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CCFP Exam 2021 > Review Course Content > Flashcards

Review Course Content Flashcards

1
Q

Fever in returning traveler is ____ until proven otherwise?

A

Malaria - falciparum malaria can kill you in 24-48 hours!!

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2
Q

Pre-travel history?

A 
When, where, how long are you going and why are you going there?
ie. food tourism = high risk for cholera, GI illness, typhoid fever, parasites
SE Asia (Bankok, Thailand for business meetings) - lower risk profile.
PHx, PMHx, Family Hx
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3
Q

Management of traveler with fever?

A

More than meds!

Twinrix and ciprofloxacin

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4
Q

When is typhoid vaccine indicated in Canadian guidelines?

A

Southeast Asia & surrounding region

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5
Q

Biggest risk type of travel for fever in traveler?

A

Visiting relatives!

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6
Q

Antimalarials and comparison as per PHAC 2014?

A
  1. Atovaquone - proguanil - daily x 7 days post exposure. Daily dosing and $$$$
  2. Doxycycline - cheap, daily, photosensitivity rash and need it 30 days post exposure
  3. Mefloquine - once weekly dosing, frequent side effects including wild dreams!! And psychiatric sx. THUS not first line anymore!
  4. Primoquine - need blood test before medication taken -G6PD deficiency test. ONLY 7 days after exposure.
  5. Chloroquine - cheap and long term safety data
    * **WIDESPREAD RESISTANCE (Check before prescribing) also has skin and corneal side effects.
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7
Q

Non-pharmacological management and recommendations for pre-travel counseling

A
  1. PREVENT - Limit high risk activity - night driving (don’t do it), sex tourism (use PREP or condoms)
  2. QUIT - smoking, don’t check meds in luggage!!, risky activity
  3. REFER -travel clinic
  4. Travelers diarrhea
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8
Q

BIGGEST M&M In patients who are travelers?

A

MVA’s!!!!

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9
Q

How to prep for travelers diarrhea?

A
  1. Pack: Oral rehydration solution, loperamide*, azithromycin, bismuth subsalicylate** (can take QID for prevention)
  • Take loperamide for mild diarrhea if no dysentry or blood.
  • *Pepto bismol - can take QID for prevention
    2. Boil it, peel it, cook it, or forget it
    3. Ice cubes, salads, uncooked veg
    4. Use bottled water
    5. Wash and sanitize hands often
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10
Q

How to manage altitude sickness?

A 
Acetazolamide 125 mg BID
Dexamethasone 4 mg BID**
Nifedipine
Sildenafil/Tadalafil
Prophylactic salmeterol

**Also treats high altitude cerebral edema AND get em off the mountain!

NOT recommended: ginko biloba

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11
Q

Aspirin a day?

A

Primary prevention for CV disease? DON’T START IT!
If already taking? Evidence to discontinue less clear. Do risk assessment

Studies: ASPREE, ARRIVE, ASCEND, ACCEPT-D

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12
Q

HCV Screening? Who are the higher risk patients?

A

NOPE.
Unless higher risk:
Hx incarceration, blood products/organ transplant before 1992, recent immigrants, IVDU

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13
Q

AAA Screening?

A

Men 65-80 yo - one time abdo ultrasound

Women - NOPE

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14
Q

CFPC Preventive Health Checklist?

A

Learn it. CFP 2020. Get it off bit.ly/vitalfm-checklist

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15
Q

CFPC Preventive Health Checklist?

A

Learn it. CFP 2020. Get it off bit.ly/vitalfm-checklist

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16
Q

FALL in PM? How can we prevent the hip fractures?

A

Best question: How many falls in the last one year?

FALL: review active health status, screen for FALLS yearly
P: Review pain control
M: Medications?

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17
Q

Immigrants and Refugees Guidelines?

A

Check out Ottawa guidelines from CMAJ 2011 or CPS have good one: caringforkids.ca new to Canada

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18
Q

Immigrants & Refugee Canadian Practice Recommendations?

A
  1. Infectious Disease - OFFER testing and vaccines, INTERPRETER, Consider RISK LEVEL for country (ex. HIV, TB, HCV
  2. Chronic Disease
  3. Mental Health
  4. Women’s Health
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19
Q

Recommends for Interpreter?

A
  1. Not a family member
  2. Don’t pull someone from waiting room
  3. LOTS of access for interpreters!
  4. Don’t use google translate as not standard of care
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20
Q

How do we test for TB?

A

Intradermal (IGRA)-interferon gamma release assay
>95% Specificity for latent TB only
-Don’t use to dx ACTIVE TB

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21
Q

4 meds to tx TB?

A

Rifampin
Isoniazid
P
E

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22
Q

4 meds to tx TB?

A

Rifampin
Isoniazid
Pyrazinamide
Ethambutol

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23
Q

Painless hematuria is

A

CANCER until proven otherwise

ALSO a sx. of schistosomias and consider this for

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24
Q

If fever and travel test for malaria. If asymptomatic?

A

asyx: DON’T Test
Test via: Thick & thin smear
Test for malaria antigen

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25
Q

If patient has no vaccine record and is immigrant?

A

GIVE THESE!!! (50% don’t have them on avg.)
TDAP-IPV
MMR

TEST first:
HBV
Varicella (if over 13 years old)

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26
Q

Immigrants Screening?

A

Dentist
Diabetes (use HgbA1C)
Vision - optometrist
Lead poisoning

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27
Q

What mental health like conditions should you NOT screen for in immigrants? What should you screen for?

A

Don’t screen for maltreatment of children, domestic violence or PTSD unless presenting complaints.

  1. Are you down, depressed or hopeless? Little interest in doing things? (anhedonia)
    - This is the PHQ-2 and first 2 questions of PHQ-9.
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28
Q

Women’s Health in immigrants?

A

OFFER screening: serum iron or ferritin

women and Children FERST

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29
Q

TRAVEL HISTORY?
Years later…patient has a cough?
Vague GI sx?

A

TB risk region?

Test for strongyloides if walking barefoot!

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30
Q

TRAVEL HISTORY?
Years later…patient has a cough?
Vague GI sx?

A

TB risk region?

Test for strongyloides if walking barefoot!

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31
Q

SCZ Guidelines - Initial Workup?

A

Full history

FUNCTION (sexual function - pregnant????)

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32
Q

SCZ Guidelines Top 5 Recs?

A 
1st episode: antipsychotic
How long? 18 months
1st vs. 2nd gen are equal
Oral = Depot (patient preference) -NNT = 7 to avoid patient admission
Treat Comorbid depression
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33
Q

NMS symptoms and treatment?

A 
FARM:
Fever
Autonomic dysregulation
Rigidity
Mental status changes

-Even low dose, any stage of treatment, can be if escalating doses or dose changes.

Tx:
Stop medication
IVNS
Ice packs
Dantrolene
Bromocriptine
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34
Q

Management of SCZ?

A 
Meds
Safety first!! -SI and HI
Family counseling
Vocational rehab
Finances?
Day hospital?
Admission?
Detox?
Adherence?
Pregnant?
SUD?
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35
Q

Adult non resolving pneumonia?

A

Is it the wrong bug, drug, or diagnosis!?
Typical?
Atypical?
Mycobacterium? Pneumocystis?

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36
Q

Non- abx treatment for abscess, sepsis, appendicitis, laceration and nec fasc?

A

Abscess - drain it, and de-capsulate
Sepsis - supportive (fluids, pressors, blood cx)
Appendicitis - conservative therapy treatment emerging
Laceration - TETANUS BRO
Nec Fasc - EMERGENTLY DEBRIDE!

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37
Q

Abx Trends?

A

ORAL after IV? May be non-inferior to prolonged IV

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38
Q

Pneumonia Guidelines (2019)

A 
DON'T 
-use term healthcare associated PNA term
-DON't use CURB-65 score.
-procalcitocin
-order sputum C&S or blood culture unless patient is sick!
Sick = severe CAP as per PSI score.
-prescribe steroids
-XRAY not required

DO:

  • use PSI score
  • Test for influenza (at risk for MRSA PNA)
  • Treat with antiviral if influenza positive AND abx if PNA expected
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39
Q

Non-resolving PNA: 37 M non smoker, low grade fever, SOBOE and occasional cough. Pulse 102 / 22/ 106/68, afebrile
Generalized lymphadenopathy
Prev got mixofloxacin and hasn’t improved
WBS of 3.6 and low lymphocytes
CXR is normal.

A

TROC history
Vitals
Treating the wrong bug? drug? or diagnosis?

Repeat CXR: Diffuse interstitial infiltrates, CD4 110, bronchoscopy was PJP!

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40
Q

Weird and Wonderful ddx of PNA?

A 
PJP - pneumocystis Jirovecii pneumonia
Mycobacterium Avium Complex (MAC)
TB
Influenza
Toxoplasmosis
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41
Q

CXR normal! Clinical picture unclear?

A

Get SERIAL dude!!!
Serial exams, serial ECG’s, Serial Imaging

*Also relevant for chest pain etc. Imaging evolves over time!

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42
Q

What 3 infectious diagnoses should you think about testing together?

A

HIV-TB-HCV

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43
Q

4 factors affect antibiotic choice in pneumonia (and one bonus)?

A
  1. Allergies
  2. Drug drug Interactions (ex. warfarin)
  3. COPD co-treatment needed?
  4. Are we covering for aspiration PNA? (anaerobes!)
  5. Outbreak!? (Think legionaires, COVID-19)
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44
Q

When do you use antibiotics in COPD?

A

In exacerbations!

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45
Q

COVID-19 CXR imaging?

A

Interstitial PNA

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46
Q

Most common cause for PNA in ALL people?

A

Strep Pneumoniae!!!!

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47
Q

In kids…uncomplicated PNA recommendations?

A

Amoxicillin - banana flavoured!! is still first-line

Routine X-ray post treatment is NOT recommended unless clinically indicated.

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48
Q

Hypertension screening best practice?

A

Automated> manual
Gold standard 24 h ambulatory
If chubby or muscly arm? Use wrist device (sit at level of heart)
-Take BP when patient relaxed, no coffee, no smoking, feet flat, no gum

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49
Q

Out of office measurements of BP recommendations?

A
  • CRITICAL!!
  • White coat HTN effect is real!
  • BP cuffs aren’t that expensive anymore
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50
Q

Diagnosis of HTN?

A

Automated office BP mean >135/85
Office BP >140/90
Diabetes >130/80 if 3 office measurements on different days

If any above: get outpatient BP
Amb >135/85
Diabetic 130/80

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51
Q

Workup for HTN?

A

Do a lipid panel
Non fasting OK
Also K, Na, Creatinine, urinalysis, HbA1c, diabetic patients (urinary albumin), ECG
-MAKE SURE NOT PREGO!!

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52
Q

% of cases are essential HTN?

A

90%

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53
Q

Secondary HTN?

A 
Atherosclerosis
Big belly, bruits, bad kidneys
Catecholamines (pheo)
Drug, diet
Endocrine
sleep apnea and stress
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54
Q

CPAP does NOT?

A

Decrease cardiovascular events

or decrease mortality

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55
Q

First line for eHTN?

A
  1. Diet

2. Lifestyle

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56
Q

When do you start treatment for eHTN?

A

Based on RF’s:

Low
High
Diabetes
All others

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57
Q

HCTZ and skin cancer?

A
  • uncertain and not proven
  • Possible 4x incr risk after 3 years of:
  • Non melanoma skin CA
  • Inform patients and

-consider switch if higher risk:
light skin
personal or fam hx
Immunosuppressed

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58
Q

HTN ABC’s to avoid!?

A

AVOID:
Alpha blocker alone
Beta blocker if older than 60 yo
ACE or chlorthalidone if black

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59
Q

Chlorthalidone in HTN?

A

Incr risk diabetes, renal, e’lyte abnormalities VS HCTZ (similar CV benefit for both)

Prefer LONG acting diuretics (chlorthalidone or indapamide)

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60
Q

What does taking antiHTN at bedtime do?

A

Reduce CV disease risk by nearly half (hazard ratio is ~0.55?)

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61
Q

HTN urgency vs. Emergency?

A

Urgent: Rapid treatment is NOT successful or necessary
Emergency: Asymptomatic DBP >130
Acute heart, brain, aorta or kidney damage
Pre-eclampsia or PHEO

Treat with:
Nifedipine
Labetolol
Captopril
Clonidine
Nitrates
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62
Q

Resistant HTN definition? #1 reason?

A

if on 3 meds REFER! This = resistant
4th agent: Spironolactone has BEST effect to lower BP (monitor kidney fcn)

Reason: NOT TAKING THE MEDICATION!
Other: not appropriately prescribed?
Lifestyle: salt, tobacco, sedentary, obesity, alcohol
Other meds: naproxen, NSAID’s, contraception, steroids, licorice, OTC medications

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63
Q

HTN in kids?

A

> 3yo then measure
Check in RIGHT arm because if coarctation of aorta then falsely low BP in LEFT arm

Workup = ECHO and CVD risk assessment

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64
Q

HTN in pregnancy?

A

AVOID/CONTRAINDICATED: ACE and ARB pre-conception and in pregnancy

BREASTFEEDING: Choose labetalol, methyldopa, nifedipine

COUNSELING PRE-CONCEPTION: Look at BMI!

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65
Q

Lifestyle treatments of HTN?

A

Sodium <2000 mg/day (drop 5mmHg)
Weight decrease 4.5 kg (drop 7 mmHg)
Alcohol -decrease by 2.7 drinks/day (drop 4 mmHg)
Exercise Rx - 30-45 mins 3x/week (10 mmHg)
Diet - DASH (10 mmHg)
Relaxation - CBT (10 mmHg)

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66
Q

When do you start treatment for HTN?

A 
START treatment if?
Low risk: >160/100 (goal: <140/90)
High risk: >130 (<120 sys)
Diabetes: >130/80 (<130/80)
All others: >140/90 (<140/90)
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67
Q

Febrile neutropenia?

A
  1. Recognize early!!!
  2. Stabilize (fluids and ABX)
  3. Avoid rectal temp, look in mouth (mucositis), look for source (consider fungal)
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68
Q

Fever without cause -when to do tissue biopsy? What other tests?

A

Full workup previously normal….

Tissue biopsy?
Liver
Node
Temporal artery
Bone marrow
SPEP
Vasculitis/autoimmune
ECHO
HIV, TB test
Dental assessment
Viral cultures
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69
Q

No idea wtf going on with this weird AF PNA?

A

Serial exams
Serial ECG’s
Serial imaging

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70
Q

Serotonin Syndrome

A
  • GI symptoms and NMS does not

- myoclonus

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71
Q

Kid prevents with 5 days of fever and he is 5yo?

A

KAWASAKI’s

CRASH

Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hands and feet

Bad bad bad -CAA: Coronary artery aneurysm

ASA and IVIG in KAWASAKI

Don’t forget about MIS-C!!
-Children 0-19 with fever >3 days and COVID 19 positive or close contact, and unexplained ESR/CRP elevation

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72
Q

Kid presents with 5 days of fever and he is 5yo?

A

KAWASAKI’s

CRASH

Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hands and feet

Bad bad bad -CAA: Coronary artery aneurysm

ASA and IVIG in KAWASAKI

Don’t forget about MIS-C!!
-Children 0-19 with fever >3 days and COVID 19 positive or close contact, and unexplained ESR/CRP elevation

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73
Q

Issues with Framingham?

A

OVER ESTIMATES RISK

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74
Q

Screen who for hyper

A

Men >40yo
Women >50 (or post menopauisal)

EARLIER:
Smoker

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75
Q

Screen who for hyperlipidemia? (incomplete)

A

Men >40yo
Women >50 (or post menopauisal)

EARLIER:
Smoker

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76
Q

DO NOT in hyperlipidemia

A 
Treat LDL target (CCS disagrees rx. to <2 or 50% reduction or <1.8 if ACS)
Use framingham in renal dz
make patients fast
Order Apo-B, CRP
Use ezetimibe for primary prevention
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77
Q

DO NOTs in hyperlipidemia

A 
DO NOT in HYPERLIPIDEMIA:
Treat LDL target (CCS disagrees rx. to <2 or 50% reduction reduction or <1.8 if ACS)
Use framingham in renal dz
make patients fast
Order Apo-B, CRP
Use ezetimibe for primary prevention
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78
Q

CAM for high lipids?

A

O3FA FIRST LINE FOR HYPERTRIGLYCERIDEMIA

25% risk reductions
Effective and safe except poor GI sx

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79
Q

CAM for high lipids?

A

O3FA FIRST LINE FOR HYPERTRIGLYCERIDEMIA

25% risk reductions
Effective and safe except poor GI sx

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80
Q

Dumb Mnemonic for Dizziness that is validated?

A

TiTrATE (validated tool):

Timing
a. How long does it last? seconds, minutes, days. When feel dizziness how long does it last? Does it go away?
Triggers
A thorough exam

Don’t need to ask med school questions for lightheaded or room spinning? Get a double yes that is UNHELPFUL

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81
Q

Dizziness timeline clues?
In shower, look up, and dizzy but resolves in 30 seconds?
20-30 mins long ladsting?
Constant/days?

A

BPPV
Orthostatic Hypotension

Meniere’s last longer
Migraine, neuritis, stroke

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82
Q

Triggers of dizziness?

A

Medication start or change
Trauma (barotrauma)
BPPV or orthostatic hypotension

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83
Q

Associated symptoms of dizziness?

A

Migraine aura - think migraine
Blood, Blisters, Back of neck pain -Ramsay hunt, trauma, vertebral artery dissection
Chest pain - aortic dissection
Deafness (1 side) -Meniere’s (tinnitus, fullness, dizziness)

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84
Q

Vertigo exam includes?

A

Orthostatic BP
GAIT (stroke?)
HINTS + loss of hearing exam - head impulse, nystagmus, test of skew
Dix-Hallpike

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85
Q

Where to REFER for dizziness?

A 
ENT
Neurology
Vestibular rehab
Physiotherapy
OT
Psychiatric comorbidity with vertigo: 37-50%
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86
Q

Tdap in pregnancy?

A

EVERY pregnancy at 28-32 weeks to prevent pertussis in the lil infant even if the mom got it recently.

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87
Q

YEARS criteria?

A

Look it up RIGHT NOW!

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88
Q

PNA and steroids?

A

NO (IDSA guidelines)

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89
Q

Red or black stool ddx?

A

IF not blood:
beets
iron
bismuth subsalicylate

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90
Q

Deprescribe PPI?

A

Stop or taper slowly
Step down (H2 antagonist)
Reduce: on demand, EOD

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91
Q

Ddx of Lower GI bleed?

A 
ROYAL Family:
Kate is always pregnant = Hemorrhoids (statistically)
Queen Elisabeth (old AF) = Probably your aspirin (RULE OUT BAD THINGS)
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92
Q

Treatment for EVERY Acute Situation?

A

ABC MOVIES

Airway
Breathing
Circulation

Monitor
Oxygen
Vitals
IV
ECG
Sugar check

SERIAL ABC’s, VITALS, ECGs

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93
Q

Acute GI bleed myths and facts?

A

Increase hemoglobin? Transfuse ONLY if fluids not working and Hb <70
Decrease stomach contents? Decrease acid! PPI bolus (non variceal), Decrease blood/clots? Erythromycin

Scope Urgently? Scope by 6 hours does NOT reduce mortality compared to 24 hours.

Ceftriaxone? IF cirrhosis or varices? Ceftriaxone and somatostatin

NO varices? NO other drugs - don’t give transexamic acid as NO benefit and doubles risk of VTE

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94
Q

Prevent GI bleed?

A

PPI and H2RA

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95
Q

Anxiety RFs? Don’t miss!?!?

A 
Family history
PHx of mood or anxiety
ACEs
Female
Chronic medical illness
Behavioural inhibition

Don’t MISS: SUICIDE Assessment!
-Anxiety is INDEPENDENT RF for suicide completion (controlling for mood disorders)

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96
Q

PTSD treatment?

A 
VPS + F:
Venlafaxine
Paroxetine
Sertraline
Fluoxetine

CBT (trauma focused)

Group Therapy

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97
Q

Debrief all trauma victims?

A

NO WAY!

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98
Q

OCD

A
  • Obsessions and/OR compulsions
  • time consuming or distressing
  • Significant impairment in social or occupational functioning

OCD: O’s are ego dystonic

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99
Q

OCD treatment?

A

SSRI’s except citalopram
First line augmentation: aripiprazole, risperidone

Exposure response prevention (ERP) (Gold standard type of CBT)

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100
Q

Generalized anxiety disorder meds? Most effective for GAD?

A 
VPS PEAD: 
Venlafaxine
Paroxetine
Sertraline
Pregabalin
Escitalopram
Agomelatine
Duloxetine

MOST effective: Pregabalin, duloxetine, venlafaxine, escitalopram,
Also (but smaller): Mirtazapine, sertraline, buspirone, agomelatine AND quetiapine, paroxetine and BZD’s.

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101
Q

A word on BZD’s for anxiety…

A
  • NOT monotherapy
  • Avoid if on opioids
  • Consider risk and discuss dependence
  • Avoid high doses or large quantities
  • Avoid in elderly!! Increases all cause mortality.
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102
Q

Social anxiety treatment?

A

VPS PEF: Venlafaxine, paroxetine, sertraline, pregabalin, escitalopram, fluvoxamine

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103
Q

New SADPERSONS?

A 
Precipitating factors:
Drugs/alcohol (50% of SA's involve EtOH)
Access to means
Life events
New terminal/chronic dz diagnosis
Media effects
Predisposing factors:
Neuropsychiatric disorders
Family history
Previous attempts
ACEs
Socioeconomic status
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104
Q

CFI-S?

A

Convergent functional assessment for suicide

  • good to excellent predictive value
  • 22 questions
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105
Q

Antidepressant efficacy?

A

AD’s effective by 6 weeks?

-Up to 1/3 will not show early response by 6 weeks

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106
Q

DSM-5 Mimics of depression

A 
Hormones
Grief
Drugs
Bipolar
Tumor
Delirium
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107
Q

Bipolar disorder or MDD?

A

<25 yo
>5 episodes
-Quick on/off of episodes
-Atypical features (hyperphagia, hypersomnia, leaden paralysis, longstanding interpersonal rejection sensitivity)
-depression with psychotic features
-quick response, but wear off of efficacy.

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108
Q

WOW FRAMEWORK for delivering bad news?

A

Wish we didn’t have to discuss this hard topic?
Worry convo will be difficult?
Wonder if?

GOALS are VITAL
Recognize Strengths (trauma and violence informed discussion)
Recognize abilites
Family

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109
Q

Teach when breaking difficult news?

A

Advanced directives (CPR, feeding tubes, intubation)
Estate planning?
Will?
Teach how to break news to family - offer to help

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110
Q

When can you terminate a patient-physician relationship?

A

Check with regulatory body!

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111
Q

Cluster A PD’s? B? C?

A

A:
Schizoid - Evyn Peters (no emotions, enjoys nothing, likes to be alone)
Schizotypal - Willy Wonka
Paranoid - suspicious AF

B:
Borderline - fear abandonment, self harm, identity issues
Narcissistic - entitled, no empathy, think they’re special
Histrionic - Anjena
ASPD - No remorse, lies, steals,

C:
Dependent - can’t make any decisions ever
Avoidant - extreme version of social anxiety
OCPD - all med students ever. Neurotic, controlling, morally scrupulous, perfectionistic

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112
Q

URTI’s and honey?

A

Honey works the BEST for kids with URTI’s!

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113
Q

Side effects of lithium

A

Nausea, vomiting, confusion, concentration, hypothyroid, tremor, diarrhea, ataxia, ECG changes (inverted T waves), weight gain

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114
Q

Labwork for lithium

A

Lithium level, creatinine, TSH, beta-HCG, calcium

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115
Q

Therapeutic window for lithium

A

0.6-1.2

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116
Q

3 Methods other than injected anethetic

A

Topical anesthetic, distraction, sedation

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117
Q

How to reduce pain of injection

A

Smallest needle possible, warm anesthetic, bicarb, injecting slowly

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118
Q

Alternatives to lidocaine

A

Tetracaine, procaine, preservative free lidocaine

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119
Q

Complications from toe surgery

A

Cellulitis, ischemia, nec fasc, reperfusion injury, allergic reaction

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120
Q

Key features of infection

A

Proximal migration of the lesion, leukocytosis, bony involvement on x-ray, CRP, Pain with passive stretch, fever

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121
Q

Treatment for pediatric asymptomatic bacteriuria

A

Nothing

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122
Q

When do you treat asymptomatic bacteriuria? List 2

A

Renal transplant, invasive urologic procedures

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123
Q

What drugs are most likely to cause serotonin syndrome? List 3

A

SSRI, SNRI, MaOIs

Also triptans, stimulants.

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124
Q

What is on your differential for altered mental status? List 7

A 
Drugs - anti-cholinergic toxicity, malignant hyperthermia, NMS, EtOH/benzo withdrawal
Infection - meningitis, encephalitis
Metabolic - thyroid storm
Failure (liver/kidney)
Anemia
Cerebral infarct/bleed
Endocrine
Structural/space occupy
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125
Q

What are the signs and symptoms of serotonin syndrome? List 6

A 
Mental status changes (agitation, delirium)
Autonomic dysfunction (changes in vitals)
Neuromuscular dysfunction
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126
Q

What is one different symptom in Neuroleptic Malignant Syndrome and not in Serotonin syndrome?

A

NMS = Rigidity

Serotonin syndrome = Gi symptoms and hypereflexia/clonus

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127
Q

What is the treatment for a Toddles Fracture (Childhood Accidental Spiral Tibial fracture (CAST))?

A

Non-surgical. Backslab or boot.

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128
Q

What are 5 diagnoses for pediatric limp?

A

Leg-calves-Perthes
Infection/Inflammation
Malginancy (Ewing’s sarcoma/osteoscarcoma
Pain (fracture)
Slipped capital femoral epiphysis (Half black/half hispanic obese boy)
Something else (referred from above or below)

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129
Q

What is the most common organism for pediatric osteomyelitis?

A

S. aureus

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130
Q

What are the cutoff values for postural hypotension

A

20 systolic, 10 diastolic within 3 minutes of standing.

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131
Q

List 8 causes of orthostatic hypotension with compensatory tachycardia.

A

Dehydration (diarrhea/adrenal insufficiency, dialysis, diuretics, digoxin, antibiotics, cholinesterase inhibitors.
Dysfunctional Heart (myocardium, aortic stenosis)
Drugs (anti-hypertensives, anti-anginas, anti-parkinsonians, anti-depressants, anti-psychotics, anti-BPH meds)
Deconditioning

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132
Q

List 2 causes of orthostatic hypotension without compensatory tachycardia.

A

Low B12, hypothyroidism, EtOH abuse, diabetic neuropathy, parkinsonism, amyloidosis, beta blocker.

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133
Q

What are 6 possible treatment options for plantar fasciitis?

A

Weight loss, NSAIDs, stretching, glucorticoid injection, night splinting, orthotics, hypotension.

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134
Q

What is on your differential for anal mass?

A 
Colorectal cancer, 
Rectal porolapse/varices
Anal wart
Polyp
Skin tag`
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135
Q

What conservative measures are used to treat hemorrhoids?

List 4

A 
PEG
Weight loss
Increase fibre intake
Increase fluid intake
Increase physical activity
Stool softener
Cold packs
Sitz baths
Baby wipes
NSAIDs
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136
Q

When can you start sleep training?

A

6 months.

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137
Q

How do you teach sleep training?

A

Bedtime routine.
Put baby to bed when tired
If crying allow for 2-5 minutes then reassure if needed. Then return and increase intervals between consoling

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138
Q

Maternal benefits to sleep training.

A

Better quality maternal sleep
Better maternal mood
Better maternal energy

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139
Q

Differential for fever and diarrhea. List 8

A 
Malaria
Dengue fever
Rickettsial disease (Typhus)
Waterborne (Typhoid)
Urinary infection
Respiratory infection
Skin infection
Traveler's diarrhea
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140
Q

What tests to do for stool parasites?

A

Stool O&P
Rectal biopsy
Urine examination for parasite eggs

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141
Q

What drugs treats trematode flatworms?

A

Praziquantel

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142
Q

What is acute shistosemiasis syndrome?

A

Katayama fever

143
Q

What office based test for diabetes? List 2

A

Random glucose

U/A (ketonuria/glysuria)

144
Q

What are important elements of history in new diagnosis of diabetes?

A

Polyuria
Polydyspsia
Polyphagia
Weight loss

145
Q

What conditions are associated with aortic dissection? List 5

A 
Hypertension
Marfan's
Ehlers-Danlos
Bicuspid aortic valve
Cocaine/Meth
Lupus
Polycystic Kidney Disease
Trauma
Giant Cell Arteritis
146
Q

Peak incidence age range for aortic dissection

A

60-70

30-40 (connective tissue diseases)

147
Q

What are 5 indications for medical marijuana?

A 
Spasticity secondary to spinal trauma
Spasticity secondary to MS
Chemotherapy induced N/V
Neuropathic pain
Palliative pain
148
Q

What is the medication given to neonates and what is the dose?

A

Vitamin K - 1 mg

149
Q

What is an alternative to a vitamin K injection?

A

PO vitamin K

150
Q

List 4 of the most common reasons for accessing MAID?

A 
Suffering/fear of suffering
Loss of independence or physical abilities
Loss of autonomy
Loss of pleasure
Unacceptable quality of life
Difficulty communicating
151
Q

What is the third line treatment for dyslipidemia?

A

PCSK9 inhibitors

152
Q

What is the mechanism of action of a PCSK9 inhibitor?

A

PCSK9 inhibitors attack to PCSK9. This prevents them from attaching to the LDL receptors in the liver thus allowing the LDL receptor to not be lysed.

153
Q

Physical exam findings as a result of vertebral compression fractures. List two.

A

Tenderness to palpation
Visible deformity
Kaiphosis and height loss

154
Q

What are the conservative treatments for a compression fracture? List 6

A 
Rest
NSAIDs
Acetaminophen
Calcium
Vit D
Smoking cessation
Weightbearing exercises
Bisphosphonate
Short term opiates
155
Q

What surgical intervention can be used for compression fractures?

A

Vertebraplasty

156
Q

What is the t-score cutoff for osteoporosis?

A

-2.5

157
Q

What are the contraindications for bisphosphonate drug holiday?

A

Fragility fractures of hip or spine.

158
Q

What are the elements of the FRAX score/what are important elements in history taking for bone health?

A 
Age
BMI
Femoral head t-score
Smoking
Race
Gender
EtOH
Previous fracture
Family history of fracture
Glucocorticoid use
RA
Secondary Osteoporosis
159
Q

What clinical features of a hand fracture warrants referral to plastics?

A 
Open fracture
Rotational deformities
Tendon rupture
Unstable fracture
Intra-articular
160
Q

What needs to be documented prior to manipulation?

A

Neurologic status

Vascular status

161
Q

What are three types of hand tendon injuries that warrant surgical intervention?

A

Jersey finger
Mallet finger
Central slip rupture

162
Q

What are the most common treatment options for fingertip amputation? List 3

A

Secondary intention
Reattach fingertip as composite graft
Revision amputation.

163
Q

Antenatal care?

A

Safety
U/S
Measure mom and baby at each visit
LABS

164
Q

Complications

A 
Lots more on here - divide into antenatal, in pregnancy, and post-partum
Gestational HTN (140/90)
PROM
TOLAC: labour if no contraindications, but increased risk if <18 mo
Labour latent/active 4cm dilation
Dystocia (<2cm in 2 hours)
Abnormal fetal heartrate
Uterine rupture
Shoulder dystocia
165
Q

Shoulder dystocia?

A

flip woman over (and other stuff John add please and thanks so much yes yes yes)

166
Q

Postpartum!

A 
Breast/chestfeeding
bottom
bowels
bladder
bleeding
baby
belly
blues birth control
boinking
167
Q

Mifeprisone for abortion?

A

Confirm gestational age
__________
CI: asthma, adrenal failure, steroid use, blood disorders, remove IUD
Advise
how to take, risks, severe pain (opioids) etc.

168
Q

How to RULE OUT major cardiac events?

A 
>18yo
CC/ Chest pain 
NO ECG changes
-Troponin and serial at 3 hours. IF negative, home with follow up
-LOW risk: 0.9% 30 day MACE

***CLINICAL SUSPICION&raquo_space; ECG, trops or heart score

169
Q

AVOID MISSING AORTIC DISSECTION by asking WHAT!?

A

History: Character, onset, duration, quality, radiation

ASK about >2 then 94% correct diagnosis. If <2 20% are missed!

170
Q

MONA?

A

Main goal: PCI <120 mins
Morphine (increased mortality for NSTEMI)
Oxygen >90%
Nitrates for analgesia or pain (no mortality benefit)
ASA 27% mortality benefit

171
Q

Non cardiac causes of Chest pain?

A

LUNG - PE< pneumothorax, infxn, pus, blood
Heart - valves, muscle, sac, infection, MI
Esophagus - inflam, acid, spasm, foreign body, rupture, ear
Viral swab for ZOSTER
Hiatus hernia - barium swallor/scope
Esophageal spasm

172
Q

Dressler’s syndrome is say what?

A

ddx: ACS, dressler’s (pericarditis), Aunxiety or PNA/PE
Test: CRP, ECHO, CXR
TREAT: High dose ASA and NSAIDS

173
Q

Colchicine for CVD?

A

Antiinflammatories- trial for effectiveness ongoing.

eg. Colchicine after MI = significantly lower risk of ischemic CV events.

ONLY WORKS FOR SECONDARY PREVENTION

174
Q

Heart failure mortality?

A

50% mortality after 5 years

175
Q

2 types of heart failure?

A

HFpEF - manage rate, volume, risk factors

Reduced EF: modulate neurohormonal pathway, meds, device therapy

176
Q

SLGT2 meds are good for what?

A

3 places where SLGT2 meds are great:

DM and CVdz,
DM2+over 50 +risk of CV disease,
DM, age >30yo (and something else re: renal dz)

177
Q

Treatment for preserved EF or not in Heart failure

A 
HF:
ACE or ARB
Beta blocker
Corticoid antagonist
PLUS diuretic
ALSO SLGT2 EVEN IF NO DIABETUS!
178
Q

Cardiac amyloidosis FUN FACTS?

A

NEW TREATMENT!
1/4 over 80yo
If HF unexplained or associated with NEUROPATHY or CARPAL TUNNEL (bilateral)
-Order SPEP, EPEP, and sFLC

Monoclonal protein??

179
Q

Heart failure non med treatment?

A 
Diet
Exercise
Smoking
Symptom and weight monitoring, vaccines
sx control and palliative care early
Med adherence
Self monitoring symptoms and weight
180
Q

Non-modifiable risk factors to breast CA

A 
Age >50
PHx
Sex
FHx
CUMULATIVE estrogen exposure!!
Radiation
181
Q

What affects cumulative estrogen exposure for breast cancer?

A 
Estrogen
early menarche
older menopause
Nulliparity
Postmenopausal HRT
Post menopausal obesity
182
Q

Screening for Breast CA?

A

NO!

No mammogram <50 yo, no breast self exam, no clinician breast exam

183
Q

Breast CA approach

A 
RED FLAGS:
Risk factors
Firm, fixed and lymph nodes
Past or family hx
???? more

MONITOR: smooth, rubbery, mobile, cystic

IF worried and >30 yo: Mammogram, U/S and core biopsy

184
Q

Side effects of treatment for breast CA?

A 
CMO
Valvular dz
fatigue
secondary malignancy
ovarian insufficiency (not failure)
lymphedema
185
Q

REFER for breast ca?

A 
Nursing breast advocate
Breast surgeon
Cancer agency
Rapid access breast clinic
Counselling
Physio/massage (lymphatic drainage)
Medical genetics (if extensive family history (BRCA?)
186
Q

Treatment for obesity (conservative tx failed)?

A

bupropion - naltrexone
Orlistat
Liraglutide (3cc/day injection)

Sx: gastric bypass, sleeve gastrectomy, gastric band,

COUNSEL: major procedure and surgical risk.
TREAT: like new patient

187
Q

Obesity

A 
ASK
ASSESS - MRS SWELPS
ADVISE - as your doc, I recommend
AGREE
ARRANGE
ADVOCATE
188
Q

Vaping for smoking cessation?

A

DON’T VAPE!

-vaping related lung injury!

189
Q

Treatment for obesity (conservative tx failed)?

A

bupropion - naltrexone
Orlistat
Liraglutide (3cc/day injection)
…..1 more

Sx: gastric bypass, sleeve gastrectomy, gastric band,

COUNSEL: major procedure and surgical risk.
TREAT: like new patient

190
Q

Obesity questions? (there are 6 A’s lol)

A 
ASK
ASSESS - MRS SWELPS
ADVISE - as your doc, I recommend
AGREE
ARRANGE
ADVOCATE
191
Q

M-SASQ?

A

> 8 drinks men, >6 female ??? Finish me!

192
Q

Pharmacological options for smoking cessation?

A

In order of most-least effective:

  1. Varenicline (no black box suicide warning)
  2. Bupropion UNLESS: sz d/o, eating d/o, EtOH withdrawal, allergy, MAO-i use
  3. Patch, gum, pills, spray, lozenge, inhaler
193
Q

M-SASQ?

A

Screen better than CAGE for alcohol use disorder:

> 8 drinks men, >6 female ??? Finish me!

194
Q

Low risk alcohol use guidelines?

A

Women: 2/day. 10/week

Men 3/day and 15/week

195
Q

Meds for Alcohol use disorder (AUD)

A

Naltrexone - NNT: 12. Don’t use if liver enzymes >3ULN
Acamprosate (666mg TID) - 2nd best
Disulfiram (antabuse) - only if CLOSE supervision (ie. exam says concerned wife) as can have cardiac issues or choke on their vom and dieeeeee

196
Q

Opioid Assisted Therapy?

A

Methadone - may have better uptake
Buprenorphine-naloxone

SE: CAT: constipation, amenorrhea, lower testosterone

197
Q

NSAIDs for acute MSK pain?

A

Ibuprofen
Use 200-400 mg is equivalent to 600-800 mg and NO greater pain relief
Don’t duplicate treatment

Ketorolac: lower dose is better for moderate to severe acute pain in adults.
Use 10 mg IV/IM
Offer analgesia with investigation

198
Q

Opioid guideline dosing and indication?

A

-Chronic cancer pain

Chronic non cancer pain:
New starts: Maximum 50 mg MED
Taper to 90 mg if currently higher

MED: morphine equivalents/day

199
Q

Non-opioid treatment for pain?

A

ONLY if no other options:
TCA
Nabilone
NSAIDS

Non meds
CBT
Exercise
Physio
Self-management
200
Q

Opioids in acute pain in elderly?

A

Morphine = hydromorphone
Rx: <3 days, rarely >7

Slow taper:
5% drop every 2-8 weeks
Taper rest periods

-make agreement with patient so they share your pain in prescribing opiates.

201
Q

Opioid withdrawal?

A 
Pain - neuropathic or not?
Agitated (clonidine if BP >90/50 and pulse >50
Diarrhea
Cramping
Sweating - oxybutinin
202
Q

Cannabis indications?

A

Refractory neuropathic, palliative pain, chemotherapy induced nausea and vomiting
Spasticity

203
Q

CFPC’s position on marijuana?

A

<25 yo,
History of psychotic illness,
Avoid in pregnancy
Assess for MOOD, ANXIETY, ABUSE

204
Q

Driving and pot?

A

4-6-8 Don’t Drive IF:
>4 hours post inhalation
>6 hrs post ingestion
>8 hours if experienced euphoria

205
Q

Cannabis use in geriatrics?

A

AVOID if: mental health, SUD, brain or banlance issues, CV dz

Assess:
CUDIT (cannabis use disorder inventory) screen
Falls and driving risk

206
Q

4 R’s of chronic pain management long term?

A

Ressass regularly
Relationship and shared decision-making
Reconsider diagnosis
Refer when appropriate

207
Q

Canadian C-Spine rules?

A

High risk? Radiography
Low risk? ROM
Able to ROM neck? Yes? No rads

High risk: >65 yo
Dangerous mechanism
Paresthesia

LOW:
Simple rearend MVA
Sitting in ED
Ambulatory at any time
Delayed onset of pain
Absence of midline tenderness
Does NOT apply IF:
Acute paralysis
Known vertebral disease
Previous C-spine injury
Outside of trauma
Unstable vitals or GCS <15

<16 yo (Use NEXUS)

NO C-spine rules for kids 
No neuro deficit
spinal
alert
intoxicated ??
208
Q

Unstable neck stuff (incomplete)

A

Jefferson’s fracture

Bilateral cervical facet dislocation?

209
Q

C-Spine standard of care?

A

CT. Skip X-ray.

210
Q

Chronic neck pain imaging indications:

A

Pain in ONE or BOTH upper extremities
Motor/sensory/reflex deficits

IMAGING not needed unless:
Hx of trauma
Persistent symptoms IF >4-6 w treatment
Red flags: malignancy, myelopathy, abscess…think about IVDU!

211
Q

Neck pain that isn’t neck pain…Name 7!

A 
MI
Carotid artery dissection
Basilar artery dissection
Mass/cancer
Foreign body
Lymphoma
Polymyalgia rheumatica (typical: Female >50yo)
212
Q

Common causes of neck pain (ergonomics)

A

Occupational (ergonomics!)
Driving
Neurology - refer

213
Q

QRS approach to neck pain

A

Quit spine board - remove ASAP
Refere - massage, physio, chiro, massage, neurosx if alarm features
Start - anesthesia, neck brace, c-collar

214
Q

Menopause conservative treatment start and stops?

A

STOP: smoking, drinking, caffeine
START: exercise and weight loss

  • Can be managed WITHOUT HRT or meds!!
  • CAM: Just say NO!
215
Q

Bloodwork for menopause?

A

Nah. Clinical diagnosis.

Just say NO to FSH!

216
Q

Pharm and non-pharm vasomotor symptoms of menopause?

A

Vasomotor treatment:

Menopause 5?

Fan
Layers
Cool environment
No hot drinks
Optimize sleep

Meds?

HRT
SSRI
Anticonvulsants
TCA
Progestin
OCPs
217
Q

Vaginal or internal sx of menopause treatment?

A

START:

Lubricant
Non-medicated gel
Estrogen tabs (reduce MILD not severe sx), moisture, rings or creams.

218
Q

Hormone sensitive breast CA and topical estrogens?

A

NO man. Defs not.

219
Q

Psych/Sex symptoms of menopause?

A

Treat confounders:

Sleep
Relationship
QU sx. of menopause (formerly vag atrophy and urinary sx)
SSRI

220
Q

Menopause +/- uterus treatment considerations?

A

DO they have a uterus?
GIVE PROGESTIN or BAZEDOXIFENE

No uterus: no progestin

221
Q

HRT for Intolerable menopause symptoms?

A

SAFE if:
Safe for < 5 years (risk increases 2%/y for negative outcome).
within 10 years of LMP
Transdermal patches work best

222
Q

Who cannot have estrogen for menopause?

A 
THINK CLOT RISK!!!!
Migraine w aura
Smoker >35yo
Uncontrolled HTN
Malignancy
DVT
Stroke
CAD
DM with end organ damage
Liver disease
FHx. or PHx of clotting dz
223
Q

Who cannot have estrogen for menopause?

A 
THINK CLOT RISK!!!!
Migraine w aura
Smoker >35yo
Uncontrolled HTN
Malignancy
DVT
Stroke
CAD
DM with end organ damage
Liver disease
FHx. or PHx of clotting dz
224
Q

Approach to cat bite?

A

Cat bite:
typical pathogen - pasteurella multocida
which abx? Amox-clav prophylactic. If pen allergy: ??
how to close it? DON’T
Vaccines? Tetanus and rabies
lidocaine with epi? OK to use in fingers, nose, ears

225
Q

Rabies guidelines?

A

Dog, cat and ferret - give RabIg and 4 doses of HDCV or PCECV and test animal

226
Q

Bites tx?

A 
Bites:
- add abx
if closing: stitches loose and drain
dog bites? ok to close
Cat? Avoid closing
227
Q

Peds laceration repair?

A

Intranasal midazolam or fentanyl
IV/IM ketamine
Blanket burrito
Topical LET (lidocaine, epi, tetracaine)

228
Q

How to close a wound?

A

Suture for close approximation
Staple for scalp or non cosmetic
Steri-strip
Glue for low tension tears/flaps

Deep: absorbable
Cosmetic? Doesn’t matter

229
Q

DON’T close wound if?

A

Deep puncture
Hi-tension
Infected
“Smelly Sneaker Syndrome”-pseudomonas and think of osteomyelitis

Timing:
18 hours old on face,
24 hours on head,
consult plastics

230
Q

When do you remove sutures?

A

face -5 days
over a joint or scalp 10-14d
Everything else: 7 days

F/U sooner if signs of infection

231
Q

MOST important steps in management of poisonings?

A

ABC’s
Consider SECOND or many poisons!!!
Call poison control

232
Q

If patient unconscious in the ED and you don’t know why???

A

Dextrose
Oxygen
Narcan (0.4 mg to start, but up to 10 mg)
Thiamine

233
Q

Stimulant vs. Anticholinergic toxidrome….

A

Vitals high and pupils dilated:
Sweating: stimulant (sympathomimetics like coffee, cocaine, amphetamine or ecstacy)
Treatment: none really

Vitals up and pupils dilated:
Flushed and not sweating…Anticholinergic toxidrome!
TCA, tegretol, anti-parkinson’s, antipsychotic, jimson weed
Treatment: physostigmine

234
Q

Antidotes to OD of beta blocker, iron, acetaminophen?

A

Betablocker OD - use glucagon
Iron OD: Deferoxamine
Acetaminophen OD - NAC and ABC’s

235
Q

Best medicine for poisoning?

A

Prevention!!!!

236
Q

Recurrent Otitis Media …refer to ENT when?

A

> 3 episodes in 6 mo

>4 independent episodes that you’re sure is acute otitis media in 1 year

237
Q

Conjunctivitis - to treat or not to treat?

A

65% goes away without antibiotics
All antibiotics have equal evidence
If wear contacts? Fluoroquinolone tx.

238
Q

Stable vs. unstable fracture?

A

Stable = Won’t displace under normal physiologic circumstance or stress

239
Q

Vitals, pupils and sweating in cholinergic, opioid, benzo and sedative-hypnotic toxidromes? Treatment?

A

Cholinergic: Normal vitals, pinpoint pupils, diaphoretic
Tx: Atropine, pralidoxime

Opioid: Decreased vitals, pinpoint pupils, No sweating
Tx: Naloxone

Sedative hypnotic - decreased vitals, normal pupils
Tx: None really

Benzo’s - normal vitals, pupils and no sweating
Tx. Flumazenil (seizure risk!!)

240
Q

What causes a cholinergic toxidrome?

A

Mushrooms

Organophosphates/insecticides/nerve agents/Sarin gas

241
Q

Causes of Sedative-hypnotic toxidrome?

A

Anti-epileptics, barbiturates, muscle relaxants

242
Q

Before treatment of UTI what questions

A

Allergies? Recent UTI? Recent urine cx?

Consult local resistance algorithm

243
Q

Uncomplicated UTI rx?

A

Septra DS

Nitrofurantoin

244
Q

Complicated UTI rx?

A 
Fluoroquinolone
3rd gen cefalosporin
Broad if severe:
Penem
Pip-tazo

Get blood cx before ABX!

245
Q

When should I sound alarm for UTI?

A 
Pyelonephritis
Sepsis
Obstruction
Impacted stone
Retention
246
Q

Risks of UTI?

A 
Very young
Very old
Middle age man with BPH (obstructive voiding)
Prenatal
Chronic pancreatitis
247
Q

Reinfection v. relapse of UTI?

A

Culture
Re-treat for 7-14 days
Reconsider diagnosis
Refer - upper tract imaging, cystoscopy, urodynamics
Diagnose recurrent UTI if all this ruled out- consider self treatment or prophylaxis?
–> prophylactic daily if menopausal woman, post coital if younger woman. Think of prostate U/S for BPH men.

248
Q

Treatment in children’s UTI

A

Cefixime 7-10 days and is weight based

249
Q

Which kids need bladder U/S post UTI

A

Febrile and <2yo with UTI
Recurrent
Complicated

MUST be: within 2 week window of UTI because looking for hydronephrosis. This is Positive U/S and THEN you will order VCUG

250
Q

Asymptomatic bacteriuria ALWAYS….EXCEPT….

A

If prego eggo’s as it can increase risk of preterm labour

251
Q

Epistaxis

A

Anterior are 90%

90% resolve with pressure and packing.

252
Q

Causes of epistaxis?

A 
Trauma/tumor
Infection
Meds
Exogenous (temp, weather
Bleeding disorder
253
Q

Mgmt MILD epistaxis? SEVERE? Posterior bleed?

A

Mgmt mild epistaxis:
-blow dose
2 sprays oxymetazoline
-Pinch x 10 mins

Severe:
ABC's
Movies
LABS
Tranexamic acid can help!
Freeze & cauterize* and pack with gauze, rapid rhino, foley

Do NOT cauterize both sides.

Posterior - identify by packing and keep bleeding. Call ENT!

254
Q

Next steps management for nosebleeds?

A

SAFETY - admit for monitoring if posterior
Next Visit - follow up w family doctor
OFFER labs only if severe.
Refer all unless anterior, source clearly identified.

NO antibiotics needed.

255
Q

Croup - remember 6! Age of onset and Mild to severe croup pharm and non-pharm

A

Occurs from 6 mo-36 mo…CAN have up to age 6yo.

MILD tx: ABC’s, antipyretics, fever, PO fluid, reassure parents, humidified O2. Dexamethasone 0.15 mg/kg

MODERATE: Dexamethasone = 0.6 mg per kg. (Likely to be equivalent to prednisolone 1 mg/kg)

SEVERE: Inhale epinephrine

256
Q

Bugs of croup!

A 
#1 cause: Parainfluenza
Influenza
RSV
Adenovirus (also in pink eye!)
Metapneumovirus
257
Q

Ddx stridor?

A

Croup
Foreign body (UNTIL PROVEN OTHERWISE!)
Tracheo-malacia

Safety- protect airway, ensure no foreign ingestion.
Next visit - If epinephrine given then see <24h later.

258
Q

Recurrent Croup tx approach?

A

Recurrent croup: Refer
Start antipyretics and analgesia, but NOT abx as ALWAYS viral!
Teach that course can fluctuate but symptoms should resolve in 3-4 days.

NO dexamethasone if recurrent croup. Must consider if it is more severe: Bacterial Tracheitis

259
Q

Wheeze, stridor, not improving in 1 week, looks bad..what is the black box if NOT croup?

A

Bacterial Tracheitis….

DON’T give dex!!!

260
Q

Meningitis tests?

A

Kernig - extend Knee with hip flex
Brudzinski Lift Brain (head) off bed

-mod PPV but no NPV.

261
Q

Management for Meningitis?

A

Do NOT wait for lab
Start IV Abx and droplet precautions NOW!

Abx are a RESUSCITATION DRUG in meningitis!

262
Q

What type of meningitis needs steroids?

A

Good for strep. pneumococcal specifically..but won’t know that right away.
BUT doesn’t make others worse! Dex needs to be given 15-20 mins or at same time of Abx. NO VALUE if given afterwards.

263
Q

Meningitis Investigations?

A

LP:
Bloodwork incl cultures
CT if indication that is NOT meningitis, worry focal lesion causing.

*Consider CT before LP if worried about increased ICP. (has specific risk facters)

264
Q

Who needs a CT before LP?

A 
Immunocompromised
Hx. CNS dz or lesions
New onset sz
Papilledema
Decreased GCS
Focal neuro deficits
265
Q

LP results and tx. meningitis

A

Bacteria: Made of protein and eat glucose. High protein, low glucose, lots of WBC…

Once treated will decrease protein, increase glucose, and WBC’s

Ceftriaxone and vanco
Add ampicillin if listeria
Add valacyclovir if viral.

266
Q

Peds patients meningitis: Steroids only if H. flu and <2 hours from antibiotics
ALWAYS attempt LP

A

All start with CTX and vanco

267
Q

Contraindications to LP in peds?

A

ALWAYS attempt UNLESS contraindicated:

Bleeding (coagulopathy)
Blisters
Brain
Low BP

268
Q

Peds meningitis

A

Ecoli and GBS

Ceftriaxone, vanco, ampicillin if listeria concern or immunocompromised

269
Q

Prophylaxis timeline and meds for meningitis

A

Must give if exposed 7 days before sx onset to 24 h post treatment.

Rifampin, ciprofloxacin and ceftriaxone

REPORTABLE DISEASE!! esp meningitis secondary to neisseria.

270
Q

Anaphylaxis approach

A 
Call 911
ABC's
Movies
Supine UNLESS seizure, pregnant or decreased LOC
epinephrine
271
Q

Epi dose for anaphylaxis?

A

Dose: 0.01 mg/kg (1:1000) 1 mg/mL
Route: Intramuscular NOT subcutaneous!

272
Q

Allergy alphabet

A 
Adrenaline
Breathing
Corticosteroids
Diphenhydramine
Epi again or IV fluits
Fluids
Glucagon if on beta blocker
H2 blocker ranitidine
Inhaled salbutamol
273
Q

Anaphylaxis discharge?

A

Discharge criteria:
Observe for at least 4-8 hours
Rebound in 23% - Steroids do NOT help reduce this.

274
Q

Doses for anaphylaxis?

A

Rule of 5’s

275
Q

Gender for eating disorders?

A

BOTH!

276
Q

Screening tool for EDs? SCOFF!

A 
SICK when you are feeling full
Lost CONTROL
Lost more than 1 stone (14 lbs in 3 mo?)
Believe yourself to be fat when others say you are thin
Feel food dominates your life?
277
Q

Consider eating disorder if…

A

Weight loss
Palpitations
Excess exercise

Amenorrhea NO LONGER REQ’D for anorexia diagnosis

278
Q

Types of eating disorders?

A

Anorexia
Bulimia
Binge Eating

279
Q

ED differential?

A 
Anxiety
OCD
Personality disorder
Bullying
Poverty/access to food
Excessive exercise
Depression
Substance use
280
Q

Ameonorrhea and NO ED?

A

Relative energy deficiency in sport RED-S
Formerly female athlete triad!
Occurs in any gender

281
Q

ED non-pharm management

A 
Dietitian
Psychiatrist
Group or individual counseling
Psychologist
Online training/course
CBT
School counselor
282
Q

BMI in eating disorders?

A

Mild: <17.5
Mod: 16-16.99
Severe: 15-15.99
Extreme: <15

283
Q

Sexual abuse (rule of 3 not to forget if treatment)

A

Medical assessment is NOT same as forensic assessment

Pregnancy prevention

STI counseling / Post exposure prophylaxis

284
Q

Sexual assault medical history/assessment?

A
  • Medically pertinent hx
  • Pregnancy risk
  • STI risk
  • Does patient want exam?
285
Q

Pregnancy prevention post assault

A

Copper IUD (up to 5 days)
Levonorgestrel
Ullipristal
Combined hormonal contraceptive

286
Q

How do you prevent and support future of sexual assault patient?

A

Prevent:
Mental health

COunselling
SQ
Sexual assault crisis centre
Victim assistance
Psychiatry if indicated.
287
Q

WHen do you report sexual assault?

A

VOLUNTARY unless under 18yo

288
Q

What do you want to provide education on to patients post sexual assault?

A

This is sexual assault
Not their fault
I support your decisions

“many people feel” , “it’s common to feel”… “It seems to me you are…”

289
Q

Higher risk for interpersonal (domestic) violence?

A
  • Elderly
  • Pregnant women
  • Children
  • Immigrant
290
Q

What MUST you do for patients of domestic violence?

A

Safety plan!!!! Get detailed! Repeat this at every visit.
Warn of escalation
Assess danger (first, worst, last)
-Write it down (maybe), NUMBERS in their phone (shelters? etc.)
-Guns, isolated, cell reception?

291
Q

Learning disabilities ddx?

A

3E’s:

Visual impairment
Hearing impairment
Education - intellectual disability, neurocutaneous disorders, TBI, seizure disorder
Sleep disorder

292
Q

ADHD onset?

Adult ADHD…does it exist?

A

Symptoms before 12 years old. (6/9)

Yes! (5/9)

293
Q

ADHD Med classes?

A

Stimulants - methylphenidate or amphetamine. First line = long acting

NRI - atomoxetine

Alpha 2 agonist - guanfacine, clonidine

294
Q

CADDRA - “DATER” mnemonic for considerations of medication not working in ADHD?

A

Dosage - increase, and duration of effect long enough?
All 1st line trialed
Time for response and side effects to normalize?
Examine targets. Standardized measures?
Review como’s and lifestyle

295
Q

CADDRA - “DATER” mnemonic for considerations of what to do if medication not working in ADHD?

A

Dosage - increase, and duration of effect long enough?
All 1st line trialed
Time for response and side effects to normalize?
Examine targets. Standardized measures?
Review como’s and lifestyle

296
Q

Non-medication treatments for ADHD?

A 
Patient and family psychoeducation
Psychological treatment
Educational accommodations
Occupational accomodations
Psychoeducational assessment
CBT
297
Q

Fun fact about bisphosphonates? (Random fact)

A

Bisphosphonates increase bone density by 3-5%

Bone density readings must be 6-10% apart to be trusted…otherwise, could be due to something else.

298
Q

ADHD treatment if has SUD?

A

Consider atomoxetine or vyvanse (prodrug) first!

299
Q

Dirty wound?

A 
Is there dirt in it?
Open wound
Crush
Tear
Burn
Frostbite
?vaccinated or <3 tetanus vaccines
300
Q

Lipid testing and the elderly?

A

Canadian:

>75 yo do NOT test lipids

301
Q

Lipid testing and the elderly?

A

Canadian:

>75 yo do NOT test lipids

302
Q

Vaginal bleeding… get worried IF…

A

First trimester?
Abnormal uterine bleeding?
Post menopause?

303
Q

Vaginal bleeding in first trimester ddx?

A
  1. Threatened abortion - viable intrauterine pregnancy

Mangement: serial U/S, Serial beta HCG, preautions

  1. Missed abortion - no fetal heartbeat or growth failure
MGMT:
Surgical (96%)
Medical Management? (81%)
Expectant management (56%)
- % = success rate
  1. Complete abortion - bleeding, cramping have stopped
    Mgmt: NOTHING unless major bleed / Rh Neg (WinRHO)
  2. Ectopic Pregnancy
    -Pain, <7 weeks, tubal risk factors
    Mgmt: Expectant, medical or surgical, serial bHCG and U/S and consult surgical candidate to save the tube!
304
Q

Risk factors for abnormal uterine bleeding?

A

RF: estrogen exposure, hyperandrogenism

305
Q

Abnormal uterine bleeding (AUB) investigations?

A

Endometrial biopsy
Pap
Colposcopy

We worry about cancer! So do they!

306
Q

Mgmt of Abnormal Uterine Bleeding?

A

Hormonal - LNG, IUS, OCP, progestin

Non-hormonal: NSAIDs and tranexamic acid

Surgical - ablation, hysterectomy, polypectomy, myomectomy

307
Q

Who do you investigate when post-menopausal vaginal bleeding? What tests?

A

Everyone with a uterus!!!

Pelvic exam, pap, U/S or endometrial biopsy, REFER!

308
Q

Vaginitis diagnosis?

A
  1. History - LMP, G’s and P’s
  2. Look at the skin / vagine
  3. Do some tests!

What tests?

Swabs
Wet mount
pH test
KOH prep
Biopsy
309
Q

Ddx of itchy vag?

A

Not all that itches is yeast
Not all discharge is yeast
Not all yeast much be treated

Ddx:
Eczema, psoriasis, lichen sclerosis, or simplex, neoplasm - VIN, vulvar cancer

GU syndrome of menopause (atrophic vaginitis)

Rashes - contact dermatitis

Bugs: HSV, Trich, PID, BV

310
Q

Vagine discharge with normal tests and normal skin?

A

Normal Variant!! Physiological discharge. Can be thin, thick, more often discharge…can change with hormones or pregnancy

311
Q

Screen for vaginitis?

A

Don’t screen
Even if pregnant
Not even for BV

Only if symptomatic vaginitis

312
Q

Vaginitis in kids?

A

Foreign body
STI …REPORTABLE!!!!
Irritant
UNLIKELY yeast!

313
Q

67 yo Male w nocturia, frequency, urgency. Screen?

A

NOT ONE IF THERE ARE SYMPTOMS!!!

314
Q

PSA?

A

One recommendation: Don’t use for screening
Uro recs: If > 10 years life expectancy then DISCUSS PSA.
Start at 50 yo if lower risk and 40 yo if higher

315
Q

PSA test comes back elevated (22ug/L). Next step?

A

CFP 2015 guideline

Think 10-20 rule:

If PSA is 10-20 it’s semiurgent
<10 is low risk
>20 is hi risk / urgent

Physical exam
IF abnormal and PSA >10 then URGENT
IF normal and PSA <10 non urgent

Then REFER TO UROLOGY FOR PROSTATE BIOPSY URGENTLY!

316
Q

What is high risk for prostate CA?

A 
Age
Hi-risk race
Family Hx
Smoking
Obesity
317
Q

BPH Management?

A

Dx with hx and physical - don’t forget abdominal exam (urinary retention) and rectal exam.

U/A and midstream C/S

PSA if alive for >10 years

Treat ONLY IF BOTHERSOME. Use IPSS (international prostate symptom score

318
Q

Non pharm mgmt and pharm mgmt for BPH?

A

D/C NSAIDs, saw palmetto, antihistamines, decongestants, and excess fluid, caffeine, alcohol

Start:

  1. Alpha blocker (tamsulosin)
  2. 5 alpha reductase inhibitor
  3. 1 & 2
  4. Antimuscarinics
  5. 1 & 4
  6. PDE 5 inhibitors

REFER:
If suspect prostate CA
If bothered +/- meds ineffective for surgery considerations

319
Q

Prostatitis

A

If no fevers, chills, myalgia or malaise?

More likely UTI or STI… they would look shitty if had prostatitis as systemic.

320
Q

Most common bugs for prostatitis?

A

UTI bugs (which are???)

321
Q

Infertility?

A

(An)ovulatory?
Variable menstrual interval and flow?

Tubal dysfcn (?scarring)
Inflammation - endometriosis, ectopic, surgery, crohns
Infection - STI’s, PID, ruptured appendix
Anatomic
Adhesions

Tx: Pelvic U/S

322
Q

Infertility don’t forget the….

A 
MAN!
-Sperm
Partner
Underwear
Work environment?

Also think of:

Erectile dysfunction
Coital frequency and timing
Dysparenuia

323
Q

Freeze the eggs? Risks?

A

Thawed oocyte survival rates are 80-90%
Live birth rates likely similar to fresh
Age of freezing matters

RISKS: Infection, anesthesia, Controlled ovarian stimulation, oocyte retrieval and pregnancy at advanced maternal age

324
Q

Ovarian reserve testing?

A

Consider Anti mullerian hormone for women aged:
>35 y

<35 y with RF for decreased ovarian reserve?
single ovary
ovarian surgery
poor response to FSH
Chemo/radiation
Unexplained fertility
325
Q

Infertility tx beyond referral

A

Referral (ya but what else…)
Testing
Treatment options
Adoption

326
Q

Investigations in infertility?

A

Pelvic
Pap
Partner

Ovulation - Day 3 FSH, Estrogen, TSH, prolactin, midluteal progesterone

Hyperandro
DHEA-S, 17-OH progesterone, total

Pelvic us or hysterosalpingogram

Semen analysis

327
Q

Prevention of infertility?

A

Screen and treat for STI
Counsel re risk of tubal damange
Quit smoking, MJ, optimize BMI

328
Q

Referral for infertility?

A

12 mo if no RFs
6 mo if RF’s or >35 yo
IMMEDIATELY if >40y

329
Q

What % of people conceive in 12 months?

A

90%

330
Q

If unexplained infertility what do you NOT treat with?

A

Do not offer if unexplained infertility:

Natural - cycle intrauterine insemination
Clomiphene citrate alone
Aromatase inhibitors alone

331
Q

Consider further investigations/tx with infertility?

A

IF: No pregnancy after 12 mo, regular intercourse, normal ovulator fcn, normal semen, 1 patent tube

Laparoscopy only if tubal/pelvic pathology suspected, invitro fertilization etc.

332
Q

PID tx?

A
  1. Antibiotics:
    Cefoxitin and docycycline
    Ceftriaxone and doxy
    Clindamycin and gentamycin
  2. Treat partner,
  3. contact tracing,
  4. NO SEX x 7 days
333
Q

Contraindications, risk, side effects

A

Start OCP on sunday and won’t get period on weekend

334
Q

Who can’t have estrogen?

A 
Migraine w aura
Smoker >35y >15 cigs
uncontrolled HTN
Malignancy
DVT
Stroke
CAD
DM with end organ damage
Liver disease
335
Q

Conception counseling…START…

A

folic acid
Iron
Vaccines

QUIT: smoking, teratogenic meds, alcohol, drugs

336
Q

Sex PLUS…

A 
History is the ABC's:
Abuse
Babies/contraception
Cancer
s: STI's
337
Q

Gender diversity history taking?

A 
What is(are) your partner(s) genders?
What kind of sex do you have?
How do you refer to your genitals?

“anything you’d like me to know about your gender identity?”

338
Q

Age of consent?

A

Age of consent:
16 yo if non-exploitative
18yo if exploitative sex (power differential, porn, prostitution)

Consenting youth?
Youth: 12-13 yo - up to 2 years older
Age 14-15yo -up to 5 years older

339
Q

Contraception questions

A

Last menses?
Contraception types?
Adherence?
Infertility?

OFFER contraception and EMERGENCY contraception

340
Q

HPV vaccine?

A

HPV vaccine = cancer prevention vaccine!

341
Q

STI history taking?

A

Do you use internal or external condoms?
Prev STI?
Trade sex for money or drugs?

Discuss prevention, offer testing, treatment, and contact tracing/treatment, report to public health

342
Q

Erectile dysfunction hx taking?

A 
ASK...
Morning wood
sexual preferences
Contraception
age of partner(s)
343
Q

Erectile dysfunction hx taking?

A 
ASK...
Morning wood
sexual preferences
Contraception
age of partner(s)
344
Q

Priapism?

A

Foreverection!!!

  1. Ischemic or not?
    Doppler US
    Cavernosal blood gas

NON ISCHEMIC: watch & wait, 5 alpha reductase inhibitor - finasteride
GNRH agonist- leuprolide

ISCHEMIC:
Needle drain
Intracavernosal phenylephrine
Surgical shunt if >48h

345
Q

Sexual dysfunction in females?

A

Topical estrogen for vaginal sx
Testosterone - short term only
Sildenafil - inconsistent results

346
Q

Referrals in sexual dysfunction?

A 
Refer for counseling (individual or couples)
CBT
Mindfulness
Pelvic floor physio
Body image counseling

REFER to doctors: Urology, sexual medicine, endocrinology, psychiatry

347
Q

Investigations in sexual dysfunction?

A

Glucose
Chol/ HDL/LDL/Trig/non HDL
Testosterone
+/- PRL, TSH, LH FSH

348
Q

HIV pre-exposure prophylaxis

A

> 90% reduction in HIV acquisition!!!

1 pill x __days?

349
Q

PREP labs?

A

bHCG
Hepatitis labs
Renal functions
Screen STI’s (q3mo) swab every site!!

TALK ABOUT CONDOMS….

350
Q

PREP labs?

A

bHCG
Hepatitis labs
Renal function
Screen STI’s (q3mo) swab every site!!

TALK ABOUT CONDOMS….

351
Q

lil guy OR elder abuse consideration?

A
  • Speak to patient without caregiver

- Check competence….

352
Q

PSA and DRE?

A

Post DRE can have transient PSA elevation…wait 3 days and should go back to normal

353
Q

BPH tx…make sure you pre- and post- measure?

A

Blood pressure before and after as treatment can lower BP

CCFP Exam 2021 (11 decks)

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