensory: lateral leg curving over dorsum of foot and first toe
Motor: weakness ABDuction hip, dorsiflexion, inversion, eversion but preserved plantar fexion

422
Q

S1 radiculopathy

A

Sensory: shooting pain to foot with sensory deficit along entire posterior leg and lateral foot
Motor: weakness plantar flexion (but also hip extension and knee flexion)

423
Q

S2S3S4 radiculopathy

A

Sensory: deficits straight down back of leg, perianal, perineal and radiating to back of leg sometimes
Motor: weakness anal tone, urinary retention sexual dyfunction
Reflex: bulbocavernosus reflexes diminished

424
Q

capacity vs consent

A

Capacity = the degree to which one is able to understand the information relevant to a treatment decision and appreciate the reasonably foreseeable consequences of a decision or lack of a decision.
(a question of degree)

Competence = being able to understand information relevant to a treatment decision and to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.
(all or nothing)

425
Q

Components of competence

A

four specific abilities should be assessed:

1) the ability to understand information about treatment;
2) the ability to appreciate how that information applies to their situation;
3) the ability to reason with that information;
4) and the ability to make a choice and express it.

426
Q

somatoform disorders screen

A

How has your health been for most of your life?
How have your pains affected your job, social life, relationships, and your life generally?
Are you often unwell, how often do you visit the doctor?
Do you worry that you have a serious illness? If a doctor tells you that there is nothing wrong, how does that make you feel?
Do you believe him or her?

427
Q

Physical exam consolidation

A

Consoildation increases transmission of sounds voice transmission

  • egophany (ee to ay)
  • bronchophony (enhanced transmission of spoken word 99)
  • whispered pectoriloquy (whisper 99 and heard well through stethoscope)

Also increases

  • tactile femitus (99)
  • bronchial BS
  • crackles
  • dullness to percussion
428
Q

TCA overdose medical management

A
  • typically see QRS > 100; if so give bicarb amps/drips and aim for alkalemic blood gases
  • activated charcoal IF pt presents within 2 hour of ingestion AND can protect airway (do not intubate to give activated charcoal)
  • intubate if indicated
  • monitoring for first 24 hours
  • treat seizures with benzos NOT dilantin
429
Q

Medications which cause complete heart block

A

Digitalis OD
TCA OD
b blocker
CCB

430
Q

Suicide attempt: is the pt safe to go home?

A

Is pt remorseful?
Is there support network?
What kind of attempt; cry for help or honest suicide attempt?
Is the pt actively suicde/plan/means to accomplish?
How many previous attempts
Can proper follow-up be arranged?

431
Q

Counselling pt with preeclampsia re worsening symptoms

A

Worsening signs

  • rapid weigjt gain
  • liver pain
  • visual disturbance
  • persistent headache/drowsiness
  • seizures
432
Q

Differential for 3rd trimester vaginal bleeding

A
  • placenta previa
  • bloody show
  • abruptio placenta
  • vasa previa (fetal bleed due to root vessels of umbilical cord overlying the cervical os; very dangerous to fetus

Ask about

  • sex
  • trauma to abdomen (car accident) or sexual abuse
433
Q

third trimmest vaginal bleeding; rule of thumb re vaginal exam

A

DO NOT DO VAGINAL EXAM until placenta previa has been ruled our by U/S

434
Q

Quantifying fetal hemoglobin in third trimester hemorrhage

A

Apt test

Kleihauer-Betke (quantifies amount of fetal blood to guide amt of Rhogram to give)

435
Q

Solitary pulmonary nodule

A

defined as < 3 cm (mass > 3 cm)
Bottom line: if < 8 mm can watch and wait with serial scans
If > 8 mm should do PET scan

436
Q

Risk factors for child abuse

A

Environmental: social isolation, poverty, domestic violence
Caregiver: substance abuse, parents abused, mental illness, poor social/vocational skills/below avg IQ
Child factors: disability, difficult child (temperament, premature)

437
Q

Clearing C spine

A

If high risk => radiography

  • age > 65
  • dangerous mechanism
  • parasthesias

If low risk factors AND able to rotate neck 45 degrees => no radiography
(if any low risk factors are present OR if unable to move neck 45 degrees=> radiography)
-simple rear end MVC
-sitting in ER
-ambulatory at any time
-delayed onset back pain
-absence of midline c spine tenderness

438
Q

Sacroilitis test

A 
Faber test (leg crossed and press down on crossed legs bilat)
Compression test (pt on side with pillow between leg and press on hip joint)

If positive: pressure applied reproduces pain

439
Q

Ankylosing spondylitis test

A

Schober

Lateral flexion

440
Q

Skin sutures:
Non-Absorbable sutures
Non braided

A

Prolene
Silk
Nylon
To use on skin for removal within 10 days (body) 7 days on face

441
Q

Pap test

A

Start age 21 OR when sexually active

Screen Q2-3 years

442
Q

GST PAID

A 
Grandiosity
Sleep (decreased need)
Talkativeness
Pleasurable activities, painful consequences
Activities (goal directed)
Irritability
Distractibility

LMCC II (1 decks)

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