PreTest Family Medicine: "Acute Complaints" Flashcards
True or false: constipation can cause fever in the elderly.
False
What symptoms warrant an EGD in a patient with GERD?
- Weight loss
- Dysphagia (could be from a mass!)
- Vomiting
- Bleeding
What is the most common cause of acute pancreatitis?
Gallstones
Alcohol is the leading cause of chronic pancreatitis and the second leading cause of acute pancreatitis.
__________ is a set of criteria that assesses the severity of pancreatitis.
The Ranson criteria
- Age greater than 55
- WBC greater than 16
- Glucose greater than 200
- LDH greater than 350
- AST greater than 250
Describe the diagnostic schema for IBS.
•At least 12 weeks of symptoms in the past 12 months (not necessarily consecutive)
• Abdominal pain that meets two of the following criteria:
- Relieved by defecation
- Onset associated with a change in stool frequency
- Onset associated with a change in stool consistency
Describe the syndrome of dyspepsia.
Dyspepsia is a constellation of chronic bloating, epigastric pain, heartburn, nausea, vomiting, and belching. While chronic dyspepsia can be a sign of ulcers or cancer, most cases are idiopathic.
ASCUS with negative HPV = _____________.
repeat test in one year
ASCUS with negative HPV = _____________.
colposcopy now
ASCUS with no HPV available = _____________.
repeat in 4-6 months; if ASCUS again, then colposcopy
If a colposcopy is negative after an ASCUS, then ______________.
repeat Pap in one year
If a postmenopausal woman has ASCUS, what can you do?
You can either (1) repeat Pap in 4-6 months, (2) perform colposcopy now, or (3) do a trial of topical estrogen –usually 4 weeks –and then repeat Pap.
You should do a colposcopy if the Pap smear shows ASCUS-________________.
favor LSIL
“Atypical glandular cells” warrant ______________.
colposcopy
So long as they are not thought to be of endometrial origin. If they are reported to be endometrial, then do an endometrial biopsy.
True or false: only encephalopathic Lyme disease should be treated with cephalosporins.
False
Any multisystem Lyme disease (e.g., arthritis plus pericarditis) should be treated with cephalosporins.
Go through the three treatment tiers of lice.
1) Permethrin 1%
2) Permethrin 5%
3) Lindane 1%
What body parts are usually bitten by fleas and bedbugs?
- Fleas: lower extremities
* Bedbugs: upper extremities, face, neck, and trunk
PreTest says the best treatment for an obviously infected cat bite is _____________.
hospitalization
What is a good way to differentiate between fibroadenomas and fibrocystic change?
- Singular mass: fibroadenoma
* Clusters: fibrocystic change
A 40-year-old woman has a breast mass and a negative mammogram. How should she be worked up?
Ultrasound and biopsy –up to 15% of breast cancers are silent on mammography
What kind of breast discharge is most suspicious for cancer?
Spontaneous, unilateral, bloody or serous fluid
Go through the BI-RADS scale.
- O: incomplete test
- 1-2: benign –resume normal screening
- 3: likely benign, but screen in 6 months
- 4-5: likely cancerous: further workup indicated
Why is pleuritic chest pain an important distinction?
Pleuritic chest pain is most likely not secondary to a cardiac cause.
What two ECG changes are most suggestive of ischemia?
- ST elevation (#1)
* New conduction defects (#2)
T wave inversion occurs in what non-acute cardiac complication in adults?
Left ventricular hypertrophy
T-wave inversion will present in leads V4-V6.
For chronic constipation, the best first-line agents are ______________.
bulking agents like psyllium (Metamucil)
A young woman has uncomplicated acute bronchitis which did not respond to antitussives and bronchodilators. What should you do?
Treat with an oral steroid taper
Uncomplicated acute bronchitis should not be treated with antibiotics. Some people get a post-bronchitic cough thought to be due to airway tightness. In these cases, oral steroids can help relieve tightness and cough.
Why are antibiotics given in pertussis?
- In the first, cold-like phase, they help reduce the length of illness.
- In the second, paroxysmal phase, they help reduce the length of isolation from four weeks to one week.
The best antibiotics for traveler’s diarrhea are _______________.
the fluoroquinolones
For acute viral diarrhea, the best dietary recommendations are ________________.
to eat plain foods (potatoes, rice, bread, crackers, bananas) and to stay hydrated
Dairy and alcohol should be avoided.
Talk about the better ways to describe dizziness.
- Light-headedness: feeling like you’re about to faint
- Dysequilibrium: feeling that you can’t get your balance right
- Vertigo: feeling like the room is spinning
Describe the progression of symptoms seen in acoustic neuroma.
- First: tinnitus and hearing loss
* Second: facial numbness and vertigo
How can the Dix-Hallpike maneuver be used to differentiate peripheral from central causes of stroke?
The Dix-Hallpike maneuver should cause vertigo to lessen in peripheral dizziness. With central dizziness (such as from a stroke), the dizziness will not lessen.
Vestibular dizziness should be treated with what symptoms?
Antihistamines (e.g., meclizine, diphenhydramine)
Describe the sensitivity and specificity of BNP in CHF.
An elevated BNP is extremely sensitive for CHF. If a person has a normal BNP, the odds that they have CHF are near zero.
True or false: a normal D-dimer effectively rules out a PE.
True
If the D-dimer is normal, then there is very little chance that the person has a clot.
For women with recurrent UTIs in whom preventive measures fail, you can prescribe _____________.
a one-day course of antibiotics for post-coital use
Why might you do a cystoscopy in a middle-aged woman with recurrent dysuria and hematuria who had a negative workup for UTI and stones?
Interstitial cystitis!
IC can present with lesions on the bladder.
If they give you a story that is highly suspicious for pyelonephritis (dysuria, pyuria, back pain, fever) but then tell you the man has no history of UTIs and a normal urinary tract, then they’re trying to clue you in to ____________.
acute prostatitis
Describe the diagnosis and management of temporomandibular joint dysfunction.
• Diagnosed by
- Earache that worsens when eating
- Absence of other symptoms (e.g., mastoid erythema, tooth pain)
- Normal ear canal exam
- TMJ crepitus
• Managed by
- NSAIDs
- Warm compress
- Soft diet
- ** If the above don’t alleviate pain in 3-4 weeks, then refer to a dentist for possible MRI, nerve blocks, or physical therapy.
Which of the signs of AOM is least sensitive?
Erythematous tympanic membrane
This can be caused by crying. Bulging, purulence, and immobility to insufflation are all more sensitive.
How long can effusions persist?
Up to 3 months
When should Augmentin be used instead of amoxicillin in the treatment of AOM?
When the temperature is above 102
What physical exam signs point to cellulitis as opposed to DVT?
Erythema, warmth, and pain (all indications of inflammation)
Describe the difference between primary and secondary enuresis.
- Primary enuresis: child has never been dry at night
* Secondary enuresis: child was dry at night but then started wetting again
What is thought to be the cause of enuresis in children?
Immaturity of nocturnal vasopressin release
How can you differentiate familial short stature and constitutional growth delay on a growth curve?
- In CGD, the weight decreases first, then the height.
* In FSS, the height and weight go down simulataneously.
What other features make fatigue more likely to be depression-related?
Denial of hypersomnolence and weakness
Go through PreTest’s three categories of fatigue.
- Physiologic (e.g., overwork, lack of sleep, pregnancy)
- Physical (e.g., diabetes, other endocrine disease)
- Psychological (e.g., depression, anxiety)
What is a reasonable workup for new-onset fatigue?
- CBC (anemia)
- TSH (hypothyroidism)
- Age-appropirate cancer screening (e.g., PSA, CBC for leukemia, mammogram, etc.)
- UPT
Thrombosed external hemorrhoids should be treated how?
Excision
Excruciating dyschezia followed by feeling of anal spasm is characteristic of _______________.
anal fissure
What age criteria warrants further workup of a headache?
Onset of new headache type after age 50
Which CCB has been shown to be effective in migraine prophylaxis?
Verapamil
“VErapamil VEnts the pressure.”
Describe the treatment options for cluster headaches.
• Chronic: but only during the symptomatic period
- Lithium
- Indomethacin
- Prednisone
• Acute:
- Oxygen
In general, you wait until the person has a headache and then treat with oxygen. Once the oxygen resolves the headache, initiate a chronic medicine to prevent attacks during the episode. Discontinue the prophylactic medication after the cluster episode ceases.
Which sleep aid can be used for middle-of-the-night awakenings?
Zaleplon
It has a shorter half-life than zolpidem and eszopiclone and can thus be taken halfway through the night without causing daytime somnolence.
Those with hepatitis A are most infectious _____________.
during the prodromal period – not while jaundiced
Anti-HbCAg IgG indicates _____________.
chronicity; that is, if the patient has this, it is not an acute infection
Per PreTest, what differentiates the early versus recovery status of HBV infection?
•Presence of HbSAg indicates early
Explain functional incontinence.
Functional incontinence is something that prevents patients from voiding in the bathroom (such as paralysis, bed rest, or severe dementia).
A postvoid volume greater than __________ indicates overflow incontinence.
200 mL
Describe the utility of a HIDA scan.
It can demonstrate blockage of the cystic duct (useful in the determination of cholelithiasis).
____________ bleeding (metrorhagia) is common in women younger than 20.
Anovulatory
Which common medications cause mild hyperprolactinemia?
SSRIs
Explain the utility of the progestin challenge (and the next test!).
- If bleeding occurs after progestin withdrawal, then it indicates unopposed estrogen (i.e., PCOS).
- If bleeding does not occur, then it is either outflow tract obstruction or inadequate estrogen production. An estrogen-progestin challenge can differentiate the two.
What ophthalmologic findings can be seen in someone with hypertensive emergency?
Papilledema (suggestive of hypertensive encephalopathy)
What is the difference between ileus and obstruction?
Obstruction implies a physical blockage of the intestines. Ileus implies paralysis of the bowel.
Note: hyperactive bowel sounds can distinguish the two (being a feature of obstruction, not ileus).
Psychogenic vomiting should be suspected in ________________.
cases in which the patient reports chronic symptoms but does not show signs of dehydration or malnutrition
How can you differentiate between osteoarthritis and mechanical injury as causes of neck pain?
- Osteoarthritis: worse after movement; no TTP
* Mechanical injury: worse after movement; TTP
Describe the Spurling test.
Pressing down on the person’s head while the bend their neck to the affected side can reproduce cervical stenosis symptoms (i.e., radiating pain down the UE).
The most evidence-supported treatment for torticollis is ____________.
Botox
____________ is often described as a “flipflop” in the chest.
PVC
What imaging can help evaluate endometriosis?
MRI
In addition to tonsillar exudate and oropharyngeal erythema, ____________ on pharyngeal exam is highly suggestive of GAS infection.
uvular edema
Pharyngitis and ______-itis are suggestive of a viral infection –not GAS.
laryng
Nodules on the spermatic cord are likely _____________.
spermatoceles
These are painless, non-enlarging nodules –no further workup is needed.
What habit can cause acne (and may be a good recommendation for patients with acne to stop)?
Touching face frequently with dirty hands.
The best treatment for mild acne is ________________.
benzoyl peroxide, topical antibiotics, and topical retinoids
When initiating isotretinoin, you need to have the patient discontinue what other oral acne agent?
Oral tetracycline
Accutane and tetracycline can both cause pseudotumor cerebri, so using them together is inadvisable.
The best therapy for rosacea is _____________.
oral antibiotics
___________ can look indistinguishable from basal cell carcinoma, but the main difference is that they arise in a matter of weeks.
Keratoacanthoma
Per PreTest, most cases of impetigo are caused by ________________.
S. aureus
I’ve seen S. pyogenes elsewhere.
How should hot tub folliculitis be treated?
Reassurance
Recalcitrant cases can be treated with antibiotics, but most cases resolve on their own.
Both oral and genital herpes should be treated with _______________.
daily Valtrex
True or false: daily Valtrex therapy can decrease asymptomatic shedding of HSV.
True, but it does not eliminate it –that is, you can still give someone herpes if you’re asymptomatic on Valtrex.
Review the timeline criteria for shingles and antiviral treatment.
Most people will not benefit if it has been more than 72 hours since symptom onset, but it is advised that treatment should be initiated in those
•Older than 50
•With eye involvement
•Who are immunocompromised
Antiviral treatment has been shown to decrease the duration of pain.
The best treatment for Tinea capitis is _______________.
oral griseofulvin with topical -conazoles
Which of these species is the most common cause of tinea?
•Trichophyton rubrum
•Trichophyton metagrophytes
•Trichophyton tonsurans
T. rubrum
Which symptom is more consistent with conjunctivitis, pain or photophobia?
Photophobia
Pus discharge is more characteristic of bacterial conjunctivitis, while _______________ is more consistent with viral conjunctivitis.
preauricular lymphadenopathy
You prescribe ciprofloxacin ophthalmic solution for bacterial conjunctivitis. The patient returns three days later and her symptoms have not improved. What’s going on and what should you do?
She likely has a bacterial infection from a strain that is resistant to fluoroquinolones. MRSA is a common etiology. Treat with oral Bactrim.
A middle-aged woman with rheumatoid arthritis presents with a painful, injected right eye with decreased vision that she describes as a “boring” pain. What is this?
Scleritis
This is common in those with autoimmune disorders.
List some of the features that point to a bacterial cause of sinusitis.
- Purulent nasal discharge
- Tooth pain
- A biphasic history (“I was getting better but then started to get worse again.”)
- Duration longer than 7 days
How can you help people with recurrent sinusitis from developing additional episodes of sinusitis?
• Control the risk factors:
- Stop smoking
- Treat allergic rhinitis with oral antihistamines and nasal corticosteroids
- Treat GERD with PPIs
- Do sinus rinses when congested or when symptoms start
- Refer to ENT
What is true about clinically diagnosed bacterial sinusitis and antibiotics?
Cases diagnosed without imaging have been shown to not benefit from antibiotics, while those diagnosed with CT have been shown to benefit. (That is, doctors are not able to diagnose bacterial vs. viral sinusitis effectively enough.)
How should shoulder dislocations be managed?
1) Relocate
2) Immobilize for 7-10 days
3) Physical therapy
Describe the causes and symptoms of iliotibial band syndrome.
Repetitive knee flexion activities (like long-distance running) lead to lateral knee pain.
Treatment of patellofemoral pain syndrome is through ________________.
strengthening the quadriceps muscles
When is an x-ray indicated in the workup of an ankle sprain?
When there is significant tenderness over the malleoli or metatarsals
Tilt table testing can reveal what kind of syncope?
Vasovagal
TT testing is valuable when cardiac, metabolic, and neurologic causes of syncope have been ruled out.
What is the glabella sign?
Tapping the forehead should cause a person to blink, but after tapping it for 15 times it should stop. (That is a negative sign.) Consistent blinking after 15 times is considered a positive sign and is often seen in Parkinson’s disease.
Which is the only pharmacologic therapy shown to delay disease progression in Parkinson’s disease?
Selegiline
The others –dopamine agonists and carbidopa-levodopa –provide symptomatic relief only.
Recurrent vaginal candidiasis can be treated with ______________.
treating the partner
Wheezing in someone with CHF –even right-sided CHF –should be treated with _____________.
diuretics
In patients with known asthma who are having an exacerbation, ____________ are useful to gauge severity of the exacerbation.
peak flow tests
