The Review Course Flashcards
Cough:
list acute, subacute and chronic cough ddx
Acute <3wks:
- Something fatal? pneumonia, HF, neoplasia, foreign body, PTX
- Medication: ACe inhibitors
Subacute 3-8 wks:
- Post-viral
- Infectious : bacterial, viral
- Early chronic: asthma, reflux, upper airway cough syndrome (post nasal drip), covid 19
Chronic >8 weeks:
- COPD
- Infectious (ascaris?)
- Refractory or unexplained cough
- Less common: cystic fibrosis, bronchiectasis, eosinophilic bronchitis
Always ask travel, occupation, contacts, critters
Cancer:
- Prostate
- Testicular
- Lung
- Ovarian
- Cervical
- Melanoma
- Colon
- Breast
- Pancreatic
-
- Prostate cancer : no screening for average risk
- Testicular cancer : screen if cryptorchidism, FMHx, PMHx (screen with BHCG, alpha-fetoprotein). Tx Lop it off surgery.
- Lung cancer: Low dose CT 55-74yo if 30pk/yr smoker (smoking now or in last 15 years). Annually x 3 max. No CXR. Think Radon gas 2nd leading cause of lung cancer, recommend home radon test kit.
- Ovarian: do not screen if asx low risk. High risk (BRCA positive) then screen.
- Cervical: screen 25-69 q3years (DO not screen: never sexually active, weakened immune system, HIV is every year no q3yrs, sx cervical cancer, previous abnormal screening, does not have a cervix)
- Melanoma: refer if high risk (older, male, previous skin cancer, FMHx, # nevi (low risk <15), light skin, red hair, multiple sunburns, actinic skin damage)
- Colon cancer: FIT test 50-74yrs q2yrs, not affected by NSAIDs, OACs or ASA (or flex sig q10yrs)
- Breast cancer: 50-74yrs q2-3years if average risk (otherwise shared decision making)
- Pancreatic cancer: only if high risk (BRCA1 +, FMHx, Peutz-Jeghers syndrome).
Febrile neutropenia
DOs/DONTs
DOs: look in mouth for mucositis, look for source (consider fungal)
Early abx: cipro + amox if low risk, tazo if high risk. consider antifungals.
DONTs: rectal exam/temperature
Unexplained weight loss
Investigations
Weight, height
Serum Hemoglobin
Serum sodium, potassium, eGFR
Serum urea, creatinine
Serum PSA
Fecal Occult Blood
Chest x-ray
Chest, abdomen, pelvis CT (with contrast!!!! for cancer)
CAREFUL IF THEY ASK FOR SERUM
Shortness of breath
- r/o PE with
- Wells first, if low risk then PERC
- pregnant: YEARS rule –> signs DVT, hemoptysis, PE most likely (1pt each) –> d-dimers : r/o PE if <500 (1-2-3pts), <1000 (0pt)
SOB:
investigations
ECG
Echocardiogram
Troponin
Arterial blood gas (if acute)
Chest x-ray
Pulmonary function
CT chest if no clear diagnosis
Shortness of breath
Zebra causes lung and heart
Extra pulm/cardiac causes:
Life threatening
Lung: recurrent fungal pneumonia, fibrosis, post-COVID 19 sequelae, pleural effusion
Heart: occasional arrhythmia, cardiomyopathy, malignancy, mycobacterial, aortic stenosis
Other: anxiety, abnormal thyroid, altitude, anemia, acid reflux, allergy, deconditioning
Life threatening: foreign body, anaphylaxis, pneumothorax
Pneumothorax primary spontaneous <2cm on xray: dos and donts
Do: observe 4 hours, d/c if well tolerated and stable on xray, offer needle drainage instead of chest tube (less pain, higher failure rate) but 85% DO NOT require drainage
Don’t: CT/POCUS (not necessary)
COPD
Ddx:
Does oxygen therapy change time to death/hospitalisation?
Non-pharmaco tx to think about
When can you consider opioids?
Ddx: think pre-COPD (resp sx but normal lungs)
No
Acupuncture, active mind-body therapy, yoga, tai chi
In palliative context
COPD:
3 elements to consider with treatment
- Daily macrolides (reduce exacerbations)
- Action plan (reduce hospital use)
- CPAP if COPD + OSA (reduce mortality + admission)
COPD:
Explain treatment for COPD mild vs mod/severe
Mild: LAMA or LABA (no longer SABD x 2023)
Moderate to severe:
- if lo AECOPD: LAMA + LABA + ACS
- if Hi risk AECOPD: triple + oral (roflumilast/pde-4 inhibitor, n-acetylcysteine, daily azithromycine)
ALWAYS SABD PRN
Mild = COPD Assesment test (CAT) <10, FEV1>=80%
Mod/severe = CAT>=10, FEV1<80%, mMRC scale >=2
What other one test would you order for COPD?
Blood eosinophils –> if >=300 change to ICS + LABA instead of LAMA/LABA
Can you diagnose COPD in non-smoker?
It could be second-hand but think about other causes:
- Alpha-1 anti-trypsin (if dx <65yo or <20pk/yr)
- Bronchiectasis
- Infectious
- Cardiac
- Mass
COPD:
acute exacerbation vs chronic worsening
Treatment for both
Treatment for AE
AE: days
Chronic worsening: over months
For both : stop smoking, optimize inhalers + review technic
Treatment for AE:
- Steroids
- Antibiotics if CRP >40 or 2/3 winnipeg symptoms (sputum purulence, sputum volume, dyspnea)
—> treat as per local resistance pattern
COPD:
common pathogens
Ear bugs: H.influenzae, S. pneumonia, M. catarrhalis
Complicated: ear bugs + Klebsiella, pseudomonas, gram negatives
COPD: prevention, refer, start
Prevention:
- Vaccination: influenze, pneumococcal vaccines, covid-19
- Exercise to prevent exacerbations
- smoking cessation
Refer early: respiratory therapy, pulmonary rehabilitation, respirology, smoking consellor, palliative
Start: short-acting beta-agonists if mild + intermittent sx, long-acting muscarinic antagonist if regular mild sx.
How do you mange COPD/Asthma overlap syndrome
ICS/LABA (fluticasone propionate + salmeterol) +/- LAMA (tiotropium)
Refer +/- biologic medications
Asthma:
diagnosis in pediatric population
<6 years old: reverse with salbutamol, wheezes, r/o other causes (croup, foreign body, asthma can overlap with bronchiolotis or virus induced wheeze)
> = 6 years old : PFT
Main cause of bronchiolitis:
- diagnosis
- cause
- management
- prevention
RSV bronchiolitis
- Investigation = NONE if uncomplicated. Nenonates may present with apnea or cyanosis only.
- Cause = RSV 80%, mycoplasma, pertussis
- Management = supportive (admit if needed to maintain saO2 >90%
- Prevention = vaccine
How can you assess asthma severity at ER?
PRAM score:
- <4 mild
- 2-7 mod
- >7 severe
Asses: O2 sat, retractions/indrawing, air entry, wheeze
Asthma:
what environment exposition increases risk in children?
Frequent use of cleaning products
Antibiotics without being breastfed in 1st year of life
Asthma:
3 elements of hx with adult
- triggers
- past severity
- current control
Asthma control if:
PER WEEK:
=<2 days with symptoms
<1 day night symptoms
=<2 doses of reliever
NO interference with work/school/exercise
Mild infrequent exacerbations
ASTHMA diagnostic PFT values:
ASTHMA : management
Safety : how many relievers used? (normally 1 puffer every year, 1 puffer = 200 doses. If 2 puffers <6 months, review plan. if >=3 puffers/yr consider ICS as PRN)
Next visit: when to FU, in-person for complete physical exam
Offer: PFT, chest xray
Asthma : regularly reassess
Control
Risk of exacerbation
Spirometry or PEF
Inhaler technique
Adhrence
Triggers
Comorbidities
Asthma: pharmacological
1st line: ICS PRN or (ICS + SABA)PRN (asthma should always have ICS even if mild asthma, otherwise just ventolin might increase exacerbations)
2nd line: daily low dose ICS + ICS-formoterol PRN
(other: daily leukotriene receptor antagonist)
3rd line: low dose ICS+LABA or medium dose ICS with ICS-formoterol PRN (other low dose ICS + leuko)
4th step: medium dose ICS + LABA or high dose ICS + LAMA or LTRA
5th step: high dose ICS-LABA +/- anti-IgE, anti-IL5, anti-IL4 (monoclonal biologic therapy)
What is the one test you should think of in abdominal pain?
Beta-HCG in any woman in age to procreate
Abdo pain:
List 5 alarm features other than weight loss, palpable mass or hematochezia/melena
Age > 55
Severe pain
Melena
Weight loss
Abnormal labs (Hb, CRP, Na, K)
Vomitting
Dysphagia
Mass
Family history
Previous history
Bilious vomit
BHCG
Dyspepsia: how do you treat pylori
14 days quadruple therapy:
clarithromycine, amoxicillin, metronidazole, PPI
Dyspepsia: Barrett’s esophagus
Risk factor
Management
Reflux = greatest risk factor
Management:
- Lifestyle for reflux (caffein, ETOH, smoking, weight loss)
- High dose PPI
- ASA (reduces the risk for adenocarcinoma)
When should you screen for esophageal cancer?
Never, even if high risk
What are PPIs side effects? (important cause prescribed very often in the past and now we realise there are important side effects)
- B12 deficiency
- Gastric cancer
- Fractures
- Dementia
- C. difficile
Abdo pain: non-abdo causes
- Think pelvic exam/B-HCG
- Herpes Zoster (skin exam)
- Testicular torsion? (mostly if younger male)
- PE/MI/endocarditis
Imaging 1st modality for ureteral stones?
Kidney Ultrasound
Can add Kidney Ureter Bladder Xray
What risk for pancreatitis
Rx: septra, flagyl, HCTZ, ACEi, progesterone/estrogen, atorvastatin
Medical condition: gallstones
Habitus: ETOH
Risk factors for gallstone
Female, forty, fertile, obese, OCP
Insomnia: explain types
20 sleep disorders on DSM-5
Narcolepsy
Restless leg syndrome
Sleep terrors
Sleep walking
Insomnia disorder
OSA
Hypersomnolence Disorder
Circadian rythm sleep-wake Disorders
insomnia: what are the other causes
It’s never JUST insmonia
Medications
Drugs (cocaine most days)
Drink 2 bottles of wine each day
Has a history of ADHD
Cushing (facial & neck fat prominence)
Hyperthyroidism/Hypothyroidism
Depression (YES to PHQ2 : 1) down/depressed/hopeless 2) little interest/pleasure)
Parkinson (resting tremor?)
insomnia: pharmacological consideration (deprescribe/new medication)
Deprescribe in insomnia: benzo (harm>benefit), trazodone (risk of falls + ineffective), antipsychotics (ineffective)
New medication: dayvigo (lemborexant) or lunesta (eszopiclone –> non-benzo sedative hypnotic)
Insomnia: SNOPQRST
Safety: verify if noding off at the wheel or if sleeping >10hours a day, or falling during conversation. No driving.
Next visit: physical exam + interview partner
Quit: naps, caffein (at least 6 hours before bedtime, some people very sensitive 8-10hours)
Refer: sleep medicine, level 3 sleep study, psychiatry, auricular acupuncture, CBT-INSOMNIA (dont forget the insomnia!!!!)
Teach: avoid screen time before bed, sleep diary (medication taken).
Deprescribing benzodiazepines
Deprescribing antipsychotics
restless legs syndrom
non-prescription vs prescription
Non-prescription: iron, magnesium, stretch calves, avoid caffeine, massage/heat, exercise
Prescription:
- Non-ergot dopamine agonists (pramipexole)
- Alpha-2-delta calcium channel ligand (gapapentin, pregabalin)
sleep apnea
Diagnosis: STOP questions (Snore, tired, observed apnea, High BP)
Treatment: positive airway pressure (c-pap), mandibular advancement device
family issues: how to management isolation/loneliness
Social facilitation
Animal Therapy
Psychological therapies
Skill development
FIFE +
Feelings + Ideas
Function/Fears + Expectations
Domains of Impact = MRS SWELP$
- Mental
- Relationship
- Spiritual
- Sex
- Work
- Emotional
- Legal
- Physical
- $ Financial
More relational :
- Spouse (how long together/married, risk domestic abuse, supportive?)
- Parents, siblings, children (in the same city?)
- Roommate?
- Mistress?
- If relation mentionned in SOO (my wife/children told me to consult, assess impact/expectations/fears they have and offer to talk to them) –> CAREGIVER BURNOUT?
BE CONVERSATIONAL
“it’s sound like you’re expecting” “what are you hoping we can accomplish today?” “what do you think is going on”
How can you help caregiver burnout
by staying CALM
Counselling
Appointment (separate visit)
Lifestyle advice
Mental health support
CBT tricks name 4
- Goalification (help pt find goal in each complaint - complaining about exam : you have studied for this for years, you have a plan, you did questions)
- Viewpointing (how would -insert relation- see this?)
- Scalification (1-10, why not worse)
- Reward chart (link effort and reward)
- Pathogenic beliefs (identify by listening/acting/guessing)
- Cognitive illusions (identigy thinking traps “i’ll never find…”)
- Mood Pie with 2 slices (good vs bad luck, bad luck = excuse for self-compassion)
- Thoughts record: write thoughts and associate to feelings/illusions
- Persuasion (help patients drop pathogenic beliefs)
- Systematic desensitization (increase exposure to fears)
Acute diarrhea (length, always do what?, antibiotics causing )
<14 days
Always assess if HD stable (hypovolemia) + consider BHCG
Antibiotics-associated diarrhea: clinda, cipro/levo
- prevent with probiotics
- “Antibiotics Can Trigger Loose C.Diff” : amox, clinda, tetra, levo/ciprofloxacin, cephalosporines
- if recent abx use think C.diff (treat with vanco, not metronidazole anymore)
Dehydration : fluids for peds + consideration if formula-fed in context of diarrhea
Bolus 20cc/kg
Rule 4-2-1 for maintenance (4cc/kg x 10, 2cc/kg x 10, then 1cc/kg)
Continue breastfeeding if diarrhea
Formula-fed : temporary lactose-free formula
What are direct objective measures to direct management of severe dehydration?
LAB measures: serum glucose/sodium/urea/creatinine/potassium/eGFR
Other: weight
Investigation mild gastroentritis?
None, avoid overinvestigating
Don’t always assume gastroenteritis also think of:
Infectious : meningitis, pneumonia, cholera, sepsis
Non-GI
Abuse/neglect
Medication
Diabetic ketoacidosis
Always think of how different the management could be in special populations. Special populations are:
Pregnant, infant, elderly
In a patient with shortness of breath, new rash or diarrhea, you should always ask if?
Recent travel/immigration
Diarrhea in elderly causes
- Acute ischemic bowel
- Obstruction
- Diverticulitis
- Appendicitis
- Neoplasm
Gastroenteritis = LOW on the list
Diverticulitis management complicated vs uncomplicated
Uncomplicated : no abx, treat OP, non-opioid analgesia
Complicated (perforation/abscess): antibiotics +/- surgery
C.difficile risks (5) + treatment
Healthcare-associated (recent hospit)
Older age
Immunocompromised
Previous c.diff infx
Recent antibiotics (clinda, cipro, clavulin) –> “C” antibiotics can cause “C” difficile
Treatment: first line = fidaxomicin, others (vancomycin, metronidazole), rare (fecal transplant)
+ dont forget supportive care (IVF)
What should you always assess in a chronic condition? (chronic diarrhea, chronic SOB, chronic pain, etc.)
New sx/pattern?
Exacerbation?
Complication?
Chronic diarrhea : length + investigations
> 4 weeks
Common:
- Hb, ferritin, TSH, anti-TTG (tissue transglutaminase antibody), calprotectin (IBD), FIT test, C.diff, ova& parasites stool culture
If altered bowel habits : straight to colonoscopy
Other:
- Hydrogen breath test (lactose intolerance)
- Fecal elastase (fat malabsorption)
- MRI abdomen (chronic pancreatitis)
In patients with chronic diarrhea you should always look for 3 categories of etiology (think GI and non GI sx):
- Inflammatory bowel disease (IBD):
- GI: Look for blood in stools, abdominal pain, weight loss
- Non-GI: joint pain, skin manifestations, and eye inflammation. - Malabsorption syndromes:
- GI steatorrhea, bloating
- Non GI malnutrition, vitamin deficiencies, anemia, and neurological symptoms. - Compromised immune system:
- GI: recto/melena, recurrent GI infections
- Non-GI : fever/constitutional sx, lymphadenopathy, and opportunistic infections causing persistent diarrhea.
What are therapies that should now be avoided for Crohn’s according to 2019 guidelines?
Avoid the As
- 5-ASA po –> prescribe only per rectum (not orally)
- Antibiotics
- Alternative treatments (marijuana, probiotics, omega-3, naltrexone)
Pharmacological management of Crohn’s
1st line : sulfasalazine
Steroids (not in high risk pts)
Thiopurines (not for induction)
Methotrexate
Biologics (anti-TNF therapy)
DOs for IBS
- TTG or endomysial IgA
- FODMAP diet trial
- Psyllium, prune juice
- Peppermint oil, probiotics
- CBT
- colonoscopy if >50yr or alarm features
DONTS IBS
Pharmacotherapy for IBS-D:
Dont loperamide, cholestyramine, osmotic laxatives
What would be the diagnosis for a prodound fatigue NOT improved by rest or with post-exertional malaise?
Myalgic encephalomyelitis
Fibromyalgia diagnosis + treatment
Diagnosis : diffuse body pain x 3 months with no other explanation with WPI>=7 + SS>=5 or WPI 3-6 and SS>=9 (7+5 = 12, 3+9 = 12)
- Widespread Pain Index: /19 (jaw, neck, chest, shoulders, U arms, L arms, abdomen, buttocks/hips, U legs, L legs) –> 1 pt for each side except chest/neck/abdo
- Symptom Severity: /12 (0-3 fatigue, 0-3 waking unrefreshed, 0-3 cognitive sx, 0-3 systemic sx)
Treatment: exervise, psychological (CBT), themal baths, massage
Myasthenis Gravis symptoms + tests
Masticulation difficult
Ocular (diplopia/ptosis)
Phonation (weak voice with long convo)
Test: Acetylcholine receptor antibody, tensilon test
What’s the new name for hypochrondiasis
Somatic symptom disorder (SSD-PAIN subtype if pain is a sx)
What is the investigation for somatic symptom disorder?
None
When can you diagnose somatic symptom disorder (SSD)?
After
- complete hx + PE
- thorough workup
- Referrals
- Rule out other causes: rx side effects, myasthenia gravis, abuse/trauma, DVT, necrotizing fasciitis, osteomyelitis
When a patient presents with dyscopia (inability to cope) you should think of what ddx?
Somatic symptoms, Anxiety, Depression (SAD - always think of the others when thinking of one)
Chronic pain
Sleeping disorder
Substance use disorder
Side effects
How do you manage somatic symptom disorder?
Start: PT, massage, acupuncture, naturopathy
Search: life-threatening causes
Team: PT, CBT, important to have only one primary care provider (in SOO, offer to be family doctor)
Teach: support groups, online resources & apps
Time: regular long-term follow up (building an alliance)
How do you manage thyroid storm?
BLOCK Bs
Block TSH synthesis (methimazole, PTU)
Block Conversion of T4 –> T3 (propranolol, PTU)
Block TSH release (iodine)
Beta-blockers (propranolol)
Block bile (cholestyramine)
Thyroid storm is a severe form of hyperthyroidism (like myxedma coma is the severe form of hypothyroidism) –> therefore you want to start with thionamides to decrease TSH synthesis, PTU is preferred because it also decreases conversion T4 to T3 (as T3 is more potent/active in the body ). Just after thionamide you give iodine to help decrease TSH release and finally, BB propranol helps with blocking both conversion + control sx palpit/tremors/anxiety. You can also add cholestyramine who binds TSH and is excreted in poop)
Explain management of grave disease
Same first 4 Bs:
- Block TSH synthesis (thionamides)
- Block T4 conversion (propranolol)
- Block TSH release (iodine, used less frequently)
- Beta-blockers
Radioactive iodine ablation
Thyroidectomy
Modifiable/non-modifiable risk factors of thyroid disease:
medication
sedentary
alcohol
smoking
obesity
pregnancy
Non-modifiable: FMHx, PMHx
When do you screen ASYMPTOMATIC for hypothyroidism?
At risk : pregnancy, previous thyroid disease, previous radiation, pituitary/hypothalamus disorder
Taking thyroid replacement
When do you do radioactive iodine uptake? When do you avoid RAIU?
When high TSH is confirmed (do hx + PE and px BBs while sending to scintigraphy) to r/o hot nodule(s).
You DONT for: pregnant or breastfeeding women. (also if 1000% graves like pt has exophtalmia, avoid doing it)
What do you do if there is a thyroid nodule on scintgraphy?
Hot nodule (multigoiter, toxic adenoma) : then surgery
Cold nodule: r/o neo so thyroid ultrasound and per features on US to fine needle aspiration for cytology
IF thyroid nodule
1) TSH + Thyroid US:
2) FNA if:
- >=1cm if hypoechogenic or solid (mostly if irreg, taller than wide, calcifications, extend extra-thyroid)
->=1.5 if isoechogenic or part. cystic with other worrisome features (irreg borders, microcalcifications)
- >=2 if spongiform or part. cystic without worrisome features
No FNA is completely cystic
Differential neck mass diagnosis (acute, subacute, chronic)
Acute: sialadenitis, hematoma, vascular, lymph node
Subacute: sialadenitis, neo
Chronic: carotid body tumor, congenital cyst, goiter, thyroid nodule, goiter, layngocele, lipoma
Next steo = US neck or CT Neck + CT angiography neck (add PET scan of PMHx cancer)
Suicide Risk assessment
- Ask about access to firearms
- SCARED screening tools in adolescent
What is the first thing you should do in a new presentation for anxiety?
Cardiac
Resp
Hormonal
infectious
drug (use or withdrawal)
Other psy: psychosis, bipolar, depression
Risk factors for anxiety
FMHx
PMHX (mood disorder or anxiety)
Adverse childhood experiences
Female
Chronic medical illness
Behavioural inhibition
Management of anxiety (pharmaco)
Anxiety drug classes : benzodiazepines (PRN mostly for panic disorder), SSRIs, SNRIs, buspirone
Also effective for GAD: mirtazapine, sertaline, fluoxetine, buspirone
Off label: MAOI, TCAs, atypical anti-psychotics, anticonvulsants
What are the 5 rules when prescribing benzodiazepines?
Dont combine with opioids
Avoid in high doses
Address fear - always talk about safe storage of medication if pt has children!!!
Consider dependence
Avoid in elderly
Non pharmaco for anxiety
CBT, Mindfulness-based , meditation, aerobic exercise, yoga, tai chi
PST management
SSRI, SNRI
mirtazapine, amitryptiline
CBT
Trauma-focused therapy
Group therapy
INsomnia: prazosin
debriefing of all trauma victims NOT recommended
OCD management
SSRI
CBT
Exposure with response prevention
Trichotillomania and excoriation
SSRI or antipsychotic
N-acetylcysteine
Treat the wound (abx if infx)
Tourette
similar to movements disorder
Risperidone or tetrabenazine
Botox
Habit reversal training
PICA
methylphenidate, olanzapine
treat complications (xray, bezoar?)
Diabetes: DKA 3 sx/signs
Hyperglycemia, ketosis +/- ketonuria, acidosis with anion gap
How do you manage
IVF
Insulin
Potassium
Etiology of DKA
Infection
Infant
Illegal drugs (cocaine)
Iatrogenic (medical like corticosteroids)
Insulin problem (defect, left in hot temperatures)
Ischemia/infarct
Idiopathic
DKA management post resolution
Prevention : vaccination (pneumovax)
Refer: nurse educator, dietitian, endocrinology
Teach: written information
What should you always questions in someone that was newly diagnose or with suspicion of diabetes that you see for the first time?
Symptoms : polyphagia, polyuria, polydypsia, weight loss
End organs: paresthesia, blurry vision, urine changes (polyuria)
Examination and investigation for diagnosis of Db2
Assess retinopathy, renal disease, cardiovascular, neuropathy
HbA1C (individualize target)
Arrange diabetes education (nurse educator, dietitian)
MODY : list 4 elements on history that would make you think of MODY
Onset <30
Not obese
Metformin doesnt help
Hypoglycemias with sulfonylureas
In Db1: weight loss, ketonuria, onset in weeks/days
Explain type 2 diabetes management in stepwise approach
Diagnosis
Lifestyle +/- metformin
2nd OHA (GLP1, SGTL2i, DPP4, sulfonylureas)
- NEW : GIP/GLP1R agonist (tirzepatide)
qHS Basal insulin (10u NPH qHS)
qAM basal insulin
bolus insulin
When is SGLT2 inhibitor contra-indicated?
Type 1 Diabetes
What are side effects SGLT2i
- Normoglycemic DKA
- Drop GFR (10-15% x 3 months)
- Yeast vaginitis/balanitis is common
Benefits of continuous glucose monitoring
type 1: decrease 2% severe hypoglycemia
no benefits type 2
no meaningful improvement in A1C
How do you advise patient who will be driving long hours with their risk of hypoglycemia?
RULE 2-4-6:
1) If pt is hypoglycemia unaware: check gluco q2hrs
otherwise check ever 4hours
2) If low: treat and wait 40min
3) Keep 6 lifesavers candies in the car for hypoglycemias
Name 3 neurological complication of diabetes and their management
Diabetic neuropathy:
- 1st line = TCA, SNRI, NA channel blocker (lidocaine, class IB), gabenpitnoids
- Prevent ulcers/falls
Diabetic amyotrophy:
- Severe neuropathic pain with motor weakness and proximal muscle atrophy + weight loss
- Analgesia, physiotherapy
Gastroparesis
- Prokinetics (mtoclopramide, domperidone), antiemetics
- Stop GLP1
- Look for other diabetic autonomic neuropathies (cardiac, erectile, vaginal dysfunction)
Hepatits: what are the other causes for elevated LFTs?
Investigation for hepatitis:
Hepatic cause:
- HIV, HBV, HCV, syphilis
- Liver Ultrasound
Extrahepatic:
- TSH, anti-TTG (celiac), troponin, cortisol (adrenal insufficiency), CK (myopathy), alpha1 antitrypsin
Explain steatotic liver disease
SLD (previously fatty liver) = umbrella terms for the different ETIOLOGIES:
1) Steatohepatitis (inflammation)
2) Metabolic associated (inflam + cardiometabolic)
3) Metabolic dysfunction associated steatotic liver disease (cardiometabolic risk factors)
4) Metabolic Alcohol associated liver disease (alcohol + cardiometabolic risk factors)
5) Alcohol associated liver disease (alcohol)
SLD is also a spectrum for the evolution of fatty liver disease:
1) Healthy liver
2) SLD (steatosis/fat accumulation) –> reversible
3) Steatohepatitis (steatosis + inflam) –> reversible
4) Cirrhosis (fibrotic scarring)
5) HCC (tumor) –> straight from steatohepatitis too
What is the best treatment for SLD?
Lifestyle
- Exercise
- Weight loss
Uncertain evidence GLP1, SGLT2i, bariatric etc
Not helpful = metformin
How do you manage SLD?
Fib4
- intermediate score = elastography (fibroscan)
- high score = refer
Hepatitis serologies for HBV
- Hepatitis B: HbsAb (anti-HBs), HbcAb (anti-HBc IgM), HbsAg
- anti-HBe present when infectivity is very high
Hepatitis C serologies
anti-HCV, serum HCV RNA, genotype & subtype
Resolution rate of Hep C
Spontaneous recovery in 20-45%
Management Hepatitis
A : supportive care + refer
B: refer hepatology, treat if severe (HBV DNA >2000), tenofovir/entecavir, monitor
C: hepatology, treat if sevre, interferon for treatment
How do you monitor hep B or hep C
hepatocellular cancer: liver US q6-12months
Varices: gastroscopy q1-3years
ETOH: monitor hx
Labs: ALT q 6months
Cirrhosis/fibrosis: fibroscan
Post-exposure prophylaxis hepatitis
Imaging for low back pain?
Not reuired
Management LBP non-pharmaco vs pharmaco
manage mostly with non-pharmaco
meds small benefit
steroids can help if radicular
Non-inflammatory vs inflammatory
Non-inflammatory : AM stiff<30min, worse at the end of the day
Inflammatory: AM stiffnes >30min, better at the end of the day
What are the non MSK causes of LBP you need to think of? Name 3
Stone
Aneurysm
Vascular
Myotomes L1/L2 and L3/4
Myotomes C5/C6 and C7/C8
Dermatomes LBP
Nonpharmaco options for LBP
osteopathy
CBT (chronic)
yoga (strong evidence)
Small benefit of acupuncture
Explain approach monoarthritis
Explain approach to polyarthritis
Explain the 5 common mistakes made during joint disorders investigation/diagnosis
1) Don’t miss alarm features:
- HOT (fever, warm joint)
- BOG (soft, boggy joint)
- AM : stiff >30min
- pain at night
2) don’t miss other causes: lupus, angina, systemic vasculitis, genital infx, TB, epicondylitis
—> in children acute lower extremity pain not due to trauma THINK INFECTION mostly if fever. Do blood culture
3) don’t xray everybody
4) ont mistake/ignore referred pain (knee pain could be because of hip fx)
5) don’t forget to treat the pain while investigating/referring
Four things to remember in autism:
1) review tools: modified checklist for autism in toddlers (revised, with follow up)
2) Refer early: HEARING/VISION assessment, autism clinic, OT, psychology, speech language pathology, pediatrics
3) Rx as needed: melatonin for sleep, could consider pharmacological for constipation or anxiety/depression
- Rule-out:
- global dev delay/intellectual disability
- social communication disorder
- developmental language disorder
- hearing impairment
- epilepsy
- genetic disorder
- anxiety disorder
- OCD
Behavioural Problems
NOT JUST ADOLESCENCE
- Depression/anxiety
- A medical problem
- Bullying
- Abuse
- Witnessing violence
- Substance use
- Peer issues
- Home stressors
Dx of:
- Violation of basic rights of othrs or age appropriate societal norms
- Violence against people/animals
- Running away, rule breaking
- Repetitive and persistent
Conduct Disorder
Dx of:
irritable, defiant, vindictive
Explain treatment
Oppositional defiant disorder
Tx: CBT, family therapy, parent training, social skills training
Do children in oppositional defiant disorder:
- show aggression towards people/animal?
- destroy property?
- habitually lie and steal?
No x 3
Enuresis dos and dont
DO:
- make toilet accessible
- pee before bed
- include morning clean up
- training pants
DONT:
- caffeine/chocolate
- fluid before bed
- punish child
- diapers
What is the management for enuresis (bed wetting) ?
Bedwetting alarms
Desmopressin (short term)
Imipramine (last line)
Look for other causes
management adolescent behaviour change
refer to adolescent psychiatry
List 6 things you can counsel parents when they visit for their toddlers well-baby care visit
HONEY’N’GUNS
HONEY
- No honey before 12 months
- Choking hazards (avoid grapes)
- Vit D for baby and mom
- Button battery (can give honey to slow down injury)
GUNS
- Guns
- Carbon monoxide
- Electric plugs
- Hot water heater
- Car seats
- Medication storage and to know poison control number (1-844-POISON-x)
Couselling stuttering
Males 4x more
90% recover –> reassure
Meds limited evidence
Speech language therapy
Counselling on circumcision, foreskin hygiene, phimosis mangement
No routine circumcision
Don’t force the foreskin, if adherent gently pull back
Phimosis management : 8-10yo topical steroids (bethmetasone), avoid sx
Milestones tricks:
- 2 months “coo coo”
- 4 : months (head steady), years (one fit steady). 4 months grasping object (with 4 fingers)
- 6 : sit at six
- 8 months : pincer grasp (8 la two pincers)
- 1 year: walk, one word
- 2 years: run, 2 word sentence, 2 step direction
- 3 years: 3 step directions, 3 words sentence
Pregnancy immunisation:
- TDaP each pregnancy (27-32wks)
3 vaccines cannot do during breastfeeding
BCG, japanese encephalitis, yellow fever
Who needs meningitis c vaccine?
Travelers (Hajj = mandatory, belt of africa)
Military recruits
Asplenia & sickle cell
ALL canadian adolescents (12yrs)
Who should receive flu vaccine?
> 6 months in children
65yo
High risk adults (neuro/neurodev conditions, work in health care, working with poultry, withing 30 days of MI)
WITHIN 30 DAYS OF MI
Counselling anti-vaccine
Dont: find another doc
DO: emphasize safe to vaccinate, danger in not vaccinating, pain can be reduced
How to prevent pain during vaccine for kids:
Dont aspirate
Most painful LAST
Breastfeed, hold babies (skin to skin)
topical anesthetic
oral sugar
Manage fear with CARD
Comfort
Ask questions
Relax
Distract
Managing vaccine fears and phobias
Comfort
Ask questions
relax
distract
Explain contraindications to vaccines
MIld illness is not a contrindication.
Nasal congestion then delay Live Attenuated Intranasal Vaccine
At the end of my exam, I should take a moment to remember if I forgot anything like:
HIV
Pain
Abuse
BHCG
Bugs
Suicide
Tetanus
Harm
Guns
Manage common cold:
zinc sulfate IS NOT INTRANASAL
PHARYNGITIS hx/score
CENTOR SCORE
Sinusitis
PODS
Pain - facial pain/pressure/fullness
Obstruction (Nasal)
Discharge
Smell (lack of)
Sinus alarm features + DOs/DONts
Do: if bacterial tx with amoxicillin 5-7days, nasal rinse, intranasal steroids, decongestants, analgesics, anti-inflammatories
DONT: nasal culture, dont treat if suspicion viral, NO IMAGING UNLESS RED FLAGS
Recognize MONONUCLEOSIS
ELEVATED LYMPHOCYTE COUNT not WBC so for investigation say Lymphocyte Count
NO SPORT at least 3 WEEKS –> splenomegaly in 50%, can last up to 8 weeks
Neonatal resuscitation first steps
1) tone, tears, term then
2) Dry, stimulate, warm, limit suction. Consider skin to skin.
3) PPV (20-30breaths/min) if apnea/gasping/HR<100 / CPAP if just cyanosis/laboured breathing + O2 monitoring for both, consider ECG monitoring if HR<100
4) Reassess after 30s
A) if HR<100, go through MR SOPA:
- Mask adjustment
- Reposition airway
- Suction
- Opening mouth
- Pressure (increase)
- Advanced airways
B) if HR<60, intubate then compression (3 compression for 1 ventilation)
- consider urgent UCV access
5) Reassess after 60 seconds, if HR still <60 then IV epinephrine (0.01mg/kg IV)
Don’t miss on baby exam:
Pediatric LIMPS etiologies
Never forget abuse
INjuries suggestive of abuse
Remember to look for PATTERNED BRUISING
Bruising on torso, ears, neck is suspicious
4 months or younger is suspicious
Constipation management
r/o abuse
Reflux in infants - management
Reflux in children
What are the red flags of puberty onset?
Red flags in fever
THINK KAWASAKI
- mucocutaneous lymph node syndrome
- major complication (coronary artery aneurysm –> if you CRASH, call the CAA)
- Treat with ASA, IVIG, Steroids
Name common palliative concerns
Calculate sensitivity, specitiy, PPV, NPV
SPecificity rules IN (SPIN)
SeNsitivity rules OUT (SNOUT)
ADHD med classes
EKG before starting
Consider atomoxetine or guanfacine is worried about diversion (non-psychostimulant)
Consider DATR before changing dose
Dose - increase
All- try all 1st line
Time - give enough time to response + side effects to resolve
Examine - what are the targets what standardized measures
Review - comorbidity, lifestyle
Treatment for latent TB
rifapentine + isoniazid
2 traditional medication treatment to discuss:
Cupping may have benefit for acne, pain, facial paralysis
Symptoms neuroleptic malignant
Treatment
benzo + dantrolene + bromocriptine
Name 5 ddx for pneumonia
Pneumocystis Jirovecii Pneumonia –> ALWAYS THINK HIV
IF THINK HIV then think HCV and TB
Hypertension - secondary causes
Hypertension - lifestyle management
Hypertension - treshold and target
High risk = CAD or risk >=15%, CKD, >=75
Advice for sodium, weight, alcohol exercise, diet, relaxation:
What substances could impeded the action of anti-hypertensive medications?
Hypertensive urgency vs emergency
Emergency also if asymptomatic but dBP>=130
Also consider pheochromocytoma and pre-eclampsia as hypertensive emergency
Hypertension in pregnancy - avoid, aim and acceptable rx in breastfeeding
Hypertension in children:
when do you measure?
Which arm should you check and why?
Workup if BP elevated?
HTN if >99percentile
Associated sx of vertigo
Name 4 elements on the vertigo exam
Head Impulse, Nystagmus, Test of Skew PLUS hearing loss
but ONLY for ongoing constant vertigo and nystagmus at rest NOT for BPPV
Dix-Hallpike if vertigo <2min & no nystagmus at rest
5 DONT in hyperlipidemia guidelines
Lipoprotein A once in a lifetime for everyone
- non-HDL C or apo-B preferred over LDL-C when TG>=1.5
Framingham risk score elements
calculate q5yrs
Non-pharmaco management
Pharmaco management
Statins then exetimibe
Statins in the elderly, should you give them?
Algorithm to diagnose CKD
How do you manage CKD
What are the 3 pillars of CKD management
What medication should a pt with CKD stop during a sick day/risk dehydration?
3 types of AKI
Explain the AKI spectrum (RIFLE)
AKI = eGFR decreasing otherwise AKD
First steps in managing AKI stop + star
How do you manage every acute situation?
usually ABC already done in SAMPs/SOOs so need to do something else
if not sure what to do rpt (serial) abc/vitals/ecg
How do you deprescribe PPI
1) Discontinue/taper down
2) Step down to histamine-2 receptor antagonist (ranitidine, famotidine)
3) Reduce: switch to PRN or lower the dose
How do you manage acute UPPER GI bleed
You want to decrease the stomach content by:
1) Decrease acid –> PPI bolus (for non-variceal bleeding, since variceal bleed are due to hepatic portal hypertension and not to stomach erosion/ulcers like nv bleeding)
2) Decrease the blood out of the stomach –> causing diarrhea helps stomach emptying –> ERYTHROMYCINE
3) If variceal bleed: ceftriaxone + somatostatin
4) No benefit of tranexamic acid and might increast VTE
Management of anal fissure
New suicide risk factors
THINK OF SANTA CLAUSE
PRECIPITATING FACTORS:
- drugs/ETOH (snow moutain cocaine)
- Access to means (toy guns)
- Life events (Mrs clause left him)
- New terminal/chronic disease (travels everywhere has all tropical disease)
- Media effects
PREDISPOSING FACTORS
- neuropsych disorders (talks to rudolph)
- FMHx (previous santas)
- previous attempt (always on the roof)
- Adverse childhood experiences (never had toys himself)
- Socioeconomic status (how does he afford making all the toys)
Depression management
1st line = CBT, interpersonal therapy, Behavioural activation
Recommended CBT or IP + antidepressant (escitalopram, mirtazapine, paroxetine, venlafaxine, amitriptyline = most effective)
2nd line = SSRIs, SNRIs or TCA aaaannd alpha-2 antagonist (mirtazapine, trazodone)
How do you choose the correct antidepressant for your patient?
Adverse effects, cost and other considertions
What antidepressants are most likely vs least likely to cause headaches?
How long do you wait before increasing/changing?
Risk factors of self-harm in teenagers
increases risk suicide
Question to quickly rule out anxiety
mania
OC
delusion
hallucinations
dont forget to ask for SI/plan
Bipolar II first line therapy
Pharmacology for bipolar disease acute vs maintenance
Elements in history that should orient you towards bipola
When do you transfuse in case of anemia and what should you do next?
HB<70 (80 if CAD) and symptomatic
Don’t just treat, FIND THE CAUSE
Acronym for empathetic statements
Managing symptoms of withdrawal
Name 3 contra-indication for cannabis
What should you limit in difficult patient?
Describe cluster A personality and treatment for each
shizotypal (willy wonka)
schizoid (gollum)
Describe cluster B personality and treatment for each
antisocial (hannibal, joker)
Describe cluster C personality and treatment for each
Treatment of alopecia areata
Social consequence: hairpiece, wigs
Immunotherapy
New tx : jak inhibitors
Explain Eczema coxsackieum
in differential, try to always name a new red flag
Treatment rosacea
If persistent try oxymetazoline, brimonidine gel, paroxetine
Persistent w/ telangiectasia –> laser
Eczema
Non-pharmaco tx, suggest more frequent showers = 30% improvement.
NEVER MISS THIS RASH –> what is the one question you should ask?
Travel history –> tick bite eschar
Nail fungal tx
ONYCHOMYCOSIS
CONFIRM it’s fungal before treating as fungal
Tx : terbinafine x 12 weeks –> monitor liver function with AST/ALT/ALP/GGT/bilirubin
Seborrhea treatment
General risk factors to think of for any condition.
Obesity is protective for osteoporosis
New guidelines screening by CTFPHC
We are basically screening who needs more than vitD + calcium, therefore:
1) Assess FRAX
2) BMD if patient interested in receiving medication if high risk.
Osteoporosis Canada guidelines (differ from CTFPHC)
1) Non-pharmaco prevention of osteporosis for every man >=50yo and post-menopausal women : balance, muscle strenghtening >=2/wk, Diet rich in calcium and protein and vit D 400IU daily
2) Screen risk factors + signs possible vertebral Fx
Offer BMD to everyone >=7o regardless of risk fathers, otherwise:
- 50-64 need >=2 RF
- 65-69 need 1 RF
Then NO rx if 10yr fx risk <15%, 15-19.9% <70yo SUGGEST rx, >=20% >=70yo RECOMMEND rx
3) If previous hip/spine Fx or PMHx >=2 Fx –> recommend Rx
Investigation in osteporosis
Goal is to look for 2nd causes
What are side effects for 1st line treatment of osteoporosis
Bisphophonates (1st line unless high risk) : esophageal ulcer, jaw osteonecrosis, increased atypical fractures
Raloxifene : VTE, PE
HRT: PE, DVT, stroke, breast cancer, liver disorder
Name disability supports
1) Disability tax benefit
2) Canada pension plan-disability (mental or physical, prolonged and prevents ANY work)
3) registered disability savings (only if eligible disability tax credi, max ag 59, not taxed on withdrawal(
What should you look for in development disease?
Ensure capacity for voluntary & informed consent + vision/hearing impairment + dental disease
HIV is not considered a chronic disease because of the high mortality rate. True or false?
False.
What are the medication complications of HIV medication?
What other chronic conditions should you screen for in HIV?
Name 2 anti-retrovirals used in HIV./
What are the 3 questions you should ask for in context of chronic disease mostly in SOOs?
Also ask:
is there complaint related to the disease or the medication (side effect, adverse rx, compliance) ?
ALSO THINK SANTA - lots of chronic disease (db, ETOH, etc) = suicide risk
Name the safety R.I.S.K.S
CFP Frail elderly check list (name 6) and what is missing on this list (name 6)
Cognition
Mobility
Ulcers
Pain
Med check
Rx monitoring (lithium)
Management of nocturia per underlying cause
What are the 5 ways to suddenly improve function in elderly
Glasses dont screen in your clinic, do annual optometry screening
In elderly, questions function beyond MRS SWELP$, think D.E.A.T.H for ADLs
very important to know Activities of daily living (ADL)
List independent ADL (iADLs), think SHAFT
independant activities of daily living
Anytime you assess medication what should you question?
What is the one medication you should be wary of in elderly?
benzodiazepines
Identify the 4 types of elder abuse
A woman presents with acute unilateral leg swelling and pain. You suspect DVT. While investigating her condition, how do you assess if you should start her on VTE prophylaxis?
Improve VTE calculator
Main causes blood diathesis
Main causes thrombophilia
What is disseminated intravascular coagulation (DIC)?
Underlying condition (sepsis, trauma, cancer) triggering widespread clotting causing a decrease in platelet factors and thus inducing a bleeding disorder 2nd lack of available resources to form clots.
Called a consumptive coagulopathy (Plt and clotting factors are consummed).
Name 4 conditions causing pupura in adults and 4 conditions causing purpura in children.
Meningoccemia : N meningitis creates purpura by releases endotoxins targeting endothelial walls + can trigger DIC.
