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1
Q

Critères parkinsonisme

A

Bradykinésie + soit (rigidité ou tremblement au repos)

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2
Q

Ddx syndrome parkinsonien

A

Paralysie supranucléaire progressive
Dégénérescence corticobasale
Atrophie multisystémique
Démence à corps de Lewy

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3
Q

Parkinsonisme secondaire - 2 causes

A

Vasculaire
Médicamenteux
Trauma/lésion cérébrale
Métabolique/toxique (Wilson, hémochromatose…)
Infection (encéphalite, toxoplasmose)

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4
Q

Autres symptômes du Parkinson

A

Pré-symptomatique: Micrographie, modification de al voix, hyposmie, dépression, somnolence, anxiété/dépression

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5
Q

Démarche en Parkinson?

A

Retard au démarrage, lent, petits pas, demi-tour décomposé, diminution ballant des bras

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6
Q

Dx clinique du Parkinson

A

Parkinsonisme (donc 2 des 3 critères)
Pas de critère d’exclusion
Pas drapeaux rouges

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7
Q

Démence à corps de Lewy

A

1) Fluctuation fonctions intellectuelles (attention, souvenirs, compétences visuospatiales)
2) Hallucinations visuelles
3) Trbl comportement sommeil paradoxal
4) Parkinsonisme

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8
Q

Corps Lewy VS PD: différence onset?

A

PD: démence se présente >1an après symptômes (VRAIMENT TARD)
Démence Corps Lewy: démence peut apparaître avant symptômes moteurs

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9
Q

Tremblements au repos?

A

Sos parkinsonisme

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10
Q

Tremblements ua mouvement/action

A

Essentiel, physiologique
Cérébelleux
dystonique
Médicamenteux
Métabolique
Etc

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11
Q

Acteurs à impliquer Parkinson?

A

Nous
IPS
Nutrition
Groupes: Parkinson Canada
Neurologue, urologue
PHyio/ergo

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12
Q

Tx Parkinson sauf LEvodopa

A

1) Inhibiteurs MAO-B (rasagiline, selegiline, safinamide). ES: céphalées, nausées
2) Amantadine - rarement utilisé. ES: livedo reticularis, OMI
3) Anticholinergiques si tremblements dérangeants sans bradykinésie, trbl marche significatifs. ES: trbl mémoire, confusion, halluciatninos, bouche sèche

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13
Q

Tx classique Parkinson (2) avec ES

A

Levodopa. ES: dyskinésie, nauséée, somnolence, étouridssement, céphalée,HTO

Agonists dopamine. ES: NMS, akinésie, trbl contrôle impulsion

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14
Q

Problèmes comorbides à tjrs suivre pour PD?

A

Statut fonctionnel (AVQ/AVD)
ES médications
Dépression
Démence
Chutes
Constipation
Trouble sommeil

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15
Q

Infertilité: définition

A

Absence de conception après 12 mois de coit non-protégé, 12-15% couples en âge de reproduction
Primaire = déjà eu conception, secondaire = jamais eu conception

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16
Q

Histoire pour infertilité?

A
  • Antécédents personnels et fam, médication, habitudes de vie
  • Histoire gynécologie-obstétricale avec histoire menstruelle (STI, PID, surgeries, dysmenorrhea, dyspareunia, regular cycles)
  • Habitudes sexuelles : Fréquence et moment, temps d’essai
  • Durée d’infertilité, investigations faites, résultats d’examens
  • Symptômes d’affection (thyroïdien,SOPK, hyperprolactémie, trouble alimentaire, insuffisance ovarienne) , etc.
  • Revue de système
  • ITSS

Hommes:
- Occupation (radiation, heat, chemical)
- HDV
- Problèmes érectiles et éjaculatoires
- ATCD de trauma, infections génitales, surgeries, tx of genital organs
- Causes idiopathiques : Pantalon / culotte serré, exposition à la chaleur, marijuana

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17
Q

Physical exam for fertility?

A
  • Thyroid and breast exams (signs of galactorrhea)
  • Abdominal and pelvic pain
  • Male exam
    • Genital signs of symptoms
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18
Q

Signes de l’ovulation

A
  • Présence de menstruations régulières q 28 à 35 jours
  • Syndrome prémenstruel
  • Changement de la glaire en milieu de cycle
  • Douleurs ovulatoires (Mittelschmerz)
  • Courbe de température
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19
Q

Conseils non-pharmaco infertilité

A
  • Perdre poids (si IMC > 30)
  • Cesser de fumer
  • Cesser drogues et alcool
  • Prendre des suppléments d’acide folique (1 - 5mg die) et multivitamines
  • Éviter les lubrifiants spermotoxiques
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20
Q

Infertilité algorithme femmes

A

PRISES DE SANG (CBC, TSH, proges etc)
1) Confirmation si ovulation (courbes température, détection LH urinaire/test ovulation, dosage prosgetérone sérique, biopsie endomètre)
2) Examen tubaire: hystérosonographie, hsytérosalpingographie, laparoscopie
2) Examen endométrial: Hystérosalpingographie, hystérosonographie, biopsie endomètre

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21
Q

Ddx infertilité - femmes

A

1) Tubaire
2) Ovulatoire (SOPK, hypoT4, hyperPROL, tumeurs hypophysaires, insuffisance ovarienne précoce, Cushing, tumeurs sécrétant androgènes)
3) Endométrial
4) Cervical

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22
Q

Ddx perte de poids

A
  • Malignancy
  • GI (PUD, celiac, IBD)
  • Psychiatric (depression, eating disorders)
  • Endocrine (hyperthyroidism, diabetes, adrenal insufficiency)
  • Infectious (HIV, viral hepatitis, tuberculosis, parasite)
  • Chronic disease (heart failure, renal failure, autoimmune)
  • Neuro (stroke, dementia)
  • Medications/substances
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23
Q

HPI for weight loss

A
  • Pattern of weight loss
  • Intentional vs. Unintentional (r/o eating disorder)
  • Dietary history
  • GI symptoms (N/V/D, dysphagia, abdominal pain, early satiety)
  • Malignancy (fever, fatigue, chills, night sweats)
  • Psychiatric (depression, mood)
  • Medication, Alcohol, Drugs
  • Social (Income, Activity) and Function (Dementia)
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24
Q

Définition perte de poids

A

5% over 6-12 months

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25
Q

Rapid antidotes in poisoning?

A

1) Dextrose can be given 50mL of D50W, if no IV access can give Glucagon 1mg IM

2) Oxygen, 100% O2 in carbon monoxide poisoning

3) Naloxone in life-threatening is 2mg initially up to 10mg, or if non-life-threatening 0.1mg initially doubled every two minutes up to 10mg

4) Thiamine (B1) given 100mg IV/IM/PO with 25g dextrose (50mL of D50W) to prevent Wernicke’s encephalopathy (suspect thiamine deficiency in malnutrition (alcoholics, anorexics, hyperemesis of pregnancy)

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26
Q

Safety to avoid child poisoning?

A
  • Keep items locked and out of reach/sight
  • Keep in original containers (safety lids)
  • Don’t take medications in view of children
  • Don’t refer to medicine as “candy”
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27
Q

Classic poisoning substances with antidotes

A

Antipsychotics (acute dystonic reaction) -> Benztropine, diphenhydramine

Anticholinergic -> Physostigmine salicylate (Antilirium)

Organophosphates, Carbamates (Cholinergic) -> Atropine, Pralidoxime

Digoxin -> Digoxin immune Fab (Ovine, Digibind). Consider MgSO4 to stabilize if delay in digoxin antibodies

Iron -> Deferoxamine (Desferal)

TCA (Cardiotoxicity, convulsion, coma)-> Sodium Bicarbonate 1-2mEq/kg

Cocaine, Methamphetamins, amphetamines (sympathomimetic) -> Rapid cooling, Benzos, Fluids + Nitroglycerine infusion

Cyanide -> Hydroxocobalamin 5g, Sodium nitrite 300 mg., Sodium Thiosulfate 12.5g, 100% oxygen

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28
Q

What to ask if ingestion/poisoning?

A

Patient often unreliable – use collateral sources (paramedics, police, family, friends, pharmacist)

Who - patient’s age, weight, PMH (alcoholism, renal or hepatic disease)

What - name, dosage of medications (including OTC) or substances, coingestants, amount

When

Where - Injection or ingestion

Why - intentional vs unintentional

Commonly ingested nontoxic substances

Personal care products: Soap, shampoo, lipstick, lotion, perfume (low alcohol), eye makeup, toothpaste, deodarant

Household items: Thermometers (glass potentially harmful), pen ink, crayons, chalk, candles, pencils/erasers, laundry detergent, fabric softener, bleach

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29
Q

Timeline for activated charcoal, 1-2 g/kg?
Contraindications?

A

1-2h
Non-toxic ingestion
High-risk of aspiration
Specific types of stuff: caustic acids/alkalis, alcohols, lithium, heavy metals

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30
Q

Work-up for intoxication?

A

CBC
Lytes, Glucose
Hepatic/renal function
UA
Serum osmolarity
VBG + lactate
Serum drug levels (Tylenol, Salicylates, Ethanol)
Pregnancy Test

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31
Q

Osmolar gap formula

A

Measured serum osmolarity - (2Na + Gluc + Urea)

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32
Q

What increases osmolar gap?

A

Methanol
Ethylene glycol
Sorbitol
PEG
Propylene glycol
Glycine
Malcose

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33
Q

5 toxidromes?

A

Anticholinergic
Cholinergic
Opioids
Sedatives-Hypnotics
Sympathomimetic

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34
Q

Acetaminophen Intox? Antidote?

A

Toxic 150 mg/kg (7.5-10g for an adult)

Labs: >4h Tylenol Level on Rumack-Matthew Normogram, ALT/INR

N-acetylcysteine (NAC, Mucomyst) indications:
1) known time and above treatment line
2) uknown time ing or >24h/chronic
3) any signs of liver injury

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35
Q

Indications for inpatient tx/hospitalisation in depression patients

A

Active SI/HI
Psychotic features
Major impact on functioning)

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36
Q

Patients at higher risk of depression

A

Comorbid medical d/o (CAD, hypoT4)
Comorbid psychiatric d/o (anxiety, SUD)
Low SES
Post-partum women
Chronic pain patients

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37
Q

In who/which behaviours should I be screening for depression?

A

Multiple visits with unexplained symptoms
Work/relationship dysfunction
Weight/sleep/energy/memory/cognitive complaints
Comorbidity (IBS, obesity, CVA, cancer)
Substance abuse

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38
Q

Definition criteria of depression

A

≥ 5 (with either depressed or decreased interest) for >2w with change in functioning
- Sad (depressed mood most of the day)
- Interest (loss)
- Guilt
- Energy
- Concentration, memory
- Appetite
- Psychomotor agitation/retardation
- Sleep (mostly end of night, early mornings)
- Suicidal ideation
- Other criteria
- Causing significant distress/impairment (change in functioning, occupation/social/other) - functioning impairment with impact on QoL
- Not caused by other psychiatric condition (manic, hypomanic, schizoaffective disorder, schizophrenia, delusional disorder, schizophreniform or others)
- Not caused by organic pathology or substance uses

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39
Q

Antidepressants for depression with anxious features

A

Paroxetine, Sertraline, Venlafaxine

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40
Q

Antidepressants for psychotic features

A

Quetiapine

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41
Q

Antidepressants with sleep disturbance

A

Mirtazapine, Quetiapine, Trazodone

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42
Q

Treatment for depression - non-pharmaco

A

Regular exercise - group physical activity programs
Adequate food intake
Adequate sleep
Avoid substance use
Stress management techniques
Behavioral activation

Thérapie (CBT, ITP)

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43
Q

Treamtent depression - indication for pharmacological tx

A
  • Past history of moderate/severe depression
  • Long period (>2y) of subthreshold depressive symptoms
  • Persistent symptoms after other interventions (ex CBT/IPT)
  • Moderate/severe depression in combination with CBT or IPT
  • Mild-moderate-severe depression but no access to CBT
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44
Q

Monitoring response and modify appropriately treatment in depression?

A

If >20% improvement at 2-4w, continue treatment and reassess at 6-8w
If <20% improvement at 2-4w, increased dose OR switch to another medication

DONC la réponse serait tjrs de augmenter dose max, si partial response tu peux ajouter adjunct (genre quetiapine), si aucune répnose tu changes d’agent complètement.

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45
Q

Symptômes de sevrage SSRI

A
  • FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal)
  • Typically resolves in 1-2 weeks
  • Worse with Paroxetine, Venlafaxine
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46
Q

Conditions médicales à r/o pour dépression

A
  • Adrenal insufficiency, hypercortisolism, hypothyroidism, diabetes
  • Mononucleosis
  • Multiple sclerosis, Huntington disease, Parkinson disease, systemic lupus erythematosus
  • Obstructive sleep apnea
  • Stroke, traumatic brain injury
  • Vitamin B12 insufficiency
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47
Q

2 choses à penser absolument si pt se présente avec dépression

A

r/o abus de substance
r/o abus domestique

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48
Q

Déf dysthymie (PDD)

A

1) humeur dép quais toute la journée, plus d’un jour sur deux, pendant au moins 2 ans
2) 2 ou plus de: appétit, sommeil, fatigue, faible estime de soi, trbl concentration, désespoir (PAS PERTE INTÉRÊT, PAS IS, RETARD/AGITATION, PAS TRISTESSE)
3) pas de période de 2 mois sans les 2 du critère 2

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49
Q

Adjustment d/o definition

A

1) Emotional/behavioral sx responding to a stressor wichin 3 months
2) Marked distress/significant impairment
3) Does not meet criteria for another mental disorder/exacerbation of preexisting
4) NOt normal bereavement
5) When stressor over, does not persist more than 6 months

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50
Q

Which symptoms should I ALWAYS ASK ABOUT when depression?

A

Maniac
Psychotic
Suicidality

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51
Q

Risk factors for anxiety

A

Family history of anxiety
Personal history of anxiety/mood disorder
Childhood stressful life events or trauma
Female
Chronic medical illness
Behavioral inhibition

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52
Q

Screening questions for GAD?

A

During the past 2 weeks, have you been bothered by
1) Feeling worried, tense, or anxious most of the time?
2) Not being able to stop or control worrying

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53
Q

Screening questions for panic d/o

A

In the past month, have you on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy even in situations where most people would not feel that way?

Did the spells peak within 10 minutes?

Have you spent more than a month in fear of having another attack or about the consequences of the attack?

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54
Q

Ddx for anxiety

A

Medical (palpitations, chest pain, dyspnea/trouble breathing, etc).
Cardiovascular: Myocardial Infarction, Arrhythmia, CHF, valvulopathy
Respiratory: Pulmonary Embolism, Asthma/COPD
Endocrine: Hyperthyroidism, hypoglycemia
Metabolic: Vitamin B12, porphyria
Neurologic: TBI

Psychiatric comorbidities

Medication-induced

Substance-induced: Intoxication (caffeine, stimulants) or withdrawal (benzodiazepines, alcohol)

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55
Q

Differentiate between distress (fear, nervousness, worry) and anxiety disorder

A

LEADING TO A MALADAPTIVE BEHAVIOUR, THOUGHT AND COGNITIONS AND POORER PERFORMANCE

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56
Q

What should I screen for in anxiety d/o? What should I always ask?

A

all other comorbid psychiatric conditions: mood d/o (depression, bipolar so MANIA), psychotic d/o, personnality d/o
SUBSTANCE USE D/O
dangerosity

FUNCTIONAL IMPAIRMENT

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57
Q

Treatment for anxiety
1) Self-management
2) Community resources
3) Therapy
4) Pharmacotherapy

A

1) Relaxation, breathing control skills, physical activity, self-help books, internet-based CBT
2) Support groups, SW
3) CBT, psychotherapy
4) another question honey

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58
Q

Pharmaco tx for GAD

A

Duloxetine, escitalopram, paroxetine, sertraline,venlafaxine

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59
Q

Tx for social anxiety d/o

A

CBT
Exposure therapy
Beta-blockers before presentations
Escitalopram, paroxetine, sertraline

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60
Q

Antidepressant chez enfants/ados

A

fluoxetine

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61
Q

Work-up pour r/o organic disease en anxiety

A
  • CBC
  • Electrolytes, Fasting glucose
  • TSH, LFTs
  • Lipid profile
  • UA, urine toxicology for substance abuse
  • EKG for arrhythmia
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62
Q

High-risk group for substance use?

A

Mental health comorbidities (depression, ADHD, schizophrenia, etc)
Chronic disability
Family or personal hx of SUD
Associated symptoms (functional decline, confusion, delirium, syncope)
Associated medical problems
Prescription medication that are commonly misused (opioids, sedatives, hypnotics, anxiolytics, stimulants)

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63
Q

Outil pour screen SUD?

A

CAGE

Have you ever felt you had to cut down on your drinking?
Do you get annoyed by criticism of your drinking?
Do you ever feel guilty about drinking?
Do you ever take an early-morning/eye opener drink?

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64
Q

Definition de SUD

A

1) Pattern of using a substance resulting in clinically significant impairment/distress
2) 2 or more of the following within a 12 MONTH PERIOD: impaired control, social impairment (obligations, family, work, relationships, gave up activities), risky use (driving, sex,), pharmacological indicators like withdrawal/tolerance

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65
Q

Harm-reduction strategies in SUB

A

Needle exchange
Driving and driving
Immunizations in ITSS

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66
Q

Method to dsscuss a change in habits

A

1) Ask (frequeny, amount, etc)
2) Advise: you should stop, do you wanna hear about the benefits/risk
3) Assess: are you ready to change (pre-contemplation not ready, contemplation im thinking about it, preparation actively planning a quit, action involved in a quit attempt, maintenance)
4) Assist: barriers? strategies? resources, medications?
5) Arrange FU

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67
Q

When a patient comes in with functional decline
confusion
delirium
THINK ABOUT

A

SUBSTANCE USE DISORDER

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68
Q

Signs of substance use in adolescents

A
  • School failure
  • Isolation, negative symptoms
  • Behavior change
  • Dangerous behaviors
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69
Q

Opioid-use disorder: what to do periodically? what to discuss?

A

1) Reassess clinical problem to make sure they still need the medications
2) Assess other substance use
3) Safety recommandations (do not share meds, store meds in safe location, do not receive meds from other sources)
4) Avoid use of sedatives/depressants
5) Monitor for symptoms, FUNCTION, adherence

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70
Q

Différences entre UA vs NSTEMI vs STEMI

A

UA: tropos neg
NSTEMI/STEMI: tropos pos

Changements ECG pour UA/NSTEMI, ST Elevations pour STEMI

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71
Q

Populations qui se présentent sans classique DRS?
Et définition DRS

A

Pression rétrosternal, pire avec l’effort, moins pire avec repos
Populations: gériatrique, femmes, diabétiques

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72
Q

Facteurs de risque CMP ischémique

A

Age
Homme
IRC
Diabète
MCAS
Family history
Tobacco
Physical activity
Nutrition (mediterranean, DASH)

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73
Q

What tests to rule out cardiomyopathie ischémique? Si suspicion clinique élevée et si ECG/Tropos N

A

Test à l’effort
MIBI à l’effort
Échocardio à l’effort

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74
Q

CMPi stable: gestion des symptômes? Principes du traitement

A

1) Changements d’habitudes de vie (tabac, roh, perte poids, exercise, DM/DLP/HTA)
2) Thérapie antiplaquettaire selon
3) Médications antiantineuses: BB (2 ligne CCB, nitrates)

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75
Q

QUestions à poser pour le suivi des patients avec MCAS?

A

1) Contrôle des symptpomes, IMPACT SUR LA VIE
2) adhérence aux médications
3) Modification des habitudes de vie
4) Dépistage des complications

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76
Q

Classes NYHA

A

Class 1: Pas de limitation
Class 2: Slight limitation (SOB/fatigue) during moderation exertion/stress
Class 3: symptoms with MINIMAL EXERTION with normal daily activity
Class 4: inability to carry out physical activity

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77
Q

Meds in acute coronary syndrome?

A

O2
Nitro
Morphine - only if refractory pain to nitro
Antiplaquettaires: ASA 320 x1 with either Plavix/Ticagreol 600/180 x1
Anticoagulants: 48h to 7 d, depending on when is coronarography. Hep (invasive) VS LMWH (conservative)

BB - within 24h if no signs of HF
Statin - later
IECA - later

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78
Q

DB: screen who/when?

A

Use de FINDRSICK
If low-mod-risk, no screen indicated, reassess RF annually
High risk: screen q3 years
Very high risk: screen q6-12mo (FHx DMT2, non-white, low SES, hx HDM/preDB, CV RF, associated diseases (PCOS, OSA), drugs a/w DB (atypical AP, HAART, glucocorticoids))

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79
Q

Dx of DB?

A

FPG > 7.0 (6.1-6.9)
A1c > 6.5% (6 - 6.4)
2hPG > 11.1 or random > 11.1 (7.8 -11)

2 TESTS DIFFERNET OCCASIONS
or 1 test + symptomatic

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80
Q

If HbA1c < 1.5% from target at dx, what do you do?
If HbA1c > 1.5%?
If symptomatic hyperglycemia?

A

Lifestyle x 3 months then MTF
MTF
Insuline +- MTF

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81
Q

Targets in DB?

A

< 6.5 if low risk of hypoglycemia
< 7 most adults
7.1-8.5 if recurrent hypoG, limited life expetancy, elderly, dementia

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82
Q

Labs at dx DB?

A

FSC
Lytes + Creat
Lipid profile
TSH
ALT
UA
ACR (2 positive = proteinuria)
ECG

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83
Q

What other rx to start (other than glucose control) for DB?

A

Statin (always)
ACEi/ARB (if ACR >2, CV RF)
SGLT-2 (CAD, PAD, carotid disease, not at target)
ASA (CAD, PAD, carotid disease)

84
Q

Follow-ups/exams to do in DB?

A

Neuropathy: qyear monofilament exam, with foot care qyear
Retinopathy: opto qyear
Nephropathy: ACR qyear
Lipids qyear
ECG q3-5y

85
Q

DKA

A
  • Advise patient it exists
  • Stop meds if stress/infection/unwell/etc.
  • Management: FLUIDS, insuline + glucose, serial glucose/gas with lactate. Insuline until anion gap closed.
86
Q

Screen who for HTA?

A

Anobody older than 18yo
Consider in older than 3yo

87
Q

Cut-offs for HTN dx?

A

MAPA 135/85 daytime (or 130/80 24h)
OR
Home BP 135/85

88
Q

What to ask periodically for HTN patients?

A

PMHx/FHx of CVD, HTN, DB
Lifestyle (diet, exercise, habits)
HPI:
- daytime sleepiness, morning h/a
- LLE, dyspnea, CP
- Stroke sx
- PAD sx
- h/a, tinnitus, dizziness, palpitations, epistaxis

89
Q

Initial work-up for HTN dx

A
  • CBC, Lytes + Creat/GFR
  • Calcium
  • FBG/HbA1c, lipid profile
  • TSH
  • ECG (LVH, CAD, arrhythmias)
  • Urinalysis (proteinuria)
90
Q

Causes of secondary hypertension?

A
  • Renal (Renovascular HTN (renal artery stenosis, polyarteritis nodosa, fibromusuclar dysplasia of renal arteries), Polycystic kidney disease (vasculitis of small/medium vessels), Renal failure (any disease impairing GFR), Glomerulonephritis, SLE, Renal tumors, Atrophic kidney)
  • Endocrine (hyperaldosteronism, cushing, pheochromo, hyperT4, HyperPTH)
  • OSA
  • Meds (sympatomimetic, corticos, nsaids, contraceptives)
  • Drugs (amphetamines, cocaine, caffeine, NSAIDs)
91
Q

Who should we investigate for secondary HTN?
What are the investigations?

A

1) Young, abrupt onset, high diastolic, recurrent hypertensive crisis, or refractory
2) Lytes, CBC, TSH, VBG, UA, cortisol, calcium, PTH, polysomnography, doppler renal arteries, serum metanephrines

92
Q

Lifestyle changes for HTN?

A

Exercise (150 min/week)
Weight loss
Decrease ROH
Smoking cessation
Diet: DASH, sodium < 200 mg, K increase

93
Q

Target for treatments?

A

High-risk: 120
DM: 130/80
Low-risk: 140/90

94
Q

First line for HTN treatmen?

A

If DM/CKD: ACEi/ARB
If black: Thiazide diuretics
If nothing: CCB (Amlo)

95
Q

Lifestyle changes when pregnant?

A

Folic acid (low-risk: 0.4 mg, moderate: 1 mg ad 12 weeks, high risk: 4-5 mg DIE - include Methotrexate/MTF/Sulfa, hx of fetus with neural tube defect/birth defect like facial cleft, heart diseaase, limb defect. FHx of NTD. Epilepsy. IDDM. Obesity. IBD/GI malabsorption, celiac dz, advanced hepatitis condition. Dialysis. Social components.

MEDICATIONS: stop retinoids/Vit A, ACE/ARB, Warfarin, Sulfa/Trimothoprim, Tetracycline, NSAIDs

Smoking cessation

ROH cessation

Undercooked meats, unpasteurized foods

Avoid cat litter

96
Q

What should we establish in ALL PREGNANCIES?

A

Desirability

97
Q

Who are the high-risk pregnant patients?
(psychosocial AND medical)

A

Teens
Domestic Violence Victims
Single parents
Drug abusers
Impoverished women/low SES

HIV
IVDU
Diabetic
Epileptic
Environmental exposures
Travelling
Family genetic history

99
Q

Chronic conditions to ask about in new pregnancy?

A

Diabetes (important because good glycemic control essential for good organogenesis)
Hypertension (a/w preterm birth, placental abruption, IUGR, pre-eclampsia
Asthma
Thyroid disease
Thrombophilia
Seizure disorders
Herpes
Hep B
Abnormal cytologies

100
Q

Blood tests first tremester pregnancy?

A

FSC + Groupe Rh + recherche d’anticorps
TSH
Glyc à jeun

Rubéole
Syphillis
Hep B
VIH

A/C Urine
Considérer électrophorèse Hgb si méditerranean region

101
Q

In anybody who is sexually active what should we talk about?

A

Fertility
Delayed child bearing more and more because accessible contraception, women in post-secondary education, etc.
Should be evaluated after 6 months of unprotected sex if older than 35 yo.

102
Q

Definition of PROM
Risk factors
Management

A

Rupture of membranes BEFORE labor (premature PROM = before 37w)

RFs: amniocentesis, cervical insufficiency/cerclage, prior PPROM/preterm birth, vaginal bleed, abruption, multiple pregnancy, polyhydramnios, smoking, STI, BV, low SOS

Management:
- NO DIGITAL EXAM
- Sterile speculum, pooling, ferning, nitrazine, culture for STI/GBS
- Admission
- Oxytocin, +/- abx

103
Q

Definition of hypertensive d/o of pregnancy

A

1) HTN: before 20 w

2) Gestational HTN: after 20w

3) Preeclampsia: 140/90 with proteinuria, OR hypertension with severe features of preeclampsia (end-organ-damage: decreased PLTs, high creat, pulmonary edema, high AST/ALT, h/a, visual symptoms)

4) Eclampsia: seizures

104
Q

Who is at risk for preeclampsia?

A

Nulliparity
OBesity
FHx of PE
Age 35 and up
Low SES
African American

Previous PE
Multifetal gestation
Pre-existing medical conditions (HTN, DB, renal disease)
Autoimmune disease

105
Q

Management of pre-eclampsia

A

Goal BP 140/90 (Nifedipine, Labotalol)
MgSO4 as prophylaxis (severe PE, non-severe PE with sypmtoms, HELLP)
Delivery

106
Q

Dystocia definition?
Causes?

A

First stage: 4h of < 0.5 cm/hr dilation OR no cervical dilation >2h
Second stage: >1h active pushing without descent

Causes: 4 P
- power - oxytocin
- passenger - reposition
- passage - ensure bladder empty
- psyche - pain/anxiety

Anagelsia, hydration, rest
Amniotomy
Oxytocin
Assisted vaginal birth
C-section

107
Q

Complications in labour? 4

A

Abruption
Uterine rupture
Shoulder dystocia
Non-reassuring fetal monitoring

108
Q

Abruption: RF and management

A

RF: previous abruption, smoking, hypertension, PE, PROM, chorioamnionitis, COCAINE, polyhydramnios, abdo trauma)

50% of cases result in DIC

Échographie pour localiser placenta
O2, DLG, bolus, monitoring

Si pas d’atteinte fétale, induction avec monitoring. Si atteinte fétale: accouchement d’urgence.

109
Q

Uterine rupture

A

RF: previous rupture/CS/vertical hysterectomy/IOL with misprostol.
If unscarred uterus, RF are: trauma. Weakness of myometrium. Dystocia with prolonged labor. Uterotonic drugs. Placenta Accreta. Multiparity. Multiple gestations.

OR VERY FAST

110
Q

Shoulder dystocia: RF

A

Suspected macrosomia
Diabetes
GA more than 42w
Multiparity
Previous hx of dystocia
Previous macrosomia
Weight gain
Obesity

Prolonged labour
Operative vaginal delivery
Labour induction
Epidural anesthesia

111
Q

Shoulder dystocia management

A

ALARMER

Ask for help, stop pushing
Lift legs in McRobert’s
Anterior shoulder disimptation (suprapubic pressure)
Rotate posterior shoulder like screw (Wood’s)
Manual removal posterior arm (cal lead to fracture0
Roll onto all fours
Episiotomy

112
Q

PPH: definition, causes

A

Definition: 500 cc vaginal, 1L CS

Causes:
Tone (uterine atony, distended bladder, infection)
Trauma (lacerations)
Tissue (retained products)
Thrombin (coagulopathy)

113
Q

PPH Management

A

ask for help, IVs, fluids, O2, monitoring, Foley

1) Bimanual fundal massage
2) Oxytocin
3) TXA 1g over 10min
4) Uterotonics: Hemabate, Misoprostol, Methylergonovine
5) Intrauterine tampoande with balloon
6) surgery

114
Q

PP blues vs depression

A

Blues: onset day 3-10, anxiety, irritability, decreased concentration, sleep disturbance. LESS THAN 2 WEEKS

Depression: within 1y
2w or more of symptoms
RFs: previous depression, poor social support, poor financial support, stressfull live events during pregnancy, treat SSRI/psychotherapy

115
Q

Problems with breastfeeding

A

1) Inadequate milk production:
- problems with breast like previous surgeries, radiation, endocrine
- delay in lactogenesis (obesity, HTN, PCOS)
- medications (oxytocin, SSRI, estrogen)
- offering only one side per feeding

2) Poor milk extractoin
- infrequent feeding
- inadequate latch-on
- maternal-infant separation
- use of supplemental formula

116
Q

General treatment for problems with breastfeeding

A

1) Position and latch (C-shape, baby’s chin below areaola lips wide open)
2) Lactation consultant
3) Rx: Domperidone although no data
4) Antibiotic ointment (Mupirocin, Bethamethasome)

117
Q

Risk factors for breast cancer

A

FHX of breast cancer
Previous benign breast lesions
Previous personal hx of breast cancer
Ovarian Cancer
Hormonotherapy/OCP
BRCA mutation carrier
Early menarche
Late menopause
Nulliparity

118
Q

Features on FHx increasing likelihood of BRCA1/2 hereditary cancer syndrome?

A

Hx breast cancer in more than one 1st degree
Hx bresat cancer male family member
Ashkenazi Jewish descent
Hx of ovarian cancer
Positive BRCA mutation carrier in the family
Low age onset of breast cancer

119
Q

Red flags for neck pain

A

Trauma
Cancer or constitutional symptoms
Infectious symptoms, Immunosuppression or IVDU (Epidural abscess, discitis)
Neurological signs/symptoms (cord compression, demyelinating process)
Severe ripping neck pain, unstable (carotid/vertebral dissection)
Chest pain, SOB, diaphoresis (MI)
History of rheumatoid arthritis (atlanto-axial disruption)

120
Q

SOS diagnosis in neck pain?

A

Malignancy
Carotid dissection
MI (referred pain)
Pseudotumor cerebri (referred pain)
Discitis

121
Q

Modifiable RF in OMA?

A

Second-hand smoke
Drinking supine position
Daycare
Crowded living conditions
Bottle feeding (not breastfeeding)

122
Q

Indications for tubes in OMA

A

Speech delay
Hearing loss
Atelectasis of TM/retraction
Persistent effusion
Recurrent OMA

123
Q

Abdo pain in children: non-GI causes?

A

DKA
UTI
Pneumonia

124
Q

Classes for migraines prophylaxis

A

Beta-blockers
CCB
Antidepressants TCAs
Anticonvulsivants

125
Q

Contact avec varicelle: on donne quoi aux gens à risque? Gens normaux?

A

Immunoglobuline
Rien

126
Q

Glucose control targets in GDM?

A

5-6 fasting
6-8 2h-post meal

127
Q

Questions à poser si ingestion de substance?

A
  • Who - patient’s age, weight, PMH (alcoholism, renal or hepatic disease)
  • What - name, dosage of medications (including OTC) or substances, coingestants, amount
  • When
  • Where - Injection or ingestion
  • Why - intentional vs unintentional
128
Q

How to enhance elimination of a poisoning substance?

A

Dialysis
Forced diuresis
Acidification/alcalinization of urine

129
Q

Tylenol ingestion: what labs do we do?

A

AST/ALT
INR/PT/PTT
Plaquettes

130
Q

Antidote Tylenol?

A

NAC
Mucomyst
N-acétylcystéine

131
Q

Complications des troubles alimentaires (en catégorie)
(endocrino, cardiaque, GI x2,

A

Ostéoporose
Arythmies cardiaques
REflux
Syndrome Mallory-Weiss
Suicide

132
Q

Quels facteurs liés au mode de vie pourraient entraîner une dysfonction hypothalamo-hypophysaire primitive et une anovulation subséquente?

A

Stress excessif
Exercise excessif
Régime alimentaire excessif/trbl alimentation

133
Q

Causes endocrino pour anovulation en infertilité?

A

Cushing
TSH
PCOS
Hyperprolactinémie

134
Q

Optimisation non-pharmaco de fertilité?

A

Cesser roh, tabac, cafféine
Relations sexuelles fréquentes toutes 72h
Perte poids
Chaleur testicules

135
Q

Crises épiléptiques chez pt connu/pas connu, causes?

A

GROSSESSE
Non-compliance

VITAMIN D & E
Vasculaire (stroke, bleed, hypertensive encephalopathy)
Infectious causes
Trauma
Autoimmune (NMDA, SLE)
Métabolique (hypoG/hyperG, hypoNa/K/Ca, TSH, LFTs, Urée)
Idiopathique (épilepsie de novo)
Néoplasie
Drugs
Eclampsia/pseudoseizures

136
Q

Habitudes de vie pouvat provoquer convulsions chez patient connu?

A

Alcool, drogues
Stress
Manque sommeil

137
Q

FRs pour hépatites? Quoi demander à l’histoire

A

IVDU/nasal drug use
Unprotected sex
Piercings, tattoos, contaminated needles
Blood transfusion
People with jaundice

138
Q

If a h/a treatment works, it exlucdes serious pathology?

139
Q

If treating chronic h/a or relapsing h/a, can I use barbiturate/narcotics?

140
Q

Investigation if h/a, neg CT scan and suspected SAH?

141
Q

Criteria migraine

A

1) 5 episodes lasting 4-72h
2) 2/4 of (pulsatile, unilateral, mod-severe pain, worse with activity)
3) 1/2 of (photo/sonophobia, nausea/vomiting)

142
Q

Definition tension h/a

A

1) 10 episodes/month (less than 1 day)
2) 30min-7 days duration
3) 2/4 of (pressure/tightening, mild-mod, bilateral, not worsened by activity)
4) 1/2 (no N/V, no sono/photo)

143
Q

Definition cluster

A

1) at least 5 crisis
2) 15-180 min untreated of severe deep excruciating unilateral orbital/supraorbital/temporal pain
3) one of ispilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness,miosis, ptosis

144
Q

Definition medication over h/a

A

more than 15 d of h/a per month
use of either more than 15d of analgeics

145
Q

RED FLAGS in h/a

A

SNOOPS

Systemic (fever, weight loss, scalp tenderness)
Neuro (confusion, decreased LOC, seizure, pappilledema, focal sx)
Onset (sudden, worse of life, refractory)
Older (50yo)
Progression/pattern (new, different pattern)
Papilledema
Postular aggravation (ICP)
Secondary RF (immunosuppressed, malignancy, early morning, known aneurysm, previous stroke, anticoagulants, precipitated Valsalva, fever)

IMPACT ON FUNCTIONNING !!!!!

146
Q

If suspicion of SAH, what should I do as a work-up?

A

C- (100% sensitive in first 6h)
LP if too late
IRM/angio IRM

147
Q

Non-pharmaco management/recommandations of h/a

A

Headache diary
Avoid triggers (not eating, tobacco, weather, sleep hygiene, specific foods like old cheese, fermented things, nitrites meats, alcohol, coffee, chocolate)
REGULAR EXEDRCISE
Stress management reduction

148
Q

Treatment of migraines

A

1) First line: Tylenol, NSAIDs (Naproxen/Advil)
2) TRIPTANS - always try at least 2-3 before saying it does not work

149
Q

Contraindications to Triptans

A

Migraine hémiplégique, basilaire, ophthalmoplégique
ICT, AVC
MCAS, MVAS
HTA non contrôlée
Arrhythmies cardiaques
Insuffisance hépatique grave

150
Q

3rd line for migraine?

A

Antiemetics
Ergotamines (Cafergot) - same CI as triptans
Ubropegant (new) - to consider of CI for triptans
Dexaméthasone
Valproic Acid

151
Q

Indications for prophylaxis migraines

A

4 migraines/month
Lasting more than 12h
Recurrent interfering with daily activities
Non-response to tx
Menstrual tx

152
Q

Contraindications to BB for migraine prophylaxis

A

MVAS
Raynaud
Hypotension
Bradycardia
BAV
+/- asthma

153
Q

Durationof prophylaxis rx for migraine?

A

Try at least 3 months
If it works, continue max 6-12 months
Then taper down progressively

154
Q

Tx Cluster h/a?

A

Acute: O2
Triptans
Other rx: Corticos, ergotamine, occipital nerve block
Neuro early on

155
Q

Screening cancer colorectal?

A

50-74yo
FIT q2 ans ou flexible sigmoidoscpy q10 ans

156
Q

Cancer colorectal: si
1) 1er degré avec cancer <60 ans
2) 2 parents 1er degré peu importe l’âge
3) parent 1 & 2e même côté famille

A

COLOSCOPIE Q5 ans
Dès 40 ans OU 10 avant plus jeûne âge de diagnostic

157
Q

Cervical cancer screening

A

25-60 yo, PAP q3 yr
ASCUS en bas de 30 ans: repeat at 6-12 mo
ASCUS above 30 ans: VPH, + colpo, neg PAP 12 mo

158
Q

Prostate cancer

A

No screening recommended - DISCUSS DRE/PSA with patient

APS < 1.5: repeat 2-4 yr
APS 1.5-4: repeat 1-2 yr
APS > 4: repeat 8 weeks, <4: repeat 1-2 yr, > 4: UROLOGY

159
Q

Breast cancer screening?

A

50-74 yo q 2-3y with mammography

any cancer (1st or 2nd degree) > 50: same
ANY CANCER (1st or 2nd deg) > 50: annual at 40yo

160
Q

Lung cancer screening?

A

5-74yo with ≥30 py smoking history (current or quit <15y ago)
Low-dose CTq 1y-3y max

(Task Force Guidelines)

161
Q

AAA screening?

A

men 65-80 yo
one-time abdo US

162
Q

How to manage dyspnea in pall care?

A

Position (turn, sit up, elevate head of bed)
Air circulation (fan), oxygen PRN
Manage cough, secretions, anxiety (relaxation therapy)
Opioids (eg. morphine 1mg PO), benzodiazepines, bronchodilators

163
Q

Non-pharmacological management of pain in pall care

A
  • Massage / Physical therapy
  • Pet therapy
  • Acupuncture
  • Relaxation / Hypnotherapy
  • Aromatherapy / Music therapy
  • Heat/Cold
164
Q

RF for opioid abuse

A

Young age
Hx of preadolescent sexual abuse,
Hx of depression
Hx of ADD/OCD
Bipolar d/o
Schizophrenia
PMHx of alcohol abuse/illegal drug abuse/prescription drug abuse
FHx of alcohol abuse
Illegal drug abuse

165
Q

Side effects of opioids

A

Constipation
Nausea
Sedation
Urinary retention
Neurotoxicity (hallucinations, allodynia, myoclonus, seizures, delirium)

166
Q

Management of nausea in pall care

A

1) Non-harmaco: cut some intolerant foods, control odeurs, restrict intakes, small frequent meals, cool fizzy drinks, avoid lying flat after eating, acupuncture

2) Pharmacological
- Metoclopramide (prokinetic)
- Ondansetron
- Antihistamine (dimenhydramine)
- Anticholinergic (scopolamine)
- Antipsychotic (Haldol)
- Cannabinoids

167
Q

Tx of anorexia in pall care?

A

Favorite foods
Small frequent meals
Rx: Dex 4 PO BID, progesterone, metoclopramide, mirtazapine

168
Q

Fatigue in pall care?

A

Steroids
Metamphetamines

169
Q

Pharmaco mngt secretions in pall care?

A

Glycopyrrolate
Scopolamine
Atropine

170
Q

Safety plan pour suicide? 5 points

A

Keep environment safe
Recognize early warning signs
Ways to cope PERSONNALY
Identify people to contact
Identify places to go

171
Q

In a trauma in the emergency, think about what as possibly the cause?

A

Suicide attempt

172
Q

Which drugs to ask for when suspected drug overdose in the ER?

A

ASA
Tylenol

173
Q

Risk factors for anxiety?

A

Family history of anxiety
Personal history of anxiety/mood d/o
Childhood stressful life events/trauma
Female
Chronic medical illness
Behavioral inhibition

174
Q

DEFINITION GAD

A

1) Excessive anxiety/worry more days than not for 6 months
2) Difficult to control the worry
3) 3 or more of: easily fatigued, irritability, muscle tension, decreased concentration, decreased sleep, restlessness
4) IMPAIRED FUNCTION

175
Q

Panic d/o definition

A

1) Recurrent unexpected panic attacks
2) 4 or more of (palpitations, sweating, dyspnea, trembling, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization, losing control, fear of dying)
3) at least 1 attack followed by 1 month of either persistant concern/worry about attack OR significant malapdative change genre avoidance

176
Q

Which medications have a mortality benefit in patients with CAD post-MI?

A

Aspirin/Clopidogrel
Beta-blockers within 24h
Ace-i within 24h
Statin

177
Q

What rx to start during ACS? After stabilization of the patient

A

MONA

Morphine
O2
Nitro
Aspirine

178
Q

Dx of DB

A

1 test pos + symptoms OR 2 tests pos diferent moments/diff tests

HbA1c 6,5%
FPG 7
2hPG 11.1
Random glucose 11.1

179
Q

PreDB?

A

HbA1c 6-6.4
FPG 6.1-6.9
2hPG 7.8-11

180
Q

Indications to start Insulin right away?

A

Symptomatic hyperglycemia
Metabolic decompensation (DKA/HHS)

181
Q

What 2nd line medication to start if
1) patient has clinical CVD?

in DB

182
Q

Targets for DB patients: BP and LDL

A

130/80
<2 or decrease by 50%

183
Q

Tx of hypoglycemia if
1) conscious
2) unconscious

A

1) 15g carbohydrates, D50 1 amp (25g)
2) Glucagon 1 mg SC or IM

184
Q

Complications of DB, micro and macrovascular

A

1) Micro: neuropathy, nephropathy, retinopathy
2) Macro: CAD, PVD, AVC

185
Q

Weight loss medications in DB^

A

GLP-1
SGLT-2

186
Q

Weight gain medications in DB^

A

Insuline
Sulfonylureas

187
Q

Antihyperglycemic medications contraindicated in CKD?

A

Biguanides
SGLT-2 inhibitors
Thiazolidinediones
Alpha-glucosiade inhibitors

188
Q

Prescription for Insulin

A

DC all PO hypoglycemics except MTF
Glucometer
Lancets x100
Test strips x100
Injection pen
Needles
Insulin (Lantus 10u qHS)
Sharp Container
Alcohol swabs

189
Q

HTN threshold for dx
1) NABP x1 in office
2) AOBP x1 in office
3) daytime ambulatory BP monitor (MAPA jour)
4) 24h ambulatory BP monitor (MAPA 24h)
5) home BP series patient

A

1) 180/110
2) 180/110
3) 135/85
4) 130/80
5) 135/85

190
Q

Threshold to start medications:

A

Low-risk: 160/100
Mod-risk: 140/90
High-risk/DB: 130/80

191
Q

What is considered high-risk patients in HTN guidelines?

A

> 50 yo AND sBP > 130 AND one of those:

1) older than 75
2) clinical CVD
3) CKD
4) FRS > 15%

192
Q

BP target for
1) DB
2) High-risk
3) Mod-risk
4) Low-risk

A

1) 130/80
2) 120/XX
3) 140/90
4) 140/90

193
Q

What meds increase BP?

A

Sympathomimetic drugs
Corticosteroids
COCs
NSAIDs
Antidepressants
Atypical antipsychotics
Decongestants
Stimulants (methylphenidate, amphetamines)

194
Q

What meds to treat hypertensive emergency?

A

Nitroprusside/nitroglycerine
Labetalol/Esmolol
CCB (Clevidipine, Nicardipine)
Dopamine-1 agonist (Fenoldopam)

195
Q

Meds irritating the stomach/RF for ulcers

A

ASA
NSAIDs
TYlenol
Bisphosphonates
SSRIs possibly
GLUCOCORTICOIDS

196
Q

Which ulcer causes risk of gastric cancer?

A

GASTRIC ULCERS

197
Q

Eradication therapy for H Pylori?

A

PPI
Clarithromycine
Amoxicilline

198
Q

Complications of gastric/duodenal ulcers?

A

Gastric cancer
Bleeding
Ulcer perforation
Fistulas
Gastric outlet obstruction

199
Q

Types of treatment for IBD

A

REMISSION
1) 5-ASA (5-aminosalicylates) - Sulfasalazine, Mesalamine)
2) Glucocorticoids

MAINTENANCE
1) 5-ASA
2) Immunomodulator( Azathioprine, 6-Mercaptopurine, Methotrexate)
3) ANti-NTF (infliximab)
4) Probiotics

200
Q

Extra-intestinal manifestations of IBD

A

1) Arthritis (peripheral arthritis, ankylosing spondylitis, sacroileitis)
2) Dermato (aphtous somatitis, erythema nodosum, pyoderma gangrenosum)
3) Ocular (episcleritis, scleritis, uveitis)
4) Primary sclerosing cholangitis

201
Q

Possible tx in IBS?

A

Exercise
Diet (low FODMAP)
PEG, psyllium
Antispasmodics, TCAs

202
Q

Abdo pain in children
1) <1yo
2) 1-5 yo
3) 5-12yo
4) >12yo

A

1) Food protein allergy, colic, constipation. NEC, VOLVULUS, PYLORIC STENOSIS, INTUSSUSCEPTION.
2) UTI, constipation. USP, APPENDICITIS, MECKEL
3) UTI, constipation, functional. DKA, GONADAL TORSION, APPENDICITIS, IBD.
4) Gastroenteirits, pneumonia, PANCREATITIS, PID, DKA, ECTOPIC PREGNANCY.

203
Q

Drugs that have interactions wiht COC

A

Antiepileptics (phenytoin, topiramate, carbamazepine)
Antibiotics (Rifampin)
Antivirals (HIV)
St-John’s Wort

204
Q

Contraindications progesterone:

A
  • Known or suspected pregnancy. However, pregnancies conceived in individuals taking POPs have not been associated with adverse effects.
  • Known or suspected breast cancer.
  • Undiagnosed abnormal uterine bleeding.
  • Benign or malignant liver tumors (hepatoma), severe cirrhosis, or acute liver disease.
205
Q

Types of emergency contraception

A

Copper IUD (up to 5-7 days)

Ella (Ulipristal acetate) - up to 5 days, good for higher BMI

Plan B (Levonorgestrel) - up to 3 days

Combined OCP - up to 3h (Yuzpe)

Contraindications pregnancy
Or pelvic infection/cervicitis

206
Q

Symptomatic management de TP?

A

Antipsychotic low-dose schizotypal
SSRIs for avoidant

CFPC Exam (3 decks)

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