SAMP FMRC 2018 - Sept30 Flashcards
1
Q
Risk factors of community- associated MRSA
A
- Limited access to clean water
- Overcrowding/living in a group setting
- Participation in sports teams, particularly contact sports
- Social determinants of health
- Prisoners
- Military personnel
- Use of illegal drugs in the past year
- Recent antibiotic use in the last 6 months
- HIV positive
- Regular contact with someone in a group setting, history of CA-MRSA, or IVDU in the past year
- Penetrating trauma
- Homeless persons
- Prior MRSA colonization or recent infection
- Age < 2 y/o or more than 65 years old
2
Q
OTCs or food prolonging INR when on Warfarin
A
- NSAIDS
- Vitamin E
- High-dose omega-3 (3-4 g/d)
- G natural health products – ginkgo, ginseng, garlic
- ASA
3
Q
OTHER THINGS increase INR
A
- Diarrhea
- Worsening heart failure
- Fever
- Impaired liver function
4
Q
a/e of prolonged PPI use
A
- Impaired B12 absorption
- Hypomagnesemia
- Clostridium Difficile infection
- Hip fractures
- Pneumonia
- Diarrhea
- Drug-drug interactions
5
Q
Carotid Endarterectomy indications
A
- Symptomatic with 50% stenosis
- Asymptomatic with > 60% stenosis
6
Q
Asthma medications (classes)
A
- Corticosteroid (inhaler and oral)
- ICS + long-acting beta agonist (LABA) (formoterol-budesonide – Symbicort)
- Leukotriene modifiers/ Leukotriene receptor antagonist (LTRA) – e.g., montelukast
- Chromones
- Anti – IgE e.g., Omalizumab (subcutaneous, for > 6 y/o)
- anti-IL4 and anti-IL5 antibody (immunotherapy)
7
Q
Antibiotics to treat MRSA
A
- Sulfonamides (Trimethoprim-sulfamethoxazole, septra)
- Tetracyclines (Doxycycline, Minocycline)
- Lincosamides (Clindamycin)
- Oxazolidinones (Linezolid)
- Lipopeptides (Daptomycin)
- Lipoglycopeptides (Vancomycin, Telavancin)
8
Q
management of suspected TB case at a rural hospital (after history and physicals)
A
- Airborne precautions and isolation
- Chest X-ray (Do not give the mark for “x-ray” alone)
- Sputum for TB x 3
- Risk factor assessment
- Test for HIV
- Consult TB Prevention/Public Health
- Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) to diagnose latent infection
9
Q
Risk factors for progression to active TB
A
- Chronic Renal Failure + Dialysis
- HIV-AIDS
- Diabetes
- Child < 5 years old
- Head or Neck Cancer
- Excessive EtOH use
- Malnutrition
- Smoker
- Silicosis
- Chronic steroid use
- Chronic immunosuppressant therapy
- Transplant
- Chronic Renal Failure requiring dialysis
10
Q
Undescended Testes classification
A
- Normal scrotal position
- Retractile Testis
- Palpable undescended testis
- Acquired undescended testis
- Ectopic undescended testis
- Nonpalpable undescended testis
11
Q
What imaging would you order to confirm the location of the testicle before referral for undescending testis ?
A
None
12
Q
By what age should a male child with nonpalpable testis or undescended testes be referred to a specialist?
A
After 6 months corrected gestational age
13
Q
General measures for Hidradenitis Suppurativa
A
- Smoking cessation
- Weight loss advice and goals if overweight
- Eating a healthy diet
- Wear loose cotton clothing
- Warm compresses
- Topical antiseptics (Clindamycin)
- Antibacterial soap
14
Q
Treatment options for Hidradenitis Suppurativa
A
- Topical resorcinol
- Topical clindamycin
- Oral antibiotics (Tetracycline)
- Adalimumab (tumor necrosis factor alpha inhibitor)
- Surgical procedure for definitive treatment: punch debridement and unroofing/deroofing, wide excision
Others:
- Combination therapy (Clindamycin + Rifampin)
- Hormonal Therapy (cyproterone acetate and norgestrel-containing OCP)
- Finasteride
- Oral retinoids
- Immunosuppressive agents
- Biologics
- Corticosteroid injections
15
Q
Complications of aggressive fluid or blood
product resuscitation
A
- Hypothermia
- TRALI (Transfusion Related Acute Lung Injury)
- Dilutional coagulopathy
- Hyperchloremic metabolic acidosis
- Febrile reaction
- Hyperglycemia
- Hypernatremia
- Anaphylaxis
16
Q
Life Threatening Causes of Chest Pain symptoms
A
Pulmonary Embolus Aortic Dissection Tension Pneumothorax Pericardial Tamponade Myocardial Infarction
17
Q
Causes of ascites
A
- Peritoneal malignancy/ peritoneal carcinomatosis
- Heart failure
- Nephrotic Syndrome
- Tuberculosis
- Cirrhosis
18
Q
Complications of liver cirrhosis
A
- Ascites
- Spontaneous Bacterial Peritonitis
- Hepatic encephalopathy
- Variceal hemorrhage
- Hepato-renal syndrome
- Hepatocellular Carcinoma
19
Q
Causes of liver cirrhosis
A
Most common:
viral hepatitis: Hep B, C, D
alcoholic liver disease
nonalcoholic steatohepatitis
Others:
- Wilson disease
- Alpha-1 antitrypsin
- Galactosemia
- Glycogen storage disorders
- Hemochromatosis
20
Q
Vaccinations suggested for HIV+
A
- Hepatitis A
- Hepatitis B
- Influenza
- Tetanus
- Diphtheria
- Pertussis
- Human Papillomavirus (HPV) (9- valent)
- Shingles
- Pneumococcal conjugate (PCV13)
- Pneumococcal polysaccharide (PPV23)
- **For PPSV23, it is given 8 weeks after PCV13, 2nd dose in 5 years
21
Q
HIV opportunistic infections with headache & prophylaxis
A
- Toxoplasma Gondii - CD4 < 0.1 : Septra DS
- Treponema Pallidum (syphilis)
22
Q
HIV opportunistic infection with cough - & prophylaxis
A
- Pneumocystic Jiroveci Pneumonia: CD4 < 0.2 - Septra
- disseminated Mycobacterium avium complex disease: CD4 < 0.05 - Azithromycin/ Clarithromycin
23
Q
DDx of SOB with chest pain
A
Life-threatening
- Atrial fibrillation
- Pulmonary embolism/ DVT
- Myocardial infarction
- Aortic dissection
- pericarditis
- pleuritis
- pneumonia
- unstable angina
- pneumothorax
- thoracic artery dissection
Others:
- costochondritis
- rib fracture
- anxiety
- panic attack
- influenza
24
Q
Phx for STI symptoms on non-genital systems
A
- Digital Rectal Exam (Tender Prostate/Ulceration/proctitis)
- Oropharynx (Exudate/Ulceration)
- Groin (lymphadenopathy)
- Lips (Ulceration)
- Eyes (Conjunctivitis)
25
Empiric treatment for STI-related urethritis
- Ceftriaxone 250mg IM AND Azithromycin 1g PO
OR
- Cefixime 800mg PO AND Azithromycin 1g PO
26
Complications of urogenital gonorrhea and chlamydia in males
- Infertility
- Orchitis
- Epididymitis
- Urethritis
- Prostatitis
- Proctitis
- Reactive arthritis triad (Formerly Reiter's disease, arthritis, uveitis, and urethritis)
27
Contraindications on medical history to combined oral contraceptive pills
- Age > 35 years & smoking > 15 cigarettes/day
- vascular disease
- Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
- acute Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE)
- history of DVT / PE, not receiving anticoagulant therapy, with higher risk fo recurrent venous thromboembolism
- Major surgery with prolonged immobilization
- Known thrombophilia
- Current and/or history of ischemic heart disease
- History of stroke
- Complicated valvular heart disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)
- Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies
- Migraine with aura (as defined by the International Headache Society42)
- Peripartum cardiomyopathy with moderately/severely impaired cardiac function
- Peripartum cardiomyopathy with normal/mildly impaired cardiac function <6 months
- Current breast cancer
- Severe decompensated cirrhosis
- Hepatocellular adenoma
- Malignant hepatoma
- Complicated solid organ transplantation (graft failure,
cardiac allograft vasculopathy)
- < 4 weeks postpartum (breastfeeding)
- <21 days postpartum (not breastfeeding)
28
What is one specific question you should ask about her (a 15 y/o girl's) SEX partner?
Age of partner, history of abuse from partner
29
What test should you do prior to starting combined OCPs for a 15 years old?
Urine bHCG OR Serum bHCG (Do not accept "bHCG" alone)
30
Marijuana and driving -
| Patients taking dried cannabis should be advised not to drive for at least ? hours after marijuana
a) 4 hours after inhalation (Level II)
b) 6 hours after oral ingestion (Level II)
c) 8 hours after inhalation or oral ingestion if the patient experiences euphoria (Level II)
31
indications for medical marijuana
- neuropathic pain that has failed to respond to standard treatments
- If considering authorizing dried cannabis for treatment of neuropathic pain, the physician should first consider
a) adequate trials of other pharmacologic and nonpharmacologic therapies and
b) an adequate trial of pharmaceutical cannabinoids
32
indications for medical marijuana
- neuropathic pain that has failed to respond to standard treatments (not for any other pain, such as fibromyalgia, low back)
- Dried cannabis is not an appropriate therapy for anxiety or insomnia
- If considering authorizing dried cannabis for treatment of neuropathic pain, the physician should first consider
a) adequate trials of other pharmacologic and nonpharmacologic therapies and
b) an adequate trial of pharmaceutical cannabinoids
33
Dried cannabis is not appropriate for patients who: (CFPC statement)
a) Are under the age of 25 (Level II)
b) Have a personal history or strong family history of psychosis (Level II)
c) Have a current or past cannabis use disorder (Level III)
d) Have an active substance use disorder (Level III)
e) Have cardiovascular disease (angina, peripheral vascular disease, cerebrovascular disease,
arrhythmias) (Level III)
f) Have respiratory disease (Level III) or
g) Are pregnant, planning to become pregnant, or breastfeeding (Level II)
34
Before signing a medical document authorizing dried cannabis for pain, the physician should do all of the
following...
1 ) Conduct a pain assessment (Level II)
2) Assess the patient for anxiety and mood disorders
3) Screen and assess the patient for substance use disorders
35
screening criteria for AAA
Male 65-80 years old with once abdominal ultrasound
36
screening criteria for AAA
Male 65-80 years old with once abdominal ultrasound
37
Current recommendations for an upper limit of morphine equivalents daily for opioid-naïve patients with non-cancerous pain
Less than 90 mg morphine equivalents daily (Accept answers between 50 - 90 mg)
38
If she had a history of alcohol use disorder, in remission for 5 years, what would you
recommend regarding opioid initiation?
Do not start opioids (Canadian
Guideline for Opioids for Chronic Non-
Cancer Pain 2017)
39
Physical exam findings of toxic shock syndrome
- Skin: desquamation of the hands and feet, hyperemia of mucous membranes
- GI: diarrhea, vomiting
- CNS: confusion
40
Lab findings of toxic shock syndromes
- Renal insufficiency (decreased eGFR, increased Creatinine)
- Liver (abnormal AST/ALT)
- Hematological (thrombocytopenia, leukocytosis)
41
Pathogens of TSS
- Staphylococcus aureus
| - Group A Streptococcus (GAS), also called Streptococcus pyogenes
42
Symptoms of TSS
- High fever
- Rash
- Hypotension
- Multiorgan failure (involving at least 3 or more organ systems)
- Desquamation, typically of the palms and soles, 1-2 weeks after the onset of acute illness
**** can also include severe myalgia, vomiting, diarrhea, headache, and non-focal neurologic abnormalities
43
risk factors of thyroid cancer
- rapid growth of neck mass
- head and neck irradiation
- total body irradiation for bone
marrow transplantation
- familitial thyroid carcinoma
- thyroid cancer syndrome (Multiple
endocrine neoplasia type 2, familial
adenomatous polyposis, Cowden
disease)
44
physical exam findings suggesting thyroid cancer
- dysphonia
- regional lymphadenopathy
- fixation of nodule to surrounding
tissue
45
General recommendation for general pruritus
- frequent moisturization
- avoid overbathing
- cut fingernails
- cool environment
- avoiding irritant
- behavioural therapy
46
psychogenic conditions related to pruritus
- delusional parasitosis
- formication
- obsessive compulsive disorder
- psychosis
47
life threatening cases of abdominal pain in toddlers (1-5 years old)
- intussusception
- volvulus
- pyloric stenosis
48
What are the conditions not appropriate for FIT screening?
- prior colorectal cancer
- prior polyps
- inflammatory bowel disease
- signs and symptoms of colorectal cancer
- history of colorectal cancer in 1st degree relatives
- Familial Adenomatous Polyposis
- Lynch Syndrome
49
Other than colonoscopy and FIT/FOBT, what other investigation can be used for colorectal screening
and at what interval?
Flexible sigmoidoscopy every 10 years
50
When to introduce peanuts?
4-6 months old when introducing solid food. Early peanut introduction reduces the risk of peanut allergy in high-risk infants from 17.2% to 3.2% at 5 years
51
What TWO conditions would make this patient high risk for allergy and allow for Skin Prick Testing prior to a peanut challenge in the diet?
- severe eczema
| - egg allergy
52
What are two co-morbid condition/disorder that are often present in patients with NSSI?
- Depression
- borderline personality disorder
- substance use
- developmental disorder
- eating disorder
53
List modifiable risk factors for suicide
```
- access to firearms, access to large quantities of
medication
- intoxication
SUD
- access to multiple substances
- withdrawal from cocaine/amphetamines
- extended use of sedatives/hypnotics/anxiolytics
- hopelessness
- psychic pain/anxiety
- psychological turmoil
- decreased self-esteem
- fragile narcissism
- perfectionism
- Impulsivity
- aggression
- severe anxiety
- panic attacks
- agitation.
```
54
Acute-onset diarrhea persistent after eating shellfish
Vibrio parahaemolyticus
55
medications to treat Clostridium difficile
- Metronidazole
- Vancomycin
- Fidaxomicin
- Rifampin
- Bezlotoxumab (not yet approved in Canada)
56
severe complications of Clostridium difficile
- Toxic megacolon
| - Pseudomembranous Colitis
57
Pathogens of HIV+ patient with diarrhea
- Cytomegalovirus (CMV)
- Cryptosporidiosis
- Microsporidiosis
- Mycobacterium avium complex (MAC)
58
red flag signs in acute diarrhea
- Fever
- Melena
- Severe Pain
- hematochezia
- night sweat
- weight loss
- nocturnal symptoms --> pathologic
59
orders to the nursing home and your management plan for the diarrhea outbreak
- Isolation of the patients with symptoms
- Notify Public Health
- Ban/Control visitors to the facility
- Contact precautions in the nursing home
- Inform the community
- Test patient zero/health care worker stool to determine organism
- Contact Tracing
- Collect and test samples from the nursing home
60
Is loperamide considered safe to use while breastfeeding?
Yes
61
You consider a course of Metronidazole for a breastfeeding pregnant woman to treat C. difficile as it is not associated with congenital malformations.
What advice do you give her about breastfeeding?
Stop breastfeeding until treatment is
| completed
62
59 y/o female with muscle weakness in shoulders. DDX?
```
Rheumatoid Arthritis
endocrine diseases
- Hypothyroidism
- Hyperparathyroidism
- vitamin D deficiency
```
Connective tissue diseases
- systemic vasculitis
- polymyalgia rheumatica
- giant-cell arteritis
- spondyloarthritis
- SLE?
- Fibromyalgia
63
non-pharmacologic treatment and management options for this patient with fibromyalgia
- multi-Disciplinary Team
- graded exercise program
- Sleep Hygiene information
- Cognitive Behavioural Therapy (CBT)
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Massage
- Acupuncture
- electro-acupuncture
- Tai-Chi
- Aquatic Exercises
- stress management
- patient support group referral
- treat comorbid
depression/conditions
64
blood tests that you could order to help make your diagnosis of RA?
(In Q-stem: A complete blood count that was ordered in the ER and a pregnancy test was negative)
- C-reactive protein (CRP)
- Erythrocyte sedimentation rate (ESR)
- Rheumatoid Factor
- Anti-Cyclic Citrullinated Peptide (anti-CCP)
65
A 37 yo female fell and had a x-ray at ER showing multiple joint erosions and some joint destruction in the hand. what are 3 other poor prognostic factors in her disease?
- Moderate to high disease activity after Disease Modifying Anti-Rheumatic Drugs (DMARDs)
- high number of swollen joints
- high acute phase reactant levels
- presence of extra-articular symptoms
- high degree of physical disability at onset
- RF levels high
- failure of 2 or more DMARDS
66
Name 5 medications used in treatment of her condition other than steroids, acetaminophen, opioids and Non-steroidal anti-inflammatory medications.
- Methotrexate (MTX)
- Sulfasalazine
- Leflunomide
- Hydrochloroquine
- Gold salts
- Azathioprine
Biologic receptor modulator
- infliximab
67
What are live attenuated vaccines - (need to avoid after starting biologic receptor modulator)?
- Herpes Zoster vaccine
- Bacillus Calmette-Guerin (BCG)
- live attenuated influenza
- measles
- mumps
- rotavirus
- rubella
- smallpox
- oral typhoid
- varicella
- Yellow Fever
68
32 year old female and his partner both are in your practice both diagnosed with Rheumatoid Arthritis on Methotrexate. How long should they have discontinued methotrexate before trying to conceive?
both 3 months
69
Other than blood pressure taken bilaterally and a full cardiovascular examination, what
are FIVE other findings on clinical examination you would look for for dyslipidemia?
- Waist circumference
- lipemia retinalis/retinopathy on fundoscopy
- hepatosplenomegaly
- premature arcus cornealis
- xanthomas
- xanthelasmas
70
Name THREE different groups of medications that can cause a secondary hyperlipidemia.
- Corticosteroids
- Highly active antiretroviral therapy (Accept any ONE HIV Medication or HAART)
- Hormone replacement therapy (HRT) (Accept any ONE HRT answer)
- Oral Contraceptives
- Thiazide Diuretics
- Beta-blockers
71
dietary advice for dyslipidemia patients
- reduce daily cholesterol to <300mg/day
- increase mono and polyunsaturated
fats
- increase fruit and vegetable intake (5+ servings a day)
- eat more whole grain products
- encourage dietary fibre intake
- increase omega-3 fatty acids
- limit alcohol consumption to 2 drinks/day
- limit intake of salt
- restrict saturated and trans-fatty acids
- Mediterranean, DASH, Portfolio Diet
72
After a 3-month trial of dietary interventions you recalculate his Framingham score and
his 10-year risk of Total Cardiovascular Risk is 9%. He also discloses that he asked around
about his family and a number of first degree relatives have had premature cardiovascular
disease. With this information what do you do to his risk score?
Double it (2X)
73
Non-pharmacological management for Raynaud Phenomenon
- Teach warming exercises (windmill – swinging the arms vigorously)
- Dress warmly including the head and neck
- Use warming devices in gloves/mittens and boots
- Stop smoking
- Avoid using vibrating tools
74
Topical 2% nitroglycerin ointment for Raynaud phenomenon. What are TWO possible side effects of this medication.
- Headache
| - Hypotension
75
Herpes Labialis (Cold Sore) - pathogen and ddx?
Herpes Simplex Virus-2 and Herpes Simplex Virus-1
| Herpes Zoster virus
76
Risk factors for Herpes Simplex Virus-2
- sexual activity
- female
- history of sexually transmitted disease
- multiple sexual partners
77
Other than oral antivirals suggest FIVE other medications and their route for treating Herpes Labialis (Cold Sore)
- Acetaminophen PO
- Non-steroidal anti-inflammatories PO
- Topical Hydrocortisone
- Topical Acyclovir
- Docosanol Topical
- Zinc Sulfate PO
- Topical Lidocaine/Benzocaine
78
What is the current daily maximum recommended MED in Canada for patients starting opioid therapy?
90 mg (accept 50-90 mg as an answer; recommended maximum of 90 mg MED and attempt to restrict to 50 mg MED)
79
When the patient on Percocet and Benzo begins a taper of his opioids and you follow him in your clinic, what other change would you make to his medication?
Stop/taper co-prescription of benzodiazepine
80
After congratulating him on his
success he reports that he is excited to see his grandchildren this weekend. As you hand him a
final prescription for Percocet what piece of advice would you give him?
Lock/keep medications in a safe place
| to avoid children accessing medication.
81
what medication could you provide to reverse the opioid intoxication?
Narcan (Naloxone); intramuscular, intranasal, intravenous, subctuaneous, sublingual, intralingual, submental, OR endotracheal
82
What is the recommended morphine equivalents daily prior to starting a patient on 25-ug/h fentanyl patch?
60 mg MED for at least one week
83
The recommended morphine equivalents daily prior to starting a patient on 25-ug/h fentanyl patch is ... What are possible complications of not adhering to this recommendation
- Central Nervous System depression
- flaccid skeletal muscles
- hypotension
- bradycardia
- respiratory depression
- death
84
First-line therapy for tinea capitis and onychomycosis
Oral terbinafine
85
Treatment for Kerion, and the complications if failed to treat promptly
Griseofulvin unless Trichophyton has been documented as the pathogen
Scarring and permanent hair loss
86
a/e of prolonged PPI use
- increased risk of hip fracture
- increased risk of C. difficile infection
- increased risk of pneumonia
- impaired Vitamin B12 absorption
- hypomagnesemia
- impaired iron absorption
- hypoparathyroidism
- Drug-drug interactions
87
OTCs or food can prolong INR when on Warfarin
- ASA
- NSAIDs
- Vitamin E
- High-dose omega-3 (3-4 g/d)
- natural health products – ginkgo, ginseng, garlic
88
medical conditions can increase INR when on Warferin
- Diarrhea
- Worsening heart failure
- Fever
- Impaired liver function
89
Risk factors of community- associated MRSA
- Hx of MRSA/ recent MRSA infection
- previous hospitalization for skin/ soft tissue infection
- Age < 2 y/o OR > 65
- Abx in the past 6 months
- recent invasive procedure (eg. dialysis)
- IVDU
- penetrating trauma
- being an athlete (particularly if in contact sports)
- men who have sex with men
- living in a correctional facility, homeless, incarcerated
- being military personnel
- residing in an endemic area
