SAM 2019 Flashcards
side effects caused by Lithium
- Nausea and Vomiting
- Diarrhea (often if there is dose change, or at
initiation) - Myoclonic jerks
- Ataxia
- Confusion, impaired concentration
- Any signs of hypothyroidism (10-20% of patients starting on lithium will develop hypothyroidism)
- Weight gain
lab tests you would consider ordering for a female patient taking lithium with nausea
- bHCG (lithium is teratogenic. Important to rule out pregnancy, especially with any new symptoms)
- Lithium levels
- Calcium (lithium can affect parathyroid gland)
- TSH (lithium can affect thyroid gland)
- Creatinine (assess renal function because
lithium is excreted by the kidneys)
therapeutic level range for lithium
0.6 – 1.2 mmol/L
What can you do to reduce pain before and during a laceration repair in children? List THREE techniques other than injected local anesthetic
- Needle free anaesthesia (lidocaine, epinephrine-
tetracaine, or topical L.E.T., or EMLA cream) - Injected lidocaine or bupivacaine
- Patient distraction techniques (Video/Phone)
- Procedural Sedation
You decide to use a local anesthetic for pain control during the procedure. What are 3 ways
to reduce the pain of lidocaine injection?
- Buffering lidocaine with bicarbonate
- Warming the lidocaine
- Injecting slowly at a perpendicular angle to
the skin
Just before giving the Lidocaine the mother mentions that he has an allergy to Lidocaine.
You would still like to give a local anaesthetic into the tissue. What are your options?
- preservative free Lidocaine
- Procaine
- Tetracaine
List 1 other concern you must consider in this child with laceration wound on the arm
- Child Abuse/Non-Accidental Injury
What is your differential diagnosis for this patient with a large red toe after a Vandenbos
procedure?
- Cellulitis
- Allergic Reaction
- Critical Ischemia
- Necrotizing Fasciitis
- Reperfusion injury
What are key features that would lead you to believe that his presentation would be
infectious?
- proximal migration of lesion
- Pain on passive stretch
- Fever
- Leukocytosis
- Raised inflammatory markers (C-reactive
Protein or Erythrocyte sedimentation rate) - Bony erosions (osteomyelitis)
The 5 y/o child is afebrile. List ONE treatment for this patient’s asymptomatic bacteriuria.
None
What condition or future concerns would indicate that you should treat the 5 y/o child’s asymptomatic bacteiruria? List ONE.
- child has received renal transplants
- child is undergoing invasive procedures
involving the urogenital tract
What drug classes in combination are the most worrisome and likely to cause Serotonin
Syndrome? List 3.
- Monoamine Oxidase Inhibitors (MAOI)
- Selective Serotonin Reuptake Inhibitor
(SSRI) - Serotonin-norepinephrine Reuptake
Inhibitor (SNRI)
What other diagnoses would be in your differential in a patient with fever and possible
serotonin syndrome? List 6.
(DIM FACES – Drugs; Infection;
Metabolic; Failure i.e. hepatic, cardiac, renal;
Anemia; Cerebral infarct/bleed; Endocrine;
Structural / Space-occupying lesion):
DRUGS: 1. Antidepressant discontinuation 2. Anticholinergic toxicity 3. Malignant Hyperthermia 4. Neuroleptic Malignant Syndrome (which occurs over days, while serotonin syndrome occurs within 24 hours) 5. Drug Overdose 6. Alcohol withdrawal 7. Benzodiazepine withdrawal
INFECTION: 8. Meningitis 9. Encephalitis METABOLIC: 10. Thyroid Storm STRUCTURAL: 11. Delirium from space-occupying lesion
What are the symptoms and signs of Serotonin Syndrome? List 6
- autonomic (mydriasis, diaphoresis, tachycardia, tachypnea) - neuromuscular (tremor, hyperreflexia, and clonus - altered mental status (agitation, excitement, restlessness, confusion, delirium)
What is the ONE symptom that you would see in Neuroleptic Malignant Syndrome and not
in Serotonin Syndrome?
- Clonus
orthostatic hypotension definition
Systolic BP drop of at least 20 mm Hg or diastolic BP of 10 mm Hg within 3 minutes of standing from supine BP
Causes of orthostatic hypotension with rebound tachycardia (autonomic dysfunction)
- Diabetic autonomic neuropathy
- Low Vitamin B12
- Hypothyroidism
- Ethanol abuse
- parkinsonism (Parkinson disease, progressive supranuclear palsy, multisystem atrophy)
- amyloidosis
- drug effect: beta-blocker
- idiopathic: depletion of norepinephrine from sympathetic nerve terminals
conservative management of plantar fasciitis
- NSAIDs
- steroid injections
- orthotics
- night splinting
- stretching
- weight loss
- High-Load Strength Training (HLST)
DM foot exam for?
peripheral neuropathy and diabetic foot ulcer
rectal mass, DDx?
Colorectal cancer Rectal varices Skin tag Anal wart Rectal prolapse Polyp
conservative management of hemorrhoid
Weight loss (if necessary) Increase fluid intake Increase fiber intake Increase exercise Sitz baths Not straining with bowel movement Using wipes instead of toilet paper Cold packs Over-the-counter pain relief treatments Stool softeners
surgery options for hemorrhoid
Rubber band ligation Excision Hemorrhoidectomy Staple Hemorrhoidepexy Doppler guided hemorrhoidal artery ligation Sclerotherapy
conservative management of hemorrhoid
Medical management:
stool softeners
topical over-the-counter preparations (astringents (witch hazel), protectants (zinc oxide), decongestants (phenylephrine), corticosteroids, and topical anesthetics)
topical nitroglycerine
Dietary modifications
e.g., increased fiber and water intake
Behavioral therapies: sitz baths
how to manage thrombosed external hemorrhoid
- conservative management with topical therapies (topical nitroglycerine)
- surgical removal of the thrombus within the first two to three days: leads to quicker symptom resolution, lower risk of recurrence, and a prolonged recurrence interval
when to start sleep training in infancy?
6 months old
rules to suggest for sleep training
- Put baby to bed while drowsy
- If baby cries leave him/her for 2-5 minutes.
- Respond to baby with reassurance if required and then leave for another 2-5 minutes.
- Extend intervals
benefits of sleep training in infancy for the mother
- improved parent fatigue
- improved sleep quality
- improved mood
treatment of acute schistosomiasis syndrome
Praziquantel
What conditions are associated with acute aortic dissection?
- Hypertension
- Giant cell arteritis
- Bicuspid aortic valve
- Cocaine use
- Trauma
- Polycystic kidney disease
- Systemic lupus erythematosus
- Marfan/Ehlers-Danlos
Hypertension (occurs in 70% of patients with distal Standford type B AAD)
An abrupt, transient, severe increase in blood pressure (e.g., strenuous weight lifting and use of sympathomimetic agents such as cocaine, ecstasy, or energy drinks)
Genetic conditions including Marfan syndrome (In an IRAD review, Marfan syndrome was present in 50% of those under age 40, compared with only 2% of older patients), Ehlers-Danlos syndrome, Turner syndrome, and bicuspid aortic valve, coarctation of the aorta. In patients with Marfan syndrome, cystic medial necrosis is seen in the tissues
Pre-existing aortic aneurysm
Atherosclerosis
Pregnancy and delivery (risk compounded in pregnant women with connective tissue disorders such as Marfan syndrome)
Family history
Aortic instrumentation or surgery (coronary artery bypass, aortic or mitral valve replacement, and percutaneous stenting or catheter insertion)
Inflammatory or infectious diseases that cause vasculitis (syphilis, cocaine use)
What is the peak incidence age range for Acute Aortic Dissection in previously-healthy
patients?
60-70 years old
30-40 in Marfan/Ehlers-Danlos
indications for medical marijuana based on the Canadian Simplified Guidelines for Prescribing Medical Marijuana (2018)
- neuropathic pain
- palliative and end-of-life pain
- chemotherapy-induced nausea and vomiting
- spasticity due to multiple sclerosis
- spasticity due to spinal cord injury
List 4 of the most common reasons for accessing MAID therapy
- Loss of autonomy & control
- Unacceptable quality of life
- Loss of independence or physical abilities
- Incapacity/difficulty communicating
- Loss of pleasure
- Suffering/fear of suffering
What is a 3rd line medication class for dyslipidemia after statin and ezetimibe?
Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors
Describe 2 physical exam findings which can occur as a result of vertebral compression fractures
Height loss
Kyphosis
Tenderness to palpation ON SPINAL PROCESS
Visible deformity
Non-surgical management of recurrent spinal compression fracture
- Acetaminophen
- NSAIDs
- Short term opiates
- Physiotherapy/exercise
- Bisphosphonates
- Calcium
- Vit D
- Quit smoking
From aafp:
Conservative management:
Acute VCFs may be treated with analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, narcotics, and calcitonin
Other conservative therapeutic options:
limited bed rest, bracing, physical therapy, nerve root blocks, and epidural injections.
Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, is controversial, but can be considered in patients with inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life.
List ONE surgical intervention that can be considered if there is no improvement from the above conservative treatments for compression fracture
Vertebroplasty
Kyphoplasty
criteria for bisphosphonate drug holiday
hip and vertebral fractures place patients as high risk and they are not candidates for drug holidays
What clinical features would make you refer this patient with hand injury when playing baseballs to a hand surgeon?
- open
- deformed: displaced, angulated, rotated /scissoring
- intra-articular
- unstable
- nerve and tendon injuries
What are 2 clinical findings you must document before and after any manipulation of his injury?
- Distal Neurological status
- Distal Vascular status
On examination you notice a decrease in range of movement in one of his fingers. What are
3 types of closed tendon injuries that you are concerned about that require possible surgical intervention or splinting?
- mallet finger
- central slip
- jersey finger
1. Mallet: extensor tendon injuries at distal
phalanx resulting from sudden flexion of an
extended DIPJ.
2. Central slip: extensor tendon injuries at
middle phalanx from forced flexion of
extended PIPJ.
3. Jersey: sudden hyperextension of flexed
DIPJ.
What are your management options for
a fingertip amputation past the DIP (distal interphalangeal) joint, the most common amputated body part in a child? List 2
- reattachment of the amputated fingertip as a composite graft
- healing by secondary intention
- revision amputation
What are possible side effects of anti-psychotic medications in the elderly?
- increased overall risk of death
- cerebrovascular adverse events
- extrapyramidal symptoms
- gait disturbances
- falls
- somnolence
- edema
- urinary tract infections
- weight gain
- diabetes
DEPRESCRIBE (taper/stop) antipsychotics in ELDERLY
patients and adults, indications?
ELDERLY patients taking them for INSOMNIA AND
in ADULTS who have had an adequate (3 month) trial for BPSD (Behavioural and Psychological Symptoms of Dementia) or UNRESPONSIVE/STABILIZED on treatment
What blood tests would you order at baseline before starting a second-generation antipsychotic medications?
- fasting plasma glucose
- fasting total cholesterol
- fasting low-density lipoprotein
- fasting HDL
- fasting triglyceride
- aspartate transaminase (AST)
- alanine transaminase (ALT)
- prolactin
- amylase
In addition to the bloodwork that you order what would you measure at patient’s visit? List 4
- Weight
- Height
- Waist circumference
- Blood Pressure
What findings from a clinical history would raise your suspicion and likelihood of a thyroid nodule being a malignancy?
- rapid growth of a neck mass
- head and neck irradiation
- total body irradiation for bone marrow transplantation
- familial thyroid carcinoma
- thyroid cancer syndromes (eg, multiple endocrine neoplasia type 2, familial adenomatous polyposis, Cowden disease)
What findings of physical examination would make you concerned about malignancy? List FOUR.
- dysphonia
- dysphagia
- dyspnea
- regional lymphadenopathy
- fixation of the nodule to surrounding tissue
You find a single fixed thyroid nodule greater than 1cm in diameter. What is the single most important blood test to order now?
- serum thyroid-stimulating hormone (TSH)
Briefly describe FOUR sequential steps of trauma informed care.
Step 1. Bear witness to patient’s trauma experience
Step 2. create a safe space and recognize need for physical/emotional safety
Step 3. Include patients in healing process
Step 4. Believe in the patient’s strength and resilience
Step 5. Incorporate processes that are sensitive to a patient’s culture, ethnicity, and personal and social identity
What other conditions are associated with NSSI?
- depression
- borderline personality disorder
- childhood sexual abuse
- higher risk of suicidal behaviour
Other than restless leg syndrome, what is your differential diagnosis for this presentation?
Volitional movements Akathisia Nocturnal leg cramps Leg pain (vascular claudication, peripheral neuropathy, radiculopathy) Periodic limb movement disorder
List 4 risk factors/causes for restless legs syndrome
Low iron stores Family history/genetics Uremia (Secondary to renal failure) Neuropathy (due to diabetes, alcohol, amyloid, motor neuron disease) Pregnancy Multiple sclerosis Parkinsons disease Medications (antiemetics, antihistamines, antidepressants, anticonvulsants)
List 2 possible treatment options
Iron replacement Dopamine agonist (pramipexole, ropinirole) Gabapentin, pregabalin Benzodiazepines Exercise/Stretching
In terms of cast removal what are 3 procedural, safety, or technical steps to follow when removing the cast?
- Use caution over bony prominences (malleoli)
- Mark with ink on the cast where you plan to cut
- Use an UP-AND-DOWN motion
- do NOT run the saw along tight skin
- Stop if the patient tells you to stop
- Cut the cast on both sides
- Use a cast cutting metal guard
- Display/show that the cutter does not cut skin
What is the diagnosis you are most concerned about a 14 year old with increasing pain under the cast?
Compartment Syndrome
Does early introduction of peanut to the diet increase the risk of peanut allergy?
NO
What 2 conditions put children at higher risk for having a peanut allergy?
Severe Ecemza
Egg Allergy
Adults with Intellectual and developmental disabilities have a number of medical conditions
that can be more prevalent in this patient population or can present earlier or simply go
under-recognized. List 6 conditions that would fall under these categories
- more prevalent (i.e. dementia, infectious conditions) - present earlier (menopause, diabetes) - underrecognized (i.e. epilepsy, addictions or psychiatric conditions)
Other than his medical and psychiatric-behavioural management what are the other steps
in care you need to complete? List FOUR.
- supporting and educating family
- ensuring follow-up
- engaging with community &
interprofessional services - monitoring for adverse drug reactions
- monitoring for abuse (Physical, Financial,
Mental)
What are 3 of the essential eligibility requirements for MAID?
- at least 18 years old
- capable of making the decision
- grievous and irremediable medical
condition (serious and incurable illness,
disease, or disability) that causes the patient
to endure physical or psychological suffering
that is intolerable to them and that cannot be
relieved in a manner that the patient
considers acceptable - an advanced state of irreversible decline
and natural death is reasonably foreseeable - decision not made as a result of external
pressure
What is the ONE
recommendation regarding home monitoring of her blood sugar?
Stop routine management/taking
fingerstick measurements
What type of diet do you recommend for her IBS
symptoms? List ONE
low-FODMAP (fermentable oligo-dimonosaccharides
and polyols) foods
List 4 foods to avoid, according to the FODMAP diet you recommend
- Oligosaccharides: Wheat, rye, legumes, garlic, onions.
- Disaccharides: Milk, yogurt and soft cheese.
- Monosaccharides: Mangos, honey.
- Polyols: blackberries, lychee, low calorie sweeteners.
What ONE finding on examination would make you concerned about Leprosy?
Insensate (though this is not pathognomonic)
Other than India what is ONE other country where Leprosy is endemic?
Indonesia, Brazil, and the Democratic Republic of the Congo
What are 2 risk factors for leprosy?
- low socioeconomic status
- genetic predisposition
- exposure to affected household contacts (transmission by droplet contact + nasal mucosa)
What are the concerns about elderly having long term Benzodiazepine receptor agonist (BZRA) for insomnia?
- psychological dependence
- physical dependence
- increased falls risk
greater risk of falls, motor vehicle collisions, problems with memory, and daytime sedation
What do you plan to do in terms of his Benzodiazepine prescription? List ONE management plan.
- start a slow taper
Deprescribing (slow taper) of BZRAs should
be offered to elderly adults (≥ 65 years) -
regardless of duration of use and to adults
aged 18-64 using BZRAs >4 weeks
Guideline - NOT applied to patients with other sleep disorders, untreated anxiety, depression, or physical/mental health conditions that might be
causing/aggravating insomnia
She would like to be tested for Gonorrhea and Chlamydia but the office staff have already thrown out the urine sample. She declines having a swab done in the clinic and is unable to give another urine sample.
What ONE other option can you offer her in terms of testing?
Self-collected vaginal swab (SCVS)
The next patient is a 45 year old G5P5. She reports that she will become incontinent of urine
only after laughter. Coughing and sneezing do not cause any urine loss. She is continent of
urine all night. Urine point of care is negative. What is the diagnosis? List ONE.
giggle micturition (enuresis risoria)
{A rare form of daytime wetting: involuntary,
unstoppable, complete bladder emptying
during/immediately after laughing/giggling.}37 y/o female with abnormal bleeding from her vagina not related to her normally regular periods. Name
4 diseases in your differential for her Abnormal Uterine Bleeding.
- endometrial polyp
- uterine fibroleiomyoma
- endometriosis
- endometrial hyperplasia
- endometrial carcinoma
- uterine sarcoma
- bleeding disorders
A 3 year old girl with sudden-onset elbow pain: On physical examination the patient winces when you go near her elbow. She has the arm extended and hanging by her side. Hand movement is normal and sensation and capillary refill is normal. What is the diagnosis?
Radial head subluxation (Nursemaids
Elbow)
List ONE imaging investigation you would order at this stage
None.
List ONE treatment for this condition.
- Hyperpronation maneuver OR
- supination-flexion maneuver
If the history was unclear and the mechanism included falling from a height or tumbling with
some bruising for this 3-year-old. What ONE other injury would you consider?
supracondylar humerus fracture and Non-Accidental Injury
What are FOUR symptoms of Myalgic-Encephalitis-Chronic Fatigue Syndrome (ME-CFS), Fibromyalgia, and Environmental sensitivities–multiple chemical sensitivity (ES-MCS) that are common to all 3 conditions?
- sleep disturbances
- neurologic symptoms
- cognitive symptoms
- fatigue
- at varying degrees, pain
What is distinctive about Myalgic-Encephalitis-Chronic Fatigue Syndrome (ME-CFS fatigue)? List 3 features.
3)
- fatigue is chronic, profound, and not
improved by rest, and post-exertional
malaise
After a trigger through exposure to a low level of either a chemical, biological, or physical agent, what sort of symptoms would someone suffering from Environmental sensitivities–multiple chemical sensitivity (ES-MCS) suffer from? List
THREE characteristics of these symptoms.
- usually neurocognitive
- might involve respiratory and other systems
- relief or improvement when inciting agents are removed
What TWO tests do you recommend to a female newly diagnosed with Celiac disease for concern of bone health?
- Bone Mineral Density (BMD)
- Vitamin D measurement at diagnosis and
annually (until normal)
What else do you recommend in terms of bone health to the patient newly diagnosed with Celiac disease?
- strict gluten-free diet
- supplementation with Calcium and Vitamin D
- weight bearing exercises
Red Flags in terms of back pain
- bowel incontinence
- bladder incontinence
- saddle anaesthesia
- loss of rectal tone
- fever
- night sweats
- weight loss
If he did not have a history of prior IVDU or red flags, what would be your ONE next radiological investigation at this visit?
None
What findings on history, physical examination, or laboratory would lead you to believe a
patient has appendicitis? List SIX.
fever >38° C anorexia nausea and vomiting cough/percussion/hopping tenderness RLQ tenderness migration of pain leukocytosis >10 neutrophilia >7.5
Other than the child’s abdomen, what ONE other area must you examine in this patient?
Testicular examination for torsion
What organism is the cause of whooping cough? List ONE.
Bordetella pertussis
After the catarrhal phase (1-2 wks) a paroxysmal cough begins that can last 1-10 weeks. How long is whooping cough contagious?
Communicable from catarrhal phase to
3 weeks after cough onset
If patients are given Azithromycin what is the duration of communicability of disease shortened to?
5 days
What 2 particular groups would you vaccinate if there was a confirmed outbreak?
- Pregnant women >26 weeks’ gestation
- Accelerated infant immunization (at 42 days
of age)
An elderly gentleman presents to your clinic and you observe him walking very slowly
with a cane. He looks unsteady even with the cane and slumps down into the chair. He
begins to tell you about the ‘ringing in his ears’ and that he needs his ear cleaned of wax.
He has had something similar to this in the past. On examination his external ear canal is normal and there is no wax. What are 3 red flags for
tinnitus?
- Pulsatile Tinnitus
- Unilateral Tinnitus
- Abnormal otoscopy findings
What imaging test is the best for ruling out a vascular cause? List ONE
magnetic resonance angiogram and
venogram of the brain and neck
