Q bank Flashcards
40ish female recurrent SOB improves with steroid and albuterol. CXR with pan lobular emphysema w/o smoking history. FEV1/FVC 0.67. Dx?
A1 antitrypsin deficiency
RFs: 40s, non smokerCXR with COPD, FEV1/FVC <0.7
Man with low testosterone. What test do you get next?
FSH/LH Helps to determine if primary or secondary hypogonadism (Low or normal FSH/LH suggest secondary) IF secondary - MRI If primary - Karyotyping
Kiddo with constipation, give them
Miralax
If pt is on amiodarone, they need periodic testing of?
TSH
At risk of hyper or hypo
q6mo screening
Toddler isn’t using left arm. Hold arm slightly pronated, flexed and close to body. TTP at lateral elbow. Now what?
Attempt to reduce the nurse maids with reduction of sublimed radial head
AS long as there is not e/o other injury (bruising, deformity) it is considered safe to attempt reduction w/o imaging
IVDU has a fever. Automatically get?
Blood cultures. Risk of IE is too high
1st line tx for dysmenorrhea?
NSAIDs
Pt has syx of BPH (nocturia) with normal PVR and PSA. What are your treatment options?
alpha-adrenergic blocker or PDE-5 inhibitor
MUST have enlarged prostate or PSA > 1.5 to start 5-a-reductase inhibitor (finasteride)
you suspect appy in a kiddo, what study do you order?
US
If you suspect SIADH, what confirms diagnosis?
Increased urine osmolarity
Remember, urine is too concentrated given how watered down the blood is
Also, increased arginine vasopressin
1st line BP meds for AA
Thiazide diuretics and CCBs
GLP-1 agonist that also lower risk of cardiovascular events?
Liraglutide (Victoza)
Most common sulfonylurea?
Glipizide
2 y/o with SCD needs what screening test?
Transcranial doppler - increased risk of vascular disease, especially stroke. Should be screened ages 2-16.
Signs of Fetal alcohol syndrome
Thin upper lip
Flat philtrum
Curvature of 5th digit of the hand (clinodactyly)
Flexion deformity of fingers (camptodactyly)
radioulnar synostosis
Spinal malformation/scoliosis
1st case of OM w/ effusion. Tx?
Conservative management, follow up in 3 months
Tx for low back pain w/o red flag syx?
1st line - NSAID
2nd line - NSAID + muscle relaxant
Steroids have no evidence
When would you image acute low back pain?
If red flag syx were present
Pt with parathesia in feet has A1C 5.8% and microcytic anemia. Dx?
B12 deficiency
Risk is higher with PPI use
If you’re suspicious for Addison’s disease, what BL test should you get before stim test?
ACTH
Helps to establish if primary or secondary adrenal insufficiency
ACTH 2x NL –> primary
Easy ORT for kiddos
Half strength apple juice
If you identify HCOM, what med do you start them on?
BBlocker - decreases DOE and chest pain and prevents sudden death.
Systolic murmur worse with Valsalva
can do NHD CCB if BBlock not tolerated
Demented lady doesn’t get better with redirecting. Next recommendation?
Start antipsychotic (ie Abilify)
Off label use of antipsychotics for behaviors is associated with increased mortality
D/c after 1 month if no improvement
- Vs donepezil which is prescribed to delay progression of dz
Tx for anovulatory uterine bleeding?
Hormonal IUD or 21 day cycle of Progestin
Patient with knee OA declines surgery and asks what would be most effective at pain relief
PT with quad strengthening
Intra articular steroids give short term relief, but do not effect moderate term outcomes
Pt just had PCA for angina and LDL 90. How do you manage him?
High intensity statin (Crestor 20-40mg, atorvastatin 40-80,)
indicated for all pts <75 with known CAD
Moderate intensity statins
Simvastatin 40
Pt has subclinical hyperthyroidism (low TSH, NL T4/T3), what complications are they at risk for?
Afib
CHF
Osteoporosis
Tx hyperthyroidism is patient is over 65, or TSH <0.1, Or if a comorbidity is present
What is a positive finding on Dix-Hallpike?
Nystagmus when vertigo is elicited
preferred antidepressant for elderly pt?
Lexapro
Pt with PTSD on Zoloft is having vivid dreams. Rx?
Prazosin
1st line PTSD - SSRI/SNRI, prazosin can then be added to augment therapy
OTC supplement with highest risk of drug interactions?
St. Johns wort
CYO3A4 inducer - messes up cyclosporine, warfarin, OCPs
1st line tx for social anxiety disorder?
SSRI
SNRIs are also a good choice
12 y/o with groin pain x 3 weeks, recent illness. On exam BMI >95%, limited internal rotation of hip. Dx?
Slipped capital femoral epiphysis
Most common hip disorder age 8-15
early dx essential to prevent early onset DJD of hip
Rarely associated with trauma/overuse
Need frog leg lateral views
Transient synovitis is more likely in kids under 10
Kiddo using albuterol ATC. Next step up?
Add an ICS
Next step add LABA or leukotriene receptor
What syx help to determine if palpitations are cardiac in nature
Occurs in their sleep or at work
If it happens in public places more like psych etiology
Female has scaling, redness, and irritation under her breasts x months not improving with antifungals. Dx?
Corynebacterium minutissimum
Coral pink under woods lamp
Corynebacterium minutissimum
Pale blue under woods lamp
Psuedomonas
Yellow under woods lamp
Tinea
Totally white under woods lamp
vitiligo
What’s the reasoning for not doing a pap yearly?
Annual screening does very little to prevent cervical cancer
Pt has Severely high bp in office (>180/110) w/o syx. What do you do?
Wait 30 min and recheck
For generally healthy patients (ASA II, ASA II) what preoperative testing should be done before a major surgery
CBC and renal function
You identify a stress fracture on a foot in a runner. How do you manage?
no weight bearing for a few days, followed by a walking boot, then a rigid soled shoes in 4-6 weeks
11 y/o if referred to you for persistent proteinuria. What do you do next?
A spot protein/Cr preformed first thing in am
Helps to differentiate if pathologic vs. transient exercise induced or orthostatic proteinuria
20 y/o F with very long history of vague syx with normal workup. Requesting surgical intervention. Dx?
somatic syx disorder
Commonly also abuse opioids or alcohol
Dupuytren conjecture over 30 degrees needs what intervention?
Surgery
Pt admitted for cellulitis, which abx?
Vanc
Most effective medication to prevent motion sickness?
Scopolamine (better than dramamine)
initial infertility work up, normal semen analysis
Luteal phase progesterone level (day 21 of cycle)
If NL (>5) pt should have hysterosalpingography to confirm if Fallopian tube is patent
If low (<5) check TSH, estradiol, FSH and prolactin
If unremarkable pt is candidate for clomiphene
if unsuccessful –> refer
Crohns pt s/p ideal resection has chronic diarrhea, tx?
cholestyramine QD
Pt has bile acid diarrhea and tx with bile acid sequestrate (cholestyramine) is helpful
Recommendation for child bearing age females not on OCP?
Folic acid 0.4-0.8mg
Most accurate maneuver to detect ACL tear?
Lachman
Donepezil increases risk of what side effect?
bradycardia
acts an an anticholinergic and increases vagal tone
Risk of being on a long term PPI?
Fx of hip, wrist, spine, CAP, C. diff, low mag, absorption of various vitamins
Pt has concussion without LOC. How do you manage return to sport?
Initial complete cognitive and physical rest followed by individualized graded return
Pre-op exam, patient has <1% risk of cardiac event and is asymptomatic. What additional testing is needed?
Nothing
Only get EKG if symptomatic or known CAD
Head lice observed on a kid - whence he return to class?
Immediately
discourage close contact w/ others
Otherwise healthy 40ish F has blood tinged sputum in setting of acute illness. Next?
CXR
Looking to r/o malignancy
Most common conditions associated with anterior uveitis?
Seronegative spondylarthropathies, sarcoidosis, syphilis, rheumatoid arthritis, reactive arthritis
Indication for emergent opt referral in conjunctivitis?
Reduced visual acuity
suggestive of acute angle-closure glaucoma
Significant risk factor for esophageal adenocarcinoma?
Obesity
In Europe also GERD and obesity
What would b e a worrisome syx in a patient with aortic stenosis and a systolic murmur?
DOE or dizziness
Indicator for valve replacement
Teenager has BP 130/80s (pre HTN). What do you do?
Stage I HTN
Check BMP lipids UA
Lifestyle modifications
Sarcoid pts should have annual exam of what organ system?
Ocular
Pt has thrombocytopenia (23k) without obvious cause, initial tx??
Steroids Most likely Idiopathic thrombocytopenia purport Autoimmune Tx if PLT <50k FFP only needed if signs of hemorrhage
syncope work up should include?
Orthostatic and EKG
Patient has normocytic anemia, initial work up?
Iron studies
Pt with posterior heel pain w/ nodular appearance at insertion of Achilles. Tx?
PT w/ eccentric calf-strengthening exercises
Dx: Achilles tendinopathy
chronic inflammation of eyelids
Blepharitis
Tx: warm compresses and mild shampoo
What meds can help improve mortality after an ACS NSTEMI admission?
Statin
ASA
ACEI/ARB
BBlocker
How much formula must a kiddo be on to not need Vitamin D?
At least 1L
If less than 1L they need 400 IU of vitamin D
How do you decide if scoliosis warrants referral?
Cobb angle >20 degrees
Also consider Female sex and if premenarche
If a patient has low Calcium d/t CKD what other labs are abnormal?
Elevated PTH Elevated phos This is CKD and mineral/bone disorder At increased risk of fractures and CAD phos isn't appropriately secreted
newborn has dimple on sacrum 1cm superior to anus with dark tuft of hair. Next?
Needs US
Need US when dimple is >0.5cm, wishing 2.5 cm of anal verge
US to dx spinal dysraphism
Diabetic patient has red warm foot that did not get better with abx. VSS, no SIRS criteria. Xray w/o gas or boney involvement. Now what?
Needs immobilization for Charcot neuroarthropathy
inflammatory condition in obese patients with peripheral neuropathy leading to foot deformity
What happens in a nurse maids (ie what bone has an issue?)
sublimation of the head of the radius
Tx for PAD?
Walking program Smoking cessation healthy diet statin - regardless of LDL single anti platelet
interventions for weight loss in a nursing home pt
avoid dietary restrictions
shakes
According to cardiology, what is the cut off for HTN?
130/80
Goal for fasting glucose ina gDM?
<95
2 hour Post prandial goal is <120, 1 hour <140
Tx for lyme
doxycycline 100 mg BID 7-21 days
Pt is going to be on long term steroids. How do you prevent osteoporosis?
Alendronate (Fosamax)
Pt FOOSH and + TTP over anatomical snuff box. NL Xray Tx?
Place in thumb spica splint with f/u in 2 weeks
Exam c/w scaphoid fx
Man has sTEMI, BP soft, what do you start?
ASA/Plavix, heparin
avoid Block d/t him going into cariogenic shock
Pt with syncope has murmur over RUSB, dx?
Aortic stenosis
What is the only tx that improves mortality in aortic stenosis?
Aortic valve replacement
What anxiety medication also helps with IBS?
Citalopram (Celexa)
Most sensitive/specific test for Herpes?
PCR or tissue culture
ELIZAs are sensitive, but not specific
Hallmarks of diabetes insipidus d/t lithium
Lithium levels can be therapeutic
Kidney’s ability to concentrate urine is resistant to vasopressin
Central DI responds to vasopressin
NL Sodium
Initial tx for GERD
4-8 wk of PPI
Medication that helps prevent altitude sickness?
Acetazolamide
Post partum pt with systolic heart murmur (chronic) increases intensity with valsalva. + hx of sisters with sudden cardiac death. Concern for?
HCOM Most common CM LVH w/o chamber dilatation AD inheritance Peripartum CM presents as heart failure
Patient has L main cardiac stenting with drug eluting stent for aCS and low risk of bleeding, how long should they be on dual antiplatelet?
At least 12 months in patients in pts with ACS with high risk of ischemic disease (DM, PAD, L main stenting, or h/o cardiovascular event
Abxs that increase risk of rupturing an aneurysm
Fluorquinolones (cipro, levo)
Avoid in patients with pre-existing aneurysms or at risk of them (ie, Ehlers-Danlos)
Pt with hyperthyroid on methimazole now with hyper syx and radioactive iodine uptake scan shows accumulation of tracer in multiple ares. Definitive treatment?
Thyroidectomy
dx - toxic multi nodular goiter
Which patient pop has highest prevalence of syphilis?
Men who have sex with men
When is tinnitus bothersome?
When it is unilateral, pulsatile tinnitus, or tinnitus with asymmetric hearing loss
What is the stages of change model?
Assess patient’s motivation for change and determine what stage they are in (pre contemplation, contemplation, preparation, action, maintenance)
Heel pain that is worse when a pt first gets out of bed, gets better with walking
Plantar fasciitis
achilles tendinopathy gets worse with activity
What lab tests helps to predict the severity of pancreatitis?
Hematocrit
BUN
Cr
Helps measure degree of intravascular volume depletion
When should a doc report possible child abuse?
If they suspect a child has experienced abuse or neglect
Which medications can improve survival in ACS?
Statin
ASA
ACEI
BBlockers
Pt with Sickle cell disease presents with T2DM syx, but HA1C 5.2%. What lab do you need?
Sr fuctosamine
HA1C falsely low in sickle cell d/t ban glycation
Young healthy pt presenting with SOB and LE edema. + proteinuria. Dx?
nephrotic syndrome
Check A:Cr to confirm if in nephrotic range
sewer has thumb pain over radial stylus. Dx Tx?
De Quervain’s
Immobilize in thumb spica and NSAIDS 1-4 wk
7 y/o has stinky pits and acne. Otherwise Tanner 1. Next?
Follow up in 3-6 months
Premature adrenarche with breast or pubic hair is usually idiopathy and can lead to normal development
If they have breast/pubic hair or height velocity before age 8 –> need w/u
7 y/o has elevated BP. Next?
Renal US
Most common: glomerulonephritis, congenital abnormalities, reflex nephropathy
Which medication can increase presence of calcium renal stones?
Topiramate
Tx for 5th metatarsal non displaced tuberosity avulsion fx?
Compressive dressing with weight bearing and range of motion exercises as tolerated
if minimally displaced - short leg walking boot
If >3mm displacement –> ortho referral
When do kiddos only need two doses of HPV?
If they get the first dose of HPV before age 15
vaccinate up to 21 in males, 26 in females
When is AV nodal ablation considered in fib?
When fib is refractory to medical therapy
Must be on AC for 1 month prior to procedure and several months afterwards
Patient has low back pain + shooting pain down the back of his leg x 1 week? What imaging do you get?
None
prophylactic abx after a cat bite?
Augmentin
Leading cause of death in the world?
Ischemic heart disease
Patient with hyperthyroid labs and high radioactive iodine uptake on a thyroid scan. Dx?
Graves dz
25 yo with b/l hilarious lymphadenopathy on CXR, otherwise asymptomatic. Now what?
Follow up CXR in 6 months
Possible this is asymptomatic - likely early sarcoid
this can resolve in most cases
Recommendation for vasomotor syx of menopause?
combined estrogen/progesterone
Not enough data to recommend black cohosh
Best long term management for symptomatic WPW that breaks into SVT?
catheter ablation
Patient with hip/back pain. FABER produces pain in the back. Dx?
Sacroiliac joint dysfunction
IF FABER produced pain in the groin –> femoroacetabular impingement
Tx length for provoked PE?
3 months
Initial tx for focal hyperhidrosis
TOP 20% aluminum chloride
scrotal pain. US: hyperemia, swelling, increased blood flow to testis and epidiymis. Tx?
Doxy + CTX
How should you counsel a patient regarding LASIK?
Satisfactory improvement of vision in almost all patients
May still need corrective lenses for 20/20 vision
40% experience dry eyes
20% have glares, also, starbursts
What can a patient do to reduce admission for COPD?
Written self-management plans that include smoking cessation plans
Tx for somatic symptom disorders?
SSRI (sertraline/zoloft) + CBT
SNRIs, TCAs, etc not effective
How do you interpret TSH in pregnancy
The TSH range in pregnancy is lower than the non pregnant state
hCG looks like TSH –> slightly higher T4 –> lower actual TSH
Pt with HTN and back pain has normocytic anemia and cr 1.6. NL iron levels. Now what?
Serum protein electrophoresis
C/f MM
normocytic anemia + renal insufficiency suggest MM
Pt in remission for breast cancer and has recent mamogram (<6 mo). What follow up does she need?
H&P and physical q3-6months for the first 3 years, 6-12 months for the next 2 years, then annually
kid can’t ambulate more than 2 steps after fall, now what?
X-rays
if can’t ambulate more than 4 steps needs imaging
Percentage of patients with a disease who have a positive test result
Sensitivity
Percentage of patients without the disease who have a negative test result
Specificity
What space are you targeting for rotator cuff tendinitis
Subacromial space
For stone 5-10mm what helps for expulsion from distal ureter?
Flomax
Pts with severe CAP benefit from IVF broad spectrum abx and?
Steroids
Criteria for severe increased RR, confusion, hypotension
What test is helpful in confirming post partum thyroiditis
Radioactive iodine uptake
During hyperthyroid phase radioactive iodine uptake is low which confirms dx
Can’t do this during pregnancy or BF
Elevated TPO Ab
Chronic autoimmune thyroiditis (Hashimoto’s)
Typically presents as hypothyroidism
Elevated thyrotropin receptor Ab
Graves dz
Teenager had sore throat and now is having dark urine and lower extremity swelling
acute post strep glomerulonephritis
Gross hematuria + HTN + systemic edema
Classic Microscopic UA finding in flomberuloneprhitis?
RBC cases
When do you see WBC casts on micro UA?
Pyelonephritis
When do you see EOS on micro UA?
Acute interstitial nephritis
Calcium oxalate on micro UA suggest
Stones
What can be a helpful office treatment for a patient with bad migraine refractory to po triptans
IM antiemetics - help with more than just nausea
Pancreatitis patient would like to try food on HD 2 but still has pain on exam. What do you do?
po as tolerated
recommend initiating oral food early in the course to protect gut-mucosal barrier and limit infectious complications
Does not increase LOS
Fancy word for liver spot
Solar Lentigines
bx if growing rapidly, change, painful, itch, bleeding, or atypical appearance
At 12 wks gestation women at high risk of Pre-e should start
81 ASA
Runner with heal pain, improved with rest. On exam heel I swollen and very tender when squeezed on the sides. Anterior heel and achilles ten insertion are not tender. C/f?
Calcaneal stress fx. Get MRI
Delay in dx increases risk of delayed union
Pt with morbid obesity, failed fad diets x years. Now what?
Bariratrics
Criteria for PCOS
Hyperandrogenism
Oligomenorrhea
PCOS on imaging
Pt has 50% occlusion on carotid a. Asymptomatic. Management?
Start statin and repeat in 1 year
Consider vascular referral if occlusion >70%
Tx for eosinophilic esophagitis?
Budesonide po suspension 1mg BID
or INH corticosteroid sprayed into mouth and swallowed
No systemic steroids
PTSD patient is in therapy but wants a med. Which rx?
SSRI or venlafaxine
Pt had rash after PCN in childhood. Had amoxicillin with rxn. What do you tell her?
She doesn’t have a PCN allergy
1st line tx for OA?
Exercise
what do most women with accidental pregnancy do?
Carry to term and keep baby - 58%
phenytoin increases risk of?
Osteoporosis
1 RF for AAA
long hx of smoking
In a head lice outbreak, in addition to permethrin tx, what do you recommend?
Wash closing, bedding in hot water and dry with hot air
Suspicious findings in lung nodules
non solid "ground glass" appearance size >6mm non calcified irregular borders doubling in size that takes more than 1 month but less than 1 year
Pt having a hard time falling and staying asleep after sleep hygiene and trial of doxepin, ER melatonin. What would you try next?
Eszopiclone (Lunesta)
Best fluid to cleanse a pressure wound with a shallow reddish-pink base?
Water or saline
Stage 2 pressure ulcer
4 y/o had first time seizure in setting of fever. Management?
Reassurance. Happens in 2-5% of kiddos under age 5
Pt about to undergo organ transplant wants contraception. What do you recommend?
IUD
Should avoid pregnancy in first 12 months after transplant d/t risk of preterm delivery and graft rejection
Female fertility tends to increase after transplant
IUD avoids medication interactions
Unilateral HA x months with conjunctival hyperemia and rhinorrhea. Dx and Tx?
Variant of cluster headache
Tx with indomethacin
Specific things to avoid when improving sleep hygiene
Pets in the bedroom
Caffeine after 4pm
Exercising within 2 hours of bed time
Nicotine
Tx for predominantly diarrheal IBS?
SSRIs
TCAs
Decrease abdominal pain
Pt with DOE, normal spirometry on PFTs but DLCO is low. Dx?
Chronic Pulmonary emboli CHF Connective tissue dz primary pHTN NOTE: asthma, bronchiectasis, COPD, fibrosis would have abnormalities on spirometry
Pt with artificial heart valve is allergic to PCN. What would you give?
Clinda or Azithromycin
Type of prevention who identifies at risk population and intervenes to prevent condition onset
Primary prevention
- ie childhood vaccine programs, fluoride in water, antismoking, safe sex
Type of prevention targeting people who have asymptomatic disease and applies a treatment to prevent progression
Secondary prevention
- ie BP screening, Pap tests, HA1C/cholesterol panel
Type of prevention that targets patients with known disease with goal to prevent progression
Tertiary
- Prevent MI with Block and ASA
How do you counsel patient receiving IUD about back up contraception?
If inserted within 7 days following menses, no back up needed
If more than 7 days, use back up x 7 days
Pt on HCTZ is started on carbamazepine for trigeminal neuralgia. What lab abnormality are that at risk of?
HypoNa
Carbamazepine causes SIADH
Pt with plaque psoriasis with high potency TOP steroids now has resistant plaques on trunk and arms. Now what?
Add TOP calcipotriene or TOP tazarotene
What is a modifiable risk factor for macular degeneration?
Smoking
Need urgent referral to ophthalmology
What has been shows to reduce mortality and length of stay in pancreatitis?
continuous NG enteral nutrition
kiddo has bug bites on arms/legs. Has excoriated erythematous papule on both forearms/legs that are itchy. Dx?
bed bugs
FEV1/FVC < 0.7
COPD
Start SABA
Pt has peripheral neuropathy in toes x months. NL CBC, A1C, B12. Elevated ESR and total protein. Next labs?
Sr protein electrophoresis
Elevated protein, ESR suggestive of MGUS or MM
Annual failure rate of OCP?
9%
Annual failure rate of hormonal IUD?
0.2%
Failure rate of depo?
6%
Failure rate of male condom
18%
Failure rate for pull out?
22%
All adolescents and adults should be screened for?
depression
kiddo bit by his cat and given CTX + augmentin x 10 days. Returning for persistent erythema and decreased ROm of thumb. Next?
Refer to surgery
C/f tendon sheath or joint infection
Post op patient has some confusion. What tool can you use to assess?
Confusion Assessment Method (CAM)
Useful when patient has acute change from cognitifve BL c/f delirium
- NOTE other tests like mini mental, MOCA, Mini Cog look from chronic BL function, not testing for acute change
what is true of direct observational therapy for TB?
decreases drug resistance
IN which ortho problem is a steroid INJ fix the underlying problem?
Trigger finger
- OA, epicondylitis, impingement, bursistis are all for pain control
What test should be done at a 9-11 y/o WCC?
Cholesterol panel
11-21 should also have depression screening
Fibromyalgia patient asks about adding SSRI. What do you say?
Does provide some pain reduction (up to 30%)
TCAs might be better
Patient has delirium, what’s the first thing you should do?
Determine and treat underlying cause of behavior change
Not physical or chemical restraints
Skin finding: pearly papular with telangiectasia
Basal cell carcinoma, most common skin cancer
more common on face/ears
Rarely mets
Diagnostic criteria of ADD
Syx interfere in more than one setting of: social, academic, occupational functions
Syx start before age 12
Person just used epi pen, now what?
go to ER
Tx for bacterial sinusitis
Augmentin
Must have: relapse of illness, >7 days of syx
infant has FTT and recurrent PNA. Sibling had SIDS. NL sweat test. Dx?
GERD
Syx: reccurent PNA, low growth curve, FHx of SIDS, normocytic anemia
SCD patient presents with cough, CP, hypoxia and CXR shows consolidation in RLL. Dx?
Acute chest syndrome
tx - 3rd gen cephalosporin/Azithro (need to cover mycoplasma and chlamydophila)
Screening test for vitamin D
25-dihydroxyvitamin D
1,25-dihydroxy D is better at monitoring the disease
PCOS patient wants a contraceptive to help regulate periods and decrease hirsutism. REcommend?
Combo OCP
What other condition can affect absorption of levothyroxine?
H. pylori
Atrophic gastritis
PPI use
May need a 30% reduction in dosing after treatment
Tx for uncomplicated cystitis?
Bactrim x 3 days
Nitrofuratonin x 5 days
13 y/o w/ no menses and no other secondary characteristics with short stature, NL TSH and prolactin. elevated FSH/LH. Next step in work up?
Karyotyping
Short stature, no secondary characteristics, and high FSH/LH suggest primary ovarian failure and Turner syndrome
IF you treat latent tb with with isoniazid, what other supplement do they need to prevent neuropathy?
Vitamin B6
How do you navigate an indecent elderly patient on warfarin having falls 1x/mo
Counsel benefit of AC outweighs risk
including those patients iwht cognitive impairment, faulty, or falls
Pt with chronic stable angina has HR 50s and started on ASA, statin, SL nitro. What else to start?
Isosorbide mononitrate or nifed/amlodipine
Pts with stable angina can be tx with BBlock, CCB, and/or long acting nitrates.
Avoid Block in this pt d/t bradycardia
hair dressers with numbness in unilateral 5th finger, progressive over months. worse with prolonged elbow flexion. + clumsiness with fine coordination. Intrinsic muscle weakness on exam. Dx?
Cubital tunnel syndrome
2nd most common peripheral neuropathy
ulnar n. compression in UE
For afib, what diameter of what structure on ECHO predicts likelyhood to maintain NSR after cardio version?
L Atrium
Significant enlargement makes maintaining NSR unlikely
Tx for clavicle fx?
sling for 2-6 weeks
Pt with lung cancer has new DVT. What AC do they need?
Lovenox
Considered a cancer associated thrombosis
Key DSM5 for Autism
Deficit in social communication in multiple contexts
Restricted, repetitive patter of behavior, interest or activities
Kiddo has GERD but is growing well and is comfortable. How do you counsel?
Reassurance
Generally improves with growth
Low volume feeds, elevate HOB, Thickeners
Avoid Rx in regurgitation that is effortless, painless, and not affecting growth
When can you breach patient confidentiality?
Abuse of vulnerable person (child, elderly)
Public health risk
Substantial danger to others
Blood glucose goal in septic patient?
<180
kiddo has 4 of: Irritable mood Argumentative/defiant behavior vindictiveness Must be directed toward a person other than a sibling Dx?
Oppositional defiant disorder (ODD)
Patient has post prandial fullness and early satiety with normal labs and EGD. Dx and Tx?
Functional dyspepsia
Reglan
10 y/o with CAP. Tx?
Azithromycin (preferred first line for kids 5-16)
Most likely bugs - mycoplasma, chlamydia, S. pneumonia
30s patient on 3 anti hypertensives and BP still elevated. K+ 3.0. Next test?
Plasma Aldo/renin
c/f hyperaldosteronism
Pt has Graves. What tx helps with exaphthalmos?
Methemazole
Bipolar I in remission wants to discuss d/c’ing sertraline and Seroquel. What do you do?
Continue all current meds
Pt has non painful swelling of elbow. Next?
Conservative management with ice, compression warp, activity modification
aspiration only indicated if pain or infection present
Incidental findings of non displaced wedge compression fx of T12. Management?
Early mobilization
what biostatistics value is helpful in selecting a screening test to r/o disease
Likelihood ratio
best tx for alcohol withdrawal with delirium?
Ativan
What strategy can help with challenging patients?
Motivational interviewing
Growing up around trauma increases risk of?
Alcohol/drug abuse Depression suicide obesity hyper sexuality and STDs
What BP med decreases stone formation?
HCTZ
What is the ultimate benefit of bariatric surgery?
Decrease risk of dying from obesity related illness
Constipated Pt has rectal pain and bleeding but only with BM. Dx?
More likely anal fissure
Hemorrhoids tend to have pain all the time
Contraindication to using GLP-1s for T2DM?
Thyroid cancer or MEN syndrome
In rare cases can cause pancreatitis but this is not a strict contraindication
Which region practices coin rubbing to promote healing and draw illness out of the body?
Southeast Asia (Cambodia, Korea, china, Vietnam)
When is tPA indicated in PE?
Hypotension (SBP <90)
Pt has fasting glucose of 107. Now what?
Repeat in 1-2 weeks
He has impaired fasting glucose (100-125) but needs to be confirmed on repeat testing
Infant born before 37 wk GA and exclusively BF. When should start iron supplement?
1 month of age and continue until 12 months of age
Only exception is if they receive blood transfusion in hospital
NH resident is MRSA positive. How do they control this when she returns to NH?
Strict hand washing by staff/visitors/residents
Barrier precautions to wounds
Runner with heel pain and palpable nodule over achilles. Dx tx
Achilles Tendinopathy
Eccentric calf strengthening exercises
Pt has single hyper plastic polyp on c-scope, when do they need a repeat?
10 years. This is considered a normal c-scope
A kiddos hemangioma has telangiectasia, fibrofatty tissue, dyspigmentation, and scarring. It has also involutedWhat to do?
Refer for surgical excision
Once involuted it needs excision for better outcomes
Prior to involuting tx of choice is po propranolol
Penile enlargement warrants endo eval when under what age?
9
1st line tx for SLE?
hydroxychloroquine
+ ds DNA
What can make a BNP falsely elevated?
Elevated Cr
Female >65
Low albumin
PP pt is considered about depression. What now?
Use validated screening tool for post party depression (Edinburg depression scale)
Pt gets PNA after staying in a hotel/cruise ship. Worry for?
Legionella
What is the minimum amount of time allowed between HPV vaccines?
6 months
Pt has hair thinning along pareital area and frontal hairline is preserved. Dx and tx?
female pattern hair loss
Minoxidil 2% BID
kiddo is being bullied. Approach?
See if high school counselors can address
spiritual assessments can be completed by?
Physician
COPD pt using albuterol ATC. Next step up?
Lon acting anticholinergic INH
Kiddo has round lesion with crusting. Dx Tx
Impetigo (S aureus)
Mucopirocin
9 y/o with knee pain. On exam lateral patellar tracking with knee extension. Dx?
Patellofemoral syndrome
Fib on AC has a STEMI no s/p drug eluting stent. how do you manage AC going forward?
AC + dual anti platelet
Can stop ASA at 1 month
benefits of probiotics in kids
Decrease abx associated diarrhea
reduce pain associated with IBS
Reduces crying up to an hour in breastfed infants
prevention of eczema and URI
Type of lung disease in systemic sclerosis?
ILD
Restrictive dz
pHTN is also common
Testicular pain better with elevation
Epididimytis
tx with Doxy/CTX
US: Hyperemia, swelling, increased blood flow
which polyp type has the highest likelihood of becoming malignant?
villous adenomas
What fingerstick glucose numbers qualify for T2DM
Fasting glucose >126
2hr ogtt >200
symptomatic pt with glucose >200
Dietary changes in cirrhosis
Low sodium
High protein
Pt has orthostasis and hyperpigmentation. Next work up?
ACTH stimulation test
Work up for primary adrenal insufficiency
What A1C range in a T2DM over 65 has the lowest mortality?
7.0-7.9%
healthy patient has elevated all phos. Now what?
Get a GGT. Helps determine if liver or bone
Medications that improve mortality in HFrEF
ACEI/ARB
Block
aldosterone antagonists
preferred vasopressor for septic shock?
Norepinephrine (levophed)
fewer side effects than dopamine
When in menses cycle can IUD be put in?
Anytime
Vaccinated kid has meningitis + roomie. now?
treat all kids in dorm with cipro x 1 (or azithro, CTX, rifampin.
PEEP indicated regardless of vax status w/in 14 days of exposure
40s F with proximal muscle weakness, dysphagia, pain in large joints x weeks. Difficulty getting out of chair. Violaceous rash over periorbital skin and macular erythema over thighs. Dx and other findings?
Dermatomyositis
Macules over extensor surfaces of joints (Gottron’s papule)
Toddler has 3days of viral URI syx and on day 4 has fever of 104. Now afebrile, fine maculopapular rash on trunk/extremities. Dx?
Roseola infant
Herpesvirus 6
Self limited dz
What is Erythema infectiousum
Fifth disease
“slapped check” appearance
parvo
What is molluscum contagiosum
poxvirus with scattered flesh colored papule with umbilicate centers
47 y/o is having longer, heavier periods. Next?
TVUS
premenopausal women account for 20% of endometrial cancers
Screen women with AUB if >45 or if they have a hx of unopposed estrogen exposure
Tx for manic episode
Lithium
Anticonvulsant (divalproex)
Antipsychotic (olanzapine)
Dancer can’t weight bear after standing on his toes and putting weight on lateral part of foot
Xray - Proximal 5th metatarsal metadiphyseal fx.
Dx and Tx
Jones fx
Tx depends on how active the patient is
Active patients - can return to sport sooner if they undergo surgery
Less active - posterior splint and f/u in 3-5 days, then non weight bearing cast x 6 weeks. If Xray shows healing can slowly start weight bearing. If no healing, non weight bearing status gets extended
45 y/o F has incidental adnexal fullness on exam, simple cyst on tVUS. Now what?
Repeat TVUS in 8-12 weeks
Most resolve after 2-3 menses
kiddo has ear ventilation tubes now with ear discharge. Management?
Cipro ear drops +/- steroid
Cut offs in transudative vs. exudative fluid?
fluid protein:Sr protein >0.5 = exudative
fluid LDH: Sr LDH = exudative
how do you manage an splenic patient?
Give po amoxicillin or levofloxacin to empirically treat fever until they can get medical care
initial tx for acne
TOP benzoyl peroxide, TOP retinoid, OCPs
Bariatric labs
CBC CMP Folic acid Iron studies PTH Lipids Vitamin B12 24h urinary calcium 25-hydroxyvitamin D DEXA q2yr
progesterone only contraception
levonorgesterel IUD Depot POPs Nexplanon safe for pts where estrogen is contraindicated
How do you handle iron deficiency in a bariatric pt?
They need IV iron d/t poor ability to absorb iron through gut
Pt taking Roxy regularly has a negative UDS. Now what?
Get a chromatography
Oxy is often negative on UDS
Pt has PLT of 100k, no syx. What do you do?
Review med list
Consider the H2 blockers as they can lower PLT
Pt with syncope has a big tongue, cardiomegaly and b/l carpal tunnel. Ddx?
Amyloid
Extracellular deposition of fibrous amyloid protein
Syx: proteinuria, peripheral neuropathy, tongue enlargement, cardiomegaly, malabsorption, b/l CTS, orthostatic hypotension.
Amyloid can be idiopathic or can be seen w/ MM
Asthmatic with a bad flare, having hard time weaning off red. Now what?
Increase dose of his maintenance INH, specifically ICS
1st line tx for depression in adolescent?
fluoxetine (prozac)
Monitor weekly x 4 weeks
1st line meds to rate control a fib?
Beta blocker or nondi CCB
Greatest risk factor for t2DM?
Personal hx of gDM
Medical care is paid on a fee for service, but his can go up or down based on quality or efficiency measures. What is this?
Value based reimbursement
Pt has dysphagia and unintentional 20lb weight loss. What does she need?
EGD to r/o esophageal CA
NOT a barium swallow
When do you need to r/o PNA in someone with acute bronchitis
dyspnea, tachypnea, tachycardia
T >100F
bloody sputum
Focal consolidation on lung exam
Nail goes through a kids shoes and makes a puncture wound. 2 days later it is warm and draining purulent fluid. tx?
Cipro
apparently nail through shoe is high risk for pseudomonas and only cipro has coverage (not reflex, doxy, Bactrim, augmenting)
back pain that awakens a kiddo from sleep nearly nightly. Dx?
Discitis osteomyelitis diskitis osteoid osteoma osteoblastoma spinal cord tumor
Tx for salmonella
supportive care
only abx if septic
when doc relies on an initial diagnostic impression despite subsequent information that suggested alternative dx could be more likely
Anchoring bias
How do you decide if a pt needs BRCA testing?
Administer a familiar risk stratification tool
kiddo has a barking cough, they need?
po dexamethasone
Male pt with h/o cryptorchidism s/p orchiopexy has a lump on testicle and US reveals hypo echoic mass. Now what?
Refer to urology (not check labs or re-asses in a few months)
High risk for testicular CA
Cannot biopsy d/t high risk of seeding cells
Next step would be radical inguinal orchiectomy - diagnostic and therapeutic
Pt has hyperthyroid syx/labs. Radioactive iodine uptake shows low uptake. Dx?
Subacute thyroiditis
“destructive phase” has hyperthyroid syx but uptake scan is negative
Uptake would be high in Graves and Multinodular goiter
All overweight or obese patients should be screened for T2DM after what age?
40
Can be done earlier if other RF present (Fix, gDM, PCOS)
F teen, anterior knee pain, worse with running down hill
patellofemoral syndrome
What T2DM med can you use in a pt that also has CHF class III and CKED (Cr 2, GFR 40)
GLP-1s (liraglutide = Victoza) Metformin contraindicated if Cr > 1.5 SGLT 2s (Invokana) contraindicated in GFR < 50 Tiazolidinedione (rosiglitazone = Avandia) not recommended in Class III or Class IV HF
Older adult with watery diarrhea up to 12 x day. Ddx and W/u
Microscopic colitis
Need bx of transverse colon
How long are fibronolytics contraindicated after ischemic stroke?
3 months
Based on Ottawa rules, when should you get foot and ankle Xrays
Inability to bear weight for less than 4 steps
TTP - posterior malleolus, 5th metatarsal, navicular
99% sensitive for detecting fracture
best way to assess a pts response to po iron?
Reticulocyte count in 1-2 weeks
Tx for chronic uticaria not responsive to loratadine?
H1 antihistamines - cimetidine
Doxepine
GLP1s
Liraglutide (Victoza) - only one with CV benefit
Exenatide (Byetta)
Dulaglutide (trulicity)
When do you consider treating subclinical hyperthyroidism?
ABN DEXA scan
A fib
CHF
Asyx smoker wants to be screened for COPD. What do you do?
No screening
Would get spirometry if they developed DOE or chronic cough
Pt with obesity, T2DM has thrombocytopenia with PLT 70k. LFTS mildly elevated. Dx?
Chronic liver dz from NASH
