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Family Medicine > Shelf Review > Flashcards

Shelf Review Flashcards

1
Q

Abdominal aortic aneurysm (AAA)

A
  • Start screening at age 65
  • if patient have history of smoking
  • if patient have family history of aortic aneurysm rupture (without smoking)
  • perform abdominal ultrasound
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2
Q

Lung cancer screening

A
  • anyone age > 55 with history of 30 pack of cigarette smoking per year or currently smoking or have quit in 15 years
  • perform a low-dose CT scan of the chest
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3
Q

Colon cancer screening

A
  • starts at age 50
  • performed every 10 years if negative colonoscopy or every 1 year if FIT test
  • if patient have a family history with colon cancer:
    1. Perform colonoscopy at age of 40
    Or
    2. Perform colonoscopy 10 years before the age the family history was diagnosed

(Whatever comes first)

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4
Q

Pap smear

A
  • start at age of 21
  • performed every 3 years, if pap smear alone & every 5 years if pap smear & HPV testing (can be started at age 29)
  • stopped at age 65
  • results:
  1. Askus
    - atypical squamous cell of undetermined significance
    - next step: HPV Test (if positive, proceed to colposcopy)
    - if the mom is pregnant during the pap smear & have askus ( do Pap smear after birth, because she is unlikely to have cancer)
  2. Low grade or High grade
    - proceed with colposcopy (use speculum & view cervix under microscopy + biopsy the lesion)
    - if come back as CIN 1, 2, or 3
    - if cancerous, proceed with hysterectomy
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5
Q

Mammogram

A
  • start at age of 40
  • performed every 1-2 years
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6
Q

Screening for osteoporosis

A
  • start at age of 65
  • using DEXA scan (score of -2.5 diagnostic) of the lumbar spine
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7
Q

Varicella Zoster vaccine

A
  • given at age of 60 (elderly)
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8
Q

HPV

A
  • given at age 9-26 (mainly female)
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9
Q

Chlamydya & Ghonorrhea screening

A
  • in female who are sexually active < 24 years old
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10
Q

HIV screening

A
  • performed at age 15-65 years old
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11
Q

COPD
(Mild, moderate, severe, very severe)

A
  • require spirometry= shows (FEV1/FVC <0.7) post-bronchodilator (not reversible)
  • always seen with smokers
  • categorized based on FEV1
  1. Mild COPD (stage1)
    - FEV1 (80%) - give albuterol (SABA)
  2. Moderate COPD (stage2)
    - FEV1 (50-80%) - give albuterol (SABA) + salmeterol (LABA)
  3. Severe COPD (stage 3)
    - FEV1 ( 30-50%) - give albuterol (SABA) + salmeterol (LABA) + inhaled GC
  4. Very severe COPD (stage 4)
    - FEV1 (< 30%) - give albuterol (SABA) + salmeterol (LABA) + inhaled GC + oxygen
  5. Acute Exacerbated COPD:
    - give albuterol (SABA) + oral GC ± antibiotics (usually macrolide) ± oxygen

Medication:
- SABA for acute symptoms

  • 1st line daily medication is:
    1. SAMA (ipratropium & tiotropium)
  • 2nd line medication:
    1. LABA
    2. Inhaled GC + LABA combination
    3. Theophylline
  • decreased mortality rate:
    1. Stop smoking
    2. Oxygen therapy

Note:
- inhaled GC is not as good as in asthma, can lead to DM

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12
Q

Criteria for NIPPV oxygen therapy in COPD at home

A
  1. Oxygen saturation< 88%
  2. Oxygen pressure < 55%
  3. Hematocrit > 55% ( polycythemia)
  4. Pulmonary HTN ( exertional dyspnea + right-sided heart failure)
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13
Q

Gout

A
  • acute + severe onset of pain in the MTP of the big toe
  • signs: red + swelling + severe pain (awaken patient for night sleeping)
  • joint is filled with needle-shaped, negative birefringen
  • diagnosis: aspiration
  • management:
    1. Acute gout:
  • NSAID (indomethacin)
  • steroid
  • colchicine
  1. Chronic gout:
    - allopurinol (xanthine oxidase inhibitor) (use if, urine uric acid is high; kidney produce too much)
  • probenecid (use if, urine uric acid is low; kidney not excreting)
  • febuxostat
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14
Q

Pseudogout

A
  • positive birefringen, rhomboid-shaped
  • contain calcium pyrophosphate dihydrate crystal
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15
Q

Septic arthritis

A
  • commonly occurs in hip & knee
  • secondary to systemic infection (bacteremia)
  • signs: tender/severe painful joint + swelling joint + red + can’t bear weight on joint ( can’t flex knee) + fever + leukocytosis
  • diagnosis: arthrocentesis/aspiration of the fluid ( shows WBC > 50,000 + neutrophil of 90%)
  • management: IV antibiotics
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16
Q

Prenatal care
( first visit, visit at 28 weeks, visit at 35-37 weeks)

A

First visit:
- CBC + urinalysis + STD + HIV + Hepatitis B + pap smear + blood typing + rubella

Visit at 28 weeks:
- CBC + diabetes screening (to diagnose gestational diabetes) + Rhogam shot ( if they are RH negative)

  • gestational diabetes: hour 1 ( > 180), hour 2 ( > 160), hour 3 ( > 140) —> 2 out of the 3 are high

Visit at 35-37 weeks:
- group B strep test + vaginal/rectal swab
- if positive: give penicillin prophylaxis

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17
Q

Tdap (tetanus, diphtheria, pertussis) vaccine

A
  • given during pregnancy ( week 27-36)
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18
Q

Live/attenuated vaccine is contraindicated in during pregnancy

A
  • MMR
  • Influenza
  • varicella
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19
Q

Term vs. post term

A

Term:
- starting at week 37

Post term:
- starting at week 42

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20
Q

Pediatric milestone

A

2 months:
- lift head off from ground in prone position

4 month:
- baby can roll over

6 month:
- baby can sit up on their own
- can start using toothpaste

9 month:
- baby can crawl or cruising (use coach to hold up/support them while standing)

12 months
- baby use 1-3 words other than mom/dad
- can start visiting dentist
2 years:
- use of hundreds of words + 2 word phrases

3 years:
- use of thousand words + 3 word phrases

4 years:
- start of audiometry + vision testing ( doctor appointment)
- cross eyes—> strabismus —> increased risk for ampiolopia/ blindness

5 years:
- dress themselves + write own name

6 years:
- ties shoes + identify left/right

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21
Q

Breast feeding

A
  • can occur till 6 months and then can introduce solid food
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22
Q

Influenza shot

A
  • first flu shot given after 6 months
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23
Q

Live vaccine

A
  • the first live vaccine can be given after 1 year old (MMR vaccine)
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24
Q

Runny nose due to allergies

A
  • give intra-nasal steroid (fluticasone spray)
  • side effect: epistaxis (steroid can cause atrophy of the mucosal, which predispose to bleeding)
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25
Q

Hemoglobin less than 7

A
  • need transfusion
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26
Q

Most common cause of folate deficiency

A
  • alcohol abuse
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27
Q

Acute gastroenteritis + hematochezia (bloody diarrhea)

A
  • next step: stool analysis (check for WBCs)
    1. If WBC present: inflammatory diarrhea (campylobacter, EHEC, salmonella, shigella, yersenia)
  • management for gastroenteritis:
    1. keep patient hydrated with oral/IV fluid
    2. If patient is hypotensive, give them IV fluid
    3. If patient is normotensive, give them oral rehydration therapy ( glucose + salt)
    4. Only give antibiotic, if the patient is young, immunosuppressed or very elderly
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28
Q

GLP -1 Receptor agonist ( -glutide)

A
  1. Increase glucose dependent insulin secretion
  2. Decrease glucagon secretion
  3. Decrease gastric emptying
  4. Decrease appetite
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29
Q

DDP4 inhibitors (-glibtin)

A

Similar effect as GLP-1

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30
Q

Long-standing diabetes

A
  • causes hypoglycemia
  • activate epinephrine release
  • lead to:
    1. Hypoglycemia awareness —> behavioral response —> risk for severe hypoglycemia
    2. Hepatic glucose production —> risk for severe hypoglycemia
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31
Q

Difference between prolactinoma vs. antipsychotic medication ( hyperprolactinomia secondary)

A
  • antipsychotic medication (respiradone) : causes secondary hyperprolactinoma due to their dopamine blockade effect —> lead to elevated prolactin (25-100)
  • prolactinoma: lead to exaggerate elevation in prolactin ( above 200)
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32
Q

Anterior cruciate ligament (ACL)

A
  • sport injury: soccer
    -Knee pop, significant swelling, ± hemarthrosis
    -positive test: anterior drawer test & Lachman
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33
Q

Posterior cruciate ligament (PCL)

A
  • tibial forced posteriorly with fixed ankle ( dashboard injury)
  • positive test: posterior drawer test
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34
Q

Meniscus

A
  • knee “clicking”
  • positive test: McMurray & thessaly test
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35
Q

Medial collateral ligament (MCL)

A
  • Often injured in combination with ACL & meniscus (unhappy triad)
  • positive test: laxity in Valgus stress
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36
Q

Lateral collateral ligament (LCL)

A
  • Positive test: laxity on varus stress
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37
Q

Patellar tendon

A
  • high-riding patella
  • positive test: inability to “extend knee” or “flex hip with knee straight”
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38
Q

Diabetes controlled with metformin, HbA1C = 7.4% (133; not in goal after months), BMI 31 (obese)

A
  • next best management: Semaglutide (induce weight loss)
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39
Q

Outpatient diabetes mellitus management

A
  1. Lifestyle modification
    - healthy diet, exercise
  2. ## Oral metformin
  3. ## Additional non-insulin antidiabetic drugs
  4. Insulin therapy
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40
Q

Metformin & non-insulin anti-diabetic drugs

A
  1. Metformin
    - Mechanism: inhibits mGPD, activates AMP kinase —> decrease hepatic gluconeogenesis
    - side effect: GI upset, kidney injury
    - high yield: lead to lactic acidosis (AGMA)
  2. GLP-1 agonist (-tide)
    - mechanism: Activates glucagon-like peptide-1 receptor —> decrease glucagon release + increase satiety
    - side effect: decrease appetite + weight loss + pancreatitis + gastroparesis
    - high yield: avoid in MEN syndrome (lead to thyroid or pancreatic cancer) + helpful with obesity
  3. Sulfonylureas (-ride, -zide)
    - mechanism: inhibits beta-cell K+ channels —> endogenous insulin release (even when glucose in low)
    - side effect: hypoglycemia + weight gain + disulfiram-like reaction (first generation) (produce symptoms similar to alcohol hangover)
    - high yield: avoided these days
  4. SGLT-2 antagonist (-gliflozin)
    - mechanism: inhibits SGLT-2 in the proximal tubules —> glucose excreted in urine
    - side effect: UTI (excess glucose in urine; candidiasis), dehydration —> orthostasis
    - high yield: reduce CVD mortality in diabetics & cardiovascular disease
  5. Thiazolidinediones (TZD) (-zone)
    - mechanism: activates PPAP-gamma —> increased transcription of glucose/lipid gene metabolism
    - side effect: weight gain, heart failure, osteoporosis

Note:
- fibrates: activates PPAR- alpha

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41
Q

Asymptomatic, previously healthy patient with HTN

A
  • management: initiation of CCB, ACE-I, & follow-up
  • additional test for primary HTN: fasting serum lipid
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42
Q

Primary vs secondary HTN

A

Reasons to suspect secondary HTN: (RRAS)
1. HTN refractory to 3 medications at maximum dose
2. Rapid onset of HTN (days to weeks)
3. Unusual age of onset ( < 30 years old)
4. Specific Symptoms ( abdominal bruits, electrolyte abnormality)

** if you don’t see these signs treat as uncontrolled primary HTN

Initial evaluation of HTN:
1. ECG
2. Lipid panel (Metabolic syndrome)
3. Urinalysis (kidney damage from HTN)
4. Complete metabolic panel (Electrolyte abnormality)

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43
Q

Primary HTN stages

A

Pre-HTN (120-129/<80) (SBP is 10 above normal)
- management: lifestyle modification (weight loss (iF BMI >25) —> DASH diet —> exercise —> dietary sodium restriction)

Stage 1 HTN (130-139/ 80-90)
- management: lifestyle changes ± one antihypertensive
- antihypertensive if: diabetes, CKD, ASCVD 10%+

Stage 2 HTN (> 140/>90)
-management: Lifestyle changes + two antihypertensive

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44
Q
  • If a person is diagnosed for the first time with HTN
  • Person is healthy, not overweight, no comorbidities, & has HTN at the office —> monitor BP at home (daily-weekly) & follow up in a month
A
  • suspect white-coat HTN
  • Initial management: ambulatory BP monitoring before initiation of anti-hypertensive medication
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45
Q

Primary HTN medication choices

A
  1. ACE-inhibitor (-pril)
    -Mechanism: inhibits angiotensin converting enzyme (ACE)
    -side effect: Dry cough, hyperkalemia, AKI, angioedema, avoid in pregnancy
    - high yield: Avoid in bilateral renal artery stenosis, useful in diabetic patients
    - prescribed in patient with: Diabetes, nephropathy, CHF, MI history
    - have synergistic effect when prescribed with thiazide
  2. Angiotensin 2 receptor blocker (ARBs) (- satran)
    -Mechanism: blocks angiotensin 2 receptor
    -side effect: hyperkalmeia, AKI, contraindicated in pregnancy
    - high yield: avoid ACE cough
  3. Thiazide diuretics (-thiazide)
    -Mechanism: inhibits Na/Cl cotransporter in distal convoluted tubules
    -side effect: hyponatremia, hypokalmeia, hyperglycemia, hypercalcemia, hyperurecemia (gout)
    - Used in caution in people with gout and diabetes
    - high yield: treats nephrogenic diabetic insipidus, increases lithium concentration, useful in osteoporosis
  4. Dihydropyridine CCB (-dipine)
    -Mechanism: inhibits calcium channel in vascular smooth muscle (lead to vasodilation)
    -side effect: orthostasis, lower extremity edema
    - high yield: helpful in treating Raynaud syndrome

Note:
1. non-dihydropyridine CCB: works on cardiac muscle —> verapamil & diltiazm —> can be used in HTN with atrial Fibrillation —> verapamil can cause constipation
2. With loop diuretics (furosemide)—> lead to hypocalcemia —> good to use in case of gout
3. Side effect of potassium sparing diuretics —> hyperkalemia & gynecomastia with spironolactone & contraindicated in renal failure
4. Alpha-1 blocker (-zosin) —> not first line for HTN, but can be used for BPH

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46
Q

Differential diagnosis of acute, non-traumatic testicular pain

( testicular torsion, torsion of appendix testis, epididymitis)

A

Testicular torsion
- torsion of the spermatic cord (due to sport…)
- sudden onset, scrotal edema, testis in horizontal position, absent of cremasteric reflex, no relief with testicular elevation
- ultrasound: absent doppler flow

Torsion of appendix testis
- remnant of the mullerian duct
- insidious onset, focal testicular tenderness at upper pole, blue dot sign
-ultrasound: enlarged testicular appendix, possible hydrocele, normal blood flow

Epididymitis
- STI or UTI causing inflammation of the epididymis
- tenderness at posterior pole of testis, relief of pain with elevation (Prehn sign), dysuria (urinary discharge)
- presence of cremasteric reflex
- ultrasound: increase blood flow to epididymis

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47
Q

Differential diagnosis of Chronic cough

( UACS, Asthma, GERD, ACE-i)

A
  1. Upper airway cough syndrome (UACS) (POST-nasal drip)
    - worse at night (can be related to allergies)
    - relief with antihistamine
  2. Asthma
    - young adult, worse with exercise/run
    - pulmonary function test —> methacholine challenge ( > 20% reduction in FEV1)
  3. GERD
    - Worse after eating & at night
    - relief with proton pump inhibitor ( pantoprazole)
  4. ACE-inhibitor:
    - recently started on new medication for HTN —> dry cough
    - relief after stopping ACE-inhibitor ( switch to ARBs)

Note:
—> if no improvement or suspicious symptoms (purulent sputum, immunocompromised) —> do chest X-ray

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48
Q

Differential diagnosis of shoulder injuries

A
  1. Acromioclavicular joint dislocation
    - trauma or injury
    - tenderness upon adduction of the arm across torso
    - palpable deformity at the superior aspect of the shoulder
  2. Anterior shoulder dislocation
    - posterior trauma in vulnerable position ( throwing motion)
    - axillary nerve damage (loss of sensation at deltoid, deltoid weakness)
    - flattened deltoid prominence, prominent acromion, abducted, externally rotated shoulder
  3. Posterior shoulder dislocation
    - fall on outstretch hand (FOOSH)
    - Anterior shoulder flattening
    - arm held in adduction & internal rotation
  4. Rotator cuff tear
    - recent trauma or worsening of chronic symptoms (may not appear acute if torn chronically)
    - most common is supraspinatus tendon
    - arm drop positive (can’t left arm, can’t sleep on side)
    - decrease abduction with intact sensation

Note:
- with axillary nerve injury: sensation is lost

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49
Q

Differential diagnosis of Rhinorrhea

A
  1. Allergic rhinitis
    - watery rhinorrhea + itchy eyes + sneezing
    - treat with: intranasal glucocorticoids —> oral antihistamine
  2. Non-allergic rhinitis
    - seasonal variation, no obvious trigger, later onset ( 20 + years)
    - treat with: intranasal glucocorticoid or intranasal antihistamine (azelastine)
  3. Viral sinusitis
    - rhinorrhea + nasal congestion + sore throat + cough ± fever
    - treat supportively (saline ….)
  4. Bacterial sinusitis
    - 10+ days + fever > 39 + 3 or more days of purulent discharge + initially improved then worsened ( improvement of viral —> progressed to bacterial)
    - treat with: amoxicillin + clavulanic acid (Augmentin)
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50
Q

Chest pain rapid review

A
  1. young patient with severe & sharp chest pain radiating to the back, unequal blood pressure in the right & left arm
    - aortic dissection
  2. Patient with substernal chest pain, worsen after eating or at night
    - GERD
  3. Recent viral illness, chest pain that improves when leaning forward, fever, “scratching” sound on cardiac auscultation
    - acute pericarditis
    - treat with: NSAID
    -Prevented recurrence with: colchicine
  4. Young patient with sharp chest pain, reproducible with palpation of the chest wall
    - costochondritis
  5. Recent viral illness, sharp chest pain, worsens with deep inspiration, scratching sound on auscultation that disappear while breath-holding
    - viral pleurisy
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51
Q

Abdominal pain rapid review

A
  1. Severe, acute, epigastric abdominal pain radiating to the back
    - acute pancreatitis
    - similar to AAA
  2. Long-standing history of GERD (or ulcer history), refractory symptoms, now with acute epigastric pain, rebound, abdominal rigidity
    - perforated peptic ulcer
  3. Obese patient, history of coronary artery disease, present with abdominal pain, precipitated with eating, recent food avoidance (food eversion) & weight loss
    - chronic mesenteric ischemia (intestinal angina)
  4. Middle-aged female, with epigastric pain (or RUQ) radiating to the right side & back, fever, leukocytosis
    - acute cholecystitis
  5. Severe, unilateral flank pain, groin pain that periodically worsens & improves
    - nephrolithiasis
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52
Q

Obstetrics rapid review

(Oby-gyn)

A
  1. G1P0 patient at 32 weeks with gestational diabetes presents with uterine fundus measuring 36 cm
    - polyhydramnios ( GDM —> fetal glucosuria —> excess amniotic fluid)
    - fetus exposed to high level of glucose —> have increased growth & polyuria —> result in increased amniotic fluid
    - at week 32 we expect the fundus to be 32
  2. G2P1 patient presents for prenatal appointment at 21 weeks with blood pressure 145/91 & 3+ pitting extremity edema
    - preeclampsia (diagnosed when BP 140/90 & 24-hrs Urine protein excretion of 300 mg or secondary organ dysfunction)
  3. Patient at 7 weeks gestation with persistence N/V, now has orthostatsis & electrolyte abnormalities
    - hyperemesis gravidarum (uncontrollable pregnancy-related vomiting)
    - treat with: vitamin B6, or anti-histamine, or admit to hospital for IV fluid hydration if severe electrolyte imbalance
  4. Pregnant patient with generalized pruritus, worse on the palms, elevated bile acid
    - intrahepatic cholestasis of pregnancy
    - treated with: urodeoxycholic acid ( to lower bile acid)
  5. G3P2 with chronic HTN presents with decreased fetal movement & uterine fundus smaller than expected for gestational age:
    - oligohydromnios: intrauterine growth restriction + decrease amniotic fluid

Note:
1. Diabetes —> lead to polyhydromnias (increase growth + increase amniotic fluid)
2. HTN —> lead to oligohydromnias ( intrauterine growth restriction + decrease amniotic fluid)

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53
Q

Pediatric rapid review

A
  1. Child with 6 days history of fever, red eyes, oral & tongue redness, hand/foot swelling
    - kawasaki disease
    - treat with: Salicylates, IVIG
    - CRASH & BRUNS—>
    1. Conjunctivitis (non-exudative, bilateral injection)
    2. Rash (non vesicular, no bullae)
    3. Adenopathy ( cervical, unilateral)
    4. Strawberry tongue (redness of oral mucosa, or lips, or dry peeling lips)
    5. Hand (swelling or erythema of hand or feet)
    6. Burns ( >5 days of fever)
    7. Coronary artery aneurysm
  2. 1-year old male with urinary tract infection (secondary), stool 1-2 times per week, blood on toilet paper, anal fissure
    - constipation
  3. Child with red, itchy eyes, runny nose, and rash spreading from head to rest of the body
    - measles
    - history of no vaccination or family don’t believe in vaccination
  4. 5-week old previously healthy male with projectile vomiting, formula colored
    - pyloric stenosis
  5. No childhood immunization, bilateral jaw swelling, presenting with nuchal rigidity, and brudzinski sign
    - Mumps (can cause: parotitis, meningitis, pancreatitis, bronchitis, or inflammation of the testis)
  6. 5-year old child with RUQ pain, jaundice, palpable mass
    - biliary cyst
    - need to be removed because increase risk for malignancy
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54
Q

Treatment for: Uncomplicated HTN in non-African American

A
  1. Thiazide diuretics
  2. ACE-i/ARBs
  3. CCB
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55
Q

Treatment for uncomplicated HTN in African-American & elderly

A
  1. Thiazide diuretics
  2. Long-acting CCB
56
Q

Treatment for uncomplicated HTN in younger patient

A
  1. ACE-i/ARBs
  2. Beta-blockers (not used as initial monotherapy)
57
Q

First line medication for certain comorbidities with HTN

A
  1. ACE-I/ARBs:
    - heart failure
    - systolic dysfunction
    - diabetes
    - CKD
    - History of STEMI or NSTEMI
  2. Thiazide diuretics:
    - good monotherapy in HTN & osteoporosis
  3. CCB:
    - HTN & gout
58
Q

HTN urgency vs. HTN emergency

A

HTN urgency:
1. Increased BP greater than 180/120 without any sign of end organ damage
2. Treatment: Clonidine (alpha-2 agonsit)

HTN emergency:
1. Increase in BP greater than 180/120 with impending or progressing end organ damage
2. Treatment: Nitroprusside

59
Q

Hyperlipidemia

(Includes: hypercholesterolemia & hypertriglyceridemia)

A

Screening guideline:
1. In high risk people —>
- begin around 20-25 years in males
- begin around 30-35 years in females

  1. In lower risk people—>
    - begin around age 35 in males
    - begin around age 45 for females
  2. Reassess every 5 years in patients that do not have cardiovascular disease

Target value:
1. Total cholesterol < 200
2. LDL (BAD) < 100
3. HDL (GOOD) > 60
4. Triglyceride < 150

Note:
- hypercholesterolemia ( caused by high cholesterol or LDL)
- hypertriglyceridemia ( high triglyceride)
- hyperlipidemia is the umbrella term for all of these

60
Q

Symptoms & treatment of hyperlipidemia

A

Symptoms:
1. Asymptomatic
2. Develop xanthomas (lipid deposits on the skin tendons & subcutaneous tissue)
3. Significant hypertriglycerdemia lead to pancreatitis

First line treatment:
1. Lifestyle modification (diet + exercise)

  1. Statin

Four rules to guide initiation of statin therapy:
1. Any patient with clinical atherosclerotic CVD
2. Any patient with LDL level > 190 (most likely familial)
3. Any patient aged 40-75 with an LDL > 70 & diabetes
4. Any patient aged 40-75 with LDL > 70 & estimated ASCVD risk of > 7.5%

  • gal of treatment is to lower LDL by 30%

Drugs:
1. Statin
- reduce production of cholesterol by inhibiting (rate-limiting step) thus decrease LDL
- effective in reducing LDL
- Not effective in reducing triglyceride
- contraindicated in pregnancy & lactation & liver disease
- side effect of statin: myalgias & cramps & elevated CK level

  1. Ezetimibe:
    - used with statin to further reduce level of LDL
  2. Fibrates (Gemfibrazil & phenofibrates)
    - Reduce level of triglyceride
    - increase in HDL
    - contraindicated in hepatobiliary disease and severe renal disease
    - Side effect: increase LFT & Myositits & myalgias & increase risk of gallstones
  3. Bile acid sequestrants (cholesteramine)
    - useful in combination with statin or niacin
    - reduces LDL level
    - bind bile acid in intestine
    - only cholesterol medication that is safe in pregnancy
    - used for pruritus associated with biliary obstruction
    - side effect: increase triglyceride & should bot be used in hypertriglyceremia
  4. Niacin
    - is vitamin B3
    - Increase level of HDL & Second best drug to reduce triglyceride
    - side effect: flushing ( treated with aspirin prior to niacin), headache, pruritus, hyperglycemia, hyperuricemia
    - used in caution with diabetic & gout patient
  5. Ezetimibe
  6. Omega-3 fatty acid
61
Q

Coronary artery disease

A
  • occurs when there is reduced in coronary blood supply but there is increase in demands
  • common cause is atherosclerosis (occludes coronary vessels), vasospasm, aortic stenosis, pulmonary HTN, Regurgitation, severe systemic HTN, hypertrophic cardiomyopathy
  • risk factor for CAD: HTN, smoking, diabetes, hyperlipidemia, male gender, increased age, family history, obesity
  • patient become symptomatic if there is occlusion (stenosis) of 70% or more

symptoms:
- asymptomatic
- chest discomfort & SOB
- Chest pain (angina) (stable or unstable)

Stable angina:
- predictable
-presents with a consistent amount of exertion
- relieve is achieved with rest or nitroglycerin

Unstable angina:
- unpredictable
- presents during rest
- often recurrent
- indicative of ruptured plaque with clot formation in the vessel

Diagnosis of CAD:
- Cardiac catheterization (visualize any blockage in coronary artery)

62
Q

Chest pain & angina

A

Angina pectoris (stable angina)

  • substernal chest pain
  • brought on by exertion ( due to decreased coronary blood flow & increased demand)
  • radiates to arm, teeth, jaw, back, epigastrium, or shoulder
  • chest pain relieved by rest or nitroglycerin
  • associated symptoms: dyspnea, nausea, diaphoresis
  • women or diabetics don’t have the classical chest pain presentation —> complain of dyspnea, epigastric pain or shoulder pain

Work-up:
1. ECG:
- usually normal (50% of the times)
- abnormal shows: ST depression, T-wave inversion, poor r-wave progression, Left ventricular hypertrophy

  1. Stress testing:
    - Stress ECG: Performed on treadmill or pharmacologically ( adenosine or dipyridamol are coronary vasodilator) —> positive stress test shows ( ST depression, hypo or hypertension, arrhythmia or clinical symptoms)
  • Stress echo: can be done with exercise or pharmacologically —> locate ischemia, assess wall motion abnormalities, assess LV function, assess vulvular disease —> usually paired with stress ECG for further information
  • Stress nuclear myocardial perfusion scan: done on patient with baseline ECG abnormalities, can be done with exercise or pharmacologically —> to localize regions of ischemia in the heart
  • cardiac MRI: alternative to stress test —> imaging is performed with dobutamine infusion & assess cardiac perfusion & wall motion abnormalities
  1. coronary angiography (cardiac catherization)
    - indicated for patient with CAD with negative stress test
    - indicated in patient need revascularization of coronary arteries
    - revascularization of coronary artery is done by either: percutaneous transluminal coronary angioplasty (PCI) or coronary artery bypass graft (CABG)

Note:
- adenosine & dipyridamol are constraindicated in asthma due to bronchspasm —> asthma patient receives dobutamine ( positive ionotropin & chronotrope )
- CABG (Open-heart surgery) is indicated when 3 or more vessels are blocked, or left main coronary artery, or have decreased LVEF
- patient prescribed aspirin & clopidogrel after stenting to prevent stent thrombosis

63
Q

Management of angina

A
  1. Daily aspirin
  2. Beta blocker or alternative CCB
  3. Statin
  4. Nitroglycerin as needed for chest pain

NOTE:
- Side effect of nitroglycerin—> headache + hypotension + contraindicated in patient with SBP below 90 + patient with right-ventricular MI + contraindicated in patient taken Phosphodiesterase 5 Inhibitors (viagra) in the past 48 hours

64
Q

Drugs contraindicated with asthma

A
  1. ACE-inhibitor
  2. Beta- blocker
  3. Ibuprophine
  4. Adenosine
  5. Dipyridamol

Only paracetamol is allowed in asthma

65
Q

Chronic cough

A
  1. Upper airway cough syndrome (UACS)
    -chronic cough that is worse at nigh & improve with antihistamine
  2. GERD
    - chronic cough that is worse at nigh and after eating & improve with PPI
  3. Asthma
    - chronic cough that is worse at nigh & did not improve with antihistamine
    - can be treated empirically with 2-4 weeks of inhaled glucocorticoid, if the cough improves, a diagnosis of asthma can be made
    - assess with PFT (spirometry)—> if negative, do methacholine
  4. ACE-I
    - dry cough
  5. Airway disease ( nonasthmatic eosinophilic bronchitis, chronic bronchitis, bronchiectasis, malignancy)
  6. Pulmonary parenchymal disease (lung abscess, interstitial lung disease)

Note:
1. Bronchoscopy —> assess foreign body
2. Chest CT —> suspect parenchyma lung disease or malignancy
3. Echo or direct laryngoscopy (cardiac & laryngeal testing) —> evaluate less common cause of chronic cough

66
Q

Rubella
1. Congenital (hearing loss + cataract+ patent ductus arteriosus)
2. Infant (fever + rash + lymphadenopathy+ erythematous papule on the soft palate )
3. Adolescence ( infant symptoms + arthritis)

A
  • is a mild viral illness
  • vaccine at age of 12 months & 4 years with live MMR vaccine

Symptoms: (develops 2-3 weeks after inhalation of respiratory droplet)

  1. fever (low-grade)
  2. rash (begins on face & spread to the rest of the body) (lasts < 3 days)
  3. lymphadenopathy (suboccipital, posterior auricular, posterior cervical)
  4. Erythematous soft palate (forchheimer spots)

Treatment:
- supportive

Note:
- prenatal infection leads to spontaneous abortion, fetal demise, or congenital rubella syndrome (hearing loss, cataract, patent ductus arteriosus)

67
Q

Measles

A

Symptoms:
1. Fever (high-grade)
2. Conjunctivitis
3. Cough
4. Coryza ( copious clear mucus)
5. Koplik spot (white exudate on inner side of cheek)
6. Rash (Erythematous morbilliform )
- maculopapular rash that spread cephalocuadally & after few days, coalesces & darkens ( red/brown)

68
Q

Scarlet fever

A
  • diagnosis > 3 years
  • streptococcal infection

Symptoms:
1. Fever
2. Palatal petechiae
3. Sand-paper texture rash
- starts at skinfold ( axilla, groin), then spread to trunk & extremity

69
Q

Erythema infectiosum

A
  • caused by parvovirus B19
  • occurs in school-aged children

Symptoms:
1. Prodromal symptoms ( fever + rhinorrhea)
2. Slapped-cheek rash (occurs after resolved prodromal symptoms)

70
Q

Children viral infection

A

Maternal disease lead to utero infection

  1. CMV
  2. Rubella
  3. Parvovirus B19

Viruses infect children as grow older:
1. Rhinovirus
2. Influenza virus

Vaccine-preventable infection
1. Mumps
2. Measles
3. Rubella

Antiviral drug treated infection:
1. HSV
2. Influenza virus
3. Varicella zoster virus
4. CMV

71
Q

Infectious mononucleosis
( due to EBV) (Diagnosed with positive hetrophile antibody = Monospot test)

A

Symptoms:
1. Fever + fatigue in the setting of pharyngitis
2. Absent of cough
3. enlarged cervical nodes
4. Erythematous/enlarged tonsils
5. Enlarged spleen
6. Rash development after amoxicillin

** Can lead to acute airway obstruction + AIHA/thrombocytopenia + splenic rupture
** only virus with all 4 centor criteria

Patient present with:
1. Dysphagia (difficulty swallowing)
2. Respiratory distress ( mouth breathing, tachypnea)

Treatment:
1. Corticosteroid to decrease airway edema
2. Supportive = self-resolved

72
Q

Endotracheal intubation

A
  1. Lead to acquired subglottic stenosis (narrow of larynx below the vocal cord)
73
Q

Retropharyngeal abscess

A
  1. Common in young children after upper respiratory viral infection
74
Q

Ludwig angina

A
  1. Fetal cellulitis of the submandibular space
  2. Caused by bacterial spread from adjacent infection —> most commonly bacterial abscess
75
Q

Acute rheumatic fever

A
  1. Potential sequela of group A streptococcal (GAS) pharyngitis
  2. Lead to:
    - fever
    - sore throat
    - tender anterior cervical node
    - resolve within a week
76
Q

Herpes zoster (shingles)

A
  1. rash in the dermatomes —> small papule—> evolve into vesicles or bullae with ulceration & crusting
  2. Caused by activation of varicella zoster virus
  3. Increased risk seen with decreased cell-mediated immunity ( older age or HIV)
  4. TREATMENT: antiviral agent ( acyclovir, famciclovir, valacyclovir)

Note:
- Post-herpatic neuralgia: persistence neuritic pain > 4 months after rash onset ( treated with TCA, pregabalin, Gabapentin)

77
Q

Foscarnet

A
  • for treatment of drug-resistance CMV
  • for treatment of severe VZV after failing first line treatment (not for uncomplicated shingles)
78
Q

Pediatric obstructive sleep apnea

A
  • Caused by: adenotonsillar hypertrophy ( lead to significant nasal airway obstruction by adenoid hypertrophy—> open mouth breathing)
  1. Child with nighttime loud snoring (noisy breathing at night)
  2. Gasping for air during sleeping
  3. Enuresis + parasomnias
  4. Failure to thrive ( low percentile for weight)
  5. Daytime sleepiness may not present (in contrast to adults)
  6. Daytime symptoms: inattention, learning difficulties, behavioral problems

Management of Adults OSA:
- weight loss + continuous positive airway pressure

Management of children OSA:
- tonsillectomy & adenoidectomy (T & A)

79
Q

Allergic rhinitis

A
  • open mouth breathing
  • runny nose
  • itchy eyes
  • sneezing
80
Q

Lung injury

A
  1. Pneumonia (consolidation)
    - increased breath sound + increased tactile fremitus + dullness on percussion + normal tracheal position
  2. Pleural effusion
    - decreased breath sound + decreased tactile fremitus + dullness on percussion + tracheal deviates away from affected lung
  3. Pneumothorax
    - decreased breath sound + decrease tactile fremitus + hyperresonance with percussion + tracheal deviates away from affected lung
  4. Atelectasis
    - decreased breath sound + decreased tactile fremitus + dullness with percussion + trachea deviates towards collapsed lung
81
Q

Pulmonary bleb

A
  • A pulmonary bleb is a small collection of air between the lung and the outer surface of the lung (visceral pleura) usually found in the upper lobe of the lung.
  • When a bleb ruptures the air escapes into the chest cavity causing a pneumothorax (air between the lung and chest cavity) which can result in a collapsed lung.
82
Q

Secondary Spontaneous pneumothorax
( can occur in patient with smoking, COPD, cystic fibrosis)

A
  • suspected in patient with history of lung disease (COPD, Cystic fibrosis)
  • smoking increase the risk of spontaneous pneumothorax

Etiology:
- chronic destruction of alveolar sacs leads to the formation of large alveolar blebs —> which can eventually rupture & leak air into the pleural space

Symptoms:
- SOB + chest pain + hypoxia + unilateral decreased breath sound + hyper-resonance on percussion

Diagnosis:
- chest x-ray

Management:
1. observation with supplemental oxygen
Or
2. emergency tube thoracotomy

83
Q

Pulmonary function test

A

Decrease FEV1/FVC
(obstructive lung disease= asthma, COPD/ chronic bronchitis + emphysema, bronchiectasis)

  1. Decrease DLCO —> COPD
  2. Normal/Increase DLCO —> asthma

Normal/Increased FEV1/FVC:

  1. Decreased DLCO —> interstitial lung disease ( restrictive lung disease; progressive fibrosis, asbestos, beryllium, silicon dioxide, amiodarone, nitrofurantoin, RA, scleroderma) + granulomatous disease (sarcoidosis)
  2. Normal DLCO —> chest wall weakness
84
Q

Differential diagnosis based on DLCO

A
  • Obstructive pattern ( FEV1/FVC < 70% of predicted)
  1. Decreased DLCO —> emphysema
  2. Normal DLCO —> chronic bronchitis, asthma
  3. Increased DLCO —> Asthma
  • Restrictive pattern (FEV1/FVC > 70%, with FVC < 80% predicted)
  1. Decreased DLCO —> Interstitial lung disease + sarcoidosis + asbestosis + heart failure
  2. Normal DLCO —> MSK deformity + neuromuscular disease
  3. Increased DLCO —> morbid obesity
  • Normal spirometry
  1. Decreased DLCO—> anemia + PE + Pulmonary HTN
  2. Normal DLCO —>
  3. Increased DLCO —> pulmonary hemorrhage + polycythemia
85
Q

Panacinar vs. centriacinar emphysema

A

Panacinar emphysema:
- typical of alpha-1 antitrypsin
- usually lower lobe of lung

Centriacinar emphysema:
- typical smoking-induced COPD
- upper lobe of lung

86
Q

Chronic bronchitis vs bronchiectasis

A
  • can be similar in presentation
  1. Bronchiectasis —> due to abnormal bronchial widening in the setting of recurrent infection/inflammation + more sputum production + chest x-ray shows dilated (rather than thickened) conducting airway + bacterial superinfection
87
Q

Molluscum contagiosum

A
  1. Benign skin infection & not painful
  2. Common in children
  3. Flesh-colored papule with central umbilication
  4. Lesion resolves in 6-12 months
  5. Management typically reassurance & observation in children
  6. Management can be cryotherapy, curettage , topical cantharidin in adults ( can be painful & lead to scarring)
88
Q

Chest pain differential diagnosis

A
  1. Myocardial infarction (stable angina, unstable angina, STEMI, NSTEMI)
    - stable angina
    - unstable angina
    - NSTEMI
    - STEMI
  2. Prinzmetal variant (vasospastic angina)
    - transient ST elevation (due to coronary artery vasospasm) + non exertional chest pain, often at rest
    - risk factor: smoking + cocaine abuse
    - diagnosis: coronary angiography in the CATH lab & injecting provocative agent (ergonovine), which induces vasospasm
    - treatment: CCB
  3. Pericarditis:
    - chest pain relieved when leaning forward + worse when laying supine or during inspiration
    - on exam: hearing of friction rub + fever
    - ECG: shows diffused ST-elevation in the pericordial lead (v1 through v6) + with associated PR-depression
    - echo: to rule out complication such as, pericardial effusion
    - treatment: 1. NSAID or aspirin & 2. use of colchicine to prevent recurrence
  4. Aortic dissection:
    - severe & sharp central chest pain that radiates to the back (between scapula)
    - risk factor: HTN
    - Diagnosis: MRI angiography
    - if the tear at the ascending aorta (Type A) —> the dissection is surgical emergency
    - if the tear at the descending aorta ( Type B) —> initially managed with beta-blocker
  5. Pulmonary embolism:
    - SOB + pleuritic chest pain
    -risk factor: DVT from lower extremity
    - diagnosis: helical CT scan, adjunctive venous doppler Ultrasound, V/Q scan (pregnant women), pulmonary angiography ( hemodynamically stable), chest x-ray, D-dimer
    - treatment: anticoagulation ( heparin…)
  6. Pulmonary HTN
    - exertional dyspnea + right-sided Heart failure (chest pain + edema + syncope)
    - causes: left-heart disease, chronic lung disease, mitral stenosis
    - diagnosis: right-heart catheterization (directly measures the pressure)
    - treatment of underlying cause
  7. Carditis:
    - causes chest pain or discomfort
    - most common result of rheumatic fever
    - associated symptoms: joint pain + subcutaneous nodules + erythema marginatium +seinheim chorea
    - rheumatic fever occurs 2-4 weeks after GAS infection (strep throat)
    - diagnosis: based on John’s criteria
    - treatment: aspirin & corticosteroid …& penicillin G for all patients
  8. Costochondritis:
    - pleuritic chest pain that gets worse with inspiration & palpation or movement of arms or torso
    - common after: MSK trauma or strain or viral illness where you cough a lot
    - treatment: rest & NSAIDS
89
Q

Hepatocellular pattern of liver disease
Vs.
cholestatic pattern

A

hepatocellular pattern of liver disease
- elevated AST & ALT
- seen with:
1. Autoimmune hepatitis
2. Alcoholic hepatitis
3. Hepatitis A

Cholestatic pattern:
- elevated alkaline phosphatase & bilirubin
- seen with:
1. Amlodipine (CCB)
2. Primary biliary cholangitis (PBC)

90
Q

Autoimmune hepatitis

A
  • Hepatocellular pattern of liver injury
  • asymptomatic patient present with abnormal LFT
  • symptomatic patient present with fatigue, anorexia, nausea, jaundice, can progress to fulminant liver or cirrhosis
  • can be associated with: vitiligo, autoimmune thyroiditis, celiac disease
  • findings:
    1. Elevated AST & ALT (> 300-900)
    2. Hypergammaglobinemia (high IgG) & large gamma gap ( total protein - albumin = > 4 g/dl)
    3. Elevated autoantibodies:
  • Anti-smooth
  • anti- liver/kidney microsomal type 1
  • anti-nuclear
    4. Histology: portal & periportal lymphoplasmacytic infiltration
  • treatment: prednisolone + azathioprine
91
Q

Alcoholic hepatitis

A
  • hepatocellular pattern of liver injury
  • symptomatic patient present with fever, jaundice, heavy alcohol use ( 5-6 drinks/day)
  • findings:
    1. Elevated AST> ALT (2:1), rarely exceeds 300 U/L
92
Q

Hepatitis A

A
  • hepatocellular pattern of liver injury
  • symptomatic patient present with vomiting, fever, abdominal pain
  • findings:
    1. Elevated AST & ALT > 1000
    2. AST & ALT normalize within 3 months
93
Q

Alpha-1 antitrypsin deficiency (AATD)

A
  • Autosomal codominant mutation
  • lead to: emphysema (cough + dyspnea + in the 40’s ) + liver disease ( chronic hepatitis + cirrhosis + family history of liver disease + abnormal LFT)
94
Q

Amlodipine (CCB) use

A
  • cholestatic pattern
  • symptomatic patient present with hepatotoxicity after weeks to months of amlodipine use (adverse effect)
95
Q

Primary biliary cholangitis (PBC)

A
  • cholestatic pattern
  • symptomatic patients present with: fatigue + pruritus + females
  • findings:
    1. Elevated Alkaline phosphatase (> 1.5 of the upper limit)
    2. Elevated bilirubin
    3. Elevated anti-mitochondrial antibodies
96
Q

Nonalcoholic fatty liver disease (NAFLD)

A
  • present in patient with metabolic syndrome (diabetes, & obesity, hyperdislipedemia)
  • findings:
    1. Elevated AST & ALT (ratio < 1)
    2. Hyperechoic - appearing liver on ultrasound ( due to hepatic steatosis = fat deposition on the live)
    3. Liver fibrosis & cirrhosis, if excessive fat deposition
    4. Mild hepatomegaly or minimal RUQ pain
  • treatment:
    1. Weight loss
    2. Bariatric surgery (BMI > 35)

Note:
1. Insulin resistance promotes fat deposition on the liver

97
Q

Acute fatty liver disease & preeclempsia

A
  • cause severe feature of elevated AST & ALT
  • Develop acute RUQ pain & associated thrombocytopenia in 3rd trimester
98
Q

Gallstone in pregnancy

A
  • associated with high progesterone level, which inhibits gallbladder contraction & promote gallstone formation
  • gallstone increase risk for cholecystitis & ascending cholangitis
  • patient present with: fever, leukocytosis, abdominal pain, gallbladder-wall thickening, elevated AST & ALT
99
Q

Intrahepatic cholestasis of pregnancy

A
  • Symptomatic patient present with pruritus in the palm & soles, elevated total bilirubin , elevated AST & ALT
100
Q

Colon cancer screening

A

Patient at average risk:
1. Start at age of 45
- colonoscopy every 10 years
- FIT every year
- CT colonography every 5 years
- flexible sigmoidoscopy every 5 years (or every 10 years with annual FIT)

Patient with first-degree relative or colorectal cancer or adenomatous polyp:
- colonoscopy at age of 40 (or 10 years prior to diagnosis of first-degree relative, whichever comes first)
- repeat every 5 years (or every 10 years if diagnosis of first-degree relative at age > 60)

Patient with ulcerative colitis:
- start screening 8-10 years after diagnosis
- colonoscopy every 1-3 years

101
Q

Causes of hepatocellular pattern of liver disease in pregnancy

(Abnormal LFT enzymes)

A
  1. Liver disease: acute fatty liver of pregnancy, preeclempsia
  2. Viral hepatitis:
    - diagnosis with viral hepatitis serology
    - should be considered in pregnant women with hepatocellular pattern of liver injury (elevated AST &ALT), even in those with negative screening tests at initial prenatal visits
  3. Autoimmune hepatitis:
102
Q

Crying in young infant

A

Normal:
1. Intermittent, consolable, < 3 hrs/day

Colic (crying for no reason)
1. > 3 hrs/day (usually evening), > 3 days/week
2. Healthy infant, age < 3 months
3. Crying usually occur on the same time of the day —> solved with reassurance of parents & review of soothing techniques for baby (pacifier, holding, rocking, swaddling the baby, minimize environmental stimulus/ dark room), upright feeding position/reduce air swallowing

GERD
1. Frequent spit-up
2. Back-arch after feeding
3. Irritability
4. Severe form: poor feeding + poor weight gain —> require treatment with H2 receptor blocker

Infection:
1. Acute otitis media: bulging tympanic membrane ± fever —> require oral antibiotics
2. Meningitis: fever, lethargy, bulging frontanel,
3. Septic arthritis: fever + limited extremity movement
4. UTI: fever + vomiting + poor feeding

Insussusception:
1. Episodic irritability with legs drawn to abdomen
2. ± bilious emesis, bloody stool
3. Present at 6- 36 months
4. Diagnosed with US

Torsion:
1. Testicular swelling or abdominal distention (ovarian)

Trauma:
1. Hair tourniquet: hair accidentally wrapped around digit
2. Corneal abrasion: tearing + photophobia + fluorescein test
3. Abuse/fracture: bruising + laceration + asymmetric movement

103
Q

Pancreatic adenocarcinoma
(Insidious + constant & gnawing epigastric pain that is worse at night + anorexia + weight loss ± jaundice)

A

Risk factors:
1. Smoking
2. Hereditary pancreatitis
3. Nonhereditary pancreatitis
4. Obesity & lack of physical activity

Clinical presentation:
1. Weight loss + anorexia
2. Epigastric Abdominal or back pain
3. Jaundice
4. Recent onset of atypical diabetes
5. Migratory thrombophlebitis ( trousseau syndrome)
- (inflammation of a vein due to a blood clot)

Laboratory:
1. Cholestatic pattern: elevated alkaline phosphatase & direct bilirubin
2. Elevated CA 19-9
3. Ultrasound for head pancreatic cancer (jaundice)
4. CT scan for tail pancreatic cancer (no jaundice)

Note:
1. Cancer in the head of pancreas: jaundice + steatorrhea

104
Q

Duodenal ulcer

A
  • episodic epigastric pain + relieved by meal
105
Q

Macrocytic anemia

A
  1. Megaloblastic anemia
    - causes: impaired DNA synthesis due to B12 or folate deficiency
    - high (MCV > 110) + high MCH+ normal MCHC + low reticulocyte + low RBC + hypersegmented neutrophils (> 5 lobes) + anisocytosis + poikilocytosis
    - diagnosis: peripheral smear + reticulocytes count + B12 & Folate levels
  2. Nonmegaloblastic anemia
    - caused by: alcohol use, liver disease, hypothyroidism, drugs
    - low/normal/high reticulocyte count (depend on etiology)
106
Q

Basophilic stippling (ribosomal precipitate)

A

Seen with:
1. Lead poisoning
2. Thalassemia
3. Alcohol use

107
Q

Bone marrow biopsy

A
  • in diagnosis of myelodesplasia
  • present with > 1 cell line cytopenia
108
Q

Autoimmune hemolytic anemia (AIHA)

A

Present with:
1. Low hemoglobin (7-10) + low heptoglubin + high reticulocyte count + high LDH + high bilirubin
2. Peripheral smear: Spherocyte

109
Q

Microcytic anemia / hypochromic anemia
( low MCV, low MCHC)

A
  • perform iron-studies to confirm diagnosis

Seen in:
1. Iron deficiency:
- decrease intake or increase blood loss
- low iron + low ferritin + high TIBG + high RDW + low transferrin

  1. Anemia of chronic disease:
    - defect in use of stored iron (& increase inflammation)
    - low iron + high ferritin + low TIBG
  2. Thalassemia:
    - reduced globin production
    - high iron + high ferritin
    - increase reticulocyte & bilirubin ( due to hemolysis)
  3. Lead poisoning or sideroblastic anemia:
    - reduced heme synthesis
    - high iron + high ferritin
    - NORMAL TIBG

Note:
- transferrin = iron/TIBG ratio

110
Q

Anemia of chronic disease
(Infection, cancer, autoimmune disorders, heart disease, diabetes, acute inflammation)

A
  • require treatment of underlying cause to improve anemia
  • examples:
  1. Rheumatoid arthritis:
    - treat with: methotrexate, hydroxychloroquine, tumor necrosis agent ( infliximab, etanercept)
    - erythropoietin may be effective if patient is unresponsive to initial treatment
    - packed red blood cell, if all other medication fail
111
Q

Hereditary spherocytosis

A
  • treated with splenectomy
112
Q

Patient with sickle cell disease complains of leg pain

A
  • caused by avascular necrosis (osteonecrosis of the femoral head)
  • findings:
  • groin/thigh/buttock pain on weight bearing
  • pain on hip abduction & internal rotation
  • no erythema, swelling, or point tenderness
  • no leukocytosis
  • normal inflammatory markers (CRP & ESR)
  • MRI: shows crescent sign

OTHER causes:
1. SLE
2. Antiphospholipid syndrome
3. Infection (osteomyelitis, HIV)
4. Decompensation sickness
5. Steroid
6. Alcohol

113
Q

Sickle cell disease (SCD) Complications

A
  1. Septic arthritis
    - due to splenic dysfunction predispose to infection with encapsulated organisms ( Strep pneumonia, H.influenza, N.meningitidis)
  2. Avascular necrosis
114
Q

Reactive arthritis

A
  • lead to assymetric arthritis typically in lower extremity after GI infection or genitourinary infection
  • can lead to: problem with vision, problem with urinating, problem with walking
115
Q

Mycoplasma pneumonia (atypical pneumonia)

A
  • common cause of community acquired pneumonia
  • occurs in young, school trips, winter
  • symptomatic patient present with: fever + fatigue + nonproductive cough + dyspnea
  • some patient can have hemolysis due to cold agglutinin
  • x-ray shows: bilateral diffuse infiltrates
  • treatment: macrolide (azithromycin) or respiratory fluoroquinolone
116
Q

Left-sided infective endocarditis

A
  • common organism: viridan streptococci
  • common cause:
    1. dental procedure —> lead to transient bacteremia
    2. Prosthetic valves
  • patient present with:
    1. Fatigue, anorexia, malaise
    2. Fever
    3. Heart murmur
    4. Splinter hemorrhage
    5. Petechiae
    6. Janeway lesions or osler nodes
    7. Complications related to local cardiac infection (heart failure) or embolism (brain)

Findings:
1. Elevated ESR
2. Hematuria (due to glomerulonephritis from septic emboli)

Evaluation:
1. Blood culture from 3 different venipuncture sites (before initiating antibiotic treatment)
2. Prescribe empiric treatment (in patient with high DUKE criteria) after blood culture are drawn
3. Delay antibiotic treatment until after result of blood culture ( in low risk patient with low duke criteria)

117
Q

Duke criteria for infective endocarditis

A
118
Q

Anti-streptolysin O titer

A
  • diagnose GAS infection in patient with rheumatic fever
  • patient present with: systemic symptoms + carditis + arthritis + CNS involvement ( sydenham chorea) + subcutaneous nodules
  • develops weeks after infection with GAS pharyngitis
119
Q

Preseptal cellulitis vs orbital cellulitis

A

Presebtal cellulitis:
- eyelid erythema
- eyelid swelling
- chemosis
- treat with: oral antibiotics
—> caused by insect bite, wound

Orbital cellulitis:
- signs of preseptal cellulitis
- pain with extraocular movement
- proptosis
- opthalmoplegia with diplopia
- treat with: IV antibiotics ± surgery (if abscess, than drainage)
—> caused by extension from bacteria from sinusitis, dental abscess, preseptal cellulitis

120
Q

Community acquired pneumonia in school-aged children

A

Focal (Lobar) pneumonia
-caused by: strep pneumonia
- clinical:
1. abrupt onset of fever, cough, chest pain
2. increased work of breathing
3. focal crackles
- treatment:
1. Outpatient: Oral amoxicillin (outpatient)
2. Inpatient: IV ampicillin or ceftriaxone

Bilateral (infiltrative) pneumonia
- caused by: mycoplasma pneumonia, chlamydia pneumonia, viruses (rare)
- clinical:
1. Fever, malaise, headache, sore throat
2. Prolonged & gradual worsening cough
3. Patient continue normal activities (walking pneumonia)
4. Bilateral crackles, wheezing, rhonchi
- treatment:
1. Macrolide ( azithromycin)

121
Q

Live vaccines
( MMR, influenza, varicella, oral typhoid)

A
  • should be avoided in immunocompromised ( severe combined immunodeficiency)
  • should be avoided in immunosuppressed ( taken azathioprine or adalimumab)
122
Q

CDC immunization schedule

A

Hep B: (hepatitis B)
- months: birth, 1-2, 6-18

RV: (rotavirus)
- months: 2, 4, 6

Dtap: ( diaphtheria, tetanus, pertussis)
- months: 2, 4, 6, 15-18, 4-6 years

HiB: (hemophilus influenza type B)
- months: 2, 4, 6, 12-15

PCP: (pneumococcal conjugate vaccine)
- months: 2, 4, 6, 12-15

IPV: (inactivated poliovirus)
- months: 2, 4, 6-18, 4-6 years

HepA:
- months: 12-23 ( first & second dose)

MMR:
- months: 12, 4-6 years

VZV:
- months: 12, 4-6 years

Tdap:
- years: 11-12

HPV:
- Years: 11-12 ( first & second doses)

MCV (meningococcal conjugate vaccine)
- years: 11-12, 16

MenB (meningococcal serogroup B)
- year: 16 ( first & second dose)

Inactivated influenza (annually)
- start age: 6 months

123
Q

MCV vaccine recommended

A
  • primary vaccine at age 11-12 years
  • booster shot at age 16 years

Other uses:
- complement deficiency
- asplenia
- college students
- traveler to endemic area (central africa, alhaj)

124
Q

Diarrhea caused by

A
  1. ETEC
    - traveller diarrhea
    - watery diarrhea + abdominal pain
    - starts within 1-3 days
    - resolves in 5 days
    - severe diarrhea: dehydration (dry mucous membrane, reduced capillary refill, tachycardia) + prerenal azotemia ( BUN/CR> 20) + hypernatremia
  2. Giardia
    - watery diarrhea
    - starts within > 1 week
  3. Rotavirus
    - severe, watery diarrhea in unimmunized children age < 2 years
  4. Salmonella S Typhi
    - high fever for a week + followed by abdominal pain with or without diarrhea
  5. Shiga toxin-producing E.coli
    - bloody diarrhea
    - cause hemolytic uremic syndrome (HUS) after 1-2 weeks (typically intrinsic AKI, BUN/Cr < 20)
    - associated with anemia + thrombocytopenia
125
Q

Acute epididymitis

A

Age < 35:
- sexually transmitted ( chlamydia or gonorrhea)

Age > 35:
- bladder outlet obstruction ( E.coli)

Findings:
- unilateral posterior testicular pain
- epididymal swelling
- pain improves with testicular elevation
- dysuria + frequency (with coliform infection, > 35 age)

Diagnosis:
- NAAT ( chalamydia or gonorrhea)
- urinalysis + culture

126
Q

Differentiation of conjunctivitis

A

Viral:
1. Unilateral & bilateral eye involvement
2. Eye stuck and shut
3. Watery, scant, stringy discharge
4. No discharge appearing after wiping
5. Burning sensation
6. Sometime prodromal symptoms
7. Diffuse injection; follicular or bumpy appearance of conjunctival
—> associated with URI (rhinorrhea, sore throat, cough)

Bacterial:
1. unilateral or bilateral eye involvement
2. Eye stuck & shut
3. Purulent, thick discharge
4. Discharge appear after wiping
5. Sensation of unremitting discharge
6. No prodromal symptoms
7. Diffuse injection; non-follicular appearing conjunctival
—> adult: caused by staph aureus
—> children: caused by H.influenza, Maroxella, strep pneumonia

Allergic:
1. Bilateral eye involvement
2. Eye stuck and shut
3. Water, scant, stringy discharge
4. No discharge appear after wiping
5. Itchy sensation
6. No prodromal symptoms
7. Diffuse injection; follicular or bumpy + conjunctival edema (chemosis)

127
Q

Osteomyelitis

A
  • bacterial infection of the bone
  • presents with fever + focal bony pain
  • most common cause is staph aureus
  • treatment: vancomycin
128
Q

Bordetella pertusis

A
  • causes severe coughing paroxysms that lasts for weeks
  • associated with syncope & signs of elevated capillary pressure ( subconjunctival hemorrhage)
  • diagnosis: pertussis PCR & culture
  • treatment: azithromycin
129
Q

Meningitis

A

Listeria monocytogenes:
- less than 1 month
- unlikely to cause meningitis in immunocompetent 18-month old

Menongococcal meningitis: (Neisseria Meningitidis)
- less than 1 month to adolescence
- lead to:
1. Initial: nonspecific fever + headache + vomiting + myalgia + sore throat
2. Within 12-24 hours: petechiae/purpura + meningeal signs + AMS

  1. Young children: fever + neck rigidity+ vomiting + petechial rash on the extremity
  2. Older children: headache + severe myalgias ( leg pain)
    - symptoms progress rapidly (over 12-24 hours) to include purpuric rash & altered mental status
    - brudzinki sign is common, but absent in patient age < 1 year
    - diagnosis: lumbar puncture
    - treatment: ceftriaxone
    - chemoprophylaxis for close contact (rifampin, ciprofloxacin, or ceftriaxone)
    - can be fetal & causing: shock, multi-organ failure, DIC, death

Group B strep.:
- less than 3 months
- unlikely to cause meningitis in immunocompetent 18-month old

H. Influenza:
- not associated with rash
- unlikely meningitis in fully immunized child

Enteroviruses ( coxsackievirus)
- lead to: meningitis ( fever, headache, neck rigidity) + posterior pharyngeal sores + maculopapular rash on palms/soles.
- symptoms develop over days

130
Q

Investigation of colorectal cancer in suspected patient

A

In clinic exam:
1. Digital rectal examination & anoscopy

Laboratory:
1. CBC (ferritin) , LFT, renal function

FIT test:
1. Blood in stool (microscopic amount of blood in stool)

Colonoscopy:
1. Diagnosis (not screening ) within 24 hours

131
Q

Osteoporosis

A

Bisphosphonate take drug once a week and starts to work (effectiveness) in 6 months

132
Q

Acute pharyngitis

A

Can be caused by:
1. Viral —> more common
2. Bacteria —> group A strep.

centor criteria:
1. In adult is often used to evaluate acute pharyngitis
2. In children is less predictive
- GAS or viral infection can shows: tonsillar erythema & exudate, tender anterior cervical node & palatal petechiae
- viral additional symp.: cough, rhinorrhea, congestion &/or oral ulcer

Evaluation:
1. Initial rapid antigen detection testing (RADT)
- the risk for acute rheumatic fever is higher in children with untreated streptococcal pharyngitis
- a negative RADT in children should be confirmed with throat culture ( but confirmation is not required in adults)

133
Q

Antistreptolysin O antibodies

A
  • peaks a month after streptococcal infection
  • is not diagnostic for acute pharyngitis
134
Q

Heterophile antibody

A
  • diagnostic for infectious mononucleosis (IM)
  • caused by EBV
  • symptoms: fever + exudative tonsillitis + posterior cervical lymphadenopathy + splenomegaly
135
Q

Rapid Influenza testing

A
  • to guide for antiviral treatment of influenza
  • symptoms: fever+ pharyngitis + viral symptoms (cough + rhinorrhea)

Family Medicine (5 decks)

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