Shared Flashcard Set

Details

Family Medicine
Family medicine clerkship
166
Medical
Professional
10/01/2012

Additional Medical Flashcards

 


 

Cards

Term
What physical exam finding is suggestive of hypertrophic cardiomyopathy?
Definition
  • Systolic murmur that increases in intensity when the patient is standing and also with the Valsalva maneuver (decreased ventricular filling, increased obstruction).
  • This contrasts with most fxnal outflow murmurs that decrease in intensity when standing up or doing Valsalva.
Term
Murmurs that should be referred to a cardiologist  (6)
Definition
  1. any murmur of III/VI or greater
  2. diastolic murmurs
  3. holosystolic
  4. continous
  5. murmur that increases in intensity with valsalva or standing
  6. signs of Marfan's syndrome (arachnodactyly, tall-thin, arm span greater than height, pectus excavatum, high-arched palate).
Term
What vaccines should be offered at the pre-adolescent visit (11-12 yo)?
Definition
  • Tdap (adult series, q10 yrs starting @ age 11)
  • meningitis: MCV4. 11/12 with booster at 16.
  • HPV
  • "catch-up" immunizations, VZV if never had chickenpox.
Term
How are echocardiography and electrocardiogram useful in the diagnostic work-up of HCM?
Definition
  • Echocardiography is the study of choice for the dx of HCM
  • Note: electrocardiogram is abnormal in >90% of patients with HCM, and is thus a good screening test. Electrocardiogram should be done in anyone that has syncope (r/o arrhythmic d/os like prolonged QT).
Term
psychosocial issues to address with adolescents
Definition
  • HEEADSSS
  • Home
  • Education/employment
  • Eating 
  • Activity
  • Drugs
  • Sex
  • Suicide/depression
  • Safety/violence
Term
Differential Dx of acute leg pain and swelling (5)
Definition
  1. Superficial thrombophlebitis - very common (VC)
  2. Trauma - fx, muscle tear, hematoma (VC)
  3. Cellulitis - Group A Strep or Staph. (VC)
  4. Dermatitis (VC)
  5. DVT - uncommon
Term
Differential Dx of chronic leg pain and swelling (5)
Definition
  1. Chronic venous insufficiency (VC)
  2. CHF - uncommon  (UC)
  3. Pretibial myxedema - hypothyroidism, nonpitting (UC)
  4. Hypoabluminemia (rare) - pitting edema
  5. Postphlebitic syndrome (UC)

Note - chronic causes are usually bilateral vs. unilateral

Term
First step in evaluation a patient with sx of DVT
Definition
  • Apply Wells Clinical Decision Rule to evaluate the probability of DVT (low, moderate, or high risk - 3,17, 75%) using signs and sx from the H&P.
Term
How is D-dimer used in evaluating pts at risk for DVT? (2)
Definition
  • Useful for ruling out DVT in low-risk patients. (If positive, then do US).
  • Useful in patients with moderate or high risk and a normal duplex ultrasound result. 
Term

A patient with moderate risk has a normal ultrasound and positive D-dimer. What is the next step?

What if the patient had a positive US?

Definition
  • Follow up studies: 2nd ultrasound in 7 days or venography.
  • If US is positive in a patient with moderate or high risk, treat for DVT.
Term
What is the standard of care for patients with uncomplicated venous thromboembolism with a clear provoking factor (ex. immobility)?
Definition
  • anticoagulation with LMW heparin followed by at least 3 months of warfarin
Term
4 types of pharmacological tx of allergic rhinitis
Definition
  1. antihistamines - good for pts with mild & intermittent sx
  2. decongestants
  3. intranasal corticosteroids
  4. systemic corticosteroids
Term
nasal decongestants - example, route, mechanism, adverse effects
Definition
  • ex: pseudoephedrine
  • can give orally or intranasally
  • agonist of alpha receptor - constricts blood vessels in nasal mucosa and reduces overall volume of nasal mucosa
  • oral decongestants can cause tachycardia, tremor, insomnia
  • nasal decongestants - can have rebound hyperemia or worsening of sx with chronic use or upon discontinuation
Term
nasal corticosteroid sprays to treat allergic rhinitis -indication? mechanism? Adverse effects? Time to achieve max effectiveness?
Definition
  • first line tx for longterm management of mild to moderate persistent sx
  • reduce production of inflammatory mediators and recruitment of inflammatory cells
  • Systemic absorption is low. 
  • Side effects; nosebleeds, pharyngitis, URT infxns.
  • Max effectiveness after 2-4 wks of use
Term
leukotriene inhibitors - examples (3), indications
Definition
  • zafirlukast, montelukast, zileuton (all oral, Rx)
  • used for both allergic rhinitis and maintenance therapy for persistent asthma
  • Esp useful in pts with both asthma and allergies or in those whose asthma may be triggered by allergens
  • NOT proven to be superior to nasal corticosteroids alone.
Term
systemic corticosteroids - when are they used? adverse effects?
Definition
  • used only for severe cases, in lowest effective dose, for shortest period possible
  • Adverse effects: suppression of HPA axis, hyperglycemia. With long-term use: peptic ulcers, immunosuppression, reduced bone density
Term
Desensitization therapy - indications, process, adverse effects
Definition
  • attempted in pts who remain symptomatic despite maximal medical tx
  • specific antigens to which pt is allergic are identified and highly diluted concentrations are injected, gradually increasing the concentration over time.
  • May have severe (even anaphylactic) reactions
Term
Manifestations of anaphylaxis (5)
Definition
  • hypotension/shock d/t widespread vasodilation
  • respiratory distress from bronchospasm or laryngeal edema
  • GI and uterine muscle contraction
  • urticaria (pruritic wheals)
  • angioedema (painless sub-q swelling, often in face).
Term
What should be done when anaphylaxis is first suspected? What do you do next?
Definition
  • Subcutaneous or intramuscular injection of aqueous epinephrine 1:1000. 
  • Dose: 0.2-0.5 mL.
  • Repeat injections can be given evey 15-30 min if needed.
  • Ensure ABCs (IV fluids, intubation, etc when necessary)
  • Monitor patient for a period of time
Term
4 components of management of allergic rhinitis
Definition
  1. patient education
  2. allergen avoidance
  3. pharmacologic management
  4. immunotherapy
Term
Chronic bronchitis - definition
Definition
cough and sputum production on most days for at least 3 months during at least 2 consecutive years
Term
emphysema - definition
Definition
SOB caused by enlargement of the respiratory bronchioles and alveoli caused by destruction of lung tissue
Term
medical management of exacerbations of asthma or COPD (3 components)
Definition
  1. oxygen
  2. bronchodilators (fast acting)
  3. steriods (effect takes hours to occur)
Term
Main etiologies of COPD (2)
Definition
  1. cigarette smoking (MC) - associated with 90% of COPD cases
  2. genetic alpha-1-anti-trypsin deficiency - more common in Caucasians; consider when COPD develops before 45 yo, esp in nonsmokers.
Term
Most common initial symptom of COPD 
Definition
  • Cough - often productive of thick, white mucus 
  • may have intermittent exacerbations due to infxns (cough worsens, green/yellow mucus)
Term
How does symptomatic COPD correlate with pulmonary function?
Definition

By the time sx develop, the patients FEV1 will be reduced by ~ 50%. 

Term
What are the FEV1 and FVC in patients with COPD? How is "reversibility" defined?
Definition
  • COPD pts have a decreased FVC, FEV1, and FEV1:FVC ratio.
  • FEV1:FVC < 0.7 in patients with COPD, indicating airway obstruction.
  • Reversibility is defined as an increase in FEV1 of >12% or 200 mL. 
Term
Tx recommendation for patients with any stage of COPD (3)
Definition
  • Smoking cessation - smoking cessation does not result in significant imporvement in pulm fxn, but it reduces the rate of further deterioration.
  • Vaccinations: pneumococcus, influenza
  • Exercise & maintain normal body weight
Term
Stage 0 COPD 
Definition
  • person is at risk (smokes, chemical exposure)
  • cough, sputum production
  • spirometry normal
Term
 Stage I COPD - definition, tx
Definition
  • mild
  • FEV1/FVC < 0.7
  • FEV1 ≥ 80% predicted
  • with or without sx
  • tx: shortacting bronchodilators: mainly beta agonists (albuterol), also anticholinergics (ipratropium). Inhaled is preferred over oral d/t fewer SE. 
Term
 Stage II COPD - definition
Definition
  • moderate COPD
  • FEV1/FVC <0.7
  • FEV1 is 50-80% of predicted
  • with or without sx
Term
 Stage II COPD - tx
Definition
  • add long-acting bronchodilators; short-acting agents still used as rescue-therapy in exacerbations
  • long acting include: salmeterol (inhaled beta agonist) and tiotropium (inhaled anticholinergic)
  • Oral methylxanthines (theophylline) may be used but have narrow therapeutic windows and more drug-drug interactions. 
Term
 Stage III COPD - definition, tx
Definition
  • severe COPD
  • FEV1/FVC<0.7
  • FEV1 is 30-50% of predicted
  • with or without sx
  • tx: inhaled steroids
Term
 Stage IV COPD - definition, tx
Definition
  • very severe COPD
  • FEV1/FVC<0.7
  • FEV1<30% predicted
  • FEV1 >30% predicted, but with chronic hypoxemia
  • tx: inhaled steroids, O2 therapy if there is hypoxemia, consider surgical interventions
Term
Why are inhaled steroids only used in stages III & IV COPD with frequent exacerbations?
Definition
  • Inhaled steroids (fluticasone, triamcinolone, mometasone, etc) do not affect rate of decline of lung fxn in COPD, but they reduce frequency of exacerbations.
  • Long-term tx with oral steroids is NOT recommended.
Term
Use of oxygen therapy for Stage IV COPD
Definition
  • Oxygen therapy is the only intervention that has been shown to decrease mortality
  • Must be worn for at least 15 hours/day.
  • [O2 saturation should be >90% or PaO2 >60)
Term
Cor pulmonale - definition
Definition
R. heart failure d/t chronically elevated pressures in the pulmonary circulation. Sx: JVD, liver congestions, lower extremity edema. 
Term
Microscopic hematuria - definition
Definition
  • presence of 3 or more RBCs/high power field on 2 or more properly* collected urinalyses.

*Properly collected: important to instruct pts on proper technique for "clean catch" urine sample to reduce the # of FP findings.

Term
Work-up of asymptomatic microscopic hematuria
Definition
  1. Check for risk factors (H&P)
  2. Repeat urinanalysis. If still shows RBCs, then:
  3. Imaging of urinary tract to evaluate for malignancy AND
  4. Perform urine culture to check of infxn.
Term
Common ways of imaging the urinary tract (upper and lower)
Definition
  • Upper (kidneys & ureters) - IVP or CT scan
  • Lower (bladder and urethra)  - cystoscopy
Term

How to differentiate hematuria with glomerular vs.

renal (nonglomerular) vs. urologic origin

Definition
  • Glomerular: proteinura, dysmorphic RBCs, RBC casts.
  • Renal (nonglomerular): proteinuria, no dysmorphic RBCs or RBC casts
  • Urologic: hematuria with out proteinuria, dysmorphic RBCs, or RBC casts. 
Term
What test helps differentiate hematuria due to glomerular disease vs. that due to interstitial nephritis?
Definition
Urinary sediment: check for red cell casts and dysmorphic RBCs (glomerular) and for eosinophils (interstitial, often caused by analgesics/ other drugs).
Term
Asymptomatic microscopic hematuria: If thorough work-up is negative, what is the next step?
Definition
  • Follow up bp measurements, UA, and voided urine cytologic studies at 6, 12, 24, and 36 months in case there is an underlying lesion.
  • If work up remains negative for 36 mo, no further f/u is necessary. 
Term
Substance abuse: how much does genetic susceptibility account for one's predisposition to substance abuse? 
Definition
Genetics accounts for 40-60% of a person's vulnerability to addiction.
Term
what populations are at increased risk for substance abuse? (2)
Definition
Adolescents; People with h/o psychiatric d/o
Term

Dyspepsia - what "alarm symptoms" should prompt the clinician to do an early endoscopy as part of the workup?

(9) 

Definition
  • unintentional weight loss
  • progressive dysphagia
  • odynophagia
  • recurrent vomiting
  • unexplained anemia
  • GI bleeding/hematemesis
  • FHx of CA, esp upper GI CA
  • H/o of gastric surgery 
  • jaundice
  • Esp. in pts >55 yo or >45-50 yo and of Asian, Hispanic, or Afro-Caribbean descent
Term
Are gastric or duodenal ulcers more common?
Definition
Duodenal ulcers are more common overall. Gastric ulcers are more common in NSAID users.
Term
Risk factors for developing PUD (5)
Definition
  • H. pylori infxn (present in 48% of cases)
  • NSAID use
  • Cigarette smoking
  • Personal of family h/o PUD
  • Race: more commin in Blacks and Hispanics
Term
PUD - common sx (4) 
Definition
  • epigastric pain that improveswith ingestion of food 
  • pain develops a few after eating
  • nocturnal pain
  • OTC antacids provide some relief
Term
PUD - what is the preferred, non-invasive office test for detecting H. pylori? What is an alternative? What is the "gold standard" for diagnosis of H. pylori infxn?
Definition
  • Preferred office test = stool antigen testing. For test to be accurate, pt must take no PPIs 2 weeks prior to testing.
  • Alternative = serologic testing of H. pylori Abs (serum IgA ELISA). Does  not distinguish active infxn from treated infxn. Follow with urea breath test to determine presence of active infxn. 
  • gold standard = endoscopy with biopsy testing for H. pylori
Term
PUD - tx regimens (general idea, specific examples)
Definition
  • Overall - give mutliple abx plus PPI
  • ex. of triple therapy: omeprazole (PPI), clarithromycin, and either amoxicillin or metronidazole (if pt is allergic to PCN)
  • ex. quadruple tx: omeprazole, bismuth subsalicylate, metronidazole, tetracycline.
Term
What is the most effective primary prevention in children?
Definition
Immunizations
Term
Health maintenance visits - 4 main areas (RISE)
Definition
Risk assessment, Immuinzations, Screening, Education
Term
According to the CDC recommendations, who should get tested for HIV?
Definition
HIV testing should be universal for everyone ages 13-64. (Note: the USPSTF rates this as a "c" recommedation)
Term
What are the cut-offs for a + screen for DM? (fasting glucose and A1c)
Definition
  • Fasting glucose > 126 is positive.
  • A1c > 6.5 is positive.
Term
What is the best predictor of low bone mineral density? What is the best predictor of hip fx?
Definition
  • Best predictor of low BMD =low body weight (2nd = low ER)
  • Best predictor of hip fx = DEXA sca of femoral neck
Term
When should men and women be tested for hyperlipidemia?
Definition
  • Men begin at age 35
  • Women begin at age 45
  • If pt has risk factors (smoking, DM HTN, FHx) start earlier.
  • Screen q5 years if results are normal.
Term
Top 3 causes of death for 1) 25-44 yo, 2) 45-64 yo, 3) 65 and older
Definition
  • 25-44: 1)unintentional injuries, 2)CA, 3) heart dz
  • 46-64: 1)CA, 2)heart dz, 3)injuries
  • 65+: 1)heart dz, 2)CA, 3)cerebrovascular dz
Term
BPH - risk factors that predict progressive BPH (4)
Definition
  • change in size and force of stream
  • sensation of incomplete emptying
  • enlarged prostate on DRE
  • advancing age
Term
Work-up for suspected BPH
Definition
  • Start with UA
  • If UA shows RBCs: consider cystoscopy (CA)
  • If UA shows WBCs: consider cystitis or prostatits infxn.
  • Optional tests: urine cytology (bladder CA), PVR volume (>350), max urinary flow rate
Term
Medical tx of BPH (2) and gold standard surgical tx
Definition
  • alpha blockers (doxazosin, tamsulosin) are 1st line. They treat the dynamic component of urinary obstruction.
  • 5-alpha-reductase inhibitors (dutasteride, finasteride) - Only helpful if prostate is enlarged
  • The 2 have synergistic effect when prostate is enlarged.
  • gold standard surgical tx: transurethral resection of prostate (TURP)
Term
Acute prostatitis - cause, prevalence, sx, physical exam, labs, tx.
Definition
  • Usually d/t ascending UTI
  • Least common type of prostatits
  • Sx: urinary sx and perineal/pelvic pain, fever
  • PE: tender, boggy prostate on DRE
  • labs: UA (WBCs) and urine culture
  • Tx: abx (TMP-SMX or fluoroquinolone) for 4-6 wks and NSAIDs for pain
  • Can become septic --> hospitalize.
Term
Chronic bacterial prostatitis - sx, PE, labs, tx
Definition
  • Sx: gradual onset of mild-modersate urinary sx with or without h/o acute prostatitis. Low back pain, perineal pain, painful ejaculation or hematospermia
  • PE: minimally tender or normal DRE
  • labs: UA is consistent with UTI. Do urine culture.
  • Tx: TMP/SMX or fluoroquinolone for 6-12 wks.
Term
Chronic abacterial prostatitis/chronic pelvic pain syndrome - prevalence, sx, labs, tx
Definition
  • MC prostatitis syndrome
  • Sx are similar to chronic bacterial prostatitis, but no known source of infxn.
  • UA is not consistent with UTI.
  • Tx - alpha blockers, NSAIDs for 6 mo.
Term
prostate CA risk factors (4)
Definition
  • Age: rare before 45 yo. 
  • Race: more common in AA
  • Genetics: patients with 1st degree relatives have 2x risk; BRCA may increase risk
  • Diet: high in animal fat or low in vegetables increases risk. 
Term
Pneumococcal conjugate vaccine (PCV13) vs. pneumococcal polysaccharide vaccine (PPV)
Definition
  • PVC13 - can give to kids < 2yo
  • PPV - give to ages 2 and up.
Term
Gross hematuria in 50 yo male: #1 on ddx?
Definition
Cancer until proven otherwise!
Term
What risks are increased with protein undernutrition in the elderly? (4)
Definition
  • Have increased risk of:
  • infxn
  • anemia
  • orthostatic hypotension
  • decubitus ulcers
Term
Causes of vision loss in the elderly? (5) Which is most common among elderly in US? Which is most common cause of severe vision loss in elderly in US?
Definition
  • presbyopia 
  • ARMD - leading cause of severe vision loss in elderly
  • glaucoma
  • senile cataracts - MC cause of blindness worldwide
  • Diabetic reitnopathy
Term
What is presbycusis?
Definition
  • Age-related sensorineural hearing loss.
  • MC form of hearing loss in the elderly
  • Selective high frequency loss and difficults with speech discrimination 
  • Dx of exclusion
  • Hearing aids helpful
Term
2 biggest risk factors for stroke in elderly 
Definition
  1. HTN
  2. A fib
Term
What should the work-up for a child with HTN always include?
Definition
  • Work-up should looking for renal parenchymal dz: UA, urine culture, renal ultrasound.
Term
4 components of Metabolic Syndrome
Definition
  • Abdominal obesity - waist circumference>40" in men or 35" in women OR waist:hip ratio>0.9 in men or 0.85 in women.
  • Dyslipidemia - defined as TG of 150 or more, HDL<40 in men or <50 in women
  • bp above 130/85
  • fasting glucose of 100 or more
Term
What additional lab work should be done in routine care of obese pts? (4)
Definition
  • fasting blood sugar
  • lipids
  • TSH
  • liver enzymes
Term
Which patients qualify for bariatric surgery?
Definition
  • Pts with BMI>40 who failed diet/exercise (with or without meds) OR
  • pts with BMI>35 with comorbidities.
Term
Who should be screened for hyperlipidemia? How often?
Definition
  • Everyone >20
  • q5 years (if no risk factors present)
Term
5 risk factors that are considered when determining LDL goal (in addition to CHD or CHD equivalents)
Definition
  1. cigarette smoking
  2. HTN (140/90+) OR pt taking antihypertensive agent
  3. low HDL (<40) [*HDL of 60 or more is negative RF]
  4. FHx of premature CHD (male 1st-degree relatives 55 or younger, females 65 or younger).
  5. Age - 45 and above for males, 55 and above for females
Term
How is "CHD risk equivalent" defined? What are some examples?
Definition
  • A  CHD risk equivalent indicates the risk of CHD is 20% or greater within 10 years.
  • Ex: atherosclerotic dz (AAA, peripheral artery dz, CVA); T2DM
Term
What is the LDL goal for someone with CHD or a CHD risk equivalent? What about pts at "VERY high risk"? What pts are at "very high risk"? (4)
Definition
  • LDL<100 mg/dL
  • Start meds at 130 (before meds do lifestyle changes, meds optional for 101-129)
  • Optional LDL goal for pts at very high risk is < 70. 
  • "very high risk" = pts with CHD AND either multiple risk factors (esp DM), poorly controlled risk factors (smoking), multiple traits of metabolic syndrome, or acute coronary syndrome.
Term
What is the LDL goal for someone with 2 or more risk factors?
Definition
  • Must do invididual risk assessment (using individual risk assessment calculator). Then:
  • if risk is 10-20% (intermediate) goal is 130 or less. Would start meds at 160.
  • if risk is 20% or more: LDL goal<100 (start meds at 130)
Term
What is the LDL goal for someone with 0-1 risk factors?
Definition
  • Goal is <160
  • Start meds at 190
Term
What is unique about metformin as an oral medication for DM?
Definition
  • Metformin CANNOT cause hypoglycemia! It decreases glucose synthesis via hepatic gluconeogensis. Has been shown to result in evidence-based decrease in M&M.
Term
What lifestyle and dietary changes are recommended as the first step for lowering cholesterol? (4)
Definition
  • Increase physical activity
  • Stop smoking
  • Diet: limit saturated fats to less than 7% total calories, limit cholesterol intake to less than 200 mg per day
  • Addition of dietary soluble fiber (10-25mg) and plant stanols/sterols (2g)
Term
What are the side effects of statins (3)? How should these be monitored in pts?
Definition
  • SE include myopathy, myaglia, and increased liver enzymes
  • Pts that are taking statins must have LFTs monitored - initially q 6-12 weeks, later q 16-12 months).
Term

What is the 1st line medication for lowering LDL?

Which medications (2) are most effect for lowering TG and raising HDL?

Definition
  • 1st line med for lowering LDL: statin
  • Best for lowering TGs and raising HDL: nicotinic acids (niacin), fibric acids (gemfibrozil, fenofibrate)
  • (Niacin somewhat more effective than fibrates for HDL. )
Term
Categories of etiologies of dyspnea (4)
Definition
  • cardiac (ex. CHF)
  • pulmonary
  • hematologic (anemia)
  • psychogenic (panic disorder)
Term
4 common findings in COPD on physical exam
Definition
  • wheezes
  • increased AP diameter
  • decreased diaphragmatic excursion
  • prolonged expiratory phase
Term
Common findings in CHF on physical exam (6)
Definition
  • pulmonary edema evidenced by inspiratory crackles and/or dullness to percussion
  • JVD
  • S3
  • PMI diffuse and laterally displaced
  • peripheral edema
  • hepatojugular reflex
Term
What are indicators for prescribing abx to a pt with acute exacerbation of COPD? (3)
Definition
  • acute worsening of dyspnea
  • change in sputum color
  • increased volume of sputum
Term
How might one distinguish peripheral vs. central etiologies of vertigo?
Definition
  • Peripheral etiologies often will have:
  • unidirectional nystagmus that resolves with gaze fixation 
  • the nystagmus does not change direction
  • + head thrust test
Term
What 3 peripheral causes of vertigo, and how can they be differentiated from one another?
Definition
  • BPPV - vertigo occurs with changes in position and not constant
  • vestibular neuritis - vertigo not position-dependent; may follow URI
  • Meniere's dz - vertigo accompanied by hearing loss & tinnitus
Term
What are 1st and 2nd MC causes of vertigo in primary care?
Definition
  • #1: BPPV (Dix-Hallpike)
  • #2: vestibular neuritis (or acute labyrinthitis)
Term
4 Treatments of peripheral vertigo
Definition
  1. diuretics, low salt diet - Meniere's dz (inconclusive evidence)
  2. Epley maneuvers (canalith repositioning) - main tx for BPPV
  3. Vestibular rehabilitation (PT)
  4. Vestibular suppressant medications: anticholinergics like meclizine and dimenhydrinate, anti-emetics: metoclopromaide, promethazine
Term
2 Treatments for Primary Insomnia that have been proven to be efficacious in the elderly
Definition
  • CBT = best tx, particularly sleep restriction/sleep compression therapy.
  • Zolpidem
Term
Tx of GAS pharyngitis  (3 abx)
Definition
  • cephalosporin for 7-10 d
  • penicillin VK 250 mg PO QID for 10 d
  • amoxicillin 1g PO BID for 6 d
Term
What unique symptom is seen in atypical pneumonia caused by legionella? What is the tx of pneumonia d/t legionella?
Definition
  • diarrhea
  • Tx: erythromycin
Term
What organism commonly causes secondary pneumonia in pts with influenza? What is the tx?
Definition
  • Staph aureus
  • erythromycin
Term
What is the tx for MRSA? What is the tx for pneumonia caused by: H. influenza? strep pneumo?
Definition
  • MRSA - vancomycin
  • H. influenza - cefuroxime
  • Strep pneumo - PCN
Term
What should you do when a pt presents with unstable angina pectoris suspicious for MI?
Definition
  1. immediate tx includes meds to decrease damage to myocardium and reduce bp: nitroglycerin, beta blockers. Also: aspirin, oxygen, morphine.
  2. ECG and CXR, constant monitoring & continuous telemetry
  3. stat labs
Term
ECG changes associated with MI (4)
Definition
  • ST elevation or depression
  • T-wave inversion
  • Pathologic Q wave suggests necrosis from a previous, completed infarction.
  • NOT All MIs will have ECG changes!
Term
How is unstable angina defined? (3)
Definition
  • new onset
  • at rest or with minimal exertion
  •  pattern with episodes of increasing frequency, severity, or duration
Term
What is the gold standard diagnostic modality to determine mechanism of CHF?
Definition
  • Echocardiogram: help identify cardiac wall abnormalities, cardiomyopathy, ventricular or septal hypertrophy, cardiac ejection fraction, tamponade, pericardial constriction, PE , valvular abnormalities
Term
Pt education for management of CHF as outpatient (3)
Definition
  • Restrict sodium and fluid intake. Initial restriction of Na should be 2-4 g/d; may need further restriction in severe cases.
  • Weight loss through diet and exercise if pt is overweight
  • strict management of bp and modification of cardiac risk factors
Term
What is 1st line pharmacological tx in pts with CHF and reduced LV fxn? How does this help? What is an alternative for pts that cannot tolerate these drugs?
Definition
  • ACE-I - reduces preload, afterload, improves CO, resulting in improved sx and reduced mortality. Also delays development of sx in asymptomatic pts w/ reduced EF. 
  • Alternative = ARB
Term
Contraindications of ACE-I's (5)
Definition
  • pregnancy
  • hypotension
  • hyperkalemia
  • bilateral renal a. stenosis
  • use cautiously in pts with renal insufficiency
Term
What is the 1st line agent in an acute CHF exacerbation with pulmonary edema?
Definition
furosemide
Term
risk factors of acute pyelonephritis in healthy women (6)
Definition
  • recent UTI
  • DM
  • recent incontinence
  • new sexual partners
  • use of spermicide
  • mother with h/o UTI
Term
Nonasthma causes of acute wheezing in children (5)
Definition
  • foreign object aspiration - never do blind finger sweep!
  • Bronchiolitis: MC lower respiratory dz of infants and MC reason for hospitalization of infants < 1 yr
  • Croup: MC cause of airway obstruction in 6 mo - 6 yo. MC reason for hospitalization in kids <4 yrs.
  • Epiglottitis - usually affects kids < 5yo
  • Deep neck abscess (retropharyngeal or peritonsillar)
  • Note: sufficient airflow is required to produce wheezing sound. Disappearance of wheezing in pt who initially presents with wheezing suggests complete blockage of airway/imminent respiratory failure
Term
Bronchiolitis - common cause, tx
Definition
  • RSV accounts for 70% cases
  • Tx: supplemental oxygen if SpO2 < 90% and supportive care (fluids and suction nasal and pharyngeal secretions).
Term
Croup - cause, x-ray finding, tx
Definition
  • cause: viral infxn (often parainfluenza) that leads to inflammation of subglottic region
  • frontal neck x-ray: steeple sign
  • Tx - depends on severity (chest retractions, stridor at rest, cyanosis, LOC). Often includes glucocorticoids +/- nebulized epinephrine
Term
Epiglottitis - cause, sx, X-ray finding, tx
Definition
  • bacterial (commonly Hib) infxn of supraglottic tissue
  • muffled "hot potato" voice, toxic appearance, drooling
  • lateral neck x-ray: thumb sign
  • medical emergency: visualization is preferably done in OR. Tx is airway management (may need intubation) and abx
Term
2 contraindications to immediate wound closure (suture)
Definition
  • wounds > 18 hours old (>24 hrs on the face)
  • animal and human bite wounds (exceptions: facial wounds and large wounds from dog bites)
Term
Risk factors for development of acute otitis media and peak age of onset (7)
Definition
  • age < 2 years (peak age of onset: first 6 years of life)
  • male
  • genetic predisposition
  • previous episodes of otitis media
  • cigarette smoking in household
  • attendance at daycare
  • recent URI
Term
What are the red flags for patients with ear pain and what do they suggests? (4)
Definition
  • ear lobule erythema - erysipelas (begin antistreptococcal abx immediately to stop spreading)
  • CN VII palsy - malignant otitis externa
  • ulceration or non-healing lesion in ear canal - tumor
  • tenderness over mastoid  - mastoiditis (often requires surgery)
Term
What is malignant otitis externa? What pts are at increased risk? What is the tx?
Definition
  • otitis externa with invasion of adjoining tissue
  • usually caused by infection with P. aeruginosa
  • can lead to widespread local invasion and bacteremia with sepsis and death
  • associated with 7th nerve palsy on affected side
  • Pts with DM are at increased risk
  • Tx - surgical debridement of necrotic tissue and 4-6 wks of IV abx if cranial bones are involved.
Term
When a patient presents with sore throat (pharyngitis), what more serious conditions should you rule out? (3) What findings are associated with these conidtions?
Definition
  • epiglottitis - stridor, drooling, toxic appearance, patient in "tripod" position
  • peritonsillar abscess - peritonisillar swelling with tonsil pushed toward midline and contralateral uvula deviation, trismus (pain with chewing)
  • GAS infection - abrupt onset of sore throat & fever, palatal petechiae, tender cervical adenopathy, absence of cough, +/- sandpaper rash.
Term
What are the sx of mono?
Definition
  • Sx are very similar to those seen with GAS infxn, including: sore throat, palatal petetchiae, tonsillo-pharyngeal exudate, etc.
  • In addition, in mono: retrocervical or generalized adenopathy, hepatosplenomegaly, atypical lymphocytes of blood smear
Term
Tx of acute bronchitis
Definition
  • bronchodilators, ex. albuterol
  • antitussives: dextromethorphan, codeine
  • RTC in 2 - 3 wks.
  • do not give abx b/c it's usually a viral etiology! (exception=pertussis)
Term
H&P findings that are suspicious for pneumonia (3). What should be done as a next step if pneumonia is suspected?
Definition
  • Prolonged fever
  • Abnormal vital signs: HR>100, RR>24, Temp>100.5
  • findings consistent with pulmonary consolidation (dullness to percussion in one area, vocal fremitus, etc).
  • Next step: chest x-ray.
Term
Sx of acute bacterial rhinosinusitis
Definition
  • purulent nasal discharge
  • maxillary, tooth, or facial pain
  • unilateral maxillary sinus tenderness
  • worsening sx after initial improvement
  • sx last longer than 7-10 days (vs viral - shorter)
Term
Pathogens associated with acute bacterial rhinosinutis in adults (2) and children (3)
Definition
  • Adults: Strep pneumoiae, haemophilus influenzae
  • Children: S. pneumoniae, H. influenza, Moraxella catarrhalis.
  • [chronic sinusitis - anerobes: bacteroides, peptostrepto, fusobacterium]
Term
Tx of acute sinusitis
Definition
  • directly at likely causative pathogens
  • First line: amoxicillin and TMP-SMX, 10-14 days. 
  • decongestants & NSAIDs for sx relief as needed
Term
Pharyngitis: most common causes (in broad terms), peak incidence, causes in teens/young adults, children
Definition
  • In adults, vast majority is viral.
  • Peak incidence is btwn ages 4 and 7
  • Causes in young adults: Mycoplasma pneumoniae, chlamydia pneumonia, and arcanobacterium haemolyticus
  • Group A Strep causes 30% of pediatric cases and 15% of adult cases. 
Term

Tests for GAS pharyngitis (2)

 

Definition
  • rapid Ag test = quick in-office test; highly specific, but lower sensitivity
  • throat culture = gold standard
Term
Complications from untreated GAS infections (6)
Definition
  • rheumatic fever
  • glomerulonephritis (may occur whether or not pt receives appropriate abx)
  • TSS
  • peritonsillar abscess
  • meningitis
  • bacteremia
Term
What are the MC bacterial pathogens that cause AOM (3)? What is the tx of AOM?
Definition
  • MC pathogens: S. pneumonia, H. influenza, M. catarrhalis.
  • Tx: most cases resolve spontaneously. If sx are prolonged, recurrent, or severe tx, or child is < 2 yo,  with abx is indicated: amoxicillin (1st line) for 5-7 days. 
Term
4 components of a "plan" (SOAP note)
Definition
  • Diagnosis or diagnostic work-up
  • Treatment
  • Pt education/prevention
  • Follow up
Term
Kleinman Questions for Understanding Patients' Persceptives on Illness (6)
Definition

"As a physician it's important for me to understand:"

  1. How  do you view your health condition/illness?
  2. What do you think is causing it?
  3. What do you think are the main problems tht the sickness is causing?
  4. What do you fear most or worry about regarding your illness?
  5. What tx do think you should receive for it?
  6. What are the most important results you hope to receive from the tx?
Term
4 types of melanoma and their relative prevalences
Definition
  1. Superficial spreading melanoma - MC type 
  2. Lentigo maligna - least common type
  3. Acral lentiginous melanoma - MC type in AA and Asians
  4. Nodular melanoma - Most aggressive and 2nd MC type. 
Term
Superficial spreading melanoma - course, common sites for men and women, appearance
Definition
  • radial/superficial growth phase is slower than the vertical (invasive) growth phase
  • Men - upper torso
  • Women - legs
  • Appearance: raised borders and brown lesions with pink, white, gray, or blue
Term
Lentigo maligna - who, where, appearance
Definition
  • Most often in elderly patients (60s)
  • Usually occurs on chronic sun-damaged skin: face, ears, arms, and upper trunk
  • Tan/brown lesions with very irregular borders
Term
Acral lentiginous melanoma - who, where, appearance
Definition
  • MC type in AA and Asians
  • Usually found under nails, on soles of feet, or on palms of hands
  • Appearance: flat, irregular, dark brown to black.
Term
Tx of suspicious skin lesions
Definition
  • If there is a change in a pre-existing lesion or if any of the ABCDE signs are presents (D: > 6mm) - excise completely w/ 2-3 mm margin if possible
  • If you want to avoid to excising completely, do biospy in several areas. 
Term
Tx and px of malignant melanoma
Definition
  • Tx - complete excision wth 5 mm margins
  • Px - depends on thickness. Melanomas < 1 mm thick have a low rate of mets and high cure rate with excision.
Term
Bite wounds - what % of dog-bite wounds become infected? What antibiotic is given for infection prophylaxis bite wounds? When should this be given?
Definition
  • 20% of dog-bite wounds become infected, whereas cat and human bites have higher rates of infection.
  • Amoxicillin-clavulanate given orally (7-14 days) is appropriate prophylaxis for most bite wounds. 
  • Abx prophylaxis should be given in high-risk bites (those on hands, late presentation, cat bites).
Term
What should you do if someone has been stung and the stinger remains in the skin?
Definition
  • Scrape or brush off the stinger (vs. grasping it at the base which may result in increased venom release)
  • Rapidly removing the stinger is preferable to taking the time to locate scraping implements if one is not readily available. 
Term
3 reactions that may occur after insect stings
Definition
  • Local reaction: occurs immediately and lasts a few hours. Response to toxic properties of the venom.
  • Delayed reaction, "large local allergic reaction": mediated by IgE reacting to hymenoptera venom. A large area of redness and warmth develops over 24-48 hrs. Best treated with steroid initiated early after sting.
  • Anaphylaxis - treated with subQ or IM injection of 0.3-0.4 mL of 1:1000 epi. May also need to give antihistamines, steroids, and bronchodilators. 
Term
When a person sustains a human "bite" during a "close fist injury" (i.e. punching someone in the face), what organism is most likely to be isolated?
Definition
Eikenella corrodens
Term
Non-musculoskeletal causes of referred shoulder pain (4)
Definition
  • MI
  • cholecystitis
  • lung cancer
  • ruptured ectopic pregnancy
Term
Shoulder pain: physical findings in joint dz vs. muscle/tendon pathology
Definition
  • Joint disease: loss of active AND passive ROM
  • Muscle/tendon pathology: only lose active ROM
Term
Shoulder pain caused by joint diseases (3 ex and typical pt)
Definition
  • adhesive capsulitis: MC in diabetes and pts with decreased movement of shoulder (ex post injury or stroke)
  • Glenohumeral joint arthritis: MC >60 yo; less common site for OA
  • Acromioclavicular joint arthritis: all ages with h/o repetitive overhead lifting/heavy weight training. 
Term
Apley scratch test: what movements does it test (3)? what can an abnormal test indicate (3)?
Definition
  • Tests abduction and external rotation with flexed elbow; internal rotation
  • Some pain/decreased ROM: rotator cuff tendonitis
  • Unable raise arm above head: rotator cuff tear
  • Significant pain/decreased ROM: impingement, bursitis, adhesive capsulitis (older pts, DM)
Term

Which tests look for a labrum tear?

(labrum = fibrous structure that encircles th glenoid fossa)

Definition
  • O'brien test - pt has arm at 90 degrees forward flexion, adducted 45 degrees across body. Pt resists downwards force applied by examiner with pt's arm first interally rotated (thumb down) and then with arm externally rotated.Pain or popping/clicking = + test. Can have a FP if there's AC or rotator cuff pathology.
  • Crank (clunk) test - with pt's arm overhead, elbow flexed, press head of humerus into glenoid & labrum, then move joint (external and internal rotation).  Popping or clicking = + test.
Term
What muscle/action is tested by the "lift off" test?
Definition
Subscapularis - internal rotation
Term
What tests (3) assess the supraspinatus muscle?
Definition
  1. Empty can - pt has shoulders abducted to 90 degrees and arms 30 degrees from horizontal. Pt attempts to resist downward overpressure applied by examiner.
  2. Full can - strength test for supraspinatus
  3. Drop arm - large supraspinatus tear
Term
Which tests look for Subacromial Impingement Syndrome (3)? What are possible underlying pathologies for someone with findings of SIS (3)? 
Definition
  • Neer Test - passive forward flexion of shoulder
  • Hawkins - baby-bird position - apply pressure of internal rotation
  • Painful arc - 60-120 degrees
  • Consistent with: rotator cuff tendonitis, inflammation of subacromial bursa
Term
Thiazide diuretics (5)
Definition
  • 1st line tx for HTN
  • most cost effective medication for HTN
  • requires periodic monitoring of electrolyte serum levels (can cause hyponatremia)
  • should be avoided in pts with gout
  • can cause elderly pts to have urinary incontinence
Term
Tx of HTN that does not respond to single agent (most cases of stage 2 HTN) (4)
Definition
  • If thiazide diuretic by itself does not sufficiently lower bp, add another agent:
  • ARB, ACE-I, CCB, BB
Term
What lifestyle modification has greatest impact in terms of reducing HTN?
Definition
Weight loss
Term
How is resistant HTN defined? What are common causes/contributors to resistant HTN?
Definition
  • Resistant HTN = failure to achieve goal bp (<140/90) on full doses of an appropriate 3 drug regimen that includes a diuretic.
  • Contributors: improper bp measurement, excess sodium intake, inadequate dose of diuretic, medication problems (inadequate doses, drug interactions, etc), excess alcohol intake, underlying causes of HTN (secondary HTN). 
Term
Weight classifications in children according to BMI for age percentile
Definition
  • Healthy weight: 5% to 85%
  • Overweight: 85% to 95%
  • Obese: equal to or greater than 95%
Term
Criteria for diagnosing DM (4 choices)
Definition
  • random glucose of 200 or more with classic sx
  • 2 hour glucose tolerance test of 200 or more after 75-g glucose load
  • fasting glucose more than 125
  • HbA1c of 6.5% or more
Term
Tests for biceps tendonitis (2)
Definition
  • Speed's test - pt has arm forward, elbow extended, palm facing up. Pt flexes arm (overhead) while examiner applies downward pressure. Pain in biceps groove = biceps tendonitis.
  • Yergason test - Pt has elbow at side, flexed forward 90 degrees, hand protonated. While examiner palpates bicipital groove, ptt attempts to supinate arm and externally rotate against examiner's resistance. Pain or clicking = + test. 
Term
Polymyalgia rheumatica  - who? sx? labs? tx? common comorbidity?
Definition
  • older woman with pain and stiffness in cervical spine, shoulder & hip girdles. 
  • Pt often has malaise, weight loss, sweats, fever
  • Elevated ESR, anemia, sometimes elevated ALP and LFTs.
  • Tx - low dose steroids for weeks to months.
  • 10-20% also have giant cell (temporal) arteritis. 
Term
Reiter Syndrome (reactive arthritis) - who, when, triad of sx
Definition
  • follows GI (shigella, salmonella, campylobacter) or GU (C. trachomatis) infxn
  • MC in young, HLA-B27+ males Increased incidenence in HIV +.
  • Triad: non-gonococcal urethritis, oligo-articular arthritis, conjunctivitis. (+/- rash on plams/soles)
Term
Work-up for initial dx of HTN (4)
Definition
  • Assess overall CV risks: DM, smoking, obesity, FHx, ROS.
  • Look for 2ndary causes of HTN: renal, endocrine, obstructive sleep apnea
  • Check end-organ damage: retinopathy, atherosclerosis, AAA
  • Labs: serum K+, creatinine/GFR, Ca, glucose, Hct, UA (proteinuria, cells), ECG (LVH, CAD)
Term
When should a pt be started on combination therapy (>1 antihypertensive agent)?
Definition
  • If pt is 20/10 mmHg above goal bp (140/90 or 130/80 is pt has DM and renal dz)
  • Pt has stage II HTN (160/100).
Term
How do most ankle sprains occur?
Definition
 Most ankle sprains result from inversion of an ankle that is plantar flexed.
Term
What part of the ankle and which ligaments are most commonly injured in an ankle sprain?
Definition
  • The lateral ankle is injured much more commonly than the medial ankle.
  • The anterior talofibular ligament (ATFL) is the most commonly injured ligament, followed by the calcaneofibular ligament (CFL).
  • [the ligaments of the lateral ankle: ATFL, PTFL, CFL).
Term
What are the indications for a foot x-ray after an ankle injury? (Ottawa ankle rules)
Definition
  • bony tenderness over medial (navicular bone) or lateral  (fifth metatarsal bone) midfoot
  • inability to bear weight
Term
Management of ankle sprains (mnemonic)
Definition
  • PRICE
  • Protection - split or cast to prevent further injury
  • Rest
  • Ice
  • Compression
  • Elevation
  • also: NSAIDs or acetaminophen for pain. 
Term
Sprain vs. Strain
Definition
  • Sprain: stretching or tearing injury of a ligament.
  • Strain: stretching or tearing injury of a muscle or tendon. 
Term
What are the indications of an x-ray after a knee injury (5)? (Ottawa knee rules)
Definition
  • age 55 or older
  • isolated patella tenderness
  • tenderness of the head of the fibula
  • inability to flex knee to 90 degrees
  • inability to bear weight for 4 steps (regardless of limping)
Term
What must an adequate x-ray series include?
Definition
An adequate x-ray series must include at least 2 views at 90 degrees to each other. 
Term
What is a herniated disc?
Definition

It is when there is rupture of the fibrocartilarge between the vertebrae, leading to leakage of the nucleus pulposus that may imping on the nerve roots and cause pain. 

[Sciatica is usually caused by a herniated disc in the lumbar spine.]

Term
Red Flag Symptoms in Low Back Pain (3 main categories)
Definition
  • Infectious sx: chronic corticosteroids, immunosuppression, fever.
  • Things that suggest CA: h/o CA, worsening pain at night, weight loss. 
  • Sx of cauda equina syndrome: neurologic deficits, leg weaknes, bow and urinary incontinence, "saddle" paresthesia/anesthesia
  • others: trauma, suspcicion of AS, osteoporosis
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