Family Medicine

How do you classify alcohol dependence?

"Alcohol dependence" requires three or more of the following: Tolerance Withdrawal Substance taken in larger quantity than intended Persistent desire to cut down or control use Significant time spent obtaining, using, or recovering from alcohol use Social, occupational, or recreational tasks are sacrificed Use continues despite physical and psychological problems

How do you test sensation with a monofilament? And how do you score it?

"Ask the patient to look up or at a specific object across the room so she cannot see when you are touching her feet. Ask the patient to say 'now' when she feels anything touch the bottom of her feet. Apply the 10-gram monofilament perpendicular to the skin pressing hard enough to initiate bending of the monofilament. Hold 1 second and then withdraw from foot. Test 6 different areas on the plantar surface of the foot [(see diagram): diagram is attached to card 14 in fm diabetes case]. Do not test calloused areas of skin. Record results as normal sensation if the patients is sensate in all six areas. Record, "decreased sensation to monofilament testing in x out of 6 areas" when loss of sensation is detected. Some medical records provide a diagram for noting the exact location of decreased sensation. Inability to sense the monofilament in two areas on one foot is considered criteria for loss of protective sensation."

How do you classify risky/hazardous drinking? Problem drinking? And alcohol abuse?

"Risky/hazardous drinking" means the patient's alcohol consumption exceeds the National Institute on Alcohol Abuse and Alcoholism per occasion threshold for men of 4 drinks per occasion. "Problem drinking" entails significant physical, social, or psychological harm from drinking. "Alcohol abuse" requires a maladaptive pattern of use with one or more of the following: Failure to fulfill work, school, or social obligations Recurrent substance use in physically hazardous situations Recurrent legal problems related to substance use Continued use despite alcohol-related social or interpersonal problems

What are the 2 approved first line treatments for H. Pylori infection?

"Triple therapy" for 10-14 days (70-85% eradication rate): PPI standard dose twice daily (esomeprazole is dosed once daily) Amoxicillin 1 gram twice daily Clarithromycin 500 mg twice daily "Quadruple therapy" for 10-14 days (75-90% eradication rate): PPI standard dose once or twice daily (OR ranitidine 150 mg twice daily) Metronidazole 250 mg four times daily Tetracycline 500 mg four times daily Bismuth subsalicylate 525 mg four times daily

If you are considering treating a person at risk for suicide outpatient, what agreement should be discussed?

"no-harm contract" should be discussed. This is an arrangement in which the patient agrees to contact their doctor if they are considering harming themselves. An alternative, such as talking with another doctor, counselor, suicide hotline, or emergency room personnel, should be agreed upon if the main provider can not be contacted.

What is the Stage 1. Prevention Plus guidelines for weight management in children? - starting place for all children and adolescents who are overweight or obese

(5-2-1-0) counseling 5 serving of fruits and vegetables 2 hours of screen time 1 hour of physical activity 0 sugar-sweetened beverages

How do you initiate and monitor therapy with Levothyroxine (Synthroid)?

- A typical starting dose of thyroxine in primary hypothyroidism (such as that which occurs following radioactive iodine treatment) is 1.5-1.8 mcg per kilogram. - Increasing the dose slowly is important, especially in elderly patients and in patients like Ms. Waters who are mildly hypothyroid. TSH should be repeated in six weeks. - When a stable TSH level has been achieved in primary hypothyroidism, TSH can be checked once or twice annually. - Some people who have radioactive iodine treatment still have enough thyroid left to relapse. Occasionally they need a second treatment.

By consensus between ACOG, ACS, USPSTF, and ASCCP, what are the guidelines for cervical cancer screening?

- At 21 years of age -- cervical cancer screening should begin. - Between the ages of 21-29 years -- screening should be performed every three years. - Between the ages of 30-65 years -- screening can be done every five years if co-tested for HPV (preferred) or ever three years with cytology alone (acceptable). However, they stipulate that certain risk groups need to have more frequent screening.

How common is Toxic Nodular Goiter? And what are the salient features?

- Causes about 5% of cases of hyperthyroidism. - Thyroid nodules are common, but most are not symptomatic, and only 4-5% are cancerous. - Thyroid nodules are more common in patients over 40. - These older patients more often have multinodular disease; whereas, solitary nodules are seen more often in younger patients and can be associated with iodine deficiency.

What features in the history might point towards a cardiac cause of palpitations?

- Duration of palpitations greater than five minutes - Description of an irregular beat (for example, the patient can tap it out with their fingers) - Previous history of heart disease - Male sex

What are the dietary recommendations for all adults to prevent ASCVD?

- Mediterranean-style diet (the DASH dietary pattern achieves this) Rich in: Vegetables Fresh fruits Whole grains Lean meats: poultry, pork, fish Legumes: e.g. lentils Non-tropical vegetable oils: e.g. olive oil Tree nuts: pecans, cashews, etc. (not peanuts) Low in: Sugar-sweetened beverages Sweets Red meats Strong quality evidence (A)

If a woman presents with a "breast lump" what elements are important in the history?

- Precise location of the lump - How it was first noticed (accidentally, by breast self-examination, clinical breast examination, or mammogram) - How long it has been present - Presence of nipple discharge, and - Any change in size of the lump (especially ask whether the lump changes in size according to phase of the menstrual cycle)

What are the dietary recommendations for lowering LDL levels?

- Reduce percent of calories from saturated fat, aiming for a goal of 5% to 6% of calories from saturated fats. Saturated fats come from: Animal fats (meat and dairy) Some vegetable oils (particularly coconut and palm oils) - Reduce percent of calories from trans fat. These come from: Partially hydrogenated oils Oils used for deep frying Vegetable shortenings Many pre-packaged baked goods and chips

What dietary recommendation can lower BP? (which if done can negate the need for meds, unlike with cholesterol)

- Reduce sodium intake (A-strong) - Limit sodium intake to 2,400 mg per day (A-strong) - Limiting of sodium to 1,500 mg/day further lowers BP (B-moderate)

What is Thyroiditis? And when is it most likely to occur?

- Thyroid hormone leaks from an inflamed thyroid. - Happens after a viral illness or pregnancy. - May be painful and tender when caused by infarction, radiation, or trauma - Painless when caused by autoimmune conditions, medications, or an idiopathic fibrotic process - May have hypothyroidism, euthyroidism, or hyperthyroidism

How common is Graves' Disease? And what are the salient features?

- Toxic diffuse goiter (Graves' disease) accounts for the majority (60-80%) of hyperthyroidism. - Is an autoimmune disease caused by an antibody that acts at the thyroid-stimulating hormone (TSH) receptor and stimulates the gland to synthesize and secrete excess thyroid hormone. - Hypervascularity of the thyroid may result in a bruit or thrill upon auscultation that is not present in other etiologies of hyperthyroidism. - Exophthalmos is characteristic. - Pretibial myxedema, a rare finding, is most common in Graves' disease and is caused by the deposition of hyaluronic acid in the dermis and subcutaneous tissues.

What are the macrovasculature complications of diabetes?

- coronary heart disease (CHD) or cerebrovascular disease/stroke

What are the microvasculature complications of diabetes?

- retinopathy - nephropathy - neuropathy (sensory, including history of foot lesions; autonomic dysfunction, including sexual dysfunction and gastroparesis).

What are the different approaches to evaluating a patient's nutrition?

-Gathering a Complete Nutrition History -24-hour Dietary Recalls: -Food Frequency Questionnaire: Usually covers food intake over the period of a month. Often used in combination with the 24-hour recall, it is the quickest way to determine nutritional deficiencies and excesses Daily Dietary Intake Records (or Food Diaries) (3-4 days) Usual Diet History Observed Intake (usually for research) Weighed Intakes (most accurate)

What are some notable safety precautions in RAI therapy?

-May be a small increased risk of vascular mortality or thyroid cancer with RAI. Since head to head studies have not been done, it is hard to know if this is from underlying disease or the treatment. -Depending on the dose of RAI used, there are restrictions on close contact particularly with young children and pregnant women. For example, if given a relatively low dose of RAI, patients should not get closer than 1 meter (40 inches) to children less than three years old for 21 days. -Since RAI is excreted through urine and sweat, it is recommended that patients flush the toilet twice to be sure the RAI is flushed thoroughly.

What are the possible complications of RAI therapy? And how may some of these be avoided?

-Patients with severe disease or younger patients may need more than one dose of RAI. -Patients with eye disease may get worsening of their eye disease with RAI. This can be prevented with administration of oral steroids after treatment. -Patients with severe hyperthyroidism should be treated with an antithyroid drug before and after RAI to prevent worsening of disease, and rarely thyroid storm (you are giving iodine).

What are the diagnostic criteria for diabetes mellitus?

1. A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia like polyuria or unexplained weight loss, or hyperglycemic crisis. 2. A fasting plasma glucose of greater than or equal to 126 mg/dL. 3. A hemoglobin A1C greater than or equal to 6.5%. 4. Oral Glucose Tolerance Test (OGTT) is more sensitive and a little more specific than a fasting glucose, but it is difficult to do and poorly reproducible, so it is not recommended for routine clinical use. The fasting glucose, OGTT and the A1C need to be confirmed on a different day unless the patient has unequivocal or unquestionable symptoms of hyperglycemia.

What are the 7 components of the supine portion of the back exam?

1. Abdominal Exam (sure to assess for AAA bruit) 2. Rectal Exam (only if red flag symptoms) 3. Passive Straight Leg Raise 4. Crossed Leg Raise 5. FABER test 6. Pelvic Compression Test 7. Muscle Atrophy (quadriceps and calf muscles; lack of atrophy, despite patient's complaints of long-term weakness, suggests malingering)

What are the qualities of a good screening test?

1. Accuracy (high sensitivity and specificity) 2. Able to detect disease in an asymptomatic phase 3. Minimal associated risk 4. Reasonable cost 5. Acceptable to patient 6. Have an available treatment for the disease

What are the Deyo high-yield criteria for obtaining lumbar films?

1. Age over 50 2. Significant trauma 3. Neurologic defect (sensory or motor) 4. Weight loss of 10 pounds 5. History of ankylosing spondylitis 6. Drug or alcohol abuse 7. History of malignancy 8. Fever of 100 degrees or higher 9. Revisit without improvement or financial compensation

What are the 3 components of the seated portion of the back exam?

1. Check for CVA tenderness 2. Modified version of the straight leg raise (SLR) test 3. Neurological exam

What is the step-wise fashion of evaluating an lateral lumbar spine plain film?

1. Check for height loss in the vertebral bodies. This height loss may be due to trauma, metabolic disease, or metastatic disease. 2. Look at the configuration of the end plates. Are the end plates crisp? Irregular endplates could reflect degeneration or infectious disease. 3. Look at the disc space thickness. The disc space thickness should diminish as you go down the spine, but this should be subtly and uniformly. 4. Check for alignment in the AP direction. Are the anterior and posterior spinal lines intact? 5. Look to see if there any osteophytes projecting from the vertebral bodies. Are there any calcifications in discs? 6. Check that the spinous processes are present. Did the patient have previous spine surgery? 7. Last but not least, look for other abdomen and pelvic pathology. AP and lateral films can show calcifications in the kidney, vascular calcifications, or foreign bodies.

What is the AAP recommendation for weight loss goals in children?

1. Children younger than seven years old who have a BMI at or above the 95 percentile without secondary complications should attempt to maintain their weight. Those with complications should pursue weight loss until their BMI is at or below the 85th percentile. The general recommendation is about one pound per month. 2. For children over seven years old if they have a BMI between the 85th and 95th percentile, weight loss is recommended to achieve a BMI at or below the 85th percentile.

What is the step-wise fashion of evaluating an AP lumbar spine plain film?

1. Count the lumbar vertebral bodies (these are the non-rib bearing vertebra). An individual with classic anatomy will have 5 lumbar vertebral bodies, but there is quite a bit of normal variation. 2. Look to see that each vertebral body has 2 "eyes" (pedicles) and 1 "nose" (spinous process). 3. Look for vertical alignment of the spinous processes. Misalignment suggests a rotational injury such as unilateral facet dislocation 4. Look for smooth undulating borders. 5. Look for uniformity among the disc spaces. 6. Compare the pedicles with the spinous processes. Widening of the pedicles may represent a compression fracture. Comparison of these will also show rotation of the spine. 7. Look at the lateral curvature, which may reveal scoliosis. 8. Look at the sacroiliac joints to ensure the white margin is intact. Is the joint sclerotic, ankylosed (fused), or destroyed?

What are the 2 etiological factors producing the symptoms of GERD and what are the symptoms?

1. Gastroesophageal reflux -- epigastric burning that sometimes radiates to the throat and tends to worsen when: gastric volume is increased (after large meals) gastric contents are located near the gastroesophageal junction (reclining or bending) intra-abdominal pressure is increased (such as with obesity, pregnancy, tight binders or girdles). 2. Esophageal spasm -- sharp, stabbing, substernal pain and can be triggered by temperature extremes (e.g. hot coffee, ice water). Heartburn and esophageal reflux and spasm commonly occur at night or after the consumption of a large meal. Symptoms of GERD may also be precipitated by: spicy and fatty foods chocolate mint smoking alcohol and caffeinated beverages eating large portions lying flat in close proximity to a meal wearing tight clothing around the waist some medications (calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives) When severe reflux reaches the pharynx and mouth or is aspirated, it can cause atypical signs and symptoms of GERD, or laryngopharyngeal reflux (LPR). Atypical symptoms may point to (but don't sufficiently support by themselves) a diagnosis of GERD.

What non-medical things can patients do to help manage their HAs?

1. Headache diary Make note each day of whether or not you have a headache. Keep track of the severity of the headaches and which treatments are effective. Identify and avoid headache triggers. Use a list of things that trigger headaches, and monitor which of these triggers worsen your headaches. 2. Caffeine Slowly decrease the use of diet sodas. The caffeine worsens both migraines and tension type headaches, but coming off of caffeine too quickly may make things worse in the short term. 3. Sleep Try to get more sleep. Aim for eight hours each night and establish a regular sleep routine, meaning try to go to sleep at the same time each night.

How do HAs present secondary to anxiety?

1. Headache due to depression or anxiety Features Similar to tension type headache: Bilateral, pressing, and/or tight Last from 30 minutes to 7 days Some experts feel that depression or anxiety can trigger tension type headaches. In those cases tension-type headaches are considered secondary, not primary headaches.

How does JNC-8 recommend step up therapy in patients with HTN not meeting their goals?

1. Lifestyle Modification 2. Initiate medication based on ASCVD risk 3. If not at goal, select a titration strategy: -Maximize dose of first med OR -Add second med before maximizing first OR -Start with two med classes separately or as fixed-dose combination OR -If not meeting goals with two drugs, titrate up doses until BP optimal 4. If not at goal with two drugs, continue adding drugs from other classes until goal met (never add ACEI + ARB)

What are the red flags for a significant herniated nucleus pulposus in LBP?

1. Major muscle weakness (strength 3 of 5 or less) 2. Foot drop

How do you manage rhythm control in patient's with afib?

1. Onset of symptoms <48 hours; or no evidence of left atrial thrombus on TEE: Patients presenting with acute AF of <48 hours' duration and no evidence of left atrial (LA) thrombus on TEE should have DC or pharmacological cardioversion. DC cardioversion is fast, safe and efficient. Pharmacologic cardioversion is accomplished with the use of antiarrhythmic agents. However, these must be used with caution as they may cause bradycardia or tachyarrhythmia. Anti-arrhythmic agents with variable, but proven, efficacy for cardioversion of acute AF include flecainide, propafenone, ibutilide and amiodarone. Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents (flecainide and propafenone) in conversion to sinus rhythm.

What are the ADA recommendations for screening for T2DM?

1. Overweight or obese patients (body mass index 25 kg/m2) who have one or more of the following additional risk factors: Physical inactivity Race/ethnicity (e.g., Native American, Pacific Islander, Latino, African American, Asian American) First-degree relative with diabetes Previously diagnosed impaired fasting glucose (100-125 mg/dL) or impaired glucose tolerance (2-hour plasma glucose > 140 mg/dL following a 75 gram glucose load) Hypertension (Blood pressure > 140/90 mmHg) HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL (2.83 mmol/L) History of gestational diabetes mellitus, or delivering a baby > 9 lbs. Polycystic ovarian syndrome History of cardiovascular disease A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans, severe obesity) 2. In the absence of the above risk factors, screening should begin at 45 years of age. 3. If results are normal, testing should be repeated at least at three-year intervals, with consideration of more frequent testing depending on risk status and initial results.

What are the red flags for infection in LBP?

1. Persistent fever (temperature over 100.4 F) 2. History of intravenous drug abuse 3. Recent bacterial infection, particularly bacteremia (UTI, cellulitis, pneumonia) 4. Immunocompromised states (chronic steroid use, diabetes, HIV)

What are the red flags for vertebral fracture in LBP?

1. Prolonged use of corticosteroids 2. Mild trauma over age 50 years 3. Age greater than 70 years 4. History of osteoporosis 5. Recent significant trauma at any age (car accident, fall from substantial height) 6. Previous vertebral fracture

What are the 3 categories that cervical cytology pathology results are given in?

1. Specimen adequacy In order to be 'adequate', the Pap smear must contain over 5,000 squamous cells and have sufficient endocervical cells. (Endocervical cells are columnar epithelial cells found just proximal to the squamo-columnar junction, the site of beginning dysplastic changes.) If they are present, it shows that you have sampled the transformation zone, and therefore the specimen is 'adequate'. 2. General categorization of results Is there any evidence of intraepithelial lesion or malignancy? 3. Interpretation of results Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories.

What are the red flags for cauda equina syndrome in LBP?

1. Urinary incontinence or retention 2. Saddle anesthesia 3. Anal sphincter tone decreased or fecal incontinence 4. Bilateral lower extremity weakness or numbness 5. Progressive neurologic deficits

What are the 4 mechanisms that may cause stroke? How common is thrombotic vs others/

1.Embolic Most commonly from the heart or carotid artery-- arrhythmias may produce emboli from mural thrombi, atrial appendages, or from diseased heart valves 2.Thrombotic Native clot within the intracranial vasculature -- 85% of strokes are caused by vascular occlusion (thrombotic) 3.Cardiogenic Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation 4.Hemorrhagic Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.

How many tension HAs have to occur for diagnosis?

10 episodes needed for diagnosis.

What is the 1st tier of Tx's for T2DM?

1st Tier (Well-validated studies support this approach) Step 1: Diagnosis = HbA1C > 6.5% = Lifestyle changes plus Metformin Step 2: Assessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + Add either a sulfonylurea (Glyburide, Glipizide (both second generation) or Glimepiride (third generation)) or basal insulin (Insulin Glargine (Lantus) or Insulin Detemir (Levemir) on intermediate-acting insulin (NPH). Step 3: Reassessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + add basal insulin or (if already added) intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia.

What are the rates of healthy infant crying behavior?

2 weeks of age 2 hours/day 6 weeks of age 3 hours/day 3 months of age 1 hour/day

How do HAs secondary to medication overuse present?

2. Medication overuse headache (also called analgesic rebound headache) Chronic use of any analgesic can cause this type of headache. Features Mild to moderate in severity Diffuse, bilateral headaches that occur almost daily and are often present on first waking up in the morning. Often aggravated by mild physical or mental exertion. Can be associated with restlessness, nausea, forgetfulness, and depression. Headaches may improve slightly with analgesics but worsen when the medication wears off. Tolerance develops to abortive medications and there is decreased responsiveness to preventive medications. Medication overuse headache can occur at varying doses for different types of medication; it may occur with as low as an average of 18 doses of triptans per month, but may require as high as an average of 114 doses of analgesics per month.

What must be done prior to cardioversion for a patient who has had afib for an indeterminant amount of time or greater than 48 hours?

2. Onset of symptoms >48 hours or unknown; or presence of LA thrombus on TEE: Cases of acute AF should not be cardioverted if duration is greater than 48 hours or if the duration is unknown, until sufficient anticoagulation is achieved. Anticoagulation with IV heparin (aPTT of 45 to 60 seconds) or subcutaneous low molecular weight heparin should be started while the patient is being evaluated for future cardioversion and long-term anticoagulation. Low thromboembolic risk patients may be cardioverted once heparin is started (provided TEE is negative) and then continued on long term aspirin. High thromboembolic risk patients and those with LA thrombus on TEE should receive oral anticoagulation with warfarin and IV heparin. Heparin therapy should be continued until a therapeutic INR (2.0 - 3.0 with warfarin is achieved. Anticoagulation with warfarin should be established for 3 to 4 weeks prior to any attempt to restore sinus rhythm.

How common is sleep apnea in elderly patients?

20-70% of elderly patients

In the United States, the lifetime risk of becoming obese is what?

25%

What are the 2nd tier recommendations for Tx of T2DM?

2nd Tier (LESS well-validated studies support this approach) Step 4: Explore other treatment options: Adding rapid acting insulin with meals Thiazolidinediones: Pioglitazone (Actos), Rosigilitazone (Avandia) - useful for those who cannot tolerate the gastrointestinal side effects of metformin, who have hypoglycemia with sulfonylureas or in addition to these agents. A major concern is that these agents can increase risk of heart failure, edema, and bone fractures. Meglitinides: Nateglinide (Starlix), Repaglinide (Prandin) GLP-1 analogs: Exenatide (Byetta), Liraglutide (Victoza) - given via sub Q injection. DPP-4: Sitagliptin (Januvia), Saxagliptin (Onglyza), Alogliptin (Nesina) Amylin analog: Pramlintide (Symlin) - given via sub Q injection Alpha-glucosidase inhibitors: Acarbose (Precose), Miglitol (Glyset)

What percentage of perpetrators of intimate partner violence also abuse the children in the household?

30% to 60% of perpetrators of intimate partner violence also abuse children in the household.

Episodes of biliary colic typically last how long?

4-6 hours

Patient's with sleeping difficulties should be cautioned to avoid caffeine and alcohol for how many hours before bedtime?

4-6 hours

While inserting and removing the speculum, it should be rotated to what?

45 degrees

How many migraines are needed for diagnosis?

5 episodes needed for diagnosis.

At what age does the definition of HTN change to >150/90? What is the exception?

60 years old Unless w/ CKD or DM, in which case the goal remains <140/90

How effective are spermacides against pregnancy? What are some of the risks and potential complications?

68-91% effective against pregnancy with significant variability secondary to user error, lack of use, and anatomy. The sponge poses risk for toxic shock syndrome; nonoxyno9 increases risk of transmission of HIV. These methods are best if used with condoms.

Is obtaining MRI correlated with improved clinical outcomes?

75% of herniated discs improve with six weeks of conservative therapy. MRI testing is not associated with clinical benefit in randomized trials. Early MRI is not associated with improved outcomes in patients with acute back pain or radiculopathy (Level 2/mid-level evidence). If surgery is being considered, some physicians recommend, in the absence of red flags, to obtain an imaging study after one month of symptoms.

What is the prevalence of cold vs hot nodules? And what is the association of each with malignancy?

85% of thyroid nodules are cold, 10% are warm, and 5% are hot. Remember that 85% of cold nodules are benign, 90% of warm nodules are benign, and 95% of hot nodules are benign.

If pharmacological Tx is given for depression, how long should it be continued?

9-12 months (stopping any sooner runs a high risk for recurrence) Recurrent episodes treated for 2-3 years

What questionaires can be used to screen for depression?

9-item depression survey from the Patient Health Questionnaire (PHQ-9), which has been demonstrated to be useful in diagnosis and tracking the severity of symptoms among patients with major depression. The length of the questionnaire has been a barrier to its use as a screening tool in primary care, where physicians are under considerable time pressure and face competing demands. More recently, a shortened two-item version (PHQ-2) has been developed and validated in primary care. The PHQ-2 asks patients, "Over the last 2 weeks, how often have you been bothered by any of the following problems?" The two symptoms are "little interest or pleasure in doing things" and "feeling down, depressed, or hopeless." For each question the patient can answer: "not at all" (0 points) "several days" (1 point) "more than half the days" (2 points), "nearly every day" (3 points).

What is the most common cause of HTN in the united states?

95 - 98% of the hypertension in the United States is essential hypertension - chronically higher blood pressure readings than normal with no underlying identifiable cause.

What percentage of LBP is from mechanical issues? And what are the 3 most common?

97% 1. lumbar strain/sprain - 70% 2. age-related degenerative joint changes in the disks and facets - 10%. 3. herniated disc - 4%

At what age does the guideling for HTN diagnosis/control change? What is the cutoff for pre-HTN?

< 60 years old, cutoff is 140/90 > 60 years old, cutoff is 150/90 Pre-HTN is above 120/80

How effective is acupuncture for OA?

A 2006 systematic review showed that acupuncture is better than sham-control interventions for peripheral joint osteoarthritis. Also shown to reduce pain and improve function in patients with OA of the knee when used as an adjunct treatment. (grade B evidence)

What may be seen on CT scan of a pt with chronic sinusitis?

A CT of the sinuses may show inflammation of the paranasal sinuses, masses including sinonasal polyps, anatomic deformities. A CT scan of the sinus does not necessarily correlate with the severity of the patient's symptoms, but is an objective method to monitor chronic or recurrent sinus disease.

How do you perform "compression" as a part of RICE with an ankle sprain?

A Cochrane review demonstrated that semi-rigid ankle support led to quicker return to sports, work and less instability of the ankle compared to simple wraps and bandages. It also is more helpful with persistent swelling.

What T-score is diagnostic of osteoporosis?

A DEXA scan is a bone densitometry study that usually looks at the lumbar spine and hip density to determine if someone has osteoporosis. This is done based on a T-score. A T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia. Osteopenia is not a clinical diagnosis and just indicates the degree of bone decline since peak bone mass. It is usually not an indication for treatment aside from lifestyle. A T-score of less than -2.5 indicates osteoporosis. Based on the patient's risk for fracture and their T-score, we can then make recommendations for treatment of osteoporosis.

What are the important historical elements in the evaluation of nipple discharge?

A comprehensive history and breast exam are necessary to evaluate the discharge. For example, it is important to know if the discharge appears milky, purulent or bloody. Palpate nipples and check for any discharge.

When should you consider Dx of pertussis in a child? How much does the vaccine protect them from the illness?

A diagnosis of pertussis should be considered for any child with a prolonged cough, even when appropriately immunized. No vaccine is 100% effective at preventing disease, and previously immunized, or under-immunized, children will often present with milder symptoms. Infection with Bordetella pertussis is transmitted from person to person by aerosolization of droplets from coughing and sneezing. Pertussis is a clinical diagnosis. Early on in the disease, patients present with general upper respiratory symptoms: sneezing, runny nose, and typically just a mild cough. The classic paroxysmal cough and inspiratory "whoop" do not become prominent symptoms until about 14 days into the illness. Pertussis is very contagious and can cause serious, even life-threatening, illness, particularly in infants. Universal immunization of children younger than age 7 has been essential to the control of pertussis. Vaccination with acellular pertussis is highly effective, providing 64% protection against mild disease, and 95% protection against serious disease after completion of the primary series. However, pertussis is the only vaccine-preventable illness whose incidence rate has continued to rise over the last 20 years, especially in adolescents and adults, and outbreaks occur among both immunized and unimmunized populations.

What is ankylosing spondylitis?

A form of spondyloarthritis commonly associated with the HLA-B27 genotype that typically occurs in young adults. It is a chronic inflammatory process of the axial skeleton, resulting in chronic back pain and progressive loss of motion of the spine. Hips are sometimes affected as well.

How is therapy with opiods initiated? And what are the end-goals?

A long-acting opioid might also be a good option. Often a short-acting opioid is given first to see how much is needed to control pain adequately over a 24-hour period, and then is converted to a long-acting alternative. If the long-acting opioid alone is not sufficient, then use either acetaminophen or a short-acting opioid for breakthrough pain. The goal should always be to use the smallest sufficient dose for the shortest period of time to achieve adequate pain control.

When should you screen for AAA in women?

A one-time ultrasound to screen for an abdominal aortic aneurysm is recommended in men 65-75 years old who have any history of smoking, but the USPSTF recommends against routine screening for AAA in women.

How effective are glucosamine injections for OA?

A randomized controlled trial (RCT), followed by a meta-analysis failed to show a decrease in pain or slowed progression of joint space narrowing related to glucosamine use. A small subset of participants in the GAIT study with moderate-to-severe pain did show statistically significant pain relief when glucosamine was combined with chondroitin sulfate as compared to placebo, but more investigation was recommended to confirm this finding because of the small sample size. The same was not true of the mild pain subset which showed no improvement over placebo.

Should ASA therapy be started in all patients with diabetes?

A recent meta-analysis has demonstrated that aspirin does not reduce the likelihood of cardiovascular events in patients with diabetes without pre-existing disease, except to decrease the risk of myocardial infarction in men. Therefore, we do not need to specifically target patients with diabetes for aspirin therapy; we should consider them for aspirin therapy just as we would any patient without diabetes.

What is considered to be a positive finding of orthostatic HTN?

A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has accommodated to the supine position assumes a standing or sitting position. Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the elderly).

What will a simple joint effusion result as after arthrocentesis?

A simple joint effusion produces clear, straw-colored transudative fluid. This can happen with osteoarthritis and degenerative meniscal injuries.

Is there a medicine that can treat biliary colic?

A three-month trial of ursodiol (Actigall) - an agent that is sometimes effective in dissolving gallstones and preventing future gallstones - would be equivalent to watchful waiting in many clinical circumstances. If the patient is having more atypical symptoms with visible stones, which may or may not account for the symptoms, then such a medical trial might be warranted. If symptoms resolve, then they may have been from the gallstones and subsequent therapy can be planned. If symptoms do not resolve, then plans can likewise be made.

What screening tool is useful in evaluating domestic violence?

A valuable screening tool is the SAFE series of questions: Stress/safety: "Do you feel safe in your relationship?" Afraid/Abused: "Have you ever been in a relationship where you were threatened, hurt, or afraid?" Friends/Family: "Are your friends or family aware that you have been hurt? Could you tell them and would they be able to give you support?" Emergency Plan: "Do you have a safe place to go and the resources you need in an emergency?"

What are the DSM-V criteria for Panic Disorder?

A. Recurrent unexpected panic attacks (See above) B. At least one of the attacks has been followed by a month or more of one or both of the following: Persistent concern or worry about additional panic attacks or their consequences (eg, losing control, having a heart attack, "going crazy"). A significant maladaptive change in behavior related to the attacks (eg, behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). C. The disturbance is not attributable to the physiological effects of a substance (eg, medication or illicit drug) or another medical condition (eg, hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder. As examples, the panic attacks do not occur only in response to Feared social situations, as in social anxiety disorder Circumscribed phobic objects or situations, as in specific phobia; Obsessions, as in obsessive-compulsive disorder Reminders of traumatic events, as in posttraumatic stress disorder Separation from attachment figures, as in separation anxiety disorder

What is a reasonable goal for glycemic control in a T2 diabetic?

A1c < 7 % (higher for older diabetics)

What are the 5 USPSTF classifications for recommendations?

A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is substantial. B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is fair or fair certainty that the net benefit is moderate - substantial. C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved - net benefit is small. However there may be occasions that warrant provision of this service in a patient. D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits or harms outweigh benefits. I: There is insufficient evidence to recommend for or against the service.

What BP medications may elevate serum creatinine?

ACE inhibitors, ARBs, and diuretics

What is the difference between the ACS and USPSTF breast CA screening guidelines?

ACS uses both EBM and expert opinion (may be more aggressive) USPSTF uses only EBM without bias (also reviews guidelines from other organizations)

What age do practicioners usually wait for before they will diagnose a child with ADHD? And why is this done?

ADHD is a possibility, but the diagnosis of ADHD is not usually made until a child is six years old. It is very common for normal and age-appropriate activity to be mistaken for ADHD in younger children. The symptoms must be more frequent or severe compared to other children the same age. In addition, the behaviors must be present in at least two settings, such as home and school and be present for at least six months.

What is corneal arcus?

AKA Arcus senilis (or arcus senilis corneae) is a white, grey, or blue opaque ring in the corneal margin (peripheral corneal opacity), or white ring in front of the periphery of the iris. It is present at birth, but then fades; however, it is quite commonly present in the elderly.

Abortion is legal up until what week of pregnancy?

Abortion is legal up to 22 weeks of pregnancy.

What condition do some pregnant women experience that evolves extreme persistent N/V?

About 1 in 200 women develop persistent vomiting, which leads to dehydration, ketosis, electrolyte disturbances, and weight loss, a condition called hyperemesis gravidarum.

What symptoms are indicative that there may be complications from GERD?

About 60% of cases of GERD can be classified as non-erosive reflux disease (NERD). Unfortunately, symptom frequency, duration, and severity do not help to differentiate the grade of esophagitis and cannot be used to reliably diagnose complications of GERD.

What is the most likely cause of miscarriage and how common is miscarriage?

About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities. You are not alone in this, it is very common: about one-third of all pregnancies end in miscarriage.

What are the red flag S/S that may suggest life threatening condition?

Abrupt onset of severe pain Shock with hypotension and tachycardia Distension Peritoneal irritation signs Rigid abdomen Pulsatile abdominal mass Absent bowel sounds Fever Vomiting Diarrhea Weight loss Menstrual changes Trauma, prior surgeries, or operative scars History/presence of blood in emesis History/presence of blood in stool Severity of the pain Ecchymoses/bruising Rebound tenderness Mass or ascites

How do you diagnose chronic sinusitis?

According to the AAO-HNS updated guidelines (2015), patients with chronic sinusitis have similar symptoms to patients with acute sinusitis, but they last at least 12 weeks. They must have two of the following symptoms: nasal obstruction or congestion mucopurulent drainage (anterior, posterior or both) facial pain, pressure or fullness decreased sense of smell They must also have signs of inflammation on physical examination or radiological studies

What is required to diagnose chronic sinusitis?

According to the AAO-HNS updated guidelines (2015), to make a diagnosis of chronic sinusitis, the patient must have at least 12 weeks of at least two of the following symptoms: nasal obstruction/congestion, mucopurulent drainage, facial pain, pressure or fullness, or a decreased sense of smell. In addition, inflammation must be demonstrated by one of the following: purulent mucus or edema in the middle meatus or ethmoid region, polyps in the nasal cavity or middle meatus area, or inflammation of the sinuses on radiographic imaging. Therefore, being able to demonstrate any inflammation on either nasal endoscopy or a CT of the sinuses will confirm the diagnosis of chronic sinusitis.

According to the ADA, when is a screening TSH level indicated in comprehensive diabetes evaluation?

According to the ADA, if not performed/available within the past year, ordering screening TSH levels is indicated in type 1 diabetes, newly diagnosed dyslipidemia, or women over age 50 years as part of the comprehensive diabetes evaluation.

Different types of melanoma:

Acral lentiginous melanoma is seen more often in dark-skinned people, and typically appears on the palms and soles of feet, including under the nails. Nodular melanoma presents as a single dark brown or black nevus on a sun-exposed area that grows deep into the skin. Superficial spreading melanoma presents as a nevus that has been growing and spreading along the skin surface. Benign nevi appear as small, symmetric, uniform colored moles. Squamous cell carcinoma tends to have a scaly, erythematous appearance more typical of a patch, plaque or nodule.

How effective is simple lifestyle modifications for treating GERD/PUD/NUD in the absence of medication for these conditions?

Addressing lifestyle modifications with patients who complain of symptoms of GERD and dyspepsia is a reasonable approach to therapy. There is reported benefit in some patients and expert opinion suggests that dietary/lifestyle changes be encouraged in patients with GERD, although there is little evidence to support improvement in symptomatic outcomes in the absence of pharmacotherapy.

USPSTF recommendation for screening for HIV?

Adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. All pregnant women, including those who present in labor who are untested and whose HIV status is unknown.

How do recommendations for the PPSV23 vaccine change in adults with asthma?

Adults aged 19 through 64 years with chronic heart disease (including congestive heart failure and cardiomyopathies, excluding hypertension), chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), chronic liver disease (including cirrhosis), alcoholism, or diabetes mellitus: Administer PPSV23.

What are the medical indications for the pneumococcal vaccine in adults younger than 65?

Adults aged 19 through 64 years with immunocompromising conditions or anatomical or functional asplenia who: Have not received PCV13 or PPSV23: Administer PCV13 followed by PPSV23 at least 8 weeks after PCV13; administer a second dose of PPSV23 at least 5 years after the first dose of PPSV23. Have not received PCV13 but have received 1 dose of PPSV23: Administer PCV13 at least 1 year after the PPSV23; administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the first dose of PPSV23. Have not received PCV13 but have received 2 doses of PPSV23: Administer PCV13 at least 1 year after the most recent dose of PPSV23. Have received PCV13 but not PPSV23: Administer PPSV23 at least 8 weeks after PCV13; administer a second dose of PPSV23 at least 5 years after the first dose of PPSV23. Have received PCV13 and 1 dose of PPSV23: Administer a second dose of PPSV23 at least 5 years after the first dose of PPSV23.

What conditions are more likely in adults with knee pain?

Adults are more prone to patellofemoral syndrome (a clinical diagnosis of exclusion for anterior knee pain), overuse syndromes (such as pes anserine bursitis), traumatic injuries (ligamentous sprains - anterior cruciate, medial collateral, lateral collateral - and meniscal tears) and inflammatory arthropaties, such as rheumatoid arthritis, septic arthritis, and Reiter's syndrome.

What other hormonal risk factors exist for BRCA?

Advanced age at first pregnancy Exposure to diethylstilbestrol Hormone therapy

How is Tx of HTN different in African Americans?

African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACE inhibitors, or ARBs compared to diuretics or CCBs. These differences are usually eliminated by adding adequate doses of a diuretic. Furthermore, BB, ACE inhibitors, and ARBs still reduce morbidity and mortality from hypertension in African Americans (renal protection, cardio-protection) separately from the blood pressure levels. African Americans, however, are 2 - 4 times more likely to develop angioedema from ACE Inhibitors than other groups. Note, JNC 8 does not recommend ACE inhibitors or ARB therapy for African Americans as a first line agent unless they have chronic kidney disease. All hypertensive African Americans can consider ACE inhibitors or ARB therapy as third of fourth line agents however.

What are the risk factors for Chlamydia infections?

Age (women and men less than 24 years old and younger are at greatest risk), history of chlamydial or other sexually transmitted infection, new or multiple sex partners, inconsistent condom use, exchanging sex for drugs or money, and african american or hispanic ethnicity (african american and hispanic women and men have higher prevalence rates than general population).

What age matches the developmental milestones : Thus far James has been meeting all his developmental milestones. Today James can feed himself, pedal a tricycle, uses three-five word sentences, can be understood by strangers 75% of the time, can copy a square, and engages in fantasy play with his siblings.

Age 3

What are the risk factors for the development of diabetes?

Age ≥ 45 years Overweight (body mass index ≥ 25 kg/m2) Family history diabetes mellitus in a first-degree relative Habitual physical inactivity Belonging to a high-risk ethnic or racial group (e.g., African-American, Hispanic, Native American, Asian-American, and Pacific Islanders) History of delivering a baby weighing > 4.1 kg (9 lb) or of gestational diabetes mellitus Hypertension (blood pressure ≥ 140/90 mmHg) Dyslipidemia defined as a serum high-density lipoprotein cholesterol concentration ≤35 mg/dL and/or a serum triglyceride concentration ≥250 mg/dL Previously identified impaired glucose tolerance or impaired fasting glucose Polycystic ovary syndrome History of vascular disease

What are the long term effects of asthma?

Airway remodelling Inflammation Mucous hypersecretion Airway smooth muscle hypertrophy Angiogenesis Subepithelial fibrosis The most concerning long-term effect is less reversibility of the airway obstruction with medication so it will be more difficult to control the patient's asthma. This is why we want to treat patients early on with appropriate medication to control symptoms and prevent all of the long-term complications.

What pharmacologic Tx's for primary insomnia in the elderly is recommended according to evidence based medicine? What are the risks/side-effects?

All drugs for the treatment of insomnia can be associated with side effects--particularly prolonged sedation and dizziness--that can result in the risk of injuries and confusion. Non-benzodiazepines (e.g., zolpidem [Ambien]) and melatonin-receptor agonists are the safest and most efficacious hypnotic drugs currently available. Benzodiazepines can be effective but have more complications and the additional risk of addiction. Antihistamines, antidepressants, anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults.

What is the Tx for chronic sinusitis?

All guidelines recommend maximizing treatment for allergic rhinitis, including regular use of nasal corticosteroids and, if indicated, allergen immunotherapy. A Cochrane review found that regular nasal saline irrigation is a useful adjunct in treating chronic sinusitis, though not as effective as nasal corticosteroids. There is no compelling evidence to support the use of antibiotics in patients with chronic sinusitis. The AAAAI/ACAAI Practice Parameter Update (2014) indicates that antibiotics can be used for acute exacerbations of chronic sinusitis. A Cochrane review concluded that there was "limited" evidence from one small study to support the use of antibiotics in patients with chronic sinusitis. A Canadian guideline recommended antibiotics for patients with chronic sinusitis only when there is pain or purulent discharge.

What are the USPSTF guidelines on screening for chlamydia?

All sexually active women <24 All pregnant women <24 All women 25+ who are at increased risk (have to use these criteria to increase the pretest probability because otherwise there would be more false pos than true pos) (can be tested by urine sample)

What are the medical Tx options for BPH?

Alpha-adrenergic antagonists decrease urinary symptoms in most men with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin and doxazosin. The American Urology Association (AUA) Guidelines Committee believes that all four medications are equally effective. 5-alpha-reductase inhibitors are more effective in men with larger prostates. Their effect on preventing acute urinary retention and reduction in need of surgery require long term treatment for more than a year. There are two 5-alpha-reductase inhibitors approved in the United States: finasteride and dutasteride.

How can oral radioactive iodine (RAI therapy) be used to treat Graves' disease? What are the risks?

Alternative to thyroid hormone suppressant medication. More commonly used in the United States. Iodine concentrated in the thyroid and has very few side effects. During the course of a few months the iodine destroys most of the overactive thyroid cells and the level of thyroid hormone falls and the thyroid gland shrinks in size. Eventually most people who have this treatment start having too little thyroid in their blood stream so that they need to start taking small doses of thyroid hormone to replace it. Low thyroid is relatively easy to manage once you have found a dose where the patient feels normal and the TSH is in the normal range. Blood levels usually need to be drawn once or twice yearly and the dose of thyroid replacement usually stays about the same.

What are the two types of ankle support?

An Aircast is usually constructed of a hard plastic and has inflatable air chambers inside to provide more stability. It allows for some plantarflexion, dorsiflexion but controls inversion/eversion. This device is appropriate for more severe ankle sprains and not mild ones. A soft lace up brace is usually made of canvas and provides more limited support. This may be useful in an individual who has had a previous sprain or is returning to active sport competition.

What are the DSM-V criteria for Panic Attack?

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following 13 symptoms occur: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, light-headed, or faint Chills or heat sensations Paresthesias (numbness or tingling sensations) Derealization (feelings of unreality) or depersonalization (being detached from oneself). Fear of losing control or "going crazy" Fear of dying

What is the alternative triple regimen treatment of H. Pylori for those who are penicillin allergic?

An alternative 10-14 day triple regimen to consider in patients who are allergic to penicillin (70-85% eradication rate): PPI standard dose twice daily Clarithromycin 500 mg twice daily Metronidazole 500 mg twice daily

What test may be done on physical exam to assess for PAD?

An ankle-brachial index (ABI) can be done to determine the presence of PVD. An ABI of <0.9 is consistent with the disease.

What is the first line Tx for patients with the classic symptoms of GERD or PUD and no red-flag symptoms?

An empiric treatment strategy for GERD, gastritis, and PUD is the most widely accepted initial therapeutic intervention in patients without red flag symptoms. (notice: not lifestyle changes, although that may be an ajuvant to this therapy) The empiric treatment strategy for a patient who exhibits the classic symptomatology of GERD with heartburn and regurgitation begins with a self-directed trial of over-the-counter anti-secretory therapy, either a histamine-2 receptor antagonist or a proton-pump inhibitor (PPI). Many patients consult their primary care physicians because their symptoms have persisted, or because they would like a prescription, which may reduce their out-of-pocket cost for anti-secretory therapy.

What is the hormonal patch? How is it administered?

An hormonal patch is a small beige transdermal patch placed on the skin once a month, and left in place for three weeks, then removed for the fourth week. Withdrawal bleeding occurs during the week without the patch. The patch slowly releases estrogen and progestin. Effectiveness, mechanism of action, and risks are essentially the same as for oral contraceptives.

What are the Ottawa Rules for knee xray?

An x-ray series is only required for knee injury patients with any of these findings: Age 55 or older Isolated tenderness of the patella (that is, no bone tenderness of the knee other than the patella). Tenderness at the head of the fibula. Inability to flex to 90 degrees. Inability to bear weight both immediately and in the emergency department (4 steps; unable to transfer weight twice onto each lower limb regardless of limping).

What are annular lesions? Subtypes?

Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull's eye lesion).

For what pain syndrome are anticonvulsants an effective therapy?

Anticonvulsants have been shown to be helpful for pain related to trigeminal neuralgia, but evidence is lacking for other chronic pain syndromes.

What other medications may be given for N/V in pregnancy?

Antihistamines Diphenhydramine, 25-50 mg every 4 to 8 hours Motility agents Metoclopramide, 5-10 mg three times daily. If severe symptoms occur associated with acute illness, IV fluids for rehydration may be indicated. In cases of prolonged or severe hyperemesis gravidarum, TPN and/or systemic corticosteriods may also be considered.

When is it recommended to give antivirals for influenza?

Antivirals such as zanamivir, oseltamivir, amantadine, and rimantadine can decrease the duration of influenza symptoms by approximately 24 hours, but they are only recommended when given within the first 48 hours of illness. The only indications for starting antivirals for influenza after 48 hours of onset of illness are: 1. if the patient has moderate to severe community acquired pneumonia with findings consistent with influenza 2. if the patient is clinically worsening at the time of the initial outpatient visit

What is the more likely etiology if a pt with palpitations complains of rapid or irregular heart beat?

Anxiety Arrhythmias - although most people with arrhythmias do not complain of palpitations

How might the history differentiate anxiety and hyperthyroidism as the cause of palpitations?

Anxiety and hyperthyroidism can be difficult to distinguish because tachycardia, tremulousness, irritability, weakness, and fatigue can be present in both disorders. In anxiety, however, systemic symptoms such as weight loss and changes in stools and menses are rare.

How effective is arthroscopic debridement in OA?

Arthroscopic debridement hasn't been proven to help pain or functioning in osteoarthritis.

What signs/symptoms indicate that a patient is in the "red zone" on my asthma action plan?

As described in "My Asthma Plan", a patient in the red zone would be very short of breath, including when walking or talking (C) and signs of cyanosis (D) (gray or blue lips or fingertips would indicate severe respiratory distress).

What are the recommendations on screening for lung CA?

As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in patients aged 55-80 years old who have smoked for 30 pack years. To be considered, the patient should also be currently smoking or have quit within the prior 15 years.

What are the risks of mammography?

As with any other screening test, there is a potential for false positive results (leading to unnecessary procedures) or false negative results (giving patients a false sense of security). The sensitivity of mammography is between 60% and 90%. Low sensitivity means more false negative results. False negative results are more common in younger women since denser breast tissue makes it harder to find abnormalities on x-rays. Mammography is a radiograph which involves some radiation exposure. However, modern mammography systems use extremely low levels of radiation, usually about 0.1 to 0.2 rad per x-ray, which is minimal and provides negligible risk. Also, mammograms can be uncomfortable for patients.

What is uterine synechiae (including other name)?

Asherman syndrome (AS), also known as uterine synechiae, is a condition characterised by formation of intrauterine adhesions. It results from injury to the endometrium, and is often associated with infertility.

What are the 5 A's when counseling someone in smoking cessation?

Ask - Identify and document tobacco use status for every patient at every visit. Advise - In a clear, strong, and personalized manner, urge every tobacco user to quit. Assess - Is the tobacco user willing to make a quit attempt at this time? Assist - For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. Arrange - Schedule followup contact, in person or by telephone, preferably within the first week after the quit date.

What are the 5 A's of counseling for behavior change?

Ask or Address the behavior needing change. Assess for interest in behavior change. Advise on methods to change behavior. Assist with motivation to change behavior. Arrange for follow-up.

How do you assess for lid lag?

Ask the patient to follow your finger with their eyes then move your finger slowly from their upper to lower field of vision. In lid lag, the upper eyelid lags behind the upper edge of the iris as the eye moves downward. Be careful when performing this maneuver; if your finger is moved too quickly, the diagnosis may be missed.

What are the most common complications of strokes?

Aspiration pneumonia Malnutrition/dehydration Pressure sores

What risk factors contribute to the development or exacerbation of PUD?

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) are the predominant pharmacologic agents that contribute to the development of PUD. Classically, the elderly are at the highest attributable risk of ulceration and perforation due to chronic NSAID use. Chronic NSAID use is a leading cause of morbidity in the elderly. Moderate to severe physiologic stress may lead to stress ulceration, predominantly in patients in the intensive care unit (ICU). Colonization of the stomach by H. pylori renders the underlying mucosa more vulnerable to peptic acid damage by disrupting the mucous layer, liberating enzymes and toxins, and adhering to the gastric epithelium. In addition, the body's immune response to H. pylori incites an inflammatory reaction that contributes to tissue injury and leads to chronic gastritis There is no evidence to support a cause-and-effect association between cigarette smoking and PUD. However, cigarette smoking does decrease vascularity to gastric mucosal cells, resulting in decreased rates of mucosal healing after insult, and in combination with NSAID use or H. pylori infection, increases the risk of ulceration.

What is Aggrenox?

Aspirin with dipyridamole (Aggrenox)

What conditions can present with wheezing?

Asthma is the most common cause of persistent cough and wheezing. Other causes of wheezing to consider include: chronic obstructive pulmonary disease congestive heart failure foreign body aspiration persistent bronchitis upper airway cough syndrome vocal cord dysfunction pulmonary embolism

What are the ABCDE's of Suspicious Skin Lesions?

Asymmetry Border irregularity Color non-uniform Diameter >6 mm Evolution or change over time

What is the ABCDE rule for skin CA?

Asymmetry: Asymmetry in two or more axes. Border: Irregular border. Color: Two or more colors. Diameter: Six millimeters or greater. Enlargement: Enlargement of the surface of the lesion.

What are the indications for exercise stress testing?

Asymptomatic male patients over 45 years of age with one or more risk factors (hypercholesterolemia, hypertension, smoking, or family history of premature coronary artery disease) may obtain useful prognostic information from exercise testing.

At what point is the fundus just palpable at the pelvic brim?

At 10 weeks

What fetal development occurs in the second trimester?

At 18 weeks, the baby will able to display facial expressions, have early skeletal development and may display perceptible movements. The baby's sex can be determined via ultrasound at this point. Soon, the baby will have visible hair, fingerprints and footprints. Over the next several weeks, the baby will continue to grow, and its lungs, liver and immune system will continue to mature.

When does the USPSTF recommend screening everybody for HTN yearly?

At age 18

CVD and stroke are together called what? And how are major and minor risk factors used to assess a persons risk?

Atherosclerotic cardiovascular disease (ASCVD) can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a patient's risk category from that determined by the major risk factors

What is the most commonly used mod-high intensity statin?

Atorvastatin 10-20mg or 40-80mg

Epithelial abnormalities on PAP test are further subdivided into what four categories?

Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous. Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress. High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion. Squamous cell carcinoma.

What is Graves' disease?

Autoimmune disease in which thyrotropin receptor antibodies (also called thyroid stimulating immunoglobulins) are produced. These antibodies stimulate the thyroid gland to enlarge and to produce more thyroid hormone. Causes about 60-80% of hyperthyroidism. Women are five to ten times more likely than men to get it. Peak incidence is between ages 40-60. Often occurs with family history of thyroid disease; can also be associated with other autoimmune diseases. Triggers include stressful life events, high iodine intake, or a recent pregnancy.

Which nicotine replacement delivery methods are OTC and which are not? How can these be combined?

Available without prescription: Gum, patch, and lozenge Require prescription: transdermal patch, inhaler, nasal spray, and sublingual tablet Although not FDA approved for heavier smokers (>1 pack per day), the patch may be combined with a short acting form of nicotine replacement for additional relief of urges and cravings.

Results of the TUG test correlate with what?

Average Number of Seconds for TUG Mobility Prediction <10 Freely mobile < 20 Mostly independent 20-29 Variable mobility > 30 Impaired mobility

"D" (not recommended) screening recommendations include?

Bacteriuria, bladder cancer, pancreatic cancer, testicular cancer, spirometry for COPD, genital herpes, gonorrhea, hemochromatosis, and hepatitis B. Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important to consider other factors, including family history, travel history, sexual history, etc.

What are the salient features of Basal cell carcinoma?

Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia. Usually there is no associated itching or change in skin color. Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere. Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize. A long history of sun exposure is a risk factor for basal cell carcinoma.

When should elderly women be screened for cervical CA?

Based on USPSTF recommendations, women over the age of 65 should not be screened for cervical cancer if they have had adequate recent screening with normal Pap smears, and are not otherwise at high risk for developing the disease.

What is the bridge to rhythm control in a patient with <48 h of afib?

Because oral anticoagulants take several days to have therapeutic effect, patients presenting with acute AF are treated with IV heparin (aPTT of 45 to 60 seconds) or subcutaneous low molecular weight heparin while they are awaiting cardioversion and being evaluated for long-term anticoagulation.

What classes of medication act as migraine prophylaxis?

Beta-blockers Neurostabilizers TCAs Herbal

What are the USPSTF recommendations for BRCA screening?

Biennial screening mammography for women aged 50-74 years (Grade B recommendation) Decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms ( Grade C recommendation)

What types of bisphosphonates are available to treat osteoporosis?

Biphosphonates are potent inhibitors of bone resorption and reduce bone turnover, resulting in increase in bone mineral density. Biphosphonates have been shown to decrease the risk of vertebral and non-vertebral fractures. Alendronate (Fosamax) and risedronate (Actonel) are available in generic form, making them more affordable. Ibandronate (Boniva) is only available in trade name and the cost may be prohibitive to some patients. Zoledronic acid, an intravenous preparation, is given annually and can be used in patients who do not tolerate the oral bisphosphonates.

How might it be normal for a pregnant female to still have her period early in pregnancy?

Bleeding can occur in early pregnancy around the time of the missed menses as a result of an invasion of the trophoblast into the decidua (implantation bleed).

When might vaginal bleeding be considered a normal finding in HRT?

Bleeding in the first 12 months of HRT can be normal, however bleeding after 12 months of therapy always requires further evaluation.

How useful are blood tests of hCG for pregnancy?

Blood tests of hCG can detect levels as low as 5 mIU/mL, although care needs to be taken regarding the potential for false positives at this very low level. Blood tests of hCG are not usually used for initial diagnosis, but can be very helpful in determining the viability of a pregnancy since hCG levels rise predictably in early pregnancy. Levels of hCG double approximately every 2.2 days over the first few weeks and then double more slowly approximately every 3.5 days by 9 weeks. Levels of hCG peak at 10-12 weeks and then decline rapidly thereafter until 22 weeks, when levels gradually rise until delivery.

What other measurements may help risk stratify obese patients?

Body fat distribution may provide additional risk stratification for coronary artery disease beyond BMI. Waist circumference and waist-hip ratio, as indicators of abdominal adiposity, are independent risk factors for coronary artery disease. Consider measuring these in overweight patients to further determine risk and need for weight loss.

How are gest HTN and preeclampsia further sub-categorized?

Both gestational hypertension and more specific categories, such as preeclampsia, can be classified as severe. This is a defined as the occurrence of an elevation in systolic blood pressure of ≥ 160 mmHg and/or diastolic blood pressure of ≥ 110 mmHg for at least six hours.

What are the complications in T1 and T2 DM?

Both types of diabetes cause the same end-damage. High blood glucose eventually affects blood vessels and therefore organs throughout the entire body. The heart, brain, kidneys, and eyes and the nerves that control sensation and autonomic function are affected.

What is Bowen's disease?

Bowen's disease is a very early form of skin cancer that's easily treatable. The main sign is a red, scaly patch on the skin. It affects the squamous cells - in the outermost layer of skin - and is sometimes referred to as "squamous cell carcinoma in situ"

What is the mechanism and side effects of Buproprion?

Bupropion (Wellbutrin, Zyban, Budeprion) Mechanism: Norepinephrine and dopamine reuptake inhibitor. Use: It is started a week before the quit smoking date. The dose is titrated up and maintained for 2-3 months. It may be used in conjunction with nicotine replacement methods, especially those that can be titrated during the day. Adverse effects: Bupropion has been associated with an increase in suicide in adolescents and young adults. Contraindications: It should not be used in patients with seizures and with caution in those with significant renal or hepatic impairment.

Information about herbal meds for migraine prophylaxis:

Butterbur (100-150mg) FDA: No Cheap Cautions: hepatotoxicity, allergic reactions in patients with plant allergies, safety not established for long-term use S/E: belching, headache, itchy eyes, GI issues, asthma, fatigue

What are the USPSTF recommendations on using CA-125 levels to screen for ovarian CA?

CA-125 level CA-125 is not indicated as a screening tool for ovarian cancer by the USPSTF. This is supported by evidence that although it may detect ovarian cancer at an earlier stage, it does not lower mortality rates. In addition, the prevalence of ovarian cancer is low, giving the test a low positive predictive value, which makes this a poor screening tool.

What mnemonic guide the practitioner in asking questions to assess for alcohol abuse?

CAGE felt the need to Cut down your drinking? felt Annoyed by criticism of your drinking? had Guilty feelings about drinking? taken a morning Eye opener?

How do you screen for alcohol abuse?

CAGE mnemonic Positive answers to two or more of the CAGE questions are sufficient to identify individuals who require more intensive evaluation. Also, a positive answer to the question, "Have you ever had a drinking problem?" plus evidence of alcohol consumption in the previous 24 hours provides greater than 90% sensitivity and specificity as a screening tool for identifying alcoholism.

What does CHA2DS2-VASc stand for?

CHF HTN Age >_75 = 2pt Diabetes Mellitus Stroke/TIA/thromboembolism Hx = 2 Vascular disease Age 65-74 = 1pt Sex is female

What are the benefits and risks of COX-2 inhibitors?

COX-2 inhibitors are a form of oral NSAID that have less risk of gastrointestinal bleeding, but increase cardiovascular risk, which is why several were removed from the market.

What mnemonic is useful for remembering the differential for low back pain?

CT MIND w/ IV contrast Congenital Traumatic Metabolic Infectious Neoplastic Degenerative Inflammatory Vascular/Visceral

What are the adverse effects of caffeine in pregnancy?

Caffeine Likely safe in moderate amounts Based on observational studies, although high caffeine consumption has been associated with spontaneous abortion and low-birth-weight infants. However, confounding factors such as smoking, alcohol use, nausea, and age cannot be ruled out.

What are the current USPSTF guidelines on Calcium and Vitamin D supplementation?

Calcium supplementation for osteoporotic fracture prevention has raised concerns that it may increase the risk of atherosclerotic vascular disease as well as for kidney stones. However, it is unclear from the present data whether intake of dietary calcium versus calcium supplementation increases cardiovascular risk or the risk for kidney stones. A USPSTF 2013 recommendation statement concluded that current evidence is insufficient to assess the risks and benefits of calcium and vitamin D supplementation for prevention of fractures in premenopausal and noninstitutionalized postmenopausal women. Therefore the USPSTF is currently recommending against calcium and vitamin D supplementation in healthy pre or post menopausal women. At this time the most prudent recommendation would be to try to increase intake of dairy and try to include weight bearing exercises such as walking into a daily routine.

How do you calculate the estimated due date?

Calculating the estimated due date (EDD - sometimes referred to as the estimated date of confinement or EDC) from the last menstrual period is a relatively simple process that can be done with an obstetric "wheel", with an electronic calculator or using Naegele's Rule.

What criteria help the clinician individualize recommendations for mammogram based on risk?

Calculating the risk using the Gail criteria is helpful in individualizing recommendations for mammogram.

How might anemia cause palpitations?

Can be associated with palpitations because of sinus tachycardia due to reduced oxygen carrying capacity in the blood (Anemia can also cause dyspnea via this mechanism). Patients with anemia severe enough to cause tachycardia typically report positional dizziness Several causes of anemia are associated with weight loss including nutritional deficiencies (vitamin B12, folate) and malignancy. A common source of anemia in menstruating women is heavy periods In rare cases occult bleeding, for example from the GI tract, can be present and cause anemia.

What other S/S point towards drug/caffeine abuse as the cause of palpitations?

Can cause palpitations. Intoxication with substances such as cocaine, methamphetamines and even alcohol can cause tachycardia. Signs such as dilated pupils, increased energy, increased blood pressure, and erratic behavior all suggest intoxication.

What makes sponlylolisthesis more likely?

Can occur at any age. Causes aching back and posterior thigh discomfort that increases with activity or bending.

What are the red flags for cancer in LBP?

Cancer 1. History of cancer 2. Unexplained weight loss >10 kg within 6 months 3. Age over 50 years or under 17 years old 4. Failure to improve with therapy 5. Pain persists for more than 4 to 6 weeks 6. Night pain or pain at rest

What anticonvulsant may decrease the effectiveness of birth control?

Carbamazepine (Tegretol) can interfere with other medications because it is a cytochrome P-450 inducer, including decreasing the effectiveness of hormonal contraception.

What carrier screening is done in preconception counseling?

Carrier screening (ethnic background): sickle cell anemia thalassemia Tay-Sachs disease Carrier screening (family history): cystic fibrosis nonsyndromic hearing loss (connexin-26)

What causes thyroid nodules and what is the main concern?

Caused by a variety of thyroid disorders. Because 5% of all palpable thyroid nodules are malignant, the main objective of evaluating nodules is to exclude malignancy.

What are common causes of secondary HTN?

Causes of secondary hypertension include sleep apnea, chronic renal disease, renovascular causes, drug-induced causes, pheochromocytoma, primary aldosteronism, chronic steroid use, Cushing's syndrome, thyroid and parathyroid disease, and coarctation of the aorta.

What are the salient features of acute pancreatitis?

Causes severe abdominal pain, associated nausea and vomiting, ill appearance on exam, and clinical signs of dehydration such as tachycardia. Pain is typically located in the epigastric area with radiation to the back and worsens with eating. Symptoms often last for many hours without relief. Acute and chronic pancreatitis may be caused by alcohol use. Remember that some patients may not be forthcoming about their actual alcohol use, especially if they perceive they are being judged or if they are in denial about problem use/abuse.

What is the utility of the Rapid Antigen Detection Test (RADT) in assessment of GABS pharyngitis?

Centaur or McIsaac criteria first to increase pretest probability. The diagnosis of group A strep pharyngitis in children must be confirmed microbiologically before antibiotic treatment is started. RADT should be the initial test instead of the "gold standard" throat culture when: You have a very high suspicion of the diagnosis of GABHS pharyngitis, and note that because of your suspicion, you will perform a throat culture if the RADT is negative. RADT has a 95% specificity for group A strep. RADT results are obtained within minutes of performing the test (throat culture must be incubated for at least 24 hours, and often up to 48 hours), thereby allowing you to treat immediately, reducing risk of morbidity, decreasing the duration of her symptoms, and decreasing risk of spreading the disease.

How immediately might you start therapy with coumadin?

Certain types of stroke are associated with an increased risk of intracranial hemorrhage at the site of the infarct with early anticoagulation. Current guidelines recommend delaying starting anticoagulation. You might recommend starting coumadin in two weeks as opposed to immediately. Do a risk assessment first with CHADS2VASC acoring.

How long does the asymptomatic phase last in cervical CA?

Cervical cancer has a long asymptomatic pre-invasive state (often a good decade or more), and there are effective treatments for pre-invasive disease.

What are the hallmark signs of PID?

Cervical motion tenderness, known as a positive "chandelier sign" is considered pathognomonic of pelvic inflammatory disease (PID). Women with pelvic infections often have mild menstrual irregularities.

What are the salient features of bacterial pneumonia?

Characterized by a temperature greater than 38 degrees C (100.4 degrees F). Most commonly caused by streptococcus pneumoniae. Streptococcal pneumonia (also called pneumococcal pneumonia) often presents abruptly in children with a fever and sputum production. Does not have prodromal symptoms such as rhinorrhea or myalgias, though myalgias can be seen in atypical or viral pneumonias. Streptococcal pneumonia in other age groups may have an abrupt or gradual onset and the usual symptoms include pleuritic chest pain, fever, chills, and dyspnea. Cough is usually present, but may not be prominent. Approximately one half of patients with streptococcal pneumonia have an accompanying pleural effusion. Crackles (formerly called rales) are a cardinal feature of pneumonia. Focal crackles in a febrile child without underlying lung disease is pneumonia until proven otherwise, though crackles will not be heard in all children with pneumonia. Other examination findings suggestive of pneumonia include focal wheezing or whistling sounds and decreased breath sounds in one lung field.

WHat are the salient features of influenze? Who presents atypically? Who is most at rrisk?

Characterized by upper and lower respiratory tract symptoms accompanied by systemic symptoms such as myalgia, fever, headache, and weakness, though children with influenza frequently present first with a headache, sore throat and generalized malaise before the upper respiratory symptoms of cough appear. Influenza is so abrupt that patients can often tell the precise time of onset. Outbreaks typically occur during the winter months. Presents in many ways, and headache can be the first symptom for some adults and children. Fever >39° C is often the first sign in younger children. However, older children can have a constellation of symptoms, and it can be difficult to determine if influenza is present. Very young children can present with febrile seizures. High fever of 102-104 F and chills are common, along withsevere myalgias and headache. The influenza virus can cause upper and lower respiratory tract symptoms resulting in rhonchi being heard on the lung exam. Rhonchi are a result of the complications of influenza and are not one of its primary physical exam findings. Affects between 15 and 42 % of preschool and school age children each year, children younger than two years of age have higher rates of complications and hospitalization.

What special considerations are given for beta-blockers? (not used in JNC-8) When is it used for HTN?

Check initial EKG and pulse. You don't have to avoid in diabetic patients as the theoretical possibility of masking hypoglycemic episodes has not been shown in real world clinical situations. Excellent for use in tachyarrhythmias / fibrillation, migraines, essential tremor, and perioperative hypertension. Usually avoid in patients with asthma (depending on receptor sensitivity of drug) and in third degree heart block.

What conditions are more likely in children with knee pain?

Children and adolescents who present with knee pain are likely to have patellar subluxation, tibial apophysitis (Osgood-Schlatter), or patellar tendonitis). Please see the Expert for additional information.

When are chlamydia cultures used?

Chlamydia cultures should only be used in cases of forensic investigation, such as rape or child abuse.

Why is screening for Chlamydia necessary?

Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality.

What chronic condition may follow a DVT?

Chronic venous insufficiency may result from DVT and/or valvular incompetence. Following DVT, the valve leaflets become thickened and contracted so that they are incapable of preventing retrograde flow of blood; the vein becomes rigid and thick-walled. Although most veins recanalize after an episode of thrombosis, some may remain occluded. Secondary incompetence develops in distal valves because high pressures distend the vein and separate the leaflets.

What are the salient features of ankylosing spodylitis?

Chronic, painful, inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the spine. Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and lumbar spine.

Why is cipro contraindicated in pregnancy?

Ciprofloxacin (and any quinolone antibiotic) is also contraindicated in pregnancy due to its potential effects on the fetal bone growth plates.

What natural changes to sleep patterns often occur in the elderly and may cause diminished sleep health? What syndrome may occur?

Circadian rhythms change, with older adults tending to get sleepy earlier in night. In advanced sleep phase syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 PM. If they go to sleep at this hour, they sleep a normal 7-8 hours, waking at 3 or 4 am. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 am. This can be difficult to distiguish from insomnia.

What are the risk factors for PAD?

Classic risk factors for PAD are smoking, diabetes mellitus, hypertension, and hyperlipidemia. Obesity (body mass index (BMI) >30) increases risk for PAD as well. Recent trials have added chronic renal insufficiency, elevated C-reactive protein levels, and hyperhomocysteinemia to the list of risk factors. The greatest modifiable risk factor for the development and progression of peripheral arterial disease (PAD) is cigarette smoking. Cigarette smoking increases the odds for PAD by 1.4 for every ten cigarettes smoked per day. Arterial insufficiency is four times more prevalent in patients with diabetes than in those without diabetes. Nearly half of patients who've had diabetes for 20 years or more have peripheral arterial disease (PAD), usually below the knees.

What are the classic signs/symptoms of DVT?

Classic symptoms of DVT include swelling, pain, and discoloration in the affected extremity. Physical examination may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation. Classic signs of DVT, including Homan's sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth, are difficult to ignore, but they are of low predictive value and can occur in other conditions such as musculoskeletal injury, cellulitis, and venous insufficiency. Patients with venous thrombosis often complain of a dull ache in the leg that worsens with prolonged standing and resolves with leg elevation. Examination reveals increased leg circumference, edema, and superficial varicose veins.

What are the JNC-8 classifications for HTN?

Classification of Blood Pressure for Adults (>18 years of age) BP Classification Systolic / Diastolic Normal <120 / <80 Prehypertension (Normal) 120 - 139 / 80 - 89 Hypertension Stage 1 140 - 159 / 90 - 99 Hypertension Stage 2 >160 / >100

What are your 4 main tasks in the initial evaluation of a patient with asthma?

Classify asthma severity. Assess the patient's knowledge and skills for self-management. Identify and control environmental factors and comorbid conditions that may aggravate asthma. Offer appropriate medications.

What are the Risk Factors for Recurrence and Metastasis of Cutaneous Squamous Cell Carcinoma?

Clinically Size bigger than two centimeters Location: Ear or lip History of radiation treatment History of treatment for squamous cell carcinoma Locally recurrent Immunosuppressed patient Rapid growth Histologically Tumor depth more than four millimeters Poorly differentiated Infiltrate deep or peripheral margins Perineural invasion

What is Colic in an infant? How common is it? When does it occur?

Colic is uncontrollable crying in an otherwise healthy baby. Your baby is considered colicky if he's younger than 5 months old and cries for more than three hours in a row on three or more days a week for at least three weeks Colic affects approximately 20-25% of all infants. Symptoms typically begin around the age of two weeks, peak at about six weeks, and gradually improve over the next several weeks, with most infants free of symptoms by twelve weeks of life.

What are the different options for screening tests for colon CA?

Colon Cancer Screening Options Screening colonoscopy every 10 years Annual testing of three stools for blood and a flexible sigmoidoscopy test every 5 years Double-contrast enemas every five years CT colography (virtual colonoscopy) is still considered experimental A rectal exam and test for occult blood are not adequate screening.

What are the USPSTF recommendations for screening for colon CA?

Colon cancer screening is recommended for everyone over the age of 50 continuing until the age of 75. There are various ways to screen, including: Stool-based tests: Usually performed annually. Guaic-based fecal occult blood tests (gFOBT) are a bit less convenient than fecal immunochemical tests (FIT) as they require collecting three samples, whereas FIT only require one sample. Studies have found FIT testing more sensitive than gFOBT testing for colorectal cancer and adenomas. Any positive stool-based screen must be evaluated with a more definitive test, usually a colonoscopy. Colonoscopy: Allows for a biopsy. Is often utilized especially if the patient has a family history of colon cancer, a change in bowel habits, or any reported rectal bleeding.

What is the full spectrum of sequelae that can result from chronic H Pylori infection?

Colonization of the stomach by H. pylori renders the underlying mucosa more vulnerable to peptic acid damage by disrupting the mucous layer, liberating enzymes and toxins, and adhering to the gastric epithelium. In addition, the body's immune response to H. pylori incites an inflammatory reaction that contributes to tissue injury and leads to chronic gastritis. In most individuals the chronic gastritis is asymptomatic and does not progress. In some cases, however, altered gastric secretion coupled with tissue injury leads to peptic ulcer disease. In other cases, gastritis progresses to mucosal atrophy, intestinal metaplasia, and eventually gastric carcinoma. Rarely, persistent immune stimulation of gastric lymphoid tissue can lead to gastric lymphoma.

What are the most common causes of HA in the outpatient setting?

Common types of headache seen in the outpatient setting: Tension type Migraine Medication overuse

What are the 3 C's of addiction?

Compulsion to use Lack of Control Continued use despite adverse consequences

What are the potential causes of each and what is the likelihood of obtaining that Dx?

Condition % of Dyspepsia Cases Functional or non-ulcer dyspepsia (specific etiology for dyspepsia can't be identified) ~ 50% Peptic ulcer disease (PUD) 20% GERD 20% Gastritis / duodenitis 15% Medication side effects Common Pancreatitis Less common Gastric, pancreatic, and esophageal cancer Important though uncommon (< 2%) Non-GI causes (such as angina and dissecting aortic aneurysm) Rare, but should always be included in ddx

What is a major and common comorbidity for patient's diagnosed with Down's syndrome?

Congenital heart disease is common in infants with Down syndrome, occurring in up to 44% of affected individuals.

What is the difference between the "conventional pap smear" and the liquid based system?

Conventional - Uses Ayers spatula (ectocervix) and cytobrush (endocervix), smeared onto slide and heat-fixed. Single slide for both samples. Liquid based - Uses Ayers spatula (ectocervix) and cytobrush (endocervix), except extended tipped plastic spatula is recommended. Samples placed into an alcohol based preservative solution (allows for co-testing of HPV) Two FDA approved liquid systems: the ThinPrep and Sure Path system, both are as good as or better than conventional method in diagnosing intraepithelial lesions and for obtaining adequate specimens.

Is it possible to use an IUD immediately post-partum?

Copper-containing IUDs are the only type of IUD approved for use postpartum and may be inserted immediately. Immediate insertion has been shown to be safe and effective, although earlier insertion has a slightly higher expulsion rate compare to insertion at 4-6 weeks postpartum. Levonorgestrel-releasing IUDs (Mirena) should not be inserted until 6 weeks post-partum (full involution of the uterus) due to a higher risk of perforation and expulsion.

What physical exam changes are associated with dyslipidemia?

Corneal arcus, xanthelasmas, acanthosis nigricans

What are the risk factors for osteoporosis?

Corticosteroid use Family history of osteoporosis, especially if a first-degree relative has fractured a hip. Previous fragility fracture defined as a low-impact fracture Smoking Heavy alcohol use Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density. Obesity (B) does not put patients at risk for osteoporosis, but neither is obesity protective against osteoporosis. Caucasian race - At any given age, African-American women on average have higher bone mineral density (BMD) than white women. The USPSTF, while acknowledging that the data for non-white women is less compelling than for whites, recommends screening all women at age 65 or earlier if they have equivalent risk.

How does couple's therapy typically fair in occurances of intimate partner abuse?

Couple's therapy has been shown to increase the level of risk for the victim. The victim exposes the abuse, and the perpetrator feels like they are losing control and tries to regain it through further violence.

What are the different types of vehicles for administration of topical steroids?

Creams: The cream base is a mixture of several different organic chemicals (oils) and water, and usually contains a preservative. It can be used in nearly any area and therefore most often prescribed. It is cosmetically most acceptable. It has a drying effect with continuous use, therefore best for acute exudative inflammation. Ointments: The ointment base contains a limited number of organic compounds consisting primarily of grease such as petroleum jelly, with little or no water. Ointment is desirable for drier skin and has a greater penetration of medicine than a cream and therefore has enhanced potency. Lotions and gels: Lotions contain alcohol, which has drying effect on an oozing lesion. Lotions are most useful in the scalp area because they penetrate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflammation, such as poison ivy.

What is the current recommendation involving pertussis in adults?

Current recommendations recommend substituting a one-time dose of Tdap for Td booster (tetanus and diphtheria) for ages 11-64 to provide additional pertussis protection, then boost with Td every 10 years

What is the DASH diet?

DASH - Dietary Approaches to Stop Hypertension Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat.

What dietary supplement should pregnant women take?

Daily prenatal vitamin, which provides the recommended folic acid (0.4 to 0.8 mg per day) and iron (30 mg per day) for pregnant women.

What changes seen on physical exam are associated with atherosclerosis?

Decreased peripheral pulses, carotid bruit

What is the diagnostic definition of Metabolic Syndrome?

Defined in adults as having at least three of the following, hypertriglyceridemia, low HDL, elevated fasting blood glucose levels, excessive waist circumference, or hypertension

What is dyspepsia?

Definition Dyspepsia is literally "bad digestion." Symptoms Patients with this condition experience upper abdominal pain or discomfort that is episodic or persistent. It is often associated with belching, bloating, heartburn, nausea, or vomiting.

How do you define chronic pain syndrome? And what is the approach to treatment?

Definition: Pain that persists beyond the expected period of healing. Usually the time interval is arbitrary and varies depending on the condition. Approach to treatment: Set clear goals with patients. Rarely possible to completely relieve pain, so aim to achieve a level of pain the patient feels he/she can live with. Measure with functional goals and numeric assessment of pain level. Use non-pharmacologic treatments such as biofeedback for chronic pelvic pain, physical therapy and cognitive behavioral therapy for chronic back pain. When using medications, first select specifically targeted non-opioid therapies such as anti-epileptic drugs for neuropathic pain or anti-inflammatories for musculoskeletal pain. When using opioids: - Use long-acting agents along with the other agents and use the lowest possible dose that improves patients' function. - Use a pain medication agreement.

What are the red flags for domestic partner abuse?

Delay in seeking medical care Non-compliance with treatment plan Partner insisting on staying close and answering questions directed to patient Hesitancy in answering questions or inconsistent or incorrect answers given to questions Shyness or reticence in answering questions

What are the risk factors for abuse in the elderly?

Dementia. Shared living situation of elder and abuser (except in financial abuse). Caregiver substance abuse or mental illness. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder's dependency and the resulting stress has not been found to predict abuse. Social isolation of the elder from people other than the abuser.

What is depo-provera? How often are the injections? Side effects?

Depo-Provera injection is a progestin injection given once every twelve weeks, which is 97-99.3% effective against pregnancy. The mechanism of action is similar to the oral contraceptive. The most common side effect is irregular to absence of vaginal bleeding, worse in the first six to nine months. Depression, weight gain, and bone loss are the most concerning complications.

Depression increases the risk for diabilities in mobility and ADLs by how much in the elderly?

Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of 6 years.

How prevalent is retinopathy in DM?

Diabetes is the most common cause of new cases of blindness among adults of working age. Five years after diagnosis of type 2 diabetes, patients with more severe or uncontrolled disease that requires insulin have a 40% prevalence of retinopathy while those on oral hypoglycemic agents have a 24% prevalence. After 15 years of diabetes, almost all patients with type 1 diabetes and two thirds of patients with type 2 diabetes have background retinopathy. By the time the patient's vision is affected, substantial retinal damage may have already occurred. Proliferative retinopathy is prevalent in 25% of the diabetes population with 25 or more years of diabetes.

How must medical treatment for certain conditions change when planning to conceive?

Diabetes: optimize control, folic acid, 1 mg per day, off ACE-inhibitors Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists, thiazide diuretics Epilepsy: optimize control; folic acid, 1 mg per day DVT: switch from warfarin (Coumadin) to heparin Depression/anxiety: avoid benzodiazepines

What criteria must a patient meet to be considered for Tx with tPA?

Diagnosis of ischemic stroke causing measurable neurologic deficit. The neurological signs should not be clearing spontaneously The neurological signs should not be minor and isolated Caution should be exercised in treating a patient with major deficits The symptoms of stroke should not be suggestive of subarachnoid hemorrhage Onset of symptoms 4.5 hours before beginning treatment No head trauma or prior stroke in previous 3 months No gastrointestinal or urinary tract hemorrhage in previous 21 days No major surgery in the previous 14 days No arterial puncture at a noncompressible site in the previous 7 days No history of intracranial hemorrhage Blood pressure not elevated (systolic <185 mmHg and diastolic <110mmHg) No evidence of active bleeding or acute trauma (fracture) on examination Not taking an oral anticoagulant or, if anticoagulant being taken, INR<=1.7 If receiving heparin in previous 48 hours, a PTTmust be in normal range Platelet count >=100 000 mm3 Blood glucose concentration .= 50 mg/dL No seizure with postictal residual neurological impairments CT does not show a multilobar infarction (hypodensity >1/3 cerebral hemisphere) The patient or family members understand the potential risks and benefits from treatment.

What are the diagnostic criteria for analgesic rebound HAs? And the treatment?

Diagnostic criteria More than 15 headaches per month. Regular overuse of an analgesic for more than three months. Development or worsening of a headache during medication overuse. Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication. Treatment Stopping the overused medication.

Jet lag and shift work may cause what sleep disorder?

Disturbances in the sleep-wake cycle

What questions do you ask to screen for exposure to lead poisoning in children?

Does your child live in or regularly visit a house or child care facility built before 1950? Does your child live in or regularly visit a house or child care facility built before 1978 that is being or has recently been renovated or remodeled (within the last six months)? Does your child have a sibling or playmate who has or did have lead poisoning?

When is brain imaging indicated for HAs?

Don't do imaging for uncomplicated headache. The American Academy of Neurology and the U.S. Headache Consortium guidelines recommend neuroimaging only if: The patient has migraine with atypical headache patterns or unexplained abnormalities on neurological examination The patient is at higher risk of a significant abnormality The results of the study would alter the management of the headache

What is the most common means for suicide attempt in the elderly?

Drug overdose is the most common means of suicide on the elderly, making the safety of medications chosen to treat the condition important.

What are the general screening recommendations for ASCVD?

Due to this risk, the United States Preventive Services Task Force recommends: ALL adults >18 yrs be screened for hypertension Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs) All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions. Clinicians should discuss aspirin chemoprevention with all men over 45 for primary prevention of myocardial infarction.

What major fetal changes occur in the first trimester?

During the first 12 weeks, the heart, spine, arms, legs, and other organs begin to develop. The neural tube closes by 4 weeks. Around 7-8 weeks, the heart will begin to beat and the fetus will begin to move.

What are the red-flag symptoms that warrant referral to GI for endoscopy?

Dysphagia -Difficulty in swallowing. Dysphagia to solids suggests possible development of peptic stricture. Rapidly progressive dysphagia potentially indicates adenocarcinoma. Dysphagia to liquids suggests development of a motility disorder. Initial onset of upper GI symptoms after age 50 -Increased chance of cancer. Early satiety -May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer). Hematemesis -Vomiting blood, which suggests bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices. Hematochezia -Passing red blood with stool, which may indicate a rapidly bleeding ulcer or mucosal erosions. Iron deficiency anemia -The presence of hematemesis, hematochezia, and/or iron deficiency anemia may indicate possible bleeding from a peptic ulcer, mucosal erosions, or cancer. Odynophagia -Painful swallowing, which is associated with infections (e.g. candida), erosions, or cancer. Recurrent vomiting -Suggestive of gastric outlet obstruction. Weight loss -Associated with malignancy.

What model is useful in communicating with those of another ethnicity with differing beliefs about medicine?

ESTF Model Explanatory model of the illness from the patient's perspective. Social and financial barriers to adherence. Fears and concerns about the medication or its potential side effects. Therapeutic contracting and playback adherence.

What are the recommendations for early ophthalmology referral in diabetic patients?

Early detection and treatment of diabetic retinopathy can improve outcomes. Yearly dilated ophthalmoscopic exams are needed because many patients with retinopathy may not complain of symptoms. The dilated exam is very sensitive for detecting retinal thickening from macular edema and for early neovascularization. The use of fundus photography is more sensitive for detecting retinopathy, but is more difficult to obtain because of the need for a trained photographer and reader. Type 1 diabetes patients should have their first annual eye exam 5 years after diagnosis. However, type 2 diabetes patients should have their first dilated exam when they are first diagnosed (evidence level B) because roughly 20% of patients will already have some degree of retinopathy at diagnosis. Evidence from 2 large trials, the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS), demonstrates the value of referring patients for photocoagulation surgery in order to prevent vision loss in diabetes patients.

Dietary guidance for pregnant females?

Eat a healthy diet with a variety of foods, including protein (meat, dairy), fruits, vegetables, and whole grains. Avoid raw eggs, unpasteurized milk or milk products, soft cheeses (such as feta, brie, veined, Camembert, and Mexican queso fresco), unwashed fruits or vegetables, raw fish, shellfish, and large, steak-like fish (such as shark, swordfish, king mackerel, and tilefish).

What is an ectropion in pregnancy?

Ectropion: When the central part of the cervix appears red from the mucous-producing endocervical epithelium protruding through the cervical os, onto the face of the cervix. It has no clinical significance and is common in women who are taking oral contraceptive pills.

What are the effects of moderate alcohol intake?

Effects of moderate alcohol intake: The best-known effect of moderate alcohol intake is a small increase in HDL cholesterol. However, regular physical activity is another effective way to raise HDL cholesterol, and niacin can be prescribed to raise it to a greater degree. Alcohol or some substances such as resveratrol found in alcoholic beverages may prevent platelets in the blood from sticking together. That may reduce clot formation and reduce the risk of heart attack or stroke. (Aspirin may help reduce blood clotting in a similar way.) How alcohol or wine affects cardiovascular risk merits further research, but right now the American Heart Association does not recommend drinking wine or any other form of alcohol to gain these potential benefits.

Is wine better for you than other types of alcohol?

Effects of red wine: Over the past several decades, many studies have been published about how drinking alcohol may be associated with reduced mortality due to heart disease in some populations. Some researchers have suggested that the benefit may be due to wine, especially red wine. Others are examining the potential benefits of components in red wine such as flavonoids and other antioxidants in reducing heart disease risk. The linkage reported in many of these studies may be due to other lifestyle factors rather than alcohol. Such factors may include increased physical activity, and a diet high in fruits and vegetables and lower in saturated fats. No direct comparison trials have been done to determine the specific effect of wine or other alcohol on the risk of developing heart disease or stroke.

What effect can alcohol have on those who have certain existing chronic diseases?

Effects with certain chronic diseases: Patients with heart failure, cardiomyopathy, diabetes, hypertension, arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol ingestion.

Why is an emergent CT done for stroke patients?

Emergency CT scanning is done to identify most cases of intracranial hemorrhage and help discriminate nonvascular causes of neurological symptoms, like a brain tumor. The CT scan can also be examined for evidence of early signs of infarction, as widespread signs of early infarction are correlated with a higher risk of hemorrhagic transformation after treatment with thrombolytic agents. But, even so, data is insufficient that any specific CT finding (with the exception of hemorrhage) should preclude treatment with rtPA within three hours of stroke onset.

What are the emergency contraception medications available? Is this the abortion pill? What are the restrictions? When must it be used by for effectiveness?

Emergency Contraception are the morning after pill (MAP) and the early contraceptive pill (ECP) which must be used within 120 hours of unprotected intercourse; the earlier the better. One of the ways it is felt to work is by making the uterus or endometrium unfavorable for implantation. Levonorgestrel is available in the United States as Plan B One-Step, a single dose emergency contraceptive containing levonorgestrel 1.5 mg in a single tablet and as Plan B pill packs that contain two 0.75 mg tablets to be taken 12 hours apart. Generic formulations for the single tablet regimen are also available (eg, Next Choice One Dose, My Way). The single 1.5 mg dose regimen is available over the counter without age restrictions. The two 0.75 mg tablet levonorgestrel regimen is available only by prescription for those under age 17 years and kept behind the pharmacy counter to facilitate proof of age prior to purchase. MAP and ECP are not to be confused with RU 486, more commonly called "the abortion pill."

What is the main diagnosis that must be considered when a postmenopausal women presents with vaginal bleeding?

Endometrial Cancer The fourth most common cancer in women, and the main diagnosis that must be considered in a woman presenting with postmenopausal bleeding. Also must be considered in women over the age of 35 with symptoms suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia). Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding.

What is the gold standard for evaluating postmenopausal bleeding or abnormal bleeding in high risk younger patients?

Endometrial biopsy A histologic evaluation of the endometrium after dilation and curettage (D&C) is the traditional gold standard for the evaluation of postmenopausal bleeding and for abnormal bleeding in younger women at high risk for endometrial cancer. Office-based sampling using the Pipelle device is now widely used for this purpose and has sensitivity for detecting endometrial cancer in postmenopausal women as high as 99%. An endometrial biopsy will obtain a tissue sample that will be sent to Pathology to look for evidence of endometrial hyperplasia or endometrial cancer.

What is post stroke depression according to the DSM-5? And how common is it in stroke survivors?

Epidemiology One third of stroke survivors experience post-stroke depression. Definition DSM 5 defines this the occurrence of a mood disorder judged to be due to the direct physiological effects of another medical condition.

What are the salient features of PUD?

Epigastric abdominal pain that improves with meals is the hallmark of PUD. However, in some cases, symptoms of PUD may worsen with meals. NSAID use is associated with the development of PUD. Hematemesis, if present, suggests more complicated disease including bleeding ulcer and warrants urgent GI referral and endoscopy. Melena commonly occurs in the setting of an upper GI bleed secondary to PUD or hemorrhagic gastritis (e.g. NSAID-gastritits). Hematochezia only occurs in the setting of an upper GI bleed when massive (e.g. variceal rupture).

What is Essure?

Essure is a form of sterilization in which a coil of metal and polymer is placed in each proximal fallopian tube through hysteroscope. The coil expands into place when released. The body mounts an inflammatory response to the device resulting in fibrosis within weeks of implantation. A follow up hysterosalpingogram (HSG) is done to confirm infertility. While expensive, the cost is significantly less expensive than tubal ligation without the risks accompanying anesthesia and surgical incision. It is reported to be 99.8% effective after confirmation of success by HSG.

What medication classes have especially an increased risk of stroke associated with them?

Estrogens and neuroleptics are both associated with increased stroke risk

How might drug induced hyperthyroidism occur?

Excessive iodine can occur through diet or a medication such as amiodarone, which can induce thyroiditis.

How effective is exercise for OA?

Exercise has been shown to improve function and decrease pain in OA. Current guidelines strongly recommend that patients with symptomatic knee OA participate in an exercise program commensurate with their ability to participate; they do not preferentially recommend aquatic or land-based exercise.

When is exopthalmos most commonly seen?

Exopthalmos (also called proptosis) is the forward projection or bulging of the eye out of the orbit. This is most commonly seen in Graves' disease and can be either bilateral or unilateral.

Why isn't "watchful waiting" the best alternative after a patient's first episode of biliary colic?

Expectant management or "watchful waiting" would not be appropriate as natural history studies document a 70% risk of progression over 2 years to complications such as cholangitis, pancreatitis, cholecystitis, choledocholithiasis, gallstone ileus and Mirizzi syndrome (gallstone compression of the hepatic duct).

What are the salient features of Gout / pseudogout?

Extreme pain with any movement; also painful to touch No fever Acute pain and swelling without prior trauma Arthrocentesis with clear or slightly cloudy synovial fluid Negatively birefringent rods in gout Positively birefringent rhomboids in pseudogout

What is the FAST test?

FACE: Ask the person to smile. Does one side of the face droop? ARMS: Ask the person to raise both arms. Does one arm drift downward? SPEECH: Ask the person to repeat a simple phrase. Is their speech slurred or strange? TIME: If you observe any of these signs, call 9-1-1 immediately.

How might FSH and LH be used to evaluate menopause?

FSH and LH level: During menopause, as aging ovarian follicles become more resistant to gonadotropin (FSH and LH) stimulation, the ovarian granulosa cells produce less inhibin. The major role of inhibin is the negative feedback regulation of the pituitary FSH secretion and synthesis. Therefore, with less inhibin production, circulating FSH and luteinizing hormone (LH) levels increase. Sufficiently elevated follicular stimulating hormone (FSH) levels can be used to confirm menopause.

What are the non-modifiable risk factors for BRCA?

Family history of breast cancer in a first-degree relative (i.e., mother or sister) Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45 Genetic predisposition (BRCA 1 or 2 mutation) Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.) Female sex Increased breast density

What is fetal movement first detected by the mother called and around what time in pregnancy does it occur?

Fetal movement or "quickening" is detected by the mother around 18-20 weeks of gestation.

What are some possible causes of Afib with RVR?

Fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction are causative.

Why is it important to distinguish the cause of stroke as either cardioembolic or non-cardioembolic?

Finding the cause of a stroke is important because the source of the stroke can help determine the treatment. For patients with a cardioembolic cause, they should be placed on coumadin therapy. For patients with an atherothrombotic stroke, they need to be placed on an anti-platelet agent. Both of these treatment options are intended to reduce the risk of stroke

What anticipatory guidance for injury prevention is important in the 5 year old well check?

Fires/burns/test smoke alarms/fire escape plan Appropriate booster seat placed in back seat; seatbelts Keep home and car smoke-free Pool/tub/water safety - swimming lessons Use bike/skating helmet Supervise near pets, mowers, driveways, streets Limit time in sun, use hat/sunscreen Childproof home (matches, poisons, guns, cigarettes, cords, cleaners, medicines, knives) Gun safety

How effective is acetaminophen for OA?

First choice analgesic for both short and long-term treatment of mild to moderate pain related to osteoarthritis because of its tolerability and low side-effect profile. Dosing is up to 4 gm per day in divided doses, though some recommend lower doses (2-3 gm/day in divided doses) if long-term use is desired. Caution patients to be aware of coincident use of other over-the-counter or prescription medications that may contain acetaminophen so that the maximum combined daily dose does not exceed 4 gm. Little risk of nephrotoxicity, and hepatotoxicity is a rare side effect if taken appropriately.

Info about neurostabilizers for migraines:

First line: Divalproex sodium (500-1500mg); Topiramate (25-200mg FDA approved: Yes Good/expensive Cautiouns: Pregnancy/risk of pregnancy Gabapentin category C Divalproex: hepatic disease Divalproex: birth defects, weight gain, alopecia, pancreatitis, ovarian cysts Topiramate: renal stones, weight loss Gabapentin: dizziness, somnolence

Info about BBs for migraines:

First line: Metoprolol (47.5-200 mg) Propranolol (20-160mg) Timolol (10-30mg) Second line: Atenolol Nadolol FDA approved: Yes Good-excellent/cheap Caution in: Asthma, depression, severe COPD, DM requiring insulin, Raynaud's disease S/E: Fatigue, bronchospasm, lightheadedness, insomnia, bradycardia, depression, sexual dysfunction

What changes in personal habits may lead to better sleep health?

Fix a bedtime and awakening time (don't deviate) Avoid daytime napping (30-45 min may be okay though) Avoid caffeine/alcohol 4-6 h before bedtime Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime (may affect ability to stay asleep) Exercise regularly, but not right before bed (at least >2h before bedtime) A cool (not cold) bedroom is best Reserve bed for sleeping and sex

What is the FABER test?

Flexion, Abduction, and External Rotation The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain from sacroiliitis). The test is performed by flexing the hip and placing the foot of the tested leg on the opposite knee. Pressure is then placed on the tested knee while stabilizing the opposite hip. The test is positive if there is pain at the hip or sacral joint or if the leg can not lower to the point of being parallel to the opposite leg. The FABER test should be done on all patients suspected of having sacroiliac pain, not just in the elderly patients. Sacroiliitis can occur in the young population as well.

Greatest SSRI side effects of the most common drugs?

Fluoxetine (Prozac) - longest half-life Sertraline (Zoloft) - Most GI side effects Paroxetine (Prozac) - Best for anxiety, Categ D in preg, most likely to cause withdrawal b/c short half-life Escitalopram (Lexapro) - Fewest sexual side-effects

What is required for the Dx of major depression?

For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of TWO WEEKS. A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure. Depressed Mood (The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):

How much exercise is recommended?

For adults to achieve "substantial health benefits", the 2015-2020 Dietary Guidelines recommend getting 150 minutes of moderate-intensity exercise, 75 minutes of vigorous intensity exercise, or a combination of both per week. For more 'extensive' benefits, double that amount is recommended. At least 2 days a week, strengthening exercises involving all muscle groups should be incorporated into exercise.

What are the recommendations for calcium supplementation for pre and post-menopausal women?

For bone health, it is recommended that premenopausal women need approximately 1000 mg of calcium daily while postmenopausal women need 1200 mg of calcium daily.

How do you interpret the BMI of a child?

For children and teens, BMI age- and sex-specific percentiles are used to interpret the BMI for two reasons: The amount of body fat changes with age. The amount of body fat differs between girls and boys. For children, the American Academy of Pediatrics designates: BMI (kg/m2) Healthy 5th - 85th percentile Overweight 85th - 95th percentile Obese >95 percentile

What medications are considered first line therapy for the secondary prevention of stroke?

For noncardioembolic (or atherthrombotic, lacunar) strokes, possible first-line therapies for secondary prevention include aspirin, aspirin in combination with extended-release dipyridamole (aggrenox), and plavix.

What are the odds of someone who is out of work greater than 6 weeks for low back pain ever returning?

For patients who are out of work greater than six months, there is only 50% chance of them returning to work; this drops to almost zero chance if greater than two years.

When might bariatric surgery be considered?

For patients with BMI >40 kg/m2 or those with BMI >35 kg/m2 with complication related to obesity who have failed diet exercise and pharmacotherapy

What ABX do you use to treat pneumonia in children?

For uncomplicated pneumonia in children more than five years old, azithromycin is indicated because the prevalence of atypical pneumonia is higher. Azithromycin is better tolerated than some other macrolides and is easy to dose. Likewise, in children three months to five years, the first line treatment is amoxicillin because it covers streptococcal pneumonia infections that are most common in those children. Amoxicillin clavulanate is another antibiotic that some physicians chose when treating pneumonia. Using high dose amoxicillin saturates the penicillin binding proteins and is the preferred antibiotic. If a child isn't getting better when they return to the office in 24 to 48 hours, change antibiotics.

What are the screening guidelines for osteoporosis?

For women > 65 years old, screening with dual energy x-ray absorptiometry (DEXA) is recommended. For women < 65 years old, the USPSTF recommends using the World Health Organization's Fracture Risk Assessment Tool to risk-stratify. Screening with DEXA is recommended if the risk of fracture is greater than or equal to that of a 65-year-old white woman without additional risk factors (9.3 percent over 10 years).

What is a gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual?

Framingham Risk Score Used in old ATP-III (2001) guidelines

What method of dating a pregnancy is equally effective to U/S in the third trimester?

Fundal height In the third trimester, ultrasound dating is generally no more accurate than dating by estimated fundal height alone. At 20 weeks, the top of the uterine fundus is usually at the level of the umbilicus, and after 20 weeks, it elevates approximately 1 cm above the umbilicus for each week of pregnancy.

How fast is the rate of rise in beta hCG? What abnormalities may be detected by an abnormal rise?

Furthermore, in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first 6-7 weeks of gestation. However, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 1500-1800. To detect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 mIU/mL. In both ectopic gestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during early gestation. Molar pregnancy and multiple gestations are both associated with higher-than-normal hCG levels.

When you see G1T1P0A0L1 in a woman's sexual history, what does it mean?

G Gravida or number of pregnancies T Number of Term pregnancies P Number of Preterm infants A Number of spontaneous or induced Abortions L Number of Living children

What are the possible complications of GERD?

GERD Esophagitis develops when the mucosal defenses that normally counteract the effect of injurious agents are overwhelmed by refluxed acid, pepsin, or bile. Peptic strictures from fibrosis and constriction occur in about 10% of patients with reflux esophagitis. Replacement of the squamous epithelium of the esophagus by columnar epithelium ( Barrett's esophagus ) may result from reflux esophagitis. Two to five percent of cases of Barrett's esophagus may be further complicated by adenocarcinoma .

What is the primary pathophysiology of GERD?

GERD is a chronic relapsing condition in which gastric contents reflux through the lower esophageal sphincter (LES) into the esophagus or oropharynx. Transient LES relaxations are believed to be the primary etiologic factor. Ineffective esophageal clearance (as seen with scleroderma, for example) and delayed gastric emptying (as seen with gastroparesis, for example) may also be contributing factors in some patients.

What is Gardner Syndrome?

Gardner syndrome is a subtype of familial adenomatous polyposis (FAP or classic FAP), which usually causes benign, meaning noncancerous, tumors to form in many different organs, such as: Multiple adenomatous colon polyps. An adenomatous polyp is an area where the normal cells that line the inside of the colon begin to make mucus and form a mass on the inside of the intestinal tract. Benign tumors, including: sebaceous cysts, which are closed sacs filled with liquid found under the skin epidermoid cysts, which are lumps in or under the skin often filled with liquid fibromas, which are fibrous tumors desmoid tumors, which are fibrous tumors that can develop anywhere in the body osteomas, which are bony growths, usually found on the jaw People with Gardner syndrome also have a higher risk of developing colorectal cancer and other FAP-related cancers. Other features of Gardner syndrome that are similar to classic FAP include extra or unerupted teeth and congenital (present at birth) hypertrophy of the retinal pigment epithelium (CHRPE), an eye condition that does not affect vision but can be seen by looking at the retina using a special instrument called an ophthalmoscope.

What are the salient features of Anterior Cruciate Ligament Sprain?

General knee pain Yes trauma; noncontact deceleration forces No fever Moderate to severe joint effusion Swelling within two hours of "pop"

What are the 1st line treatments of choice for HTN? for Blacks? Diabetics? CKD?

General population (also DM): ACE Inhibitor, ARB, calcium channel blocker, or thiazide diuretic Black population: CCB or thiazide diuretic CKD: ACE Inhibitor or ARB

What are the salient features of septic arthritis?

Generalized extreme pain with any movement No history of trauma necessary Fever Elevated WBC Elevated ESR (usually >50 mm/hr) Abrupt onset of pain and swelling Arthrocentesis with turbid synovial fluid

What are the salient features of Osteoarthritis?

Generalized or joint line tenderness; pain aggrevated by weight-bearing activities, relieved by rest No acute trauma. Past history of trauma can predispose to developing osteoarthritis No fever Chronic joint stiffness and pain Crepitus on exam Mild or no joint effusion

What is the presentation of a syndesmotic sprain?

Generally involves the interosseus membrane and the anterior inferior tibiofibular ligament. Pain and disability are often out of proportion to the injury. One would expect a positive ankle squeeze test.

When do you refer a patient with poorly controlled HTN to a specialist?

Generally, failure to achieve blood pressure goal in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic would warrant referral to a specialist. Clinicians should first review other causes of inadequate hypertension control before referring to a specialist such as: Improper blood pressure measurement Excess sodium intake Inadequate diuretic therapy Medication issues such as inadequate doses, drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives), or over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Underlying identifiable causes of hypertension (secondary hypertension)

What screening tools are available to assess for depression?

Geriatric Depression Scale - Short Form (GDS-SF) Zung Depression Scale Beck Depression Inventory

What is another name for Molar Pregnancy? And what is it?

Gestational trophoblastic disease (GTD), or molar pregnancy, is a hetergeneous constellation of conditions whereby the placenta acts like a tumor. GTDs are usually benign, but can sometimes be malignant. Typically, they have a characteristic appearance on ultrasound and are associated with markedly increased (>100,000 mIU/mL) quantitative hCG levels.

What instructions should be given to a patient with BPH?

Give yourself time to urinate completely. Do not drink alcohol, drinks with caffeine in them (coffee, tea, colas), or other fluids in the evening. Do not take decongestants like Sudafed. Do not take antihistamines like Benadryl. For moderate to severe symptoms (AUA score of 8 or more), prescribe alpha blockers to cause the muscles of the urethra to relax. Side effects of alpha blockers: feeling tired or sleepy.

What is a common physical exam finding in gout?

Gout Can be associated with tophi which are visible or palpable nodules often located on the ears or in the soft tissue. Tophi can also form in the bones, joints, and cartilage. They are typically not painful, and take years to develop.

How do you manage each Wagner grade of foot ulcer?

Grade 1-2 ulcer management generally can be done as outpatient and should include extensive debridement, local wound care, and relief of pressure. If there is significant erythema and or purulent exudate, then treatment for infection is warranted. ​ Grade 3 lesions require evaluation for possible osteomyelitis as well as peripheral arterial disease. Both of these conditions may need to be addressed prior to resolution of the ulcer. Typically at least a brief hospitalization is required to address these issues. Grade 5 lesions require emergent hospitalization and surgical consultation, often resulting in amputation.

What are the different grades for an ankle sprain?

Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress. Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point. Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.

How do you grade deep tendon reflexes?

Grading Reflexes: 0 No evidence of contraction 1+ Decreased, but still present (hyporeflexic) 2+ Normal 3+ Increased (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation

What conditions have high RAIU (>30%)?

Graves' disease Multi-nodular goiter Toxic solitary nodule TSH-secreting pituitary tumor HCG secreting tumor

What peak flow readings guide the patient on the asthma action plan?

Green Doing well > 80% Yellow Getting worse 50-79% Red Medical alert < 50%

How do you treat Tinea capitis?

Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form. Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks. In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans.

How common is gynecomasia in Graves' disease?

Gynecomastia seen in 10-40% of patients with Graves disease and is thought to be because of sex hormone binding globulins being increased in Graves disease.

How much dehydration may be present in HHS?

HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults. Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.

What are the most common forms of Thyroiditis?

Hashimoto's disease, subacute granulomatous thyroiditis, postpartum thyroiditis, subacute lymphocytic thyroiditis, and drug-induced thyroiditis (caused by amiodarone, interferon-alpha, interleukin-2, or lithium).

What is Hashimoto's disease?

Hashimoto's thyroiditis is the most common form of thyroiditis and hypothyroidism and the most common thyroid disorder in America. The disease is also known as chronic lymphocytic thyroiditis or autoimmune thyroiditis. The body attacks the thyroid gland causing it to underproduce hormones. This leads to goiter and hypothyroidism.

What is the crossed-leg test?

Have the patient cross their legs with the injured leg resting at midcalf on the knee to detect high ankle sprains (syndesmotic injury between the tibia and fibula).

What description of palpitations make them more likely pathological?

Heart beating fast

What will a hemarthrosis result as after arthrocentesis?

Hemarthrosis is typically caused by a tear of the anterior cruciate ligament or a fracture. A bloody knee aspirate can be associated with a knee sprain (i.e. ACL, PCL) or acute meniscal tear. An osteochondral fracture causes hemarthrosis with fat globules.

What is a hemiplegic migraine?

Hemiplegic migraine is a rare form of migraine that can present as headache associated with hemiparesis with sensory deficits and motor weakness. This presentation of migraine is most common during childhood and adolescence with the cessation of symptoms by mid-adult life.

Who gets screened for Hep C?

Hepatitis C virus infection: screen in persons at high risk for infection. Offer one-time screening for HCV infection to adults born between 1945 and 1965.

What are the screening guidelines for cholesterol in children? When do you treat?

High cholesterol (serum cholesterol levels greater than 200mg/dL) - has been found in 10 percent of children 2 to 19 years of age. This is higher than it was previously. Risk factors - The strongest risk factor is elevated BMI. Recommended screening - Check a fasting lipid profile on every child with a BMI of >85 percentile. The goal total cholesterol is 170 mg/dL. The goal low-density lipoprotein (LDL) is 130 mg/dL. Treatment - Initial treatment includes diet and exercise. Drug treatment is recommended for children who have an LDL >190 mg/dL or and LDL > 160 mg/dL with risk factors. Drug treatment is only recommended for children who are older than 10 and who are either Tanner stage 2 (male) or have achieved menarche.

What people are considered high risk for the Hep A vaccine?

High-risk indications for Hepatitis A vaccine: chronic liver disease; persons receiving clotting-factor concentrates; men who have sex with men, persons who use injection or non-injection illicit drugs;; and travel to a country with endemic hepatitis A.

What people are considered high risk for the Hep B vaccine?

High-risk indications for Hepatitis B vaccine: end-stage renal disease, including dialysis patients; persons seeking evaluation or treatment for a STD; HIV; chronic liver disease; persons receiving clotting-factor concentrates; workers with potential exposure to blood or body fluids; staff of institutions for the developmentally disabled; men who have sex with men; persons who use illegal drugs; and travel to a country with endemic hepatitis B. Hepatitis B vaccine is also now recommended for all diabetics aged 60 years and younger with recommendations to vaccinate as soon as possible after diagnosis. Diabetics who are aged 60 years and older may be given the hepatitis B vaccine at the discretion of the treating physician based factors such as the frequency of glucose monitoring in long term care facilities, and likelihood of acquiring hepatitis B infection.

What people are considered high risk for the MMR vaccine?

High-risk indications for MMR vaccine: recently exposed to measles or in outbreak setting; previously vaccinated with a killed measles vaccine; work in a health care facility; student in post-secondary school; or those who plan international travel.

What are the Agency for Health Care Policy and Research (AHCPR) guidelines for x-ray?

History of trauma Strenuous lifting in patient with osteoporosis Prolonged steroid use Osteoporosis Age <20 and >70 History of cancer Fever/chills/weight loss Pain worse when supine or severe at night Spinal fracture, tumor, or infection

How long do hormonal implants last for? How effective are they and what are the main side-effects?

Hormonal implant is a matchstick-sized rod implanted under the skin, which slowly releases progestin and protects against pregnancy for three years. The mechanism of action is similar to that of the oral contraceptive. Effectiveness against pregnancy is 99.95%. Infection at insertion site and depression are the side effects of greatest concern.

What are the symptoms of menopause?

Hot flashes or vasomotor symptoms are the most common symptoms of menopause, and are present in up to 80% of menopausal patients. Many women will also experience symptoms of atrophic vaginitis, which can lead to vaginal dryness and dyspareunia (pain during intercourse) and urinary symptoms. Since menopause can be associated with a variety of additional problems including sexual dysfunction, sleep disturbance, mood disturbance, and concentration difficulties, it can significantly affect a woman's daily functioning and quality of life.

What other perimenopausal symptoms exist as a result of decreases in estrogen levels?

Hot flashes: Hot flashes are brief feelings of heat that may make the face and neck flushed and cause temporary red blotches to appear on the chest, back, and arms. Sweating and chills may follow. Hot flashes vary in intensity and typically last between 30 seconds and ten minutes. Dressing in light layers, using a fan, getting regular exercise, avoiding spicy foods and heat, and managing stress may help. Vaginal dryness: This can make intercourse uncomfortable. A water-soluble lubricant may be recommended. A woman's libido may also change. Mood swings: Mood swings, especially depression, are common during perimenopause and menopause. Women should let their provider know if they are experiencing this, so that resources and support may be found.

What does the PROTECT program involve?

Hyperlipidemia All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg. Class I, Level A Hypertension Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period. The JNC 8 guidelines recommend a thiazide diuretic or a calcium channel blocker as first line therapy for African American patients with hypertension. Other agents may be added as needed to achieve the appropriate blood pressure goal. For more REQUIRED information about hypertension management, see the MedU Hypertension module. Class I, Level A Smoking All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke. Class I, Level C Diet The ACC/AHA Lifestyle Guidelines recommend all adults consume a Mediterranean diet to reduce their risk of ASCVD. Furthermore, patients with hypertension should limit sodium intake to 2,400 mg per day or less. Class I, Level A Physical activity On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity physical activity 3-4 times per week for 40 minutes per session. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended. Class IIb, Level C Stroke education Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual's own risk factors.

What are the S/S of hyperthyroidism?

Hyperthyroidism presents with multiple symptoms that vary according to the age of the patient, the duration of the illness, the magnitude of hormone excess, and presence of comorbid conditions. Symptoms are related to the thyroid hormone's stimulation of catabolism, and enhancement of sensitivity to catecholamines. In patients under the age of fifty, the most common signs and symptoms of hyperthyroidism are: Heat intolerance (92%) Tachycardia (96%) due to increased adrenergic tone and heightened conduction Fatigue (84%) Weight loss (50%) due to increased calorigenesis and gut motility causing hyperdefecation and malabsorption. Tremor (84%) Increased sweating (96%) Exertional dyspnea caused by O2 consumption, CO2 production, and respiratory muscle weakness Depression and hyperreflexia are less common but can be present. Diarrhea and light periods can also occur with hyperthyroidism.

What is Hypokalemic periodic paralysis?

Hypokalemic periodic paralysis is a rare syndrome characterized by episodes of general or focal weakness. Episodes usually begin in childhood or adolescence. Paralysis most often occurs during the rest period following vigorous physical activity.

What are the 5 components of the standing portion of the back exam?

I. Inspection: Look at posture, contour and symmetry Forward bend test increases sensitivity for: Check for lordosis Check for kyphosis Check for scoliosis II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness over bony prominences. This procedure checks for muscle spasm, vertebral fracture, or infection. III. Range of Motion (ROM) IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation. V. Stoop Test: Have the patient go from a standing to squatting position.

What views are used in xray of the knee?

If a knee x-ray is desired to evaluate for osteoarthritis (OA), anteroposterior, lateral, and standing weight-bearing views should be obtained. A Merchant's View can help evaluate the patellofemoral joint. The Merchant's view is a "top" view of the knee obtained with the knee bent at a 45-degree angle, showing the alignment of the patella in the groove of the femur (throchlear groove).

What tests are helpful if you are considering septic arthritis or an acute inflammatory arthropathy?

If concerned about septic arthritis or an acute inflammatory arthropathy, check a Complete Blood Count (CBC) with differential and erythrocyte sedimentation rate (ESR), though this test is non-specific.

How helpful is evaluating for rheumatoid factor when assessing for RA?

If considering RA, check rheumatoid factor (RF) on blood work. This test is not very sensitive and only moderately specific for rheumatoid arthritis. It would be more helpful to as a test to rule out RF (if the test is negative), than to rule it in (if the test is positive).

What initial diagnostic tests can be done for a breast lump (cystic vs solid)?

If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a procedure family physicians can do in the office. If it feels solid, mammography is the next step. Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion.

What two tests are available to detect GI bleed? What are the advantages/dysadvantages of each? What may cause false positives?

If symptoms have not improved, it is reasonable to consider fecal occult blood testing (FOBT) to rule out occult bleeding. Fecal immunochemical testing (FIT) is more sensitive and specific than FOBT for detecting occult lower GI bleeding; however, it is not suitable for detecting gastric bleeding, and it should not be used if the suspected source of bleeding is proximal to the ligament of Treitz. The guaiac-based fecal occult blood tests (FOBT), such as Hemoccult II SENSA, are best used to check for occult upper GI bleeding. Multiple negative FOBTs or FITs do not exclude the presence of either upper or lower GI blood loss. Diets high in red meat, iron, and vitamin C may cause false positive results with guaiac-based tests.

When would repeating a type & cross be useful in a pregnant mother with vaginal bleeding?

If the bleeding is of great volume, a type and screen would be warranted both for potential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the maternal circulation and with dosing RhoGam.

What imaging may be done in cases of RUQ due to suspected biliary dysfunction?

If the patient has typical symptoms of biliary colic but no visible stones on the gallbladder ultrasound, a HIDA scan might be obtained to look for gallbladder dysfunction and reproducible pain. If there was jaundice and/or gallstone pancreatitis suggestive of a common duct stone (choledocholelithiasis), an ERCP might be warranted. Another role for ERCP would be in the postoperative patient who did not have an intraoperative cholangiogram (assessing the common duct at the time of surgery) and who presents with a repeat episode of biliary colic and/or jaundice and/or pancreatitis. MRCP is a similar diagnostic modality that uses magnetic resonance. However, unlike ERCP - where treatment can take place at the time of diagnosis... MRCP is a diagnostic modality only.

What followup is indicated for a benign work up of a breast mass?

If the work-up suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast exams and mammography is indicated.

How effective has prophylaxis for stress ulcers been in the hospital setting?

In ICU patients, the number needed to treat (NNT) to prevent one clinically relevant episode of upper GI bleeding due to stress ulceration is greater than 900. Overall, this practice is over utilized, especially in non-intensive care unit patients, which results in preventable cost expenditure and increased risk of adverse events from non-judicious use of PPIs.

What is more sensitive in investigating features of ACS in women, prodromal symptoms or chest discomfort? What are the prodromal symptoms?

In a landmark article on women and prodromal symptoms of myocardial infarction, McSweeny and colleagues noted that 95% of women reported prodromal symptoms, but only 29.7% reported chest discomfort. Prodromal symptoms of ACS in women may include: fatigue dyspnea neck and jaw pain palpitations cough nausea and vomiting indigestion back pain dizziness numbness

What occurs at various stages of beta hCG?

In a normal pregnancy, levels of human chorionic gonadotropin (β-hCG) increase at a predictable rate. At the date of first missed menses, which is approximately four weeks from the last menstrual period (LMP), β-hCG should be approximately 100 mIU/mL. As the pregnancy progresses, at about five weeks (+ 2 days), the gestational sac is visible on vaginal sonography and the β-hCG should be about 1398 (+155) mIU/mL. At five weeks and six days (+ 3 days) gestation, the fetal pole is visible on vaginal sonography and β-hCG has reached 5113 (+298) mIU/mL. When the fetal heart motion is visible on vaginal sonography (six weeks and five days + 6 days), the β-hCG has climbed to 17,208 (± 3772) mIU/mL.

Why might you test serum B12 levels in a diabetic patient?

In addition to renal insufficiency, metformin can cause another side effect to take into account when deciding which labs to order. During clinical trials, up to 7% of patients receiving metformin developed asymptomatic subnormal serum vitamin B12 levels. In the setting of neuropathy, too, serum B12 levels would be a very reasonable diagnostic test to order.

What is the step-up therapy for refractory BPH?

In men with severe symptoms, those with a large prostate (>40 g), and in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, combination treatment with an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor may be desirable. In general, if bladder outlet obstruction is creating a risk for upper urinary tract injury such as hydronephrosis, renal insufficiency, or lower urinary tract injury such as urinary retention, recurrent urinary tract infection, or bladder decompensation; surgical intervention is needed. Surgery also should be considered if combination treatment fails to improve symptoms of BPH.

What is required for Dx of HTN?

In order to accurately diagnose a patient with hypertension at least two elevated measurements - five minutes apart, one in each arm, should be made on two or more visits. A patient cannot be diagnosed with hypertension if the patient is acutely ill or in acute pain. The measurements are required in each arm because on rare occasions, you may encounter an adult with an aortic anomaly, such as coarctation of the aorta, where blood pressure will be high in the right arm but low on the left.

What finding is significant during the Stoop Test?

In patients with central spinal stenosis, squatting will reduce the pain

When treating pts with gout who cannot take NSAIDs, why is it useful to know how many joints are involved?

In patients with contraindications to NSAIDs or colchicine, the choice of treatment can be guided by the number of joints involved. If one or two joints are involved, arthrocentesis with intra-articular glucocorticoid injection is appropriate. For polyarticular disease, oral glucocorticoids would be a more appropriate option.

What patients require a Hep C (HCV) screening?

In persons at high risk for infection. And one-time screening for HCV infection to adults born between 1945 and 1965.

What are the salient features of melanoma?

In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases occurring in those younger than 40 years. Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern for melanoma. Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths. The lesions of superficial spreading melanoma are dark brown or black. Slowly spreading irregular outline in the initial phase. Some areas may be a lighter shade. Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma. More than half of melanoma in women occurs on the legs. Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator. Persons with skin types that burns easily and tans with difficulty, and with red or blond hair, and freckles are at higher risk. Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.

Do progestin only OCP's cause problems if breast feeding?

In women who are breastfeeding, progestins do not appear to cause changes in the composition or volume of breast milk or have any negative effect on the infant. However, due to theoretical concerns about the role of progestins in the initiation and production of breast milk, agencies such as World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) recommend that women not begin progestin-only contraception until six weeks if exclusively breastfeeding. In clinical situations where follow-up is uncertain, it may be advisable to initiate contraception before discharge from the hospital.

What major changes occured with the 2013 guidelines for cholesterol screening?

Increased evidence-based rigor. Atherosclerotic cardiovascular disease (both stroke and myocardial infarction) targeted for prevention. Low density lipoprotein cholesterol (LDL-c) goals no longer recommended as treatment targets. Counting risk factors no longer recommended for creating cholesterol management plan. Pooled Cohort Equations developed to estimate ASCVD risk.

What is the mortality rate for Hyperosmolar Hyperglycemic State (HHS)?

Increases with increasing age and serum osmolality. The average mortality rate in many studies is 15%, but can be as high as 20-30% in the presence of significant infection.

What patients with Low Back Pain warrant early diagnostic testing, other imaging, and referral?

Indications for early diagnostic testing such as x-rays and other imaging and referral are patients with progressive neurological deficits, patients not responding to conservative treatment (which we will discuss in a minute), and patients with red flags signaling serious medical conditions such as fracture, cancer, infection, and cauda equina syndrome.

Individuals who have suffered a TIA are at what increased risk for stroke?

Individuals experiencing TIA symptoms have been shown to have an 8 - 12% chance of having a stroke within one week and an 11 - 15% chance of having a stroke within one month.

What developmental issues do pts with Down's syndrome often deal with?

Individuals with Down syndrome have a number of developmental and growth issues, including short stature, developmental delay and mental retardation, obesity, hearing loss, eye and gastrointestinal problems. They also have an increased risk for immune deficiencies, thyroid disorders, diabetes, leukemia, sleep apnea, and behavior disorders.

What events/states may precipitate HHS?

Infections, like pneumonia and urinary tract infections, accompanied by a decreased fluid intake are the most common underlying causes of HHS. Other acute conditions like stroke, MI or pulmonary embolism may also precipitate HHS.

What are the salient features of gastritis?

Inflammation of the stomach lining and can cause epigastric pain that improves immediately following a meal. The development of gastritis is associated with both alcohol and NSAID use.

What vaccines are recommended for patients with diabetes?

Influenza vaccine should be provided to patients with diabetes annually. Pneumococcal polysaccharide vaccine should be provided to all patients with diabetes over 2 years of age. A one-time revaccination is recommended for patients over 64 years of age if the vaccine was first received greater than 5 years ago. Otherwise, patients should also receive the re-vaccination if they have nephrotic syndrome, chronic renal disease or are in an immunocompromised state. Hepatitis B vaccine should be administered to all unvaccinated adults with diabetes, HIV, other immunocompromising conditions, or liver disease.

When might you consider testing a patient with DVT for inherited thrombophilia?

Initial thrombosis occurring prior to age 50 without an immediately identified risk factor (e.g., idiopathic or unprovoked venous thrombosis). A family history of venous thromboembolism. Recurrent venous thrombosis. Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins.

What foot care is recommended for diabetic patients to practice?

Inspect, wash and dry feet daily. Dry well between the toes. Report injuries, ulcers, blisters, red areas or painful areas to your physician right away. Apply moisturizer to prevent cracking, dry skin. Do not put lotion between toes. Always wear socks and close-toed shoes; never go barefoot! Cut toenails straight across, or have a health care professional cut them for you. Feel inside your shoes with your hands before putting them on to avoid injury. Purchase properly-fitted footwear preferably at the end of the day when feet are slightly swollen

What are the types of IUDs? How long do they last? And what are the potential complications?

Intrauterine device (IUD) is a small T-shaped device inserted into the cervix in a medical office. There are two different types: one contains copper which lasts 10 years (ParaGard-Copper T), the other contains progestin and is effective for five years (Mirena). They are 99.2-99.8% effective against pregnancy. Both alter the movement of the sperm and inhibit the egg from implanting in the uterus. The IUD containing progestin further suppresses ovulation and thickens the cervical mucus. Increased menstrual bleeding and dysmenorhea are not uncommon. Uterine perforation and infection post-insertion are rare, but potential consequences. The initial expense may be high, especially if IUD is not covered by the patient's insurance. It is preferred that the patient be in a monogamous relationship.

What is the presentation of intussusception? At what age does it present? And what is the danger of not diagnosing it?

Intussusception is a condition in which a portion of the alimentary tract is telescoped into an adjacent segment, most often ileocolic. It is the most common cause of intestinal obstruction in infants between the ages of three months and six years of life. More than 80% occur before the age of 24 months; it is rare in neonates, and the male to female ratio is 4:1. Incidence is 1-4/1,000 live births. Intussusception is characterized by sudden onset of severe, paroxysmal, colicky pain, recurring at frequent intervals. There may develop progressive lethargy, weakness, fever, and shock if it is not diagnosed and treated.

If a patient is suicidal, what happens to confidentiality?

It can also be helpful to talk with the patient's friends and family, maintaining appropriate confidentiality, although the professional should not agree to withhold information if a patient is truly suicidal

Why is it important to ask about Aspirin use in asthma?

It is important to ask about about aspirin in particular, as 21% of adults who have asthma have aspirin-induced asthma and should avoid NSAIDs.

What are some important considerations while diagnosing hepatitis?

It is important to determine the source of the infection. The diagnosis can usually be made by physical exam. Laboratory tests are helpful in determining the exact diagnosis. Treatment of the acute illness is generally supportive care. The history may include heavy alcohol consumption, high-risk behavior such as IV drug use, foreign travel, or multiple sexual partners.

Why is the first Tx for HTN chosen by providers often a Thiazide diuretic?

It is the most cost effective antihypertensive. Also: A 2004 JAMA meta-analysis of clinical studies indicated that low-dose (12.5 to 25 mg/d chlorthalidone or hydrochlorothiazide) and high-dose (50 mg/d or more of both drugs) diuretic therapy lowered blood pressure to a similar degree and exerted a similar benefit in reducing stroke, congestive heart failure, cardiovascular, and total mortality, but only low-dose diuretic therapy significantly reduced coronary heart disease incidence. Chlorthalidone is a thiazide-like diuretic. A 2009 Cochrane review reinforced that no other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior. In addition, low-dose inexpensive thiazides should be the first choice drug in most patients with elevated blood pressure. JNC-8 did not single out this drug as 1st choice, though (and is not listed for CKD).

Why does JNC-7 recommend measuring serum Ca levels in HTN?

JNC 7 also recommends serum calcium (Ca) level. One-third of patients with hyperparathyroidism and hypertension may have illness attributable to renal parenchymal damage due to nephrolithiasis. Increased calcium levels can also have a direct vasoconstrictive effect. It is unclear why the increased serum calcium level in hyperparathyroidism raises blood pressure, as epidemiologic studies suggest that a high calcium intake lowers blood pressure. It is also not clear why calcium channel blockers are effective antihypertensive agents.

What agents are recommended for HTN in diabetes pts by JNC-8?

JNC 8 now recommends that physicians choose any one of four agents for initial therapy: ACE Inhibitor, ARB, calcium channel blocker, or thiazide diuretic. JNC 8 has also dropped the JNC 7 recommendation about preferentially picking an ACE Inhibitor or ARB for patients with diabetes. For the general black population, including those with diabetes, a thiazide diuretic or calcium channel blocker should be started.

What medication for HTN was removed from JNC-8? And why?

JNC8 does not recommend beta-blockers as first-line drug because of one study showing a higher rate of cardiovascular morbidity and mortality (e.g., strokes, myocardial infarctions). Also poor efficacy in HTN

What are the major radiographic findings in OA?

Joint space narrowing Subchondral sclerosis (Hardening of tissue beneath the cartilage. In osteoarthritis, there is increased periarticular bone density.) Osteophytes (Also known as bone spurs; bony projections arising from the joint.) Subchondral cysts (Fluid-filled sacs in the bone marrow.)

How good are knee xrays for detecting early OA? What findings best predict disease progression?

Knee x-rays are insensitive for detecting early OA and do not correlate well with the degree of symptoms. When findings are present, patellofemoral and tibiofemoral joint osteophytes correlate best with pain, and joint space narrowing best predicts disease progression.

Match L3, L4, L5, S1 nerve roots to their respected motions:

L3 Patellar tendon reflex Lateral thigh and medial femoral condyle Extend quadriceps Squat down and rise L4 Patellar tendon reflex Medial leg and medial ankle Dorsiflex ankle Walk on heels L5 Medial hamstring Lateral leg and dorsum of foot Dorsiflex great toe Walk on heels S1 Achilles tendon reflex Posterior calf, Sole of foot, and lateral ankle Stand on toes Walk on toes (plantarflex ankle)

Difficulty with heel walk is associated with what?

L5 disc herniation

What are the advantages of LMWH over unfractionated heparin?

LMWH (Lovenox) has several advantages over unfractionated heparin: Longer biologic half-life so it can be administered subcutaneously once or twice daily Laboratory monitoring is not required Thrombocytopenia is less likely although periodic monitoring of platelets may be needed Dosing is fixed Hence, LMWH may be used in the outpatient setting; whereas unfractionated heparin requires hospitalization as it is administered intravenously with the dosage based on body weight and titrated based on the activated partial thromboplastin time. Studies exist which indicate that each of these regimens is more efficacious, safer, or both (E). Despite this comparability, the continuous unfractionated heparin IV regimen, delivered by an infusion pump, is by far the most popular in the United States.

How is progesterone useful in evaluating the status of a pregnancy?

Laboratory testing for progesterone is most useful in extreme situations. If the result is >25, it is highly associated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage or ectopic pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic pregnancy. Algorithms for the diagnosis of ectopic pregnancy emphasizing progesterone measurements have been associated with a higher use of surgical management and often miss ectopic pregnancy since 85% of ectopic pregnancies will have a normal progesterone level. Nevertheless, the test remains valuable because of its positive and negative predictive value at the extremes of the reference range. In many labs, it is a common and quick test, which makes it frequently ordered.

What are the possible causes of an enlarged thyroid (goiter)?

Lack of iodine- Worldwide, the lack of iodine is the most common cause of goiter. Hypothyroidism- Hashimoto's disease, which causes hypothyroidism, is a common cause of goiter. Hyperthyroidism- Graves' disease, which causes hyperthyroidism, also causes goiter. In fact, an enlarged thyroid can be seen in patients with too much, normal amounts or not enough thyroid hormone. Nodules- Nodules, either single or multiple, can also cause an enlarged thyroid. Thyroid cancer- Thyroid cancer is usually detected by palpating an enlarged, nodular thyroid. Pregnancy- Pregnancy can occasionally cause a slight enlargement in the thyroid. Thyroiditis- Thyroiditis can also cause an enlarged, often tender, thyroid gland.

How big of a problem is iodine deficiency and what is the best way to treat?

Lack of iodine- Worldwide, the lack of iodine is the most common cause of goiter. In fact, iodine deficiency is the most common, yet easily preventable cause of developmental delay and mental retardation in the world. Areas that are the most affected are in northern Africa and Pakistan. Iodized salt is the easiest and least expensive way to supplement iodine.

How long might a tension headache last?

Last from 30 minutes to 7 days

How long do migraines typically last?

Last from 4-72 hours.

What are the major symptoms of ASCVD that should be asked about?

Leg pain with activity may indicate claudication, a manifestation of peripheral atherosclerotic disease. Chest pain with activity may indicate angina pectoris, a manifestation of coronary artery atherosclerosis.

What are the less-common and rare complications of influenza?

Less common complications of influenza: neurologic - aseptic meningitis - Guillain-Barre syndrome - febrile seizures Rare complications of influenza: myositis myocarditis

How well do leukotreine receptor antagonists compare to LABAs for combination therapies in asthma?

Leukotriene receptor antagonists may be used in conjunction with low-dose inhaled corticosteroids, but they are expensive. A Cochrane review also revealed as additions to patients already on inhaled corticosteroids, a long-acting beta2 agonist inhaler improves symptoms and lung function, while preventing exacerbations, more effectively than leukotriene receptor antagonists.

What salvage therapy is available to patients who failed initial Tx for H. Pylori?

Levofloxacin triple therapy for 10 days (eradication rate - 87%) Standard dose PPI twice daily Amoxicillin 1 gram twice daily Levofloxacin 500mg once dailya Quadruple therapy for 14 days (eradication rate - 68%): PPI standard dose once or twice daily OR ranitidine 150mg twice daily Tetracycline 500mg three times daily Metronidazole 250mg four times daily Bismuth subsalicylate 525mg four times daily

What are the salient features of lichen planus?

Lichen planus typically presents as 2-10 mm flat-topped papules with an irregular, angulated border (polygonal papules) that are commonly located on the flexor surface of wrists and and on the legs immediately above the ankles. Most of the times, the lesions are multiple. Lichen planus is common in middle age.

How much can lifestyle modifications impact BP and which are most effective?

Lifestyle modification vs Approximate systolic BP reduction range 1. Weight Reduction 5-20 mmHg/10 kg loss 2. DASH eating plan 8-14 mmHg 3. Dietary Sodium Red 2-8 mmHg 4. Physical Activity 4-9 mmHg 5. Moderation of Alcohol 2-4 mmHg

How much alcohol is allowable according to JNC-7?

Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons.

What are the first line antihypertensive agents for pts with DM? And why?

Lisinopril, and other ACE inhibitors are the first line antihypertensive medications in patients with diabetes mellitus because of their renoprotective properties.

Which vaccines are to be avoided in immunocompromised individuals?

Live vaccines, like zoster (also MMR, OPV, and Varicella), should not be administered to immunocompromised patients, their close contacts, or to pregnant women.

What treatments are recommended for Chronic Pain Control When Initial Conservative Treatment Fails in OA?

Long-acting opiods Tramadol TCAs

What are the important components of the well check with a patient who has HTN?

Look for identifiable causes of hypertension and evidence of end organ damage and coronary vascular disease: -BMI -Funduscopic Eye Exam (AV nicking, cotton-wool spots, flame hemorrhages, exudates, and other changes associated with hypertensive retinopathy, also papilledema in HTN emergencies) -carotid, abdominal, and femoral bruits (PVD and CVD) -Palpation of the thyroid gland -Lung exam (CHF) -Heart Exam (RR, m/r/g, displaced PMI) -Abdominal exam (AAA pulsation, bruits, or masses, or enlarged kidneys as hypertension can contribute to PVD and CKD) -Lower Extremities (CVD or PVD in the lower extremities such as diminished pulses, loss of extremity hair, thick toenails, cold or red skin) -Neuro Exam (changes from ischemic or hypertensive brain disease. It is important to get a baseline.)

Which is best for stroke prevention? Low dose or high dose ASA?

Low dose ASA has the same efficacy in stroke prevention as high dose ASA but lower bleeding risk. Although in the past it was believed that patients on a 325 mg dose of aspirin compared to those on an 81 mg dose where conferred more protection from ischemic stroke, studies now show that increasing the dose of aspirin, while increasing the risk of hemorrhage, does not confer more benefit than the 81 mg dose. For that reason, the 81 mg dose of aspirin, is sufficient to help prevent a stroke in a patient with a TIA or other risk factors for stroke.

Why is low hematocrit an important finding in HTN?

Low hematocrit may reveal anemic states in hypertensive patients. Anemia makes the likelihood of a major cardiovascular event more likely (strokes, heart attacks). If a hypertensive patient is found to be anemic, the underlying cause (i.e. colon cancer or uterine fibroids) must be found and addressed, and the anemia corrected. Anemia may also be the product of target organ damage in moderate to severe end stage renal disease.

What is the A1C goal? And how does glucose control affect risk for ASCVD?

Lowering patients A1C to <7% has been shown conclusively to prevent microvascular disease (retinopathy and nephropathy). Whether this glycemic control prevents macrovascular disease has been less clear. A recent meta-analysis of 5 randomized controlled trials of intensive (A1C of 6-6.5) versus standard glycemic control (A1C of 7%) have shown a significant reduction in CVD outcomes (fatal and non-fatal myocardial infarction) but very importantly failed to show a decrease in stroke or all-cause mortality. A recent randomized trial of intensive glycemic control found no benefit for preventing CVD over 5 years, but disturbingly found an increase in all-cause mortality. This isolated finding warrants further study, but the current ADA guidelines recommend that the A1C goal is still close to or less than 7%, and that treatment should be tailored to the patient to avoid hypoglycemia and weight gain.

What is assessed during the ROM part of the exam? What findings are considered significant?

Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm. Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis. Lateral motion (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain. *Range of motion may be varied due to the patient's age and body habitus

What is the issue with lumbar spine films?

Lumbar spine films are commonly used, but lack specificity and have a high rate of false-positive findings. Patients with symptoms and pathology may have an apparently benign x-ray and asymptomatic patients may have abnormal x-rays. Deyo has suggested a series of high-yield criteria for obtaining lumbar films

What are the screening recommendations for lung CA?

Lung cancer screening: only recommended under certain circumstances... annual screening for lung cancer with low-dose computed tomography is recommended in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.

Which injury is more common: LCL sprian or MCL sprian?

MCL (more likely to have forces contact the outside of the knee and create valgus stress)

When is an MRI indicated for knee pain?

MRI would be preferred if locking, popping, or joint instability were of concern, to detect meniscal or ligament damage. However, if an x-ray shows significant joint space narrowing, an MRI would likely not be needed even if there were mechanical symptoms, unless the patient fails to improve with conservative management.

List of nouns used to describe skin lesions:

Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes "macule" is used for flat lesion of any size. Patch: A patch is a macule greater than 1 cm in diameter. Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau. Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue. Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule. Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid. Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter. Pustule: A pustule is a circumscribed elevated lesion that contains pus. Wheal: A wheal is an area of elevated edema in the upper epidermis.

What are the risk factors for CVD in a pt with HTN?

Major cardiovascular risk factors include: A patient with a history of diabetes, and/or cholesterol, and/or obesity may also have hypertension as part of metabolic syndrome. A patient with a family history of premature cardiovascular disease or death (men under age 55, women under age 65) increases the risk of cardiovascular disease or death up to eight times higher than that of the rest of the population. Tobacco smoking elevates blood pressure, contributes to increased morbidity and mortality, and interferes with the efficacy of blood pressure medications. Alcohol intake should be limited to no more than 1 oz (30 mL) of ethanol, the equivalent of two drinks per day in most men and no more than 0.5 oz of ethanol (one drink) per day in women and lighter weight persons. Cocaine and ketamine use and narcotic withdrawal can elevate blood pressure. Other major risk factors include: age (older than 55 for men, 65 for women), physical inactivity, microalbuminuria or estimated GFR 60 mL/minute.

What diagnostic studies may be done to evaluate nipple discharge? What other considerations are warranted?

Mammogram Ultrasound Ductogram, and/or Biopsy Consider hormonal testing to exclude endocrinological reasons. If discharge is milky, check the prolactin level. Review and discontinue any medications that may be the cause.

How much earlier might mammography detect BRCA before manual exam?

Mammography can help find cancer one or two years before breast cancer may be felt by breast self exam.

What are the benefits of mammography?

Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence that mammography decreases breast cancer mortality.

What are the symptoms of IBS? And what exacerbates it?

Many patients will describe abdominal pains of varying location, associated with either soft, frequent loose stools, or constipation, or alternating stool pattern. They may also describe abdominal bloating, increased flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious or depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, dietary changes, change in activity, and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. There is no specific test or lab finding to determine that a patient definitely has IBS; it is a diagnosis of exclusion. This should remain in your differential.

If alcohol makes you drowsy, why should it be avoided?

Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in your blood start to fall, there is a stimulant or wake-up effect.

What is the preferred medication for smoking cessation?

Many physicians prefer prescribing bupropion to help smokers quit. Due to side effects, varenicline is often reserved for those that have failed bupropion or if a patient specifically requests it. However, small, short-term studies comparing varenicline with bupropion show varenicline at least as effective and probably slightly more effective

What special considerations are given for CCBs?

May be useful in Raynaud's Syndrome. May be useful in certain arrhythmias. Often causes leg edema (15-30% depending on different studies). Short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies.

What is one major way that tension HAs may be difficult to distinguish from migraines?

May occur with photophobia or hyperacusis.

What additional Tx benefit might be gained through use of a thiazide diuretic?

May slow demineralization in osteoporosis

What criteria may be used to assess the need for a strep test?

McIsaac Decision Rule: A. One point is assigned for each of the following: Fever more than 38.0 Celsius Absence of cough Tonsillar exudates Anterior cervical lymphadenopathy Age less than 15 years old B. One point is taken away for age older than 45 years old. <1 no strep test, 2-3 rapid strep, >4 culture and empiric Tx

What are the salient features of a meniscal tear?

Medial or lateral joint line Yes; sudden twisting injury No fever Can occur with chronic degenerative process Mild effusion Possible atrophy of the vastus medialis obliquus portion of the quadriceps Catching/locking of the knee Can have positive McMurray test

What medical managment is available (as opposed to surgical or expectant waiting) for inevitable abortion in a female?

Medical management, despite being off-label, is a useful third option that is becoming more common. The most common protocol involves the vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this method is generally around 95%, and the time to completion is generally 3-4 days (but may take up to 2 weeks), as opposed to 2-6 weeks with expectant management. Finally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given previously, it should now be administered.

What are the two medical approaches to treating Graves' disease?

Medication to suppress thyroid hormone production Oral dose of radioactive iodine (RAI therapy)

What medications and substances might act as triggers for HAs?

Medications or substances that act as triggers: Estrogen (birth control/hormone replacement) Tobacco, caffeine or alcohol Aspartame and phenylalanine (from diet soda)

What are the screening recommendations for STI testing?

Men at increased risk for sexually transmitted infections should be screened for HIV, syphilis, chlamydia, and gonorrhea. Consider hepatitis B and C screening as well. Genital herpes testing should only be performed on symptomatic individuals. The CDC now recommends routine HIV testing for all adults after the patient is notified the testing will be performed, unless the patient declines. Some states still require informed consent before HIV testing. Those at high risk for HIV infection should be screened annually, at least.

How do women differ in their experience of menopause? What is the hallmark symptom of perimenopause? When should they be advised to call their doctor?

Menopause affects each woman differently. Some women reach menopause with little to no trouble; others experience severe symptoms that drastically hamper their lives. Menstrual irregularity is the hallmark of perimenopause. Patients should be advised to call their provider if their menses come very close together, if the bleeding is heavy, or if the bleeding lasts more than a week.

What exactly causes menopause and when does it on average occur?

Menopause is a normal process that occurs as the ovaries are depleted of follicles and produce less estrogen. It is thought to be, primarily, the lack of estrogen that leads to the majority of postmenopausal symptoms. This happens in the US at a median age of 52 years, between 40 and 58 years of age for most women. The natural process leading up to menopause may take several years. During the transition, it can be difficult to make a firm diagnosis. National guidelines define menopause as 12 months without a cycle.

What medication is used to suppress thyroid hormone production in Graves' disease? What are the risks? What percentage experience relapse?

Methimazole is the most commonly used medication to suppress thyroid hormone production. Side effects are rare, but less than 1% of people who take methimazole have a serious side effect known as agranulocytosis in which the bone marrow stops producing white blood cells. This leaves patients vulnerable to serious infections. It takes up to three months to suppress thyroid production, although patients usually start to notice improvement in their symptoms after one month. Patients typically need to stay on medications for several years. More than half of patients return to hyperthyroidism if they try stopping medications. Also may cause hepatotoxicity (jaundice, elevated LFTs) that can persist weeks after discontinuing Tx) The appropriate dose of medication fluctuates over time and people on medication need to come in for blood work often for adjustments. People on medication are more likely to have symptoms because fluctuations are hard to predict.

what is the typical presentation of gastritis?

Mid-epigastric pain may be exaggerated by stress/emotions, diet, medications particularly non-steroidal anti-inflammatory drugs and other things that cause excess acid production. The patients frequently give a history of tobacco or alcohol use; they may use NSAID'S. Patients may state that spicy foods seem to aggravate the pain.

Women who are victims of domestic partner abuse are more likely to experience what symptoms?

Migraines, frequent headaches Chronic pain syndrome Heart and blood pressure problems Arthritis Stomach ulcers, frequent indigestion, diarrhea, constipation, irritable bowel syndrome, spastic colon Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic inflammatory disease, chronic pelvic pain syndrome, and other gynecological diagnoses Invasive cervical cancer and preinvasive cervical neoplasia Depression, anxiety and post-traumatic stress Unexplained or poorly explained findings on physical exam

After the Dx of depression is confirmed, what other test is appropriate? Which test is best?

Mini-cog exam to assess for dementia and other causes of depression, also the mini mental status exam can be used. However, the mini-cog exam is faster and more sensitive and specific than the MMSE. Screening for dementia is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in demented patients.

What is the name of the syndrome that occurs with gallstone compression of the hepatic duct?

Mirizzi syndrome

What is the cage mnemonic?

Modified CAGE: Have you ever felt: 1. The need to Cut down on drinking? 2. Annoyed with criticisms about your drinking? 3. Guilt about your drinking? 4. The need to drink an Eye opener in the morning?

What type of excisional process for SCC has the best aesthetic effect?

Mohs micrographic surgery

What are the different methods for testing for Mononucleosis? And what are the advantages/disadvantages of each?

Mononucleosis tests are based on testing of serum antibodies to the Epstein-Barr virus. Because the tests rely on the immune response, delayed or serial testing may be needed for diagnosis. The heterophile antibody test ("mono spot") has a 25% false negative in the first week. The polymerase chain reaction (PCR) assay for Epstein-Barr virus DNA has also been validated as a test for monucleosis with 75% sensitivity and 98% specificity at one week, but less favorable sensitivity is expected at less than one week, especially in children. A less expensive way to evaluate for mononucleosis is a complete blood count with differential: an increased number of lymphocytes and the presence of atypical lymphoctyes are supportive of a diagnosis of mononucleosis.

What is the more likely etiology if a pt with palpitations complains of heart beating hard or increased awareness of heart beat?

More commonly due to: Strong emotion (anger or fear) Substances containing caffeine or other stimulants

What percentage of PE's began as DVT's?

More than 95% of pulmonary emboli arise from thrombi in the deep venous system of the lower extremities. Ninety percent of deaths due to pulmonary embolism result within an hour or two -- before diagnostic and therapeutic plans can be implemented. Therefore, prevention and prompt treatment of DVT is the most effective approach to prevention of, and death due to embolism.

What is the mortality rate for DKA?

Mortality rate is roughly 2% for patients under 65 years old, but as high as 22% for patients over 65 years old.

Can SSRIs be used in pregnancy? Which one is category D?

Most SSRIs are category C in pregnancy (not enough evidence but may be used if necessary) Paxil is Pregnancy Category D (evidence of harm, but may be used in extreme circumstances)

What neurotransmitters are targeted by most antidepressants? What are the 4 major classes of antidepressant?

Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are four major classes of antidepressants: 1) SSRI 2) SNRI 3) TCA 4) MAOI

What percentage of back pain

Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three months.

When do you use u/s to determine the date of a pregnancy?

Most clinicians will use dates determined by ultrasound for any discrepancy of: more than one week between the ultrasound and another method in the first trimester more than two weeks in the second trimester more than three weeks third trimester

When is cerivcal polyposis higher on your differential for vaginal bleeding?

Most common in postpartum and perimenopausal women; rare in pre-menstrual and post-menopausal women. Although cervical polyps are rare in post-menopausal women, they can occur and if present, can cause vaginal bleeding.

Should women under 40 ever get routine mammography?

Most guidelines do not recommend routine mammography for women younger than 40 years unless they fall into a high risk category such as women with a known BRCA mutation.

How might you incorporate opioid use in to treatment of chronic pain?

Most short-acting opioids such as hydrocodone and oxycodone are indicated only for use in acute pain or for breakthrough pain, when long-acting agents are insufficient to control symptoms. These drugs should be used cautiously since they cause side effects like euphoria, hence frequent overuse or diversion for other purposes. For patients with chronic pain, when non-opioid therapies are not sufficient, it is sometimes appropriate to prescribe low doses of long-acting opioids, along with other agents to improve function.

What percentage of women who miscarry will go on to have subsequent normal pregnancies?

Most women (87 percent) who have miscarriages have subsequent normal pregnancies and births.

How much Ca and Vit D are currently advised for supplementation (subject to change) and what is the upper limit?

Most women over 50 should consume an average of 1200 mg of calcium and 600 IU of vitamin D daily. Approximately 5% of women over 50 exceed the recommended upper intake level of 2,500 mg per day for calcium. The upper intake level for vitamin D in healthy adults is currently listed as 4,000 IU per day, but that amount is subject to change as more information becomes available

How common is chronic sinusitis in asthma?

Multiple studies have linked chronic sinusitis to asthma. For example, one recent paper found that 42% of patients with chronic sinusitis have asthma. There also are studies reporting similar pathologic processes in chronic sinusitis and asthma. Here are some references, which discuss this in further detail.

What are some other complications of obesity?

Musculoskeletal disorders such as Blount's disease (progressive bowing of the legs) or slipped femoral epiphysis (leads to hip or knee pain). Gastrointestinal problems including steatosis and gallbladder disease. New recommendations include screening for steatosis at age 10 if BMI is greater than 95 percentile, or if greater than the 84-94 percentile but with risk factors and every 2 years thereafter with an AST and ALT and refer to gastroenterology for levels that are twice the upper limit of normal. Gynecological problems including early menarche and polycystic ovary syndrome can also be seen in overweight females. Skin complaints such as acanthosis nigricans (darkening of the skin around the neck), and intertrigo are more common among overweight children. Psychosocial problems including: stigmatization, bullying, low self-esteem, and depression. Obstructive sleep apnea, asthma, pseudotumor cerebri are also more common among overweight children.

NSAIDs should be avoided in pts taking what other medications?

NSAIDs can increase the effect of anticoagulants, and should be avoided in patients taking warfarin.

What is Naegele's Rule?

Naegele's Rule is commonly described as starting with the first day of the last normal menstrual period, then: add 1 year subtract 3 months add 1 week

What is another way to dx chronic sinusitis that does not involve radiation?

Nasal endoscopy (Not performed in this case) is useful in demonstrating inflammation of the nasal mucosa, nasal polyps or other masses, the presence of nasal secretions and/or purulence, anatomic deformities.

What ethnicities are most at risk from T2DM?

Native Americans, African and Asian Americans, Latin Americans, and Pacific Islanders

What is the presentation of acute pancreatitis?

Nausea, vomiting and epigastric pain are hallmarks of acute pancreatitis. Typically, however, there is abdominal tenderness on exam and there is unlikely to be resolution of symptoms without prolonged bowel rest, and jaundice may be seen if there is obstruction of the common bile duct. Distinguishing acute pancreatitis from biliary colic (and any other upper abdominal disease) can be challenging, particularly because the two most common etiologies of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Gallstone pancreatitis may be preceded by an episode of biliary colic. With the onset of acute pancreatic inflammation as the pancreatic duct is obstructed, the pain worsens rapidly and radiates to the back. Some classic, though rare, physical exam signs seen in acute pancreatitis include: • Grey-Turner's sign: ecchymotic discoloration in the flank • Cullen's sign: ecchymotic discoloration in the periumbilical region Finally, the presentation of acute pancreatitis may include shock and/or coma.

What is the prevalence of nephropathy in patients with DM?

Nephropathy is common in diabetes. 20-40% of people with diabetes develop diabetic nephropathy. Diabetes is the most common cause of End Stage Renal Disease (ESRD), resulting in 44% of all newly diagnosed cases in 2005.

What signs/symptoms of LBP warrant MRI?

Neurological deficit Radiculopathy Progressive major motor weakness Cauda equina compression (sudden bowel/bladder disturbance) Suspected systemic disorder (metastatic or infectious disease) Failed six weeks of conservative care

What is the prevalence of neuropathy and how is it classified?

Neuropathy is a heterogeneous condition that is associated with nerve pathology. The condition is classified according to the nerves affected. The classification of neuropathy includes focal, diffuse, sensory, motor and autonomic neuropathy. The prevalence of neuropathy defined by loss of ankle jerk reflexes is 7% at 1 year increasing to 50% at 25 years for both type 1 and type 2 diabetes.

What are the new alternative antithrombotic agents for stroke prevention in patients with Afib?

New Alternative Antithrombotic Agents for Stroke Prevention in Patients With AF Warfarin (Class I; Level of Evidence A), dabigatran (Class I; Level of Evidence B), apixaban (Class I; Level of Evidence B), and rivaroxaban (Class IIa; Level of Evidence B) are all indicated for the prevention of first and recurrent stroke in patients with nonvalvular AF. The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in INR therapeutic range if the patient has been taking warfarin.

What is a traumatic brain injury?

Newer term for concussion Head injury with subsequent confusion and amnesia. Loss of consciousness sometimes occurs. Subsequent headache, dizziness, and nausea and vomiting. Over hours and days: mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances.

What is the name for the surgical procedure used to treat GERD/hiatal hernia? When is it indicated? And what do they do?

Nissen fundoplication In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. the gastric fundus of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid (in GERD). Although antacids and PPI drug therapy can reduce the effects of reflux acid, successful surgical treatment has the advantage of eliminating drug side-effects and damaging effects from other components of reflux such as bile or gastric contents. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.

How much more effective is a nebulizer than a MDI with spacer for asthma?

No additional benefit has been demonstrated in using a nebulizer for inhaled beta2-agonists or inhaled steroids compared to using an inhaler and spacer.

What is the role of diet, alcohol and smoking in the risk for BRCA?

No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the exception of limiting alcohol intake. And interestingly, most studies do not show that smoking increases the risk of breast cancer

What percentage of pts with palpitations do not have an identifiable etiology for their symptoms?

No etiology for palpitations occurs in about 16% of patients.

When are alpha-blockers used?

No proven decrease in morbidity and mortality demonstrated in research studies. Not mentioned in JNC 7 algorithm for treatment of essential hypertension. Only useful as adjunct in hard to control blood pressure. May be useful in prostatism but should not be used as a first line anti-hypertensive in patients with BPH.

What is the difference between hot and cold nodules? Which are associated more with CA?

Nodules that cause hyperthyroidism are hyperfunctioning and cause increased radioactive iodine uptake (hot nodules). "Cold" (non-thyroxine producing) nodules can be caused by cancer although typically in that case hyperthyroidism is not present. Diffuse increased uptake suggests Graves' disease whereas a nodular pattern indicates a single nodule or multi nodular disease.

What is functional dyspepsia?

Non-ulcer dyspepsia is sometimes called functional dyspepsia. It means that no known cause can be found for the symptoms. That is, other causes for dyspepsia such as duodenal ulcer, stomach ulcer, inflamed oesophagus (oesophagitis), inflamed stomach (gastritis), etc, are not the cause.

What nasal findings on PE are consistent with allergic rhinitis?

Nose examination may show nasal turbinates and pallor of the nasal mucosa consistent with his allergic rhinitis. Clear, watery nasal drainage may also be present in patients with allergic rhinitis.

What are the signs on newborn infant exam of Down's syndrome?

Not all features are present in a given individual, but most infants with this syndrome have between 4 and 6 of the following signs: Flat facial profile Poor Moro reflex Excessive skin at nape of the neck Slanted palpebral fissures Hypotonia Hyperflexibility of joints Dysplasia of pelvis Anomalous ears Dysplasia of midphalanx of fifth finger Transverse palmar (Simian) crease

When is Breast U/S indicated?

Not recommended for screening purposes. This tool is used for evaluation of suspected abnormalities.

When is Breast MRI indicated?

Not recommended for screening the general population of asymptomatic, average-risk women. May be indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin's disease). May be used as a diagnostic tool to identify more completely the extent of disease in patients with a recent breast cancer diagnosis. Contrast-enhanced breast MRI may be indicated in the evaluation of patients with breast augmentation in whom mammography is difficult.

Which abortive migraine medications should be used only as a last resort?

Note: Don't use opioid or butalbital treatment for migraine except as a last resort. Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments.

What anticipatory guidance is appropriate for a 5 year old well check exam?

Nutrition Remind parents to have their children eat whole grains like brown rice and wheat bread. It's also important to limit the amount of sugary drinks that kids have, even juice. No more than four to six ounces of juice a day is recommended. Physical activity Children should get 60 minutes of physical activity every day. Limiting screen time (television, computer, and video games) to two hours a day is helpful to keep children active. It's also good to keep TVs, games, and computers out of kid's bedrooms. Oral health Schedule dental appointment. Teach child to brush teeth. Discuss flossing, fluoride, sealants. Sexuality education Expect normal curiousity of genitalia and sex. Explain good touch/bad touch and that certain body parts are private.

How is the NuvaRing used? What hormones are involved and what are the risks?

NuvaRing is a small ring, 2" in diameter, containing estrogen and progestin. The ring is inserted vaginally, by the patient, once a month and left in place for three weeks followed by one week off. Effectiveness, mechanism of action, and risks are the same as oral contraceptives.

What family Hx contributes to risk for breast CA?

ONLY Hx of BRCA in a 1st degree relative (parent or sibling)

How should you advise a patient taking RAI therapy?

Obtain a pregnancy test before initiating radioactive iodine treatment. Advise patients that they should not be near pregnant women or young children for several days following radioactive iodine treatment because the radioactive iodine is excreted in urine and stool. Fetuses or young children exposed to this could have deleterious effects on their thyroid. Side effects include transient soreness of the neck or brief worsening of symptoms but they should resolve within a few days. Furthermore, people with ophthalmopathy can have worsening of eye symptoms.

How are lipid panels used in the evaluation of HTN?

Obtained after a 9 to 12 hour fast, a lipid profile that includes measurement of high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides is important. Hypertensive patients require the entire fasting cholesterol panel in order to properly assess lipid co-morbidities as part of metabolic syndrome and the risk of arteriosclerosis. These patients have fasting lipid panels as surveillance of cholesterol problems, not as a general screening tool.

What is the cause of Cauda Equina Syndrome? And how does it present?

Occurs when a large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain radiating down the leg and numbness of the leg. True emergency. Decompression should be performed within 72 hours to avoid permanent neurologic deficits. Low on the differential if the patient denies problem with bowel or bladder control. Also, saddle paresthesias.

What behavioral Tx's for primary insomnia in the elderly have been proven by evidence based medicine?

Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy

What is the presentation of viral pneumonia? And what viruses are often implicated?

Often characterized by an atypical presentation, i.e., chills, fever, dry, nonproductive cough, and the predominance of extrapulmonary symptoms such as GI symptoms and arthralgias. It can be caused by influenza (usually as part of a community outbreak in winter), respiratory syncytial virus in children or immunosuppressed individuals, and measles or varicella along with their characteristic rashes. Adenovirus, rhinovirus, and parainfluenza virus are also common causes. More common in children aged four months to five years.

What other condition does the presentation of septic arthritis closely resemble and how can you differentiate the two?

Often resembles gout or pseudogout, but can be differentiated from these by joint aspiration. In septic arthritis, the fluid appears very turbid (opaque) and has an abundance of inflammatory cells (white blood cell count 15K to > 200K; the lower part of this range (< 35K) may be associated with infections caused by low virulence or partially treated organisms, and the synovial white blood cell count may be elevated in inflammatory causes of arthritis, though usually not as markedly as in septic arthritis.) In gout or pseudogout, the fluid is usually slightly turbid with a moderate amount of white blood cells (3K - 50K), and the presence of crystals (calcium pyrophosphate or monosodium urate) is diagnostic.

How should a PPI be taken?

Omeprazole: take 20 mg every day for four weeks, on an empty stomach, 30 minutes prior to the first meal of the day.

When does avg menopause occur? How does smoking change this? What time frame confirms menopause?

On average, women reach menopause at 51. But, menopause can start earlier or later. A few women start menopause as young as 40, and a very few as late as 60. Women who smoke tend to go through menopause a few years earlier than nonsmokers. The timing of an individual's menopause cannot be predicted. Only after a woman has not menstruated for 12 straight months can menopause be confirmed.

What is the recommendation for exercise to reduce risk for ASCVD?

On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity physical activity 3-4 times per week for 40 minutes per session.

When is the zoster vaccine recommended?

One dose of zoster vaccine is recommended when patients turn 60

How prevalant is BRCA?

One in eight women will have breast cancer before they are 80 years old. The risk of developing breast cancer is related to age.

How common is it to have vaginal bleeding in pregnancy? What are the chances of miscaraige when this occurs?

One in four pregnant patients experience vaginal bleeding during the first trimester. When women have significant bleeding in the first trimester, there is a 25-50% chance of miscarriage.

What pharmacologic agents are recommended for Tx of hypercholesterolemia?

Only one pharmacologic agent recommended for lowering cholesterol: HMG Co-A Reductase Inhibitors (statins).

What are some of the reversible causes of temporary A-Fib?

Onset of atrial fibrillation (AF) reduces cardiac output by 10-20%. AF may be related to acute or temporary causes including: alcohol intake ("holiday heart syndrome"); surgery; electrocution; myocardial infarction; pericarditis; myocarditis; pulmonary embolism or other pulmonary diseases; or hyperthyroidism and other metabolic disorders. If one of these causes is present, successful treatment of the underlying condition often eliminates AF. New onset AF occurring in the setting of acute myocardial ischemia is associated with worse outcomes than when ischemic events occur in patients with pre-existing AF or sinus rhythm. AF may be associated with atrial flutter, the Wolf Parkinson White (WPW) syndrome, or AV nodal reentrant tachycardia, and treatment of the primary arrhythmias reduces or eliminates the incidence of recurrent AF. AF is a common early postoperative complication of cardiac or thoracic surgery.

Options for birth control?

Options include: oral contraceptives, medroxyprogesterone (Depo-Provera) injections, transdermal options, IUDs, and the vaginal ring (NuvaRing)

How effective are oral contraceptives against pregnancy? What are the side effects and added benefits?

Oral contraceptives are available in combination type, containing estrogen and progestin, or progestin only. Both are highly effective against pregnancy when taken regularly (92-99.7%). These work by inhibiting ovulation and by thickening the cervical mucus. The most significant risk is thromboembolism and there can be an increased risk of stroke in patients who are hypertensive, especially if they smoke tobacco. Benefits include menstrual cycle control, decreased menstrual symptoms and bleeding, and decreased acne.

What are the USPSTF recommendations for screening for osteoporosis?

Osteoporosis Osteoporosis screening is recommended by the USPSTF for all women at, or over the age of 65, and in younger women who have equivalent fracture risks to the average white woman at age 65.

What other weight loss medications are approved by the FDA? What are the risks?

Other FDA-approved medications include lorcaserin, a serotonin agonist, and phentermine-topiramate, a sympathomimetic/anticonvulsant combination -- both approved for use in male and post-menopausal female patients with obesity. They are contraindicated in pregnancy. Lorcaserin has few long term safety data and so should be discontinued if a patient does not achieve 5% loss of bodyweight in 12 weeks. Phentermine-topiramate should be avoided in patients with hypertension and coronary artery disease and due to it pregnancy category X status, requires pregnancy testing prior to, and every month while a patient of child bearing age is on it. It should also be discontinued after 12 weeks if 5% body weight loss is not achieved while on the highest dose.

What are the alternatives to HRT for hot-flashes and menopausal symptoms? What Tx's are proven to be risky or not effective?

Other prescription medications, including the antidepressants SSRIs and SNRIs, and clonidine and gabapentin, although less effective than HT for vasomotor symptoms, can be very beneficial in selected patients. NCCAM has found preliminary evidence to support the use of mind and body practices such as yoga, tai chi, qi gong, and acupuncture for management of menopausal symptoms, but outlines specific concerns and recommends against the use of compounded hormones marketed as Bioidentical Hormone Replacement therapy and against the use of DHEA. Furthermore, natural medicines, such as phytoestrogens and botanicals, have not been shown to be clearly safe and effective according to usual standards for prescription medications.

What questions are in the GAD-2?

Over the last two weeks, how often have you been bothered by the following problems? Not at all Several days Nearly half the days Nearly every day 1. Feeling nervous, anxious or on edge? 0 1 2 3 2. Not being able to stop or control worrying? 0 1 2 3 (For office scoring, total score T__ = _____ + ____ + ___ ) A positive screening test is a score >3 points.

What is fetal development like at week 27?

Over the next few weeks, the fetus' eyes will open and begin to detect light. The fetus will also practice breathing. By 36 weeks, the fetus will gain weight more quickly.

On average, uncontrolled HTN decreases life expectancy by how many years?

Overall uncontrolled hypertension decreases life expectancy by 20 years.

If a child is overweight or obese, what are the odds that they will be obese as adults?

Overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if one or more parent is overweight or obese.

What therapies are used for functional dyspepsia?

PPI therapy has been shown to be superior to placebo treatment with regard to relative risk reduction of functional dyspepsia (Number needed to treat (NNT) = 9). Evidence exists to support an empiric trial of histamine-2 receptor antagonists, although some data suggests these medications are no more beneficial than prokinetics (e.g. metoclopramide) or antacids. A subset of patients with functional dyspepsia will not respond favorably to any form of anti-secretory therapy and will continue to experience symptoms. Studies have observed an approximately 10% reduction in dyspepsia symptoms 12 months after H. pylori eradication therapy in patients with functional dyspepsia (NNT = 17).

What are the possible complications of PUD?

PUD Hemorrhage or perforation into the peritoneal cavity or adjacent organs (causing severe, persistent abdominal pain). Ulcer scar healing or inflammation can impair gastric emptying leading to gastric outlet obstruction syndrome.

What symptoms of PUD are contrasted from those of GERD making it more possible to differentiate the two? What features complicate this differentiation?

PUD Usually characterized by episodic or recurrent epigastric 'aching', 'gnawing', or 'hunger-like' pain or discomfort. Symptoms occur on an empty stomach and are commonly relieved by meals Complicated by: However, this is not always true, and there can be some differences in symptoms based on the location of an ulcer. For example, gastric ulcer pain may occur 5 to 15 minutes after eating and remain until the stomach empties, which may be up to several hours in duration, and the pain may otherwise be absent during times of fasting. Pain from duodenal ulcers is often relieved by eating, drinking milk, or taking antacids but may return anywhere from 90 minutes to 4 hours after eating a meal. Both gastric and duodenal ulcers may be associated with nausea and vomiting occurring anytime shortly after eating to several hours later.

What are the 6 P's of a limb threatening injury?

Pain Paresthesia (A skin sensation, such as burning, prickling, itching, or tingling.​) Pallor Paralysis Pulselessness Perishing cold (poikilothermia) (The inability to regulate one's body temperature.)

Which causes of LBP improve with supine position?

Pain that improves with the supine position suggests spinal stenosis and disc herniation.

How common are thyroid nodules? How many are symptomatic?

Palpable thyroid nodules occur in 4-7% of the population. Nodules found incidentally on ultrasonography suggest the prevalence of thyroid nodules is actually 16-67%. Most people with thyroid nodules are asymptomatic. Less than 1% of nodules cause hyperthyroidism or thyrotoxicosis

What is the presentation of pancreatitis?

Pancreatitis is generally a moderately severe to severe epigastric pain that often radiates to the back, and is accompanied by nausea, vomiting and anorexia. There is usually a history of excessive alcohol use/abuse or a family history of pancreatitis, although this can also be caused by gallstones, hypertriglyceridemia and other less common causes. If suspicion is high, laboratory tests (lipase, amylase) and imaging (abdominal ultrasound or CT scan) are needed to investigate further.

What other Tx's for osteoporosis are available and how well have they been proven to work? What limitations do they have?

Parathyroid hormone (Forteo) is an anabolic drug and is approved by the FDA for those with osteoporosis at high risk for fracture. It is given subcutaneously and has been shown to decrease fracture risk by 50-65%. It does not have demonstrated efficacy and safety beyond two years and is quite costly. Estrogen replacement therapy has demonstrated a fracture risk reduction of 20-34%. It is indicated primarily for the short-term treatment of moderate to severe vasomotor symptoms and is not recommended for long-term use. Calcitonin has been shown to reduce vertebral fractures, but not hip or other fractures. For most women, more effective treatments are available.

What lifestyle modifications are recommended in OA?

Participate in cardiovascular (aerobic) and/or resistance exercise - either aquatic or land-based Lose weight (for persons who are overweight)

What are the major findings in patellar subluxation? What test do you do to assess for it?

Patellar subluxation is an incomplete or partial dislocation of the kneecap. The patella repetitively subluxates and places strain on the medial restraints and excessive tension on the patellofemoral joint. This is commonly caused by running and jumping sports and activities that place large forces on the patellofemoral joint. A patellar apprehension test helps detect patellar subluxation. The test is positive if there is pain or a giving-way sensation when attempting to translate the patella laterally.

What is another name for Patellofemoral Pain Syndrome? And what are the features?

Patellofemoral Pain Syndrome (chondromalacia patellae) Anterior knee pain No trauma; overuse injury more likely No fever Typically presents in women as "theater sign"- mild to moderate anterior knee pain, worse after prolonged sitting

What is the typical presentation of IBD?

Patients have abdominal pain, bloody diarrhea and frequent stooling. The onset of symptoms frequently occurs in the late 20's or early 30's. The patient may ultimately be diagnosed with either ulcerative colitis or Crohn's Disease. Diagnosis is made by small bowel follow-through, colonoscopy, or barium enema. Ms. Bell is not complaining of bloody or frequent stools. IBD is not a likely diagnosis.

What is nonasthmatic eosinophilic bronchitis?

Patients present with a chronic cough (> 8 weeks) and a normal chest x-ray. Symptoms do improve with inhaled corticosteroids, as do symptoms in patients with asthma, but - unlike patients with asthma - these patients have normal spirometry findings. The diagnosis is confirmed with the presence of eosinophilia in either an induced sputum or a bronchial wash specimen obtained on bronchoscopy.

What information do you need to get in the history for suspected ectopic pregnancy?

Patients present with divergent symptoms ranging from no pain and normal menses, to intense pain and irregular or absent menses. A good history, the physical exam and lab testing are crucial for this diagnosis. Imaging is also usually needed. You need the date of the patient's last menstrual period (LMP), her menstrual history, most recent intercourse dates, types of contraception used in past few years, history of any vaginal or pelvic infections, and history of previous ectopic or normal pregnancies.

What risk factors predict longer recovery time from low back pain? What is the overall recurrence rate?

Patients who are older (>45) and patients who have psychosocial stress take longer to recover. Recurrence rate for back pain is high at 35 to 75%.

How might symptoms of hyperthyroidism be different in patients older than seventy?

Patients who are older than seventy may present with sinus tachycardia (71%) and/or fatigue (56%); but they can also present with atrial fibrillation or weight loss, and no other symptoms.

Physical presentation of trauma due to intimate partner violence in pregnancy?

Patients who are pregnant, or even those in whom there is the suspicion of pregnancy, are at increased risk for trauma related to intimate partner violence. Additionally, the stress of suffering intimate partner violence may cause irregular menses in some women. Abdominal pain and cramping may come not only from the inflicted trauma but also from somatization of stress. Bruises of various colors, denoting various stages of healing, can be seen on any part of the body, but are often present on the abdomen as this would cause trauma to a fetus and because they are less visible.

Quality of life in GERD?

Patients who have GERD generally report decreased quality of life, reduced productivity, and decreased well-being. In many patients, reported health-related quality of life is lower than age-matched patients who have untreated angina pectoris, diabetes mellitus or chronic heart failure.

When should you consider using migraine prophylactic medications?

Patients who have migraines more frequently than twice weekly are at risk for medication overuse headache. Migraine prophylaxis should be considered in these patients if the lifestyle changes aren't effective.

What is the presentation of PAD?

Patients with PAD have a history of claudication, which manifests as cramp-like muscle pain occurring with exercise and subsiding rapidly with rest. In addition, later in the course of the disease, patients may present with night pain, nonhealing ulcers, and skin color changes.

What is the typical presentation of gallbladder disease?

Patients with gall bladder disease usually complain of pain in the right upper quadrant, which may radiate to the right shoulder or right upper back. The patient may have a history of oral contraceptive use, often is premenopausal (fertile), may be overweight or obese (fat), middle-aged (forty), and female. Symptoms are aggravated by the patient eating fatty foods. "Fat, Fertile, Female, and Forty"

How can GERD play a role in asthma?

Patients with gastroesophageal reflux disease typically present with either heartburn symptoms or findings of esophagitis on upper endoscopy. Even if asymptomatic, reflux can trigger bronchoconstriction and serve as an exacerbating factor for patients with asthma. If a patient with asthma fails to improve with standard treatment, it is reasonable to consider whether gastroesophageal reflux is present.

What is the presentation of PID? And what are the potential sequelae?

Patients with pelvic inflammatory disease (PID) might have abdominal or pelvic pain, which is worse with sexual intercourse or with activities such as running or jumping, which cause jarring of the pelvic organs. This diagnosis has significant morbidity, which increases with the severity of the disease and with the length of time to diagnosis. Studies show that approximately one in four women who had a single episode of PID later experienced tubal infertility, chronic pelvic pain, or an ectopic pregnancy, as a result of scarring and adhesions. Tubal adhesions leading to infertility have been reported to occur in 33% of women after their first episode of PID, and up to 50% after the second pelvic infection.

When should you withhold vaccinations due to present illness of the patient?

Patients with recent exposure to infectious diseases, or patients who have a mild illness (with or without fever), should recieve their vaccines. However, if a patient has a moderate to severe illness, (including high fever, otitis, diarrhea, and vomiting) then vaccines should be postponed until they are recovering and are no longer acutely ill.

What is the typical presentation of temporal arteritis?

Patients with temporal arteritis may present with amaurosis fugax (transient monocular loss of vision) and cranial bruits. The incidence peaks in the early seventies with women representing 80% of the affected. Patients may present with symptoms including headache, malaise, scalp tenderness over the temporal artery, intermittent jaw claudication, and low-grade fever.

What will spirometry readings look like in vocal cord dysfucntion?

Patients with vocal cord dysfunction may have flattening of the inspiratory loop on spirometry, but do not typically have reversible obstructive findings on spirometry like patients with asthma. The diagnostic finding of this condition is visualizing abnormal vocal cord movement during an episode of wheezing.

What should you look for on physical exam on a patient with abnormal vaginal bleeding? What finding is concerning for uterine CA?

Pelvic Exam: Look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or dysplasia. On bimanual examination, assess the size and mobility of her uterus, as a firm, fixed uterus would be concerning for uterine cancer. Neck Exam: Thyroid exam to look for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding. Skin Exam: Look for evidence of bleeding disorders, like bruises. Also, jaundice on skin exam and hepatomegaly on abdominal exam might signify an underlying acquired coagulopathy via liver disease.

What are the choices for antibiotics in children with strep throat? What are the advantages/disadvantages of each?

Penicillin V (50 mg/kg in 2-3 divided doses for 10 days, or 250 mg 2-3 times a day for children less than 27 kg) is the antibiotic of choice for strep pharyngitis due to low cost, narrow spectrum of activity, safety and effectiveness. Penicillin V is recommended as a first-line treatment for strep pharyngitis by several organizations (AAFP: American Academy of Family Physicians, AAP: American Academy of Pediatrics, AHA: American Heart Association, WHO: World Health Organization, and IDSA: Infectious Disease Society of America). Penicillin G IM (benzathine penicillin G 600,000 units IM for children less than 27 kg) is an appropriate choice when the patient is otherwise unlikely to finish the entire course of oral antibiotics. An injection can cause significant discomfort and has an increased risk of anaphylaxis although a form of injectable penicillin mixed with benzathine/procaine (Bicillin C-R) lessens discomfort. Amoxicillin liquid is often given to children instead of penicillin because it tastes better. However, penicillin has a narrower spectrum of activity effective against strep and is less likely to contribute to antimicrobial antibiotic resistance. Amoxicillin dosing is 50 mg/kg divided 2-3 times a day for 10 days. Single dose amoxicillin is not approved for children younger than 12. First generation cephalosporins (Cephalexin and Cefadroxil) are as effective as penicillins. They also have a broader spectrum of activity than penicillin and may contribute to antibiotic resistance. They are recommended for patients who have an allergy to penicillin that is not an immediate-type hypersensitivity. Cephalexin dosing is 25-50 mg/kg divided 2-3 times a day for 10 days. Macrolides (Erythromycin ethlysuccinate or Erythromycin estolate) are reserved for patients with penicillin allergy. They also have a broader spectrum of activity than penicillin and may contribute to antibiotic resistance. Azithromycin or clarithromycin may have fewer gastrointestinal side effects than erythromycin.

What are the possible complications of D&C for pregnancy?

Perforation Incomplete evacuation Bleeding Infection Intrauterine synechiae Depression and/or other psychological sequelae

What is assessed by an arthrocentesis?

Perform an arthrocentesis and send the fluid for cell count with differential, glucose and protein, bacterial culture and sensitivity, and polarized light microscopy for crystals. An arthrocentesis can also help differentiate between simple effusion and hemarthrosis or occult osteochondral fracture.

In what order do you do a back exam?

Perform the back exam systematically in sequential order with the patient: Standing Sitting Supine

What common bursitis occurs at the medial aspect of the knee from overuse?

Pes anserine bursitis

What are some physical or environmental triggers for HAs?

Physical or environmental triggers: Intense or strenuous exercise Sleep disturbance Menses Ovulation Pregnancy (though for many women, headaches actually improve during pregnancy) Acute illness Fasting Bright or flickering lights Emotional stress

What is the PQRI?

Physician Quality Reporting Initiative (PQRI) Starting in 2016, the Centers for Medicare, Medicaid (CMS) will make incentive payments of 2% of their total allowed charges to eligible professionals who satisfy certain conditions.

What are the PQRI guidelines for diabetes care?

Physician Quality Reporting Initiative: Measures for type 1 or type 2 diabetes patients Measures: "Percentage of patients aged 18-75 years with diabetes mellitus who had...." Hemoglobin A1c Poor Control (A1C > 9%) Low Density Lipoprotein Control (LDL-C < 100 mg/dl) High Blood Pressure Control (BP < 140/80 mmHg) Dilated Eye Exam Urine Screening (nephropathy screening test or evidence of nephropathy) Foot exam

What factors influence whether or not placenta previa resolves before birth?

Placenta previa is more likely to resolve when detected earlier in pregnancy. Marginal or incomplete previas are more likely to resolve than complete previas.

Plecenta previa as the cause of 3rd trimester bleeding:

Placenta previa is the cause of 22% of cases of third trimester vaginal bleeding. Occurs when the placenta attaches low in the uterus and covers the cervical os. This can lead to excessive bleeding, jeopardizing the health of the fetus. Most commonly presents with painless vaginal bleeding after 20 weeks' gestation. The bleeding is usually bright red. Contractions occur in 10-20% of cases, but previa is usually not accompanied by abdominal pain. Bleeding from previa is often spontaneous. Patients with (unresolved) placenta previa are usually advised to omit sexual activity due to the risk of inciting bleeding.

What are the risk factors for placenta previa?

Placenta previa is uncommon, occurring in 0.3 to 0.5% of pregnancies. It is more common in women who: have had a prior pregnancy are older (>35) smoke have had twins or a higher multiple pregnancy have had previous uterine surgery, including prior cesarean section

Placental abruption as a cause of 3rd trimester bleeding:

Placental abruption is the cause of 31% of cases of third trimester vaginal bleeding. Most commonly characterized by vaginal bleeding with associated abdominal pain, uterine contractions, and a non-reassuring fetal heart tracing. Abruption occurs when the placenta peels away from the inner wall of the uterus before delivery - either partially or completely - and can occur spontaneously or after trauma. Abruptions can vary in size, from small and self-limited to near-complete separation of the placenta from the uterus. Requires immediate medical treatment, as abruption can deprive the fetus of oxygen and cause heavy bleeding in the mother.

What are the 4 P's that reduce the likelihood that chest pain is cardiac in origin?

Pleuritic Pulsating Positional reproduced by Palpation and "stabbing pain" can come too...

What risk assessment tool is used by the newer ACC/AHA Cholesterol Guidelines (2013)?

Pooled Cohort Equations produces a patient's 10-year risk of incident ASCVD based upon their major risk factors (age, gender, smoking status, hypertension and systolic blood pressure, diabetes, total and HDL cholesterol)

What are some possible dietary triggers for HAs?

Possible dietary triggers: Ripened cheeses Alcohol, especially beer and red wine Pickled or fermented foods Monosodium glutamate (MSG) Yeast-based products Chocolate Legumes and beans Onions Citrus fruits Bananas

What categories of health professionals are involved in the post-stroke rehabilitation?

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals.

What is the difference between postpartum depression and the postpartum blues?

Postpartum blues Most women (up to 85%) get what's known as 'the blues,' which usually occurs soon after childbirth, often peaks around the fourth and fifth day, and subsides by around ten days; it's marked by mood swings which can be significant, tearfulness, irritability, and fatigue, and many women associate it with their milk coming in as lactation gets established. Postpartum depression Postpartum depression can occur any time from delivery to several months later and is more serious. It is marked by traditional signs and symptoms of depression. Most clinicians feel that postpartum depression can be diagnosed up to six months after childbirth. The formal DSM-V criteria describe potential onset of postpartum depression during the peripartum period and up to 4 weeks following childbirth. Having a history of depression or a previous episode of postpartum depression puts a woman at increased risk of developing postpartum depression.

What are the "postpartum blues"? And how long do they last?

Postpartum blues refers to mild, though often rapid, fluctuations in mood within the first two weeks postpartum, often peaking at about day five. Multiple factors likely contribute to postpartum blues. They usually resolve over time with support, reassurance, and rest. Women with postpartum blues should be counseled about seeking care if symptoms worsen or are not improved by two-weeks postpartum.

How common is postpartum depression and how do you treat it?

Postpartum depression affects up to 15% of mothers and is under-recognized and undertreated by physicians. Effective treatment includes antidepressant medications, although further research is needed to more fully understand the effect of antidepressant medication on infants and exposure through breast milk. Psychosocial and psychological interventions are also effective in reducing the symptoms of postpartum depression.

What constitutes postpartum depression? And what are the risk factors for its development?

Postpartum depression occurs in about 5% of women and refers to the onset of clinical depression (using the same criteria as for those who are non-pregnant) within the first four weeks postpartum. In clinical practice, onset within the first year after delivery of an infant is often referred to as postpartum depression. Multiple risk factors have been associated with postpartum depression. Some of these include stressful life events over the preceding year; unplanned pregnancy; lack of spousal or partner support; personal history of mental disorders; and, especially relevant in this case, having an infant with a congenital malformation.

What lies at the severe end of the spectrum for postpartum depression?

Postpartum psychosis Remember that there is a severe end of the spectrum of postpartum mood problems known as postpartum psychosis; this is quite rare (only 0.2%) but can be quite rapid in onset following childbirth and is marked by true signs and symptoms of psychosis.

What are the 6 stages in the stages of change model?

Pre-contemplation Stage During the pre-contemplation stage, patients do not even consider changing. For example, smokers who are "in denial" may not see that the advice applies to them personally or patients with high cholesterol levels may feel "immune" to the health problems that strike others. Contemplation Stage During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I need to, doc, but ...") as well as the benefits of change. Preparation Stage During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, sampling low-fat foods may be an experimentation with or a move toward greater dietary modification. Action Stage At this point patients take definite action to change. Maintenance Stage This is the stage of continued commitment to sustaining new behavior. Physician should plan for follow up support and also discuss coping with relapse. Relapse Resumption of old behavior. Trigger for relapse should be evaluated. Motivation and barriers need to be reassessed and stronger coping strategies developed.

What are the Stages of Behavior Change?

Pre-contemplative - Not aware of need to change or not interested in changing behavior. Contemplative - Currently interested in changing behavior. Active - Currently making a behavior change. Relapse - Attempted behavior change but no longer making the change.

What are the physiologic causes of nipple discharge?

Pregnancy Excessive breast stimulation

What are the contraindications to RAI therapy?

Pregnancy and breast feeding are absolute contraindications. May damage the fetal/infant thyroid. Women are advised not to get pregnant for six months after a treatment and men are advised to not father children for four months after treatment. Breast feeding should be discontinued permanently or until the next pregnancy.

What factors are associated with a DECREASED risk of BRCA?

Pregnancy at an early age Late menarche Early menopause High parity Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin.

Wheat is the presentation of premature rupture of membranes (PROM)?

Premature rupture of membranes (PROM) refers to rupture of the fetal membranes prior to the onset of labor and can occur at any gestational age - even at 42 weeks' gestation and occurs in 8-10% of term pregnancies. Rupture of membranes typically presents as a large gush or steady trickle of clear vaginal fluid. Preterm PROM (defined as PROM prior to 37 weeks of gestation) is the leading identifiable cause of premature birth and accounts for approximately 18% to 20% of perinatal deaths in the United States. Therefore it is an important diagnosis to consider.

What serum screening tests can be done on the mother to determine risk for fetal aneuploidy? And when can they be done?

Prenatal maternal ("triple" or "quad") serum screening consists of measuring three or four chemical markers present in the mother's blood during pregnancy: alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol, and (only in the quad screen) dimeric inhibin A. Abnormal levels of these serum markers may indicate increased risk for neural tube defects, trisomy 21, and trisomy 18. Serum screening is not usually performed until approximately 15-21 weeks' gestation.

How might hispanics present differently with depression?

Present more often with somatic complaints. Lower rates of depression among immigrants (may be under-reported). Psychosis is no more common in Hispanics than other groups, but symptoms of perceptual distortion such as hearing noises or seeing shadows (known as celajes) are more common and must be differentiated from psychotic hallucinations.

What is the leading cause of infant mortality in the US?

Preterm labor (prior to 37 weeks) is the leading cause of infant mortality in the United States.

What are the AHA and ASA recommendations for the prevention of stroke in pts with a previous stroke or TIA?

Prevention of Stroke in Patients With a History of Stroke or TIA For patients with ischemic stroke or TIA with paroxysmal (intermittent) or permanent AF Anticoagulation with a vitamin K antagonist (target INR, 2.5; range, 2.0-3.0) is recommended (Class I; Level of Evidence A). For patients unable to take oral anticoagulants Aspirin alone (Class I; Level of Evidence A) is recommended. The combination of clopidogrel plus aspirin carries a risk of bleeding similar to that of warfarin and therefore is not recommended for patients with a hemorrhagic contraindication to warfarin (Class III; Level of Evidence B).

What are the AHA and ASA recommendations for the prevention of a first stroke? (as for pts with Afib)

Prevention of a First Stroke Adjusted-dose warfarin (target INR, 2.0-3.0) Recommended for all patients with nonvalvular AF deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive it safely (Class I; Level of Evidence A). Antiplatelet therapy with aspirin Recommended for low-risk and some moderate-risk patients with AF on the basis of patient preference, estimated bleeding risk if anticoagulated, and access to high-quality anticoagulation monitoring (Class I; Level of Evidence A). Dual-antiplatelet therapy with clopidogrel and aspirin Offers more protection against stroke than aspirin alone but with an increased risk of major bleeding and might be reasonable for high-risk patients with AF deemed unsuitable for anticoagulation (Class IIb; Level of Evidence B).

"I" screening recommendations include?

Prevention of motor vehicle injuries with seatbelt use and avoiding driving under the influence of alcohol; family and intimate partner violence screening; illicit drug use; and skin cancer screening. Depending upon the patient population, additional screening receiving an "I" recommendation are: screening for glaucoma; lung cancer screening; oral cancer screening; and thyroid disease screening

What is the difference between primary and secondary skin lesions?

Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy. Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.

What is the stages of change model?

Prochaska and DiClemente Stages of Change model The Stages of Change model shows that, for most persons, a change in behavior occurs gradually, with the patient moving from being uninterested, unaware or unwilling to make a change (precontemplation), to considering a change (contemplation), to deciding and preparing to make a change.

What antiemetics are safe in pregnancy

Prochlorperazine, 25 mg per rectum every 12 hours Promethazine, 25 mg orally or rectally every 4 hours Ondansetron, 8 mg two or three times daily

What contraceptive methods are available for use immediately postpartum? Why? Disadvantages?

Progestin-only pills, injectable progestin (Depo-Provera), and progestin implants (Implanon) can be started immediately post partum. Advantages to these methods include the minimal effect of progestins on blood pressure, coagulation factors or lipid levels, and the lack of increased risk of stroke, myocardial infarction, or venous thromboembolism with progestin-only contraceptives. Potential disadvantages include the need to take a daily pill at the same time every day (for maximum effectiveness) with a progestin-only pill and irregular bleeding, particularly within the first few months.

What is Blount's Disease?

Progressive bowing of the legs (often from obesity in childhood)

What are the pathologic causes of nipple discharge?

Prolactinoma Breast cancer -Intraductal papilloma -Mammary duct ectasia -Paget's disease of the breast -Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)

What normal response to estrogen stimulation may cause vaginal bleeding adn be confused with simple hyperplasia of the endometrium?

Proliferative endometrium Normal response to estrogen stimulation in premenopausal women. Occasionally postmenopausal patients, particularly those in higher estrogen states, can produce a similar endometrial response. On biopsy, this condition may be hard to differentiate from simple hyperplasia.

What are the risk factors for low back pain? What jobs have the highest incidence?

Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs. Deconditioning. Sub-optimal lifting and carrying habits. Repetitive bending and lifting. Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta. Obesity is a possible risk factor, but the evidence is limited and inconsistent.

What is the first step in treatment of hyperthyroidism?

Propanolol (or other BB) to decrease the adrenergic effects symptoms (tachycardia, tremor, heat intolerance)

What is the role of Warfarin in DVT?

Prothrombopenic drugs like warfarin are not suitable for initial therapy in thromboembolism because their onset of action is too slow. Their only role is in maintaining anticoagulant protection for prolonged periods. Monitor warfarin dose by measuring the INR and titrate the warfarin dose every three to seven days to an INR of 2.0-3.0.

What special tests can be done to assess for acute appendicitis?

Psoas sign - Passive extension of patient's thigh as s/he lies on his/her side with knees extended, or asking the patient to actively flex his/her thigh and hip causes abdominal pain, often indicative of appendicitis. (highly predictive) Obturator Sign - Examiner has patient supine with right hip flexed to 90 degrees- takes patient's right ankle in his right hand as he uses his left hand to externally/internally rotate patient's hip by moving the knee back and forth. Elicitation of pain in the abdomen implies acute appendicitis. Rovsing's Sign - Palpation of the LLQ elicits referred pain in the RLQ.

What are the salient features of psoriasis?

Psoriasis is usually bilateral and involves extensor surfaces of elbows and knees. Although psoriasis can present with involvement in patches, it usually plaque-like, with scaly, elevated lesions.

What are the salient features of Psoriatic Arthritis?

Psoriatic arthritis Associated with psoriatic plaques, or thickened silvery scaly plaques located on the extensor surfaces. Psoriasis must be present to make this diagnosis, but the arthritis sometimes appears before the lesions (13-17% of cases), and lesions are present but undiagnosed in about 15% of cases. Usually oligoarthritis, meaning that it affects two to four joints, or polyarthritis, when five or more joints are involved.

What is the presentation of pyloric stenosis? Treatment?

Pyloric stenosis is the most common cause of nonbilious vomiting in infants. The incidence is 1-3/1,000 infants in the US. The male to female ratio is 4:1. Genetic predisposition occurs in 20% of males and 10% of females whose mother had the condition. The etiology is unknown. It presents most typically after three weeks of age and up to five months. It may present as early as the first week of life. Vomiting may be projectile. Diagnosis is made by palpation of a firm, mobile, 2 centimeter long, olive-shaped pyloric mass located above and to the right of the umbilicus in the mid-epigastrium beneath the liver edge, present in about 70% of cases. Ultrasound is 95% sensitive for diagnosis and used when presentation suggests the diagnosis but a mass is not palpated. Treatment is surgical.

What interventions are proven to improve quit rates?

Quit rates are highest when patients are engaged in a group setting. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 - 3 times the placebo quit rate. When combined with medication, a series of one-on-one counseling sessions (as in a physician's office), enhances quit rates. Providing practical problem-solving skills, assistance with social supports, and use of relaxation/breathing techniques can increase quit rates.

What is the RISE mnemonic?

RISE Mnemonic for Preventive Visits Risk factors - Identify risk factors for serious medical conditions during history and physical exam. Immunizations - Provide recommended immunizations / chemoprophylaxis. Screening tests - Order appropriate screening tests. Education - Educate patients on ways to live healthier while reducing risks for disease.

When might you use radiation for skin CA? And when is it contraindicated?

Radiation therapy An option for the initial management of small, well-defined, primary SCCs, especially older patients and those who are not surgical candidates. However radiation therapy is contraindicated on tumors located on trunk and extremities. These areas are subjected to greater trauma and tension than skin on the head and neck, and they are more prone to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.

What is RAIU?

Radioactive iodine uptake (RAIU) test and scan measures the amount and pattern of radioactive iodine taken up by the thyroid in the 24 hours following ingestion of a set dose. Normal RAIU uptake is 15-30% of the ingested dose. The various etiologies of hyperthyroidism can be differentiated as conditions that manifest as high RAIU (>30%) or low RAIU (<15%).

What is the Crossed Leg Raise? What does it indicate?

Raise the asymptomatic leg Test is positive if pain is increased in the contralateral leg; this correlates with the degree of disc herniation. Such results imply a large central herniation. Cross SLR test is much less sensitive (0.25) but is highly specific (about 0.90). Thus, a negative test is nonspecific, but a positive test is virtually diagnostic of disc herniation.

What assessment tool is used to evaluate food frequency?

Rapid Eating and Activity assessment for Patients (REAP) is a brief validated questionnaire that assesses diet related to the Food Guide Pyramid and the 2000 U.S. Dietary Guidelines. REAP includes questions to assess intake of whole grains, calcium-rich foods, fruits and vegetables, fat, saturated fat and cholesterol, sugary beverages and foods, sodium, alcoholic beverages and physical activity. REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and how willing the patient is to make changes to eat healthier. Patients can either fill out the instrument in the waiting room or have it sent home to complete before their appointment. The REAP Physician Key includes sections on patients at risk, further evaluation and treatment as well as counseling points/further information for each major dietary area.

How common are hormone producing ovarian cancers? What is the presentation?

Rare. Most ovarian cancers do not cause postmenopausal bleeding or other significant symptoms, but postmenopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6 fold increased risk). Other possible symptoms of ovarian cancer include pelvic or abdominal pain, increase in abdominal size or bloating, and difficulty eating or feeling full.

How common is breast milk allergy when a baby is fussy all of the time?

Rarely, the exclusion of milk products from the diet of a breastfeeding mother may improve colic-like symptoms, but studies do not support doing this. Some authors recommend a one-week trial of maternal dietary restriction of dairy products to help parents feel they are doing something when colic symptoms are severe; again data supporting this is absent. Many families believe they have milk allergies in their family, and will have tried cessation of cow's milk formulas in an attempt to relieve symptoms prior to consulting the doctor. The family doctor's role in these cases is to counsel continuation of breastfeeding and reassurance that many babies have early feeding difficulties but it is well established that breastfeeding causes the fewest digestive difficulties.

How do you rate muscle strength on the neuro exam?

Rating Scale: 0/5 No movement 1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it's attached. 2/5 Voluntary movement, which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface. 3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. 4/5 Voluntary movement capable of overcoming "some" resistance 5/5 Normal strength

What supplementation should be suggested to sexually active females just in case of pregnancy? What are the benefits?

Recommend folic acid supplementation to prevent neural tube defects in the event of pregnancy The USPSTF recommends that all women of childbearing age who are capable of becoming pregnant should consume 0.4-0.8 mg (400-800 mcg) of folic acid daily, which is most easily achieved by taking a supplement "The benefits of folic acid supplementation are being investigated with regard to the prevention of other complications of pregnancy as well as chronic maternal disease states (e.g., preterm birth and cardiac disease), further emphasizing the appropriateness of prenatal care as both a model for primary care and a model for the provision of care in the context of a lifespan approach. Care provided at each visit impacts not only pregnancy outcome but ultimately long-term health outcomes for the woman and her family

What is the work of a recreational therapist?

Recreational therapists help people with a variety of disabilities develop and use their leisure time to enhance their health, independence, and quality of life.

What are the red flags for thyroid CA? And how are nodules evaluated?

Red flags for thyroid cancer include: - Male gender - Extremes in age (less than 20 or over 65 years old) - Rapid growth of nodule - Symptoms of local invasion (dysphagia, neck pain, hoarseness) - History of radiation to the head or neck - Family history of thyroid cancer or polyposis (Gardener's syndrome) Evaluation: Thyroid ultrasound and fine needle aspiration (FNA) biopsy of the nodules. Ultrasound-guided aspiration improves the diagnostic accuracy of the FNA.

How much should Na+ be reduced in diet?

Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride).

What special considerations are given for ARBs?

Reduces microalbuminuria and macroalbuminuria. Shown to have heart remodeling effects. Avoid in pregnant women (Category C drugs). Less bradykinin production.

What are the recommendations for alcohol use for men and women?

Regardless of type of alcohol, drinkers should drink in moderation: up to one drink per day for women, up to two drinks per day for men.

What are the current guidelines for screening for cervical CA?

Regular screening with Pap smears (cytology) has been very effective at reducing mortality from cervical cancer in screened populations. Extensive research and newer technologies have allowed for more precise guidelines for cervical cancer screening in patients of average risk. Recent recommendations from the American Society for Colposcopy and Cervical Pathology call for Pap smear screening to start at age 21 and continue every three years until age 30. Preferred screening from age 30-65 is with HPV testing in addition to the cytology test (Pap) every five years. Screening this age group (30-65) with cytology alone every three years is an acceptable alternative. For women with possible gynecologic pathology or certain risk factors--such as HIV, immunosuppression, DES exposure (while in utero), or history of cervical cancer--more frequent Pap smears may be indicated. These guidelines do not currently prohibit testing more often if the physician feels it is indicated, or if the patient requests more frequent screening. However, insurance coverage for more frequent tests in average risk patients will likely end once these new guidelines are accepted.

How long should you rest an ankle after a sprain?

Rest for the first seventy-two hours after an ankle sprain, as it may help with reduction of swelling and healing. Stretching is helpful after the first few days to improve range of motion and improve the function of forming scar tissue. Don't rest the ankle for too long, as not moving the ankle for extended periods of time can actually cause more harm such as decreased range of motion, persistent pain and swelling, and chronic joint instability.

What findings may be seen on fundoscopic evaluation in diabetic retinopathy?

Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction. Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages. Microaneurysms are more punctate dark lesions that indicate vascular dilatation. Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.

What are the salient features of Rheumatoid Arthritis?

Rheumatoid arthritis Can have associated subcutaneous nodules that are firm and nontender, and are located at pressure points. Joint stiffnessfor more than thirty minutes in the morning is common. Typically bilateral joint pain, involving three or more joints (in particular the hands or feet).

How does RhoGam work?

Rho(D) Immune Globulin administered at appropriate times interrupts the maternal immunologic process. You can visualize this process by imagining the RhoGAM attaching to all of the fetal Rho-D antigenic load, making it immunologically "invisible" to the maternal immune system.

What symptoms are consistent with parietal stroke?

Right hand dominant patients with strokes in the area of the brain are likely also to have left hemiplegia. Patients with right middle cerebral infarcts affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distances, or they may attempt to read holding books upside down. They may ignore people or objects in their left visual field or not pay attention to that area of the room. They may also not recognize their functional impairments (denial of stroke disability).

What are the screening recommendations for children for T2DM?

Risk factors - BMI at or above the 85 percentile, an increased fasting glucose level of 100mg/dL, and an elevated fasting insulin level. Recommended screening - Screen all children at age 10 who have a BMI >85 percentile and risk factors for diabetes or >95 percentile without risk factors, rechecking every two years thereafter.

What are the risk factors for osteoporosis?

Risk factors for osteoporosis are mainly due to low estrogen states. Low estrogen states may be caused by early menopause (i.e., before age 45 years), prolonged premenopausal amenorrhea, and low weight and body mass index. Lack of physical activity and inadequate calcium intake (which could be attributable to poor nutrition or alcoholism) are also associated with osteoporosis. Other risk factors include: Family history of osteoporotic fracture Personal history of previous fracture as an adult Dementia Cigarette smoking White race

What are the risk factors for the development of preeclampsia and eclampsia?

Risk factors for preeclampsia and eclampsia are similar. White, nulliparous women from lower socioeconomic backgrounds are at higher risk, and the incidence appears to be higher in younger (teenage and low twenties) and older (> 35 years) women.

What are the risk factors for septic arthritis?

Risk factors include diabetes, rheumatoid arthritis, prosthetic joints, recent surgery, preceding skin infection or trauma, and being over the age of 80.

Why is urinalysis by dipstick performed at every visit for prenatal patients?

Routine dipstick urinalysis is often performed at every visit for prenatal patients; however, studies have shown that it does not reliably detect proteinuria (which may indicate gestational hypertension or pre-eclampsia) and that the presence of trace glycosuria (a potential indicator of gestational diabetes) is also unreliable for screening. Some guidelines have encouraged discontinuation of routine dipstick urinalysis, although others retain it as a part of routine prenatal care visits.

Difficulty with toe walk is associated with what?

S1 disc herniation

What tool is used to assess whether a patient is seriously contemplating suicide?

SAD PERSONS scale Sex (male) Age (< 19 or > 45) Depression, diagnosis of Previous attempt(s) Ethanol or other substance abuse Rational thinking impaired (psychosis, delusions, hallucinations) Social supports lacking Organized plan for suicide No significant other Sickness (physical illness) one point is scored for each factor present: A score of 4 to 6 suggests outpatient treatment is an appropriate clinical action A score of 7 to 10 suggests hospitalization is warranted

How do you perform the Straight Leg Raise Test? And what are you assessing for? How Sensitive/Specific is it?

SLR or Lasegue's sign: The normal leg can be raised 80 degrees. If <80 degrees: tight hamstrings or sciatic nerve problem. To differentiate, raise leg to the point of pain, lower slightly, then dorsiflex the foot. If no pain with dorsiflexion, hamstrings are tight. Test is positive if pain radiates down posterior/lateral thigh past knee. Indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc. Pain will most likely occur between 40 - 70 degrees. Pain earlier than 30 degrees suggestive of malingering. Pain in opposite leg during SLR suggestive of root compression due to central disc herniation. When compared to MRI, the straight leg raise test has a sensitivity of 0.36 and specificity of 0.74 The ipsilateral straight leg raise test has a sensitivity of 0.80 and a specificity of about 0.40. Thus, a negative test makes a herniated disc unlikely, but a positive test is non-specific.

What is the first line management of post stroke depression?

SSRIs are accepted first-line therapy and have been proven to improve clinical outcomes in suffers of post-stroke depression. Selection of a particular SSRI is guided by the potential for drug-drug interactions and patient tolerance.

What are the possible complications from GABS pharyngitis?

Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanching, sandpaper-like exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia's lines). The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue). Complications of strep throat are usually divided into suppurative and non-suppurative categories. Even though rheumatic fever and post-streptococcal glomerulonephritis are serious, they are relatively rare. Other complications include: peri-tonsillar abscess, mastoiditis, meningitis, and bacteremia.

What are the USPSTF recommendations for screening for T2DM?

Screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Rating: "B" recommendation. Current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. Rating: "I" statement.

Why is screening for diabetic nephropathy so important and how is this done?

Screening for and monitoring diabetic nephropathy is important for assessing end organ damage. It is recommended at diagnosis and annually according to ADA guidelines. In addition, many diabetes medications are excreted through the kidneys and require annual monitoring to identify renal insufficiency and avoid drug toxicity (e.g. metformin, which can cause metabolic acidosis). 24-hour or timed urine collections are difficult to obtain and add little to the prediction of accuracy of protein and creatinine measurements. The spot urine albumin-to-creatinine ratio is the screening test for microalbuminuria.

When do you screen for gestational diabetes?

Screening should be performed at 24-28 weeks with a one-hour glucose tolerance test.

What are the screening methods for diabetes?

Screening tests for type 2 diabetes include measurement of fasting plasma glucose (FPG), two-hour plasma glucose during an oral glucose tolerance test (2-h OGTT), or glycosylated hemoglobin (HBA1C). The ADA has recently revised their guidelines and included the use of HBA1C as a diagnostic test. ADA recommended a cut point for HBA1C level of 6.5 % or greater to diagnose diabetes. The diagnosis should be confirmed with a repeat A1C. HBA1C within range of 5.7% -6.4 % has been included as a category of increased risk for future diabetes.

How effective are NSAIDs for OA?

Second choice to acetiminophen because of their association with gastrointestinal side-effects, including gastritis. Especially true in the geriatric population because of their increased risk of acute gastrointestinal bleeding, even when used in conjunction with antacids or proton pump inhibitors. Risk of prolonged bleeding times, a potential problem if the patient is at risk for falling.

Info about TCAs for migraines:

Second line: Amitriptyline (10-150mg) FDA approved: No (off-label) Excellent/cheap and also work for fibromyalgia and tension-type headache Cautions: Cardiac conduction defects, MAOI S/E: Drowsiness, weight gain, dry mouth

What are the salient features of a seizure?

Seizure may present with an aura of dizziness or lightheadedness. May occur with sudden and extreme elevations of blood pressure associated with papilledema. May be followed by a brief period of temporary paralysis (Todd's paralysis). The seizure is followed by partial or complete paralysis on one side of the body and may also affect speech and vision. The average duration of the paralysis is 15 hours, but can last from thirty minutes to 36 hours at which point symptoms resolve completely. Aura is a disturbance of visual, hearing, taste, smell or altered body sensation usually arising for the temporal lobe signaling impending seizure onset. Amnesia for the event and alteration of consciousness is a hallmark of seizure disorder. A seizure (idiopathic or due to an identified cause) is unlikely if the patient has recall of the event, no post-ictal period of confusion, and no evidence of focal findings, oral injury, or urinary/fecal soiling.

What are the salient features of acute bronchitis? What causes it?

Self-limited inflammation of the large airways in the lung characterized by cough. Inflammation leads to excessive tracheobronchial mucus production sufficient to cause purulent sputum in half of patients. Cause is usually viral. Symptoms of acute bronchitis during the first few days are hard to distinguish from those of a URI. However, in acute bronchitis, coughing persists for more than five days. People with bronchitis sometimes have rhonchi, sometimes they have scattered wheezes and sometimes they have a normal lung exam. Rhonchi are noises made with the large airways and are often due to mucus or inflammation in the airways.

What is sensitivity?

Sensitivity is the proportion of patients with disease who test positive. False Negative rate among those with disease = (1-Sensitivity).

What are the most serious causes of headache?

Serious causes of headache: Meningitis Brain tumor Intracranial hemmorhage Traumatic brain injury (concussion)

Why might serum PSA be done for suspected BPH?

Serum prostate specific antigen (PSA) level determination is recommended for men with a life expectancy of ten years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5 alpha reductase inhibitor.

What are some other useful smoking cessation strategies?

Setting a quit date Using nicotine replacement Joining a support group Calling 1-800-QUIT-NOW Choosing an activity to substitute for smoking (e.g., taking a walk or chewing sugarless gum when the urge to smoke occurs) Making a list of the reasons why it is important to quit smoking and keeping it handy to refer to Keeping track of where, when, and why you smoke (helps identify smoking triggers to avoid) Throwing away all tobacco and smoking paraphernalia (i.e., ashtrays, lighters, anything else associated with the smoking habit) Medication

Why might evaluating serum K+ in HTN be important?

Several blood pressure medications can cause potassium derangements (Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), and Potassium Sparing Diuretics, which all may cause or exacerbate hyperkalemia). A baseline potassium level is necessary for determining any potential changes from antihypertensive therapy. Furthermore, potassium disturbances can occur in Cushing's syndrome or primary hyperaldosteronism.

What are the proven benefits of doing a PPI trial first for empiric Tx of uncomplicated GERD/PUD?

Several randomized trials have demonstrated that the "PPI test", defined as a short-term trial of prescription-strength PPI, is both sensitive and specific for diagnosing GERD in patients with classic symptoms and can significantly reduce the need for upper endoscopy/EGD and 24-hour pH monitoring. This test has been shown to save over $350 per patient evaluated, reduce upper endoscopies by 64%, and reduce the number of esophageal monitoring tests by 53%.

What are the salient features of cluster headaches?

Severe. Associated with rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, and ptosis. Severe unilateral orbital, periorbital, supraorbital, or temporal pain. Last 15-180 minutes. Tend to recur many times in a row, appearing in "clusters" 5 episodes needed for diagnosis.

What are the risk factors for cervical CA?

Sexual behaviors associated with an increased cervical cancer risk include: Early onset of intercourse A greater number of lifetime sexual partners Other risk factors include: Diethylstilbestrol (DES) exposure in utero. Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increasing the risk by up to fourfold. Immunosuppression also significantly increases the risk of developing cervical cancer.

What are the adverse effects of mercury in pregnancy?

Shark, swordfish, king mackerel, and tilefish Mercury poisoning Large ocean fish tend to accumulate mercury in their tissues, and since exposure to high levels of mercury in fish can lead to neurologic abnormalities in women and their infants, the CDC recommends that pregnant women avoid them.

Which opiates are more likely to cause dependence? short-acting or long-acting?

Short-acting opioids actually carry more risk of tolerance than long-acting ones (C) because of their short half-life of three to four hours. Patients need to use them more frequently to control their pain adequately. Short-acting opioids tend to be helpful for flares of acute pain, but if daily use is needed, long-acting opioids should be considered.

How effective are steroid injections for OA? When should you consider using them? What is the preferred drug?

Should be considered if the knee joint is inflamed, as evidenced by swelling and pain. No more than three injections per year, and no more frequent than one injection per month. Long-acting triamcinolone is typically preferred over methylprednisolone, and 1 ml of steroid should be combined with 3-4 ml local anesthetic. 24 hours of immobilization following the injection helps maximize the effects, but prolonged rest should be avoided. Can reduce pain, limit the need for other medications, and improve function. Fewer associated side effects than NSAIDs or opiates.

What are the side effects and possible long term effects of PPI use?

Side effects are rare but can include headache, diarrhea, abdominal pain, nausea, constipation, and bloating. PPIs may interact with other medications by affecting the absorption of drugs for which bioavailability is dependent upon gastric pH (e.g. ampicillin, aspirin, iron, ketoconazole, methadone). Some PPIs may also inhibit cytochrome P-450 metabolism. Dose adjustment is rarely necessary in the elderly, patients with renal insufficiency, or those who have mild to moderate hepatic impairment. Current literature has turned its attention toward more potentially serious side effects of PPIs. Many patients who are prescribed PPIs in the ambulatory care setting do not have a valid indication, and may be left on them indefinitely without documented re-evaluation to determine appropriateness of therapy. Adverse events associated with non-judicious short- and long-term use of PPIs include community-acquired pneumonia, Clostridium difficile-associated diarrhea, osteoporotic fracture, anti-platelet agent inhibition, iron, magnesium, and vitamin B12 deficiencies.

What are the significant side effects of Tramadol?

Significant side effects can include seizures, serotonin syndrome, respiratory depression, angioedema, bronchospasm and dependency.

When doing a PE for suspected Dx of GERD/PUD, what should your exam focus on?

Signs of Complications or Other Associated Diseases Hemodynamic status-Hypotension or tachycardia may indicate significant blood loss from a gastrointestinal bleed. Signs of anemia -Brittle nails and cheilosis (cracks and sores on the lips) are signs of anemia. Pallor of palpebral (eyelid) mucosa or nail beds may also be present with anemia. Signs of malignancy -Weight loss, palpable mass, presence of signal lymph nodes (Virchow's nodes) and acanthosis nigricans (velvety, light-brown-to-black skin, usually on the neck, under the arms or in the groin) are signs of possible malignancy. Signs of gall bladder disease -Jaundice or a positive Murphy's sign Signs of hypothyroidism -Constipation, cool or pale skin, coarse hair, or non-pitting edema (myxedema) or delayed relaxation phase of deep tendon reflexes (DTRs) may be present in hypothyroidism. Hyperthyroidism -Diarrhea, warm skin, thinning hair, eyelid lag, brisk DTRs, or tachycardia may be present in hyperthyroidism. Though a very rare cause of dyspepsia, thyroid disease should be considered.

What red flag signs should you look for on PE of a patient with HA?

Signs of increased intracranial pressure - Papilledema Altered mental status Other important findings to look for - Signs of meningeal irritation such as Kernig's sign or Brudzinski's sign Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

What is the most commonly used low intensity statin?

Simvastatin 10-20mg

What are the criteria in the mnemonic SIG E CAPS?

Sleep disturbance (insomnia/hypersomnia) Interests lost (ahedonia) Guilt experienced (excessively) Energy levels decreased Concentration difficulties (or Crying) Appetite lost or increased (5% weight change in 1 mo) Psychomotor retardation (or agitation) Suicide ideation

What is sleep restriction/compression therapy?

Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last 2 weeks (as opposed to the number of hours spent in bed [awake plus asleep]). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every 5 days (if improvement is sustained) until the individual's optimal sleep time is obtained. Sleep compression therapy: The patient is counseled to decrease the amount of time spent in bed gradually to match total sleep time rather than making an immediate substantial change.

What are the risk factors for DVT?

Smoking and obesity, are the most robust risk factors in the development of DVT and are independent of other risk factors. Diabetes, sedentary lifestyle, hypertension, hyperlipidemia, increasing age, prolonged immobility, surgery, trauma, malignancy, pregnancy, estrogenic medications (e.g., oral contraceptive pills, hormone therapy, tamoxifen (Nolvadex)), congestive heart failure, hyperhomocystinemia, diseases that alter blood viscosity (e.g., polycythemia, sickle cell disease, multiple myeloma), and inherited thrombophilias are other potential risk factors in the development of DVT.

What lifestyle modifications/supplementation may help mitigate the risk of osteoporosis?

Smoking cessation. Smoking increases the risk of osteoporosis. Adequate intake of calcium and vitamin D are essential to normal human physiology including bone health. A number of organizations have recommended routine supplementation of these nutrients for a variety of reasons including the prevention of osteoporosis. However, this recommendation is now being questioned. Lifelong weight bearing exercise (bones and muscles work against gravity as the feet and legs bear the body's weight) and muscle strengthening can improve agility, strength, posture, and balance, which may reduce the risk of falls. It may also modestly increase bone density. Examples of weight bearing exercise include walking, jogging, Tai-Chi, stair climbing, dancing, and tennis.

What physical exam signs seen on pelvic exam are consistent with early pregnancy?

Softening of the cervix is known as Goodell's sign, while softening of the uterus is known as Hegar's sign. The bluish-purple hue in the cervix and vaginal walls is known as Chadwick's sign and is caused by hyperemia.

What test may be used to replace RAI scanning in the near future?

Some experts predict that color-flow Doppler ultrasound may replace RAI scanning since it has similar accuracy but is safer, less costly and easier to administer.

How is Hormone Therapy used in management of menopause and perimenopause? What are the risks?

Some women take hormone therapy (HT) to relieve menopausal symptoms. HT may also protect against osteoporosis. Estrogen and progestin are the two hormone supplements most often used in HT. Taking estrogen without progestin to balance the hormonal cycle may cause over-stimulation of the endometrial tissue. This may lead to uncontrolled tissue growth called hyperplasia, which may lead to endometrial cancer. Progestin counteracts this risk. Therefore, women who have intact uterus are usually prescribed estrogen and progestin together. Estrogen has been found to be most effective at treating vasomotor symptoms such as hot flashes and is FDA approved for this use. Estrogen therapy may be administered through oral, transdermal, or vaginal routes. HT also has risks. It can increase the risk of breast cancer, heart disease, blood clots and stroke.

What is specificity?

Specificity is the proportion of patients without disease who test negative. False Positive rate among those without disease = (1-Specificity).

Who on the care team assists stroke pts with learning how to swallow again?

Speech-language pathologists Speech-language pathologists help stroke survivors with aphasia relearn how to use language or develop alternative means of communication. They also help people improve their ability to swallow, and they work with patients to develop problem-solving and social skills needed to cope with the aftereffects of a stroke.

What are the different types of spontaneous abortions?

Spontaneous abortion is the loss of a pregnancy without outside intervention before 20 weeks' gestation. Spontaneous abortions can be subdivided into: Threatened abortion - bleeding before 20 weeks gestation. Threatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is - in some ways - a "catch-all" descriptive diagnosis. Inevitable abortion - dilated cervical os. Incomplete abortion - some but not all of the intrauterine contents (or products of conception) have been expelled. Missed abortion - fetal demise without cervical dilitation and/or uterine activity (often found incidentally on ultrasound without a presentation of bleeding). Septic abortion - with intrauterine infection (abdominal tenderness and fever usually present). Complete abortion - the products of conception have been completely expelled from the uterus.

What are the salient features of squamous cell carcinoma?

Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend have a raised base. Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center. Borders are often irregular and bleed easily. Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance. Squamous cell carcinoma comprises 20 percent of all cases of skin cancer. History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.

How effective is St. John's Wort in treating depression?

St. John's Wort has been shown to be effective for short term treatment of mild to moderate depression.

What medications have been used in the past to lower cholesterol and how has that changed now?

Statins, fibric acid derivatives, niacin, bile acid sequestrants. Any agent that could lower LDL-c or non-HDL-c. Statins now are the ONLY recommended class, as they are the only agents with trial data showing improved ASCVD outcomes.

When might stress ulcer prophylaxis be indicated?

Stress ulcer prophylaxis should be considered only for patients with specific conditions. Risk factors for stress ulcer prophylaxis: Prolonged mechanical ventilation Head injury with Glasgow coma score of <=10 or inability to obey simple commands Thermal injury involving > 35% of body surface area Partial hepatectomy Hepatic or renal transplantation Multiple trauma with injury severity score >= 16 Spinal cord injury Hepatic failure History of gastric ulceration or bleeding during one year prior to admission Presence of at least 2 of the following: Sepsis, ICU stay of greater than 1 week, Occult or overt bleeding for >=6 days, Corticosteroid therapy (>250mg hydrocortisone or equivalent daily).

What symptoms go with what occluded vessels in stroke?

Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness. Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke. A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because there is bilateral central control of this portion of the facial nerve. A peripheral injury to the facial nerve (such as Bell's Palsy) causes facial weakness of the forehead.

How do you decide when to start statin Tx in pts with dyslipidemia?

Studies demonstrate that cholesterol management is likely to be most effective when based on a patient's calculated risk of incident ASCVD. Pooled Cohort Equations produces a patient's 10-year risk of incident ASCVD based upon their major risk factors (age, gender, smoking status, hypertension and systolic blood pressure, diabetes, total and HDL cholesterol)

What conditions have low RAIU (<15%)?

Sub-acute thyroiditis Silent thyroiditis Iodine induced thyroiditis Exogenous L-Thyroxine Struma ovarii Amiodarone induced thyroiditis

How do you manage placenta previa?

Subsequent ultrasound surveillance is indicated in women who have placenta previa to document progression or resolution. In the absence of any symptoms, women with previa can be at home; however, they should be counseled about the risk of bleeding and seek prompt attention with any bleeding. If placenta previa does not resolve, delivery by cesarean is usually required.

Who do you screen for T2DM?

Sustained blood pressure 135/80+ mmHg.

What is lymphedema?

Swelling in an arm or leg caused by a lymphatic system blockage. Lymphedema is generally painless, but patients may experience a chronic dull, heavy sensation in the leg. In the early stages of lymphedema, the edema is soft and pits easily with pressure. In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic. Lymphedema initially involves the foot and gradually progresses up the leg so that the entire limb becomes edematous.

What is the presentation of psychomotor abdominal pain?

Symptoms from this type of pain are variable and can be associated with, or aggravated by other etiologies such as IBS or gastritis. The pains can occur anywhere throughout the abdomen. This usually presents as an atypical pain pattern, or in a depressed or troubled patient, and may point towards a psychogenic cause. This is a diagnosis of exclusion; continue to consider it in your differential.

WHat are the signs of complication in influenza?

Symptoms last longer than 5-7 days without any relief Difficulty breathing Worsening cough Difficulty maintaining hydration

How effective are bronchodilators and inhaled corticosteroids in COPD? And how do we differentiate it from asthma?

Symptoms of chronic obstructive pulmonary disease, like those of asthma, should improve following treatment with bronchodilators and inhaled corticosteroids. Obstructive findings are seen on spirometry with this condition, however, should not be reversible.

For what diagnoses in arthritis is synovial fluid PCR useful?

Synovial fluid PCR can aid in the diagnosis of arthritis caused by Yersina, Chlamydia, Ureoplasma urealyticum, N. gonorrhoeae, and in this case, Borrelia burgdorferi. PCR has a > 90% sensitivity for Lyme disease, and helps confirm the diagnosis.

What is the mechanism and risks of a talar dome fx?

Talar dome fracture is usually due to acute injury. Overall prognosis is related to potential for interruption of the blood supply. Talar dome fracture may occur in conjunction with an ankle sprain, and initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis after talar dome fracture.

What is the pelvic compression test?

Test is performed by forcibly pressing together the hips A positive test elicits pain in the sacroiliac joint.

When do you test for H. Pylori infection?

Testing for H. pylori is not indicated in patients with classic GERD and should be performed only in patients with dyspepsia or other upper GI complaints (e.g. nausea, epigastric pain) if the clinician plans to offer treatment for positive results. Deciding which test to use in which situation relies upon an understanding of the benefits, limitations, and costs of the individual tests, as well as the suspected prevalence of H. pylori infection in the patient population.

Summary of vaccine recommendations in the elderly:

Tetanus - Sustitute one-time dose of Tdap for Td booster, then boost with Td every 10 years Pneumococcal Polysaccharide - If > 65 years, one dose Flu - One dose annually Zoster - If > 60 years, one dose

What are the established goals for headache treatment?

The 2000 US Headache Consortium defined the following goals for preventive treatment: (1) decrease attack frequency by 50% and decrease intensity and duration; (2) improve responsiveness to acute therapy; (3) improve function and decrease disability; and (4) prevent the occurrence of a medication overuse headache (MOH) and chronic daily headache.

When is the 24-hour pH probe indicated for the evaluation of dyspepsia?

The 24-hour pH probe is most appropriately utilized when the diagnosis of GERD cannot easily be determined, when patients desire referral for surgical treatment of their GERD/hiatal hernia (Nissen fundoplication) or when patients with classic symptoms of GERD (heartburn, regurgitation) do not improve after appropriate trials of several different PPIs.

How often should A1C be tested?

The A1C is a measurement of glycosylated hemoglobin and represents plasma glucose concentrations over a 4-12 week period of time. Current standards of care recommend initial A1C testing at diagnosis, and follow-up testing at least two times a year in patients who are stable and meeting goal of A1C < 7; perform the A1C quarterly in patients when therapy is changing or they are not meeting goal.

What are the ADA and USPSTF guidelines for screening for diabetes?

The ADA recommends testing for diabetes in all adults with BMI equal or greater than 25 kg/m2 and one or more additional risk factors (see below). In individuals without risk factors, testing should begin at age 45 years. The United States Preventive Services Task Force concluded that there was insufficient evidence to recommend for or against screening for diabetes in asymptomatic adults. This conclusion was based primarily on the lack of evidence that earlier detection of diabetes improves long-term outcomes. However, the task force found that there was moderate evidence for and recommended screening in adults with hypertension (blood pressure >135/80 mmHg) as part of an integrated approach to reduce cardiovascular risk.

What fats may reduce heart disease risk when included in diet?

The AHA recommends eating fish twice a week. Eating more fatty fish like mackerel, lake trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk. Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower heart disease risk. Unfortunately, studies are showing that vitamins C, E, and folic acid do not reduce heart attacks or strokes.

What is the ADA recommendation for statin therapy in diabetics?

The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following blood cholesterol treatment for patients with diabetes and LDL-c 70-189 mg/dL: · Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (Level of Evidence A) · High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated. (Level of Evidence B)

When treating DVT, how long after initiating Warfarin do you wait before discontinuing LMWH?

The American College of Chest Physicians guidelines recommend that LMWH, UFH, or fondaparinux be continued for, "at least 5 days and until the INR is ≥2.0 for at least 24 hours".

What set of criteria help a physician determine what type of imaging is indicated for findings of a breast mass?

The American College of Radiology has created the ACR Appropriateness Criteria® which are evidence based guidelines to help physicians determine the most appropriate imaging test to be used to evaluate various clinical conditions.

What are the guidelines for initiating abortive and prophylactic therapy for migraines?

The American Migraine Prevalance and Prevention Study outlines recommendations as to when daily pharmacological treatment should be initiated: At least six headache days per month At least four headache days with at least some impairment At least three headache days with severe impairment or requiring bed rest. Prevention should be considered: Four to five migraine days per month with normal functioning Two to three migraine days per month with some impairment Two migraine days with severe impairment.

DSM-V criteria for substance abuse/addiction for opiates:

The DSM-V substance use disorder criteria combine the DSM-IV criteria for dependence, addiction, and tolerance. There is now one term, "substance use disorder," that encompasses a continuum of problems with substances from mild to severe. Each specific substance use disorder is diagnosed in similar fashion, using a list of 11 symptoms to determine the severity of illness. For opioid use disorder, the 11 symptoms are: opioids taken in larger amounts than intended unsuccessful efforts to control use significant time spent in opioid-related activities craving use results in unmet obligations at work, school, or home continued use despite significant interpersonal problems related to use other activities neglected due to use use in physically hazardous situations continued use despite physical or psychological problems related to use tolerance withdrawal Please note: the last two symptoms do not apply to patients taking opioids solely under appropriate medical supervision.

What tests for H Pylori are available and what are the advantages/disadvantages of each?

The H. pylori IgG serologic test only confirms evidence of past infection and an immunologic response to H. pylori . In a population with a high prevalence of active H. pylori infection, it is a useful first-time test. However, if the prevalence of active infection is low, then the test may yield a high number of false-positive results. It should not be used to confirm eradication of H. pylori after treatment as it can remain positive for years. The urea breath test accurately detects active infection but is more expensive than serologic testing. It is less accurate during PPI therapy, and patients would need to stop the PPI for at least two weeks before a urea breath test (bismuth and antibiotics should also be stopped for at least two weeks before a urea breath test.). However, urea breath testing may be appropriate depending on the characteristics of the population being tested. The stool antigen test for H. pylori is also accurate and widely available, but it is more expensive and less convenient than serologic testing. The stool antigen and urease breath tests may also be used as confirmatory tests after a positive serologic test. If an endoscopy is indicated (i.e. due to the presence of alarm symptoms), or in patients who have been taking a PPI, antibiotics, or bismuth, endoscopic testing for H. pylori, (which consists of tissue biopsies from the gastric body and antrum for rapid tissue urease testing or histology) should be performed in lieu of other H. pylori tests.

What model (mnemonic) helps providers have two-way dialogue to develop understanding about the patient's perspective of their disease?

The LEARN model, developed by Berlin and Fowkes, is a simple way to remember the importance of two-way dialogue with your patient about their understanding of their own disease. - Listen with empathy and understanding to the patient's perception of the problem. - Explain your perceptions of the problem and your strategy for treatment. - Acknowledge and discuss the differences and similarities between these perceptions. - Recommend treatment while remembering the patient's cultural parameters. - Negotiate agreement. It is important to understand the patient's explanatory model so that medical treatment fits in their cultural framework.

What finding on spirometry is diagnostic of asthma?

The National Asthma Education and Prevention Program Expert Panel Report 3 (2007) states that an improvement in the FEV1 value by > 12% or an increase in the percent predicted FEV1 value by 10% after a bronchodilator is given is diagnostic for asthma. Reversible obstructive findings on spirometry is the distinctive diagnostic abnormality in patients with asthma, especially early in the course. Patients with chronic, severe asthma may have less or no reversibility of their obstructive findings, very similar to patients with chronic obstructive pulmonary disease.

What are the Ottawa Foot & Ankle Rules?

The Ottawa ankle rules are a clinical decision tool designed to help in evaluation of ADULTS (age 18 and up) with acute ankle and midfoot injuries. These have been reported to have a sensitivity of 97% to 100%. Recently the rules have also been used to exclude fractures in children greater than 5 years of age presenting with ankle and midfoot injuries. The rules suggest that radiographs of the ankle are needed if: There is pain in the malleolar zone AND either bony tenderness along the distal 6 cm of the posterior edge of either malleolus OR inability to bear weight 4 steps both immediately after the injury and in the emergency department. ​ Radiographs of the foot are needed if: There is pain in the midfoot region AND one of the following: (a) bony tenderness at either the navicular bone or base of the 5th metatarsal OR (b) inability to bear weight four steps immediately after the injury and in the emergency department.

What are the possible results of the PAP test?

The Pap test generally shows one of the following: normal results low grade squamous epithelial cells (LSIL) high grade squamous epithelial cells (HSIL) atypical glandular cells of undetermined significance (AGUS), or atypical squamous cells of undetermined significance (ASC-US). ASC-US is considered an inconclusive pap test result that requires follow-up testing to determine appropriate patient management. An ASC-US Pap test result is often triaged by HPV testing when using liquid-based cytology. "Reflex HPV testing" is easily performed as a follow-up test by utilizing residual cells from the liquid-based Pap test vial to test for the presence or absence of high-risk HPV.

What are the USPSTF screening recommendations for depression?

The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression.

How common is postpartum depression and how do you screen for it?

The U.S. Preventive Services Task Force makes specific recommendations to screen for depression in adults, but makes no specific recommendation about depression screening for pregnant and postpartum women. A solid body of evidence supports depression screening during the pre and postnatal periods and continuing during well baby visits as well. Postpartum depression affects 7-15% of women in the first three months postpartum, and up to 22% of women in the 12 month period following childbirth, with an incidence of major postpartum depression of 5-8%. It is increasingly recognized as a unique and potentially serious complication of childbearing. Research has indicated that undetected postpartum depression can lead to significant impairment in well-being, work and relationship functioning, and infant cognitive and behavioral development. Postpartum depression has also been identified in fathers. Generally PHQ-2 followed by -9, or may use Edinburgh Postnatal Depression Scale

What are the USPSTF guidelines on self breast exams? And clinical breast exams?

The USPSTF does not recommend BSEs Similarly, the USPSTF concludes there is insufficient evidence to assess the additional benefits and harms of CBE beyond screening mammography in women 40 years or older. While ACS recommends that clinical breast exam (CBE) should be part of a periodic health exam, about every three years for women in their 20s and 30s and every year for women 40 and over.

When do you consider starting ASA therapy in pts with HTN?

The USPSTF recommends initiating aspirin therapy in men age 45 to 79 years to reduce the risk of myocardial infarction. In women age 55 to 79, the USPSTF advises taking aspirin to reduce the risk of ischemic stroke. For both men and women, the benefit of decreased risk from those outcomes must be weighed against an increased threat of gastrointestinal hemorrhage. In patients with hypertension, the JNC 8 makes no specific recommendations about aspirin. JNC 7 recommended waiting to prescribe aspirin use until blood pressure measurements are normal and stable since aspirin prophylaxis in a patient with uncontrolled blood pressure may place the patient at higher risk of hemorrhagic stroke.

What dose of folic acid is recommended?

The USPSTF recommends that all women "planning or capable of pregnancy" take a daily supplement containing 400 - 800 mcg of folic acid. The dose is increased for the following high-risk scenarios: 1 mg in patients with diabetes or epilepsy 4 mg in patients who bore a child with a previous neural tube defect

When should you screen for dyslipidemia in women?

The USPSTF strongly recommends screening women over 45 years old for lipid disorders if they are at increased risk of coronary heart disease. The USPSTF makes no recommendation about screening women over the age of 20 who do not have an increased risk of coronary heart disease.

When does the USPSTF recommend screening for hyperlipidemia?

The USPSTF strongly recommends that clinicians routinely screen men aged 35 years and older and women aged 45 years and older for lipid disorders and treat suboptimal lipids in people who are at increased risk for coronary heart disease. Rating: A Recommendation. The USPSTF also recommends screening men and women over 20 for lipid disorders if they are at increased risk for coronary heart disease. Rating: B Recommendation Note: The 2013 ACC/AHA Cholesterol Guidelines recommending reassessing patients' ASCVD risk every 4-6 years. Given that they recommend treating with statins all patients over 21 with an LDL-c > 190 mg/dL, it is reasonable to check fasting lipids in all adults over 21 every 4-6 years.

What are the recommendations on screening for ovarian CA?

The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians all recommend against routine screening for ovarian cancer in asymptomatic women.

How do you grade diabetic foot ulcers?

The Wagner Grading System • Grade 1: Diabetic ulcer (superficial) • Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia) • Grade 3: Deep ulcer with abscess or osteomyelitis • Grade 4: Gangrene forefoot (partial) • Grade 5: Extensive gangrene of foot

What is the difference between osteoporosis and osteopenia?

The World Health Organization (WHO) defines osteoporosis as a spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy, young women (T-score of −2.5 or below) as measured by dual energy x-ray absorptiometry (DEXA). Osteopenia is defined as a spinal or hip BMD between 1 and 2.5 standard deviations below the mean (T-score between -1 and -2.5).

What total body movements can you ask the patient to do for a "down and dirty" assessment of the etiology of knee pain?

The ability to squat is influenced by supporting musculature, ligaments, and the knee joint. Impaired squatting ability could be caused by effusion, knee arthritis, injury to the ligaments, etc., whereas the ability to perform the duck waddle assesses the stability of the knee and effectively rules out significant ligament instability, joint effusion, and significant damage to the meniscal cartilage.

What is the annual quit rate for smokers without medical intervention?

The annual quit rate for smokers without any medical interventions is about 2-3% per year.

What do the anterior drawer and inversion stress test assess for?

The anterior drawer test can be used to assess the integrity of the anteriortalofibular ligament, and the inversion stress test can be used to assess the integrity of the calcaneofibular ligament.

What is the classic presentation for infectious mononucleosis (triad)? What finding is specific for mono? What viruses cause mono? What other findings may be present?

The classic presentation of infectious mononucleosis in children and young adults consists of the triad of fever, pharyngitis, and lymphadenopathy. Posterior cervical lymphadenopathy is common and specific for mononucleosis. Palatal petechiae on the posterior oropharynx distinguishes infectious mononucleosis from other causes of viral pharyngitis. However palatal petechiae can be seen in GABHS pharyngitis, so does not help in distinguishing infectious mononucleosis from that condition. Hepatosplenomegaly also may be present. Suspicion for this diagnosis usually occurs after a negative rapid strep or throat culture in a patient who is ill for more than 7-10 days. The "Monspot" test will not become positive until at least 7 days into the illness. Common causes of infectious mononucleosis are Epstein-Barr Virus or Cytomegalovirus. Early in the course of mononucleosis, patients may present with a maculopapular generalized rash. The rash is faint, rapidly disappears, and is nonpruritic. Note that if patients with mononucleosis are misdiagnosed with strep and treated with amoxicillin or ampicillin, 90 percent will develop a classic prolonged, pruritic, maculopapular rash.

How is the classic presentation of hepatitis different from other causes of RUQ pain?

The clinical manifestations of hepatitis vary somewhat depending on etiology, but most types do not have acute onset, unlike the diseases of the gallbladder tract. While RUQ pain, nausea, and vomiting are frequently encountered, there is often associated malaise, anorexia, itching, and icterus/jaundice. Hepatomegaly is often present.

How do you categorize A-Fib as either paroxysmal or chronic/

The clinician should attempt to categorize the timing of a first-detected episode of AF, whether or not it is symptomatic or self-limited, recognizing that there may be uncertainty about the duration of the episode and about previous undetected episodes. When a patient has had two or more episodes, AF is considered recurrent. If the arrhythmia terminates spontaneously, recurrent AF is designated paroxysmal; when sustained beyond seven days, AF is designated persistent. Termination with pharmacological therapy or direct-current cardioversion does not change the designation. First-detected AF may be either paroxysmal or persistent AF. The category of persistent AF also includes cases of long-standing AF (e.g., greater than one year), usually leading to permanent AF, in which cardioversion has failed or has not been attempted.

What is the dose of ASA prescribed for CVD prevention and what is the alternative therapy?

The commonly prescribed dose in the US is 81 mg daily. For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used (Level of evidence B).

What should you do if a patient presents with all of the normal signs/symptoms of a UTI but the U/A is negative?

The constellation of typical symptoms outweighs a normal urinalysis. Therefore, based on the symptoms presented, the most reasonable treatment option is to treat empirically with a standard antibiotic for a short course. It is not unreasonable to send urine for culture but management does not need to wait till that result is available.

What amount of time do symptoms of depression have to be present after the loss of a loved one to differentiate it from bereavement?

The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present two months after the loss.

How is barrier contraception achieved? How long must it remain in place? How effective is it and what are the complications?

The diaphragm and cervical cap are synthetic discs or cups of varying sizes made out of latex (diaphragm) or silicone (cervical cap) designed to hold spermicide near the cervical os and prevent sperm from accessing the uterus and consequently the egg. The device is inserted prior to intercourse and remains in place until six hours after the last intercourse. They are 84-94% effective against pregnancy and are highly dependent on user compliance. Potential complications are vaginal or urinary tract infections and toxic shock syndrome.

What is the PROTECT program?

The disease management program called: "Preventing Recurrence of Thromboembolic Events through Coordinated Treatment" (PROTECT) implements eight secondary prevention goals at the time of discharge. Four of these goals are aimed at treatable risk factors, and four of these goals are aimed at modifiable lifestyle risk factors of recurrent thromboembolism.

How do you decide how long to anticoagulate patients after DVT?

The duration of anticoagulation depends on whether the patient has a first episode of DVT, ongoing risk factors for venous thromboembolic disease, and known thrombophilia. If provoked or high bleeding risk = 3mo Low bleeding-risk and unprovoked = extended (6mo - life)

How might you differentiate venous insufficiency from lymphedema?

The edema of venous insufficiency can be differentiated from chronic lymphedema as venous insufficiency edema is softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli. Obesity is commonly associated with venous insufficiency.

After Tx for H. Pylori, if the patient returns still complaining or symptoms, what should be done?

The fecal antigen test and urea breath test are reasonable next steps to evaluate eradication of H. pylori. The fecal antigen test involves collection of a stool sample the size of an acorn by either the clinician or the patient; the sample is then analyzed in a laboratory by trained personnel. The urea breath test requires specialized equipment and patient preparation. Both tests have been reported to have a sensitivity and specificity for active H. pylori infection of >90%. The H. pylori fecal antigen test is less expensive and may be more cost-effective than the urease breath test. If the fecal antigen test or the urea breath test is positive, the patient will require re-treatment for a resistant infection, but this should not be given prior to testing for the presence of active H. pylori infection. If the fecal antigen test or urea breath test is negative, and the patient continues to have symptoms, he should be referred to a gastroenterologist for an upper endoscopy/EGD and mucosal biopsy.

What are the top 2 prognostic factors for death in pts with HTN?

The first and best prognostic factor for death in all people is age (the older you are, the more likely you are to die). Second is LVH (reversible to a degree with proper Tx)

For what children is it recommended to have periodic screening for anemia?

The following children need selective screening for anemia at periodic visits: At risk of iron deficiency because of special health needs Low-iron diet (i.e. nonmeat diet) Environmental factors (i.e. poverty, limited access to food)

What are the risk factors for endometrial CA?

The following increase the amount of unopposed estrogen and thereby increase the risk for endometrial cancer: unopposed estrogen therapy tamoxifen (Nolvadex) obesity anovulatory cycles estrogen-secreting neoplasms early menarche (before age 12) late menopause (after age 52) menstrual cycle irregularities nulliparity Conversely, smoking seems to decrease estrogen exposure, thereby decreasing the cancer risk, and oral contraceptive use increases progestin levels, thus providing protection. Other risk factors for endometrial cancer include: hypertension, diabetes, and breast or colon cancer. Age is also a risk factor for endometrial cancer: The incidence of endometrial cancer more than doubles from 2.8 cases per 100,000 in those aged 30 to 34 years to 6.1 cases per 100,000 in those aged 35 to 39 years. Thus, the American College of Obstetricians and Gynecologists recommends endometrial evaluation in women aged 35 years and older who have abnormal uterine bleeding.

What is perimenopause? And what do patients need to know about it? How long can it last?

The gradual transition to menopause is called perimenopause. The ovaries don't abruptly stop; they slow down. During perimenopause it is still possible to get pregnant. The ovaries are still functional, and ovulation may occur, although not necessarily on a monthly basis. Perimenopause can last from two to eight years.

What is the guideline for cholesterol control targets?

The guideline for normal cholesterol is less than 170 mg/dl for the total cholesterol level and the goal LDL level is less than 130 mg/dl.

What is the half-life of Warfarin? And how long does it take to reach a steady state in the bloodstream?

The half-life of warfarin is around 40 hours, that means it will take five to seven days for the steady state to be stable.

When do you consider the diagnosis of pertussis?

The initial symptoms of pertussis are nonspecific, similar to those of the "common cold," and include runny nose, low-grade fever, and mild cough, making the diagnosis in the early stages difficult. However, symptoms from the common cold typically peak by day three, then slowly resolve and are gone by day seven to ten. The diagnosis of pertussis is considered when the cough has worsened and has been present for at least 14 days.

What is the risk of CVD and CVA in patients with DM?

The leading cause of death in patients with diabetes. People with diabetes are 2-4 times more likely to have heart disease or stroke than people without diabetes. Patients with diabetes who have a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of cardiovascular risk factors so commonly found in diabetes is therefore essential in preventing morbidity and mortality in these patients.

What is the incidence of fractures in the elderly and what risks are associated with them?

The lifetime risk of fracture for a 50-year-old woman exceed her risk of developing endometrial or breast cancer. Fractures secondary to osteoporosis place an enormous burden on the elderly personally, medically, and economically. Patients with hip fractures have an average one-year mortality rate of 20 to 25 percent. Hip fractures are associated with significant loss of independence, with 15 to 25 percent of previously independent patients require nursing home placement for at least one year, and less than 30 percent of patients regain their prefracture level of function.

Why is a urinary ablumin excretion or Alb/Crea ration useful in HTN?

The measurement of urinary albumin excretion or Albumin/Creatinine Ratio (ACR) may be useful is generally recommended in all patients (whether or not they have diabetes) > 18 years old because microalbuminuria does appear to have some prognostic implications. Those with chronic kidney disease (CKD) and hypertension should be on ACEI or ARB as they improve kidney outcomes.

For how long and in what manner should patients take PPIs for initial Dx of uncomplicated GERD/PUD?

The natural history of both GERD and non-ulcer dyspepsia are variable, and anti-secretory therapy should be stopped after a successful four- to eight-week course, or used in a pulse dose manner (daily for short periods of time when symptoms recur) to determine the need for chronic daily use. Patients should be referred for upper endoscopy/EGD in the setting of alarm or extraesophageal symptoms to rule out significant disease, or in cases that do not respond to the empiric treatment strategy after eight weeks.

What is required in order to treat a DVT on an outpatient basis?

The patient must be: Hemodynamically stable With good kidney function At low risk for bleeding The home environment must be: Stable and supportive Capable of providing the patient with daily access to INR monitoring

How should follow-up be arranged in a patient being treated with RAI therapy?

The patient needs to be seen within a few months after her radioactive iodine treatment to see when to discontinue propranolol (if prescribed) and to follow her TSH. The patient should have her TSH drawn every two to three months until it has stabilized. The time frame can be extended after that to six months or longer. Since she will become hypothyroid at some point, it is important to alert the patient to symptoms of hypothyroidism she could expect, so she can be tested earlier if need be.

What are the JNC-7 recommendations for methods to take an accurate BP?

The patient should be seated quietly for at least five minutes in a chair with their back supported, rather than on an examination table. The arm should be supported at heart level. You want to auscultate the blood pressure with your stethoscope using a properly calibrated and validated instrument. The most important point is using an appropriately sized cuff to ensure accuracy. The length of the bladder of the cuff should be at least 80% of the arm circumference, and the width of the cuff must be at least 40% of the arm circumference. A cuff that is too small will give you an erroneously high blood pressure reading. With increasing prevalence of obesity, most adults no longer will fit into an "adult" cuff, but may require an "extra large" or "thigh-sized cuff.

Who gets atypical pneumonia? And how does it present?

The patient's age is a key factor in differentiating between typical and atypical pneumonia. Young adults are more prone to atypical causes, and very young and older persons are more predisposed to typical causes. Atypical organisms, such as Mycoplasma or Chlamydia pneumoniae, are more common in older children and adolescents. In addition to the pneumonia symptoms observed in younger children, adolescents may have other symptoms such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms. In one study, patients with bacterial pneumonia were significantly more likely to present with pan-inspiratory crackles, whereas patients with atypical pneumonia were more likely to present with late inspiratory crackles.

What might a slightly enlarged uterus indicate?

The patient's uterine size is at the upper limits of normal. This is a common and normal finding in women, especially those who have had children. It may also signal the early development of changes associated with a myomatous or fibroid uterus.

What ethnic group and sex is at highest risk for suicide?

The person most likely to succeed in a suicidal attempt is a white male. While females are more likely to attempt suicide, males are more likely to be successful.

How might a DVT cause fever?

The presence of a thrombus in a vein may be accompanied by an inflammatory response in the vessel which may be minimal or may be characterized by granulocyte infiltration, loss of endothelium, and edema. This inflammatory process may also result in a low grade fever.

What are the benefits of menopausal hormonal therapy (HT)? And how can the increased risk of uterine CA be mitigated?

The primary function of menopausal hormonal therapy (HT) is to treat the bothersome symptoms of menopause. Systemic estrogen is the most effective treatment for hot flashes, or vasomotor symptoms. Patients with an intact uterus must also be treated with progesterone to decrease the risk of endometrial cancer related to unopposed estrogen. Estrogen, especially when used topically, is also the most effective treatment for symptoms of atrophic vaginitis, including vaginal dryness and dyspareunia, and may improve urinary symptoms such as urge incontinence and recurrent urinary tract infections. Topical estrogens available through the pharmaceutical companies are very safe in low doses and in low doses probably do not require coverage with progesterone even in women with an intact uterus. Menopausal hormonal therapy, especially when started in the first five years after menopause, helps prevent osteoporosis by maintaining bone density. For many years, HT was used extensively for this purpose. It is still considered an option for certain women when the risk and benefit ratio favor it over other treatments. Research on the use of HT for other quality of life issues, including cognitive and depressive symptoms which commonly occur in perimenopausal and postmenopausal women, is less clear.

Why are unnecessary lumbar plain films potentially even more harmful to women?

The radiation exposure to the ovaries in a single plain radiograph of the lumbar spine is equal to getting daily chest x-ray (CXR) for more than a year.

What size SSC has higher incidence of recurrence and metastasis? And what size nevi are higher risk for malignancy?

The squamous cell carcinoma of the skin greater than 2 cm in diameter is regarded to be in high risk for recurrence and metastasis. Nevi larger than 6 mm in diameter tend to be more malignant than the smaller nevi.

What is the standard approach to using cardiac biomarkers to detect acute MI?

The standard approach follows: Serum troponin-T (cTnT) or troponin-I (cTnI) is measured at first presentation. If the serum troponin is not elevated, the test is repeated at six to nine hours. It is not uncommon to measure a second troponin earlier than six hours in patients who are highly suspected of having ongoing non-ST-elevation myocardial infarction (NSTEMI). In an occasional patient in whom the index of suspicion for acute myocardial infarction is high but the first two serum troponin measurements are not elevated, a repeat measurement at 12 to 24 hours may be necessary. Serum CK-MB is measured when a troponin assay is not available or when reinfarction is suspected within two weeks since a cTnT elevation may represent the first event given the long half-life of the enzyme.

What are the two most common complications of influenza?

The two most common complications of influenza: bacterial pneumonia - streptococcal pneumonia present in about 2-3 % of outpatient children and up to 14% of hospitalized children - staphylococcal pneumonia otitis media (10-50% of children with influenza)

What are the initial screening tools for generalized anxiety disorder and depression?

The two questions you asked are a screening tool for anxiety in the primary care setting known as the GAD-2. There is a similar screening tool for depression known as the PHQ-2.

What is the utility of ordering an upper GI series on a patient?

The upper GI series can be useful in determining complications of GERD (e.g. esophageal stricture), but has poor utility in diagnosing GERD and should not be used for this purpose. In some cases, the upper GI series may reveal a gastric or duodenal ulcer, but it is not considered to be the gold standard test to make this diagnosis.

How useful is the WBC count in pregnancy?

The white blood cell (WBC) count is limited in its usefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have a mild leukocytosis. Nevertheless, if significantly elevated, or associated with a bandemia, this test would need to be factored into the consideration of a septic abortion.

How effective is theophylline for asthma tx?

Theophylline may also be used in conjunction with low-dose inhaled corticosteroids, but is not used that often due to the difficulty in titrating the theophylline dose to the correct level. A meta-analysis demonstrated that salmeterol (a long-acting beta2 agonist) inhaler led to improved lung function and more symptom-free days and nights compared to theophylline.

What are the environmental risk factors for BRCA?

Therapeutic radiation Obesity

What exercises may be used to heal an ankle injury and prevent future injuries?

There are a number of different exercises available. Some exercises commonly used include ankle inversion, ankle eversion, ankle plantarflexion, ankle dorsiflexion, calf stretching, and single leg balancing. Physical therapists can work with patients and teach them specific exercises called proprioceptive exercises. Studies have shown that proprioceptive exercises, in particular, help prevent and reduce the likelihood of re-injury

What contraindications exist for prescribing triptans for migraines?

There are some factors that would prevent a patient from taking this medication. Patients with a history of heart disease, stroke or uncontrolled hypertension can't take this medication. You also need to be careful with patients on an SSRI medication because the combination of sumatriptan and an SSRI can cause serotonin syndrome

The 3 different HPV vaccines protect against what percentage of cervical cancers?

There are three vaccines that effectively protect women against the viruses that cause approximately 75% of cervical cancers.

Can physical therapy and/or chiropractor Tx help for low back pain?

There is some data to show that tailored physical therapy is slightly more effective for acute back pain compared to patients who just stay active. At four weeks, patients who received physical therapy had 10-point improvement in a 100-point disability score compared to the control group. There is great variation in physical therapy because various interventions (exercises, traction, massage) and different modalities (heat, ice, ultrasound) may be used. There is also evidence that spinal manipulation is safe and can help in the short term. However, there is no difference in outcomes for use of chiropractor in the long term.

What dose of thiazide diuretic should patients be started on? And in elderly?

Thiazide diuretics should be started at lower doses in elderly patients such as 6.25mg or 12.5mg (NOT 25 mg) a day, because this population may be more sensitive to this drug class and may experience hypotensive episodes. Most other adults can start at 25mg per day. Although elderly patients start at lower doses, they may require the same amount of medication as younger persons to control their blood pressure.

What conditions might be assessed by the KOH/Saline wet prep?

This is a quick test which should be done as it could indicate inflammation (white blood cells) or diagnose trichomonas, bacterial vaginosis, or yeast vaginitis.

How effective is withdraw against pregnancy?

This method is 73-96% effective against pregnancy, with variability impacted by the difficulty with timing of withdrawal and the fact that the pre-ejaculate fluid contains enough sperm to cause fertilization.

What is antidepressant discontinuation syndrome?

This phenomenon occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of this syndrome include: flu-like symptoms insomnia nausea imbalance sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication. Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug.

What is the role of the novel anticoagulants? How do they compare to traditional drugs?

This relatively new class of drugs has the advantage of not requiring weekly lab monitoring of INR and thus makes adherence an easier process. Fondaparinux is the parental form of the drug and could be used instead of LMWH. Rivaroxaban (Xarelto) is an oral factor Xa inhibitor and might be used in place of warfarin. Although these drugs have been found to be generally as safe and effective as warfarin and LMWH, the negatives of this class of medications includes high cost and difficulty in reversing the anticoagulation in the face of a bleed.

What must be combined with beta hCG in order for the test to be diagnostic?

This test has enormous significance, and when combined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can be challenging to interpret, especially without the ultrasound results.

What antibodies are used to evaluate Graves' disease?

Thyroid peroxidase antibodies are present in 70-80% of Graves' patients. These and TSH receptor antibodies can differentiate Graves' disease from toxic nodular goiter. Some experts feel that these antibody tests can be done instead of a thyroid scan provided that silent thyroiditis can be ruled out clinically.

Why might a TSH be obtained for abnormal uterine bleeding?

Thyroid-stimulating hormone level Thyroid disorders may cause abnormal uterine bleeding and are associated with an increased risk for endomentrial cancer. We assess thyroid function via the thyroid-stimulating hormone (TSH). This is an inexpensive test.

What is another name for Osgood-Schlatter lesion?

Tibial apophysitis, or an Osgood-Schlatter lesion, is inflammation of the tibial tubercle at the site of the patellar tendon attachment. It is typically seen in adolescents who recently went through a growth spurt. They present complaining of anterior knee pain localized to the tibial tuberosity.

What are the time guidelines for t-PA administration and intra-arterial therapy for stroke?

Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within three hours, intravenous t-PA has proven benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.

How do you perform the TUG test? And what is it for?

Timed Up and Go Test Measures mobility and fall risk in people who are able to walk on their own. The person may wear their usual footwear and can use any assistive device they normally use. Instructions to the patient: 1. Sit in the chair with your back to the chair and your arms resting in your lap. 2. Without using your arms, stand up from the chair and walk 10 ft. (3m). 3. Turn around, walk back to the chair, and sit down again. Timing begins when the person starts to rise from the chair, and ends when he or she returns to the chair and sits down. The person should be given one practice trial and then three actual trials. The times from the three actual trials are averaged.

How do you treat tinea unguium?

Tinea unguium Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis) are as follows: terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only) itraconazole 200 mg twice daily as pulse therapy one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole two pulses: fingernails three pulses: toenails

What topical Tx is available for actinic keratosis? When else might it be used?

Topical 5-fluorouracil (5-FU) Approved by the United States Food and Drug Administration (FDA) for the treatment of actinic keratoses. Although topical 5 -FU is not approved for the treatment of Bowen's disease (squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in these diseases when other treatment modalities are impractical and for patients who refuse surgical treatment.

Can topical steroids have systemic effects?

Topically applied high and ultra high potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension and other systemic side effects have been reported.

By definition, how do you differentiate TIA from Stroke?

Transient ischemic attacks are defined as episodes of neurologic dysfunction caused by focal brain or retinal ischemia with clinical symptoms lasting less than 24 hours and no evidence of acute infarction on imaging. Stroke is defined as sudden onset of focal (or global) of neurologic impairment with symptoms lasting more than 24 hours.

How effective is transvaginal U/S in evaluating abnormal uterine bleeding?

Transvaginal ultrasound (TVUS) TVUS may be the most cost-effective initial test in women at low risk for endometrial cancer who have abnormal uterine bleeding. It will tell us the thickness of the endometrium. If the endometrium is less than 4 mm (some sources say < 5 mm) on ultrasound, it is reassuring and more workup may not be necessary unless the bleeding continues. Besides endometrial thickening, transvaginal ultrasonography may reveal leiomyoma (fibroids) or focal uterine masses, and may also reveal ovarian pathology. Although this imaging modality may miss endometrial polyps and submucosal fibroids, it is highly sensitive for the detection of endometrial cancer (96%) and endometrial abnormality (92%).

After H. Pylori infection has been ruled OUT, what treatments are available for functional dyspepsia?

Tricyclic antidepressants have been found to improve symptoms in patients with functional dyspepsia without affecting the sensation of gastric distention. A systematic review determined that there is insufficient evidence to support the efficacy of psychological therapies, including cognitive behavioral therapy, hypnotherapy, relaxation training and interpersonal therapy, for the treatment of functional dyspepsia. However, individual trials have reported some modest clinical benefits in symptomatic improvement. Alternative therapies are gaining popularity in patients with gastrointestinal conditions, and studies of varying quality suggest that slippery elm, capsaicin, peppermint oil, caraway oil and artichoke leaf may improve symptoms in some patients; however, there is as yet no compelling evidence on which to base a recommendation for these alternative therapies. Note: peppermint oil decreases lower esophageal sphincter pressure and may worsen GERD symptoms. Patients should be educated that herbal remedies are not regulated by the US Food and Drug Administration (FDA), may not have been studied for safety, and can have adverse side effects, which very often include GI side effects.

When might bactrim be used to Tx UTI's?

Trimethoprim/sulfamethoxazole may be used but if there is greater than 20% resistance you should consider other antibiotic options.

How are troponin and CK-MB used in the dx of AMI?

Troponins are the markers of choice for the diagnosis of myocardial infarction and should be used instead of CK-MB. Rising by four to six hours after an ischemic injury, troponins remain elevated for up to ten days, and are more specific than CK-MB. Because troponin can remain elevated for days, however, the precise timing of the injury can be difficult to determine. CK-MB may be helpful for the timing of injury, because this enzyme level rises in the serum 4 to 12 hours after the event, but remains elevated for only 36 to 48 hours. An elevated serum CK-MB can help confirm the timing of an acute myocardial infarction; in addition, repeat elevations may indicate recurrent myocardial injury.

What children should have an annual tuberculin skin test performed?

Tuberculosis screening guidelines: Children who should have annual Tuberculin Skin Test: Children infected with HIV Incarcerated adolescents Validated Questions for Determining Risk of Latent Infection: Has a family member or contact had tuberculosis disease? Has a family member had a positive tuberculin skin test? Was your child born in a high-risk country (countries other than the United States, Canada, Australia, New Zealand, or Western European countries)? Has your child traveled (had contact with resident populations) to a high-risk country for more than one week?

What is considered a positive 3 hour glucose tolerance test?

Two or more equals positive: Fasting serum glucose concentration ≥ 105 mg/dL (5.3 mmol/L) One-hour serum glucose concentration ≥ 190 mg/dL (10 mmol/L) Two-hour serum glucose concentration ≥ 165 mg/dL (8.6 mmol/L) Three-hour serum glucose concentration ≥145 mg/dL (7.8 mmol/L)

What are the most salient features of GABS pharyngitis?

Typically causes fever, sore throat, and tender cervical lymphadenopathy.

What are the salient features of septic arthritis?

Typically presents with a single painful joint. Exam is usually remarkable for swelling and warmth. Patients are typically febrile, though sometimes elderly patients will be afebrile with this diagnosis.

What two conflicting recommendations exist for screening for BRCA?

U.S. Preventive Service Task Force (USPSTF) Recommends biennal screening mammography for women aged 50-74 and that starting screening mammography prior to 50 years of age should be a decision that is individualized for each patient. (They found insufficient evidence to assess the benefits and harms for women over age 75.) The American College of Obstetricians and Gynecologists and the American Cancer Society Recommend annual screening mammography for women beginning at age 40.

What are the USPSTF guidelines for folate supplementation in preconception?

US Preventative Services Task Force (USPSTF) recommends that all women planning or capable of becoming pregnant take a 400-800 mcg daily supplement of folate to prevent neural tube defects. The recommendation increases to 1 mg daily in patients with diabetes and epilepsy. In patients who have previously had a child with a neural tube defect, the recommendation increases to 4 mg daily.

What are the values vs catagories for the BMI scale?

Underweight below 18.5 Normal 18.5 - 24.9 Overweight 25.0 - 29.9 Obese 30.0 and above Some subcategorize obesity into obese 30-35; very obese 35-40; and extremely or morbidly obese 40+

How reliable is missed periods for detecting pregnancy?

Unfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report having missed a menses. Conversely, not every adolescent who misses a menses is pregnant because anovulatory cycles are normal in the early postmenarcheal years.

What is the FRAX score?

United States Preventive Services Task Force recommends osteoporosis screening for all women over the age of 65 and for younger women who have an equivalent risk to the average 65-year-old white female (9.3% ten-year risk of any osteoporotic fracture as calculated by the FRAX score). The World Health Organization has developed a tool to calculate the risk of fracture, the FRAX, which may be helpful in evaluating individual patients. The tool adjusts for gender, ethnicity, and locale.

What features increase your index of suspicion for malignancy as the cause of LBP?

Unlikely without a history of cancer. Back pain due to malignancy is localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough. More commonly seen in patients over 50.

What are the salient features of SLE?

Unlikely without other signs and symptoms accompanying the joint pain, including fever, skin rashes, Raynaud's phenomenon, pleuritis, or chest pain. The typical rash of SLE is a malar "butterfly" rash, which appears as an erythematous maculopapular rash over the nose and cheeks that spares the nasolabial folds, and typically occurs or worsens with sun exposure. Discoid lesions can also be present, which look like discrete erythematous placques with scaling. SLE arthritis is also typically migratory.

Why is it important to identify peripheral neuropathy in a diabetic pt early?

Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot ulceration nondiabetic neuropathies may be present in patients with diabetes and may be treatable while specific treatment for the underlying nerve damage is currently not available, other than improved glycemic control, which may slow progression but not reverse neuronal loss -- effective symptomatic treatments are available for some manifestations of DPN.

What are the ADA recommendations for ASA therapy in diabetics?

Use aspirin (75-162 mg/day) as 2° prevention in diabetes patients with history of CVD (level of evidence A). Consider aspirin therapy (75-162 mg/day) as a 1° prevention strategy in those with diabetes at increased cardiovascular risk (10-year risk >10%). This includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5-10%), clinical judgment is required. Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 years and women <60 years of age with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits.

What are the USPSTF guidelines for ASA therapy in diabetics?

Use aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade: A recommendation.) Use aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Grade: A recommendation.)

Why can't combination OCPs be used postpartum?

Use of combined oral contraceptives postpartum and in lactating women is controversial. Women may benefit from reduced coagulation-related risks (such as DVT) by waiting four or more weeks postpartum, and combined oral contraceptives are known to suppress milk production in the early postpartum period. However, clinical trials have shown mixed results with regard to the effect of combined oral contraceptives on milk supply and infant growth, and a Cochrane review concluded that no evidence-based recommendation can be made about the use of combined oral contraceptives in lactating women.

What are the indications for RAI therapy?

Used to treat Graves' disease, solitary toxic adenoma, multi-nodular goiter, very large goiter in a euthyroid patient. (Can reduce the size of a goiter by 50% in one year. ) First-line treatment for Graves' disease or if treatment with an antithyroid drug has not been successful.

What is uterine rupture and when can it occur?

Uterine rupture is a serious, but uncommon cause of second and third trimester vaginal bleeding. It occurs more often during delivery than prior to it. Uterine rupture is defined as a full-thickness separation of the uterine wall and the overlying serosa. It is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta, or both into the abdominal cavity, and the need for prompt cesarean delivery, uterine repair, or hysterectomy.

For how long does the DTaP vaccine protect against pertussis?

Vaccine-induced immunity following the 5-dose primary DTaP series persists for at least five years, but the immunity wanes over time. The decreased immunity makes previously vaccinated adolescents and adults vulnerable to infection and a source for transmission of pertussis to other susceptible children and adults. Infection in previously vaccinated persons is often less intense and of shorter duration, and has a greater chance of going undiagnosed. These findings led to the recommendation of a booster vaccination of adolescents and adults with the Tdap acellular pertussis vaccine.

What is the presentation of vaginal candiasis?

Vaginal candiasis typically presents as itching in the vaginal and labial area with associated thick, whitish vaginal discharge. Is common in pregnancy, is often associated with dysuria, and can be associated with recent sexual intercourse.

What is the mechanism and side effects of Varenicline?

Varenicline (Chantix) Mechanism: Nicotine receptor blocker. Use: Started a week before the quit date, titrated up, and maintained for 2-3 months. Should NOT be used with nicotine replacement. Adverse effects: Associated with an increase in suicide. The dose should be lowered for those with renal insufficiency. Nausea, the most common side effect, may be lessened by taking it with food.

Which treatment is preferred between thyroid suppression, RAI therapy, and surgery?

Varies by physician and geography. No large scale studies comparing long term outcomes of medication, RAI,or surgical treatment. Medication treatment has a lower incidence of permanent hypothyroidism, but higher incidence of relapse and requires frequent monitoring and a prolonged course of therapy.

What is it called when menopause causes palpitations?

Vasomotor symptoms of the climacteric (menopause) May cause palpitations in peri-menopausal women Associated with heat intolerance and sweating during a hot flash

What is the presentation of croup? How common is the classic radiographic finding?

Viral croup may present with a prodrome of mild fever, and symptoms may include a sore throat. Viral croup also causes a barking cough, inspiratory stridor, and hoarse voice. The diagnosis of croup is made clinically. A Steeple sign on x-ray is suggestive, but is only present in only 50% of children with croup. The Steeple sign is a radiographic finding on a PA or AP view of the chest. It appears as a narrowing of the trachea as it joins to the larynx and is the result of a narrowed column of subglottic air.

What are the symptoms of severe preeclampsia?

Visual disturbances, severe headache, right upper quadrant or epigastric pain, nausea, vomiting, decreased urine output

What is vocal cord dysfunction?

Vocal cord dysfunction is a more unusual condition that may present very similarly to asthma, in that both conditions cause wheezing. The suggestive finding in patients with vocal cord dysfunction is that they do not respond to usual asthma medications. On spirometry, patients with vocal cord dysfunction have flattening on the inspiratory loop on spirometry, in contrast to reversible obstructive findings on spirometery in patients with asthma. The distinctive diagnostic finding is visualizing the abnormal vocal cord movement through indirect or direct laryngoscopy during an episode of wheezing. Vocal cord dysfunction can either occur by itself or it can occur in conjunction with asthma in certain patients.

What pocket card tool is designed to encourage dialogue about a patient's diet/exercise health?

WAVE is a pocket card tool designed to encourage dialogue about the patient's "Weight, Activity, Variety and Excess". Based on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of servings from the Food Guide Pyramid (Variety) and whether he or she is eating too much fat, salt, sugar, and calories (Excess) recommended in the Dietary Guidelines for Americans. The card also lists counseling tips to aid the practitioner in setting dietary goals with the patient.

What snacks before bed may help induce sleep?

Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep

What special considerations are given for ACE-I? How much rise in serum Crea is acceptable?

Watch potassium, sodium, and creatinine levels. Renal protective. Reduces microalbuminuria. First line agent in diabetes and renal disease. Shown to have direct heart remodeling effects. A rise of up to 35% above baseline in creatinine is acceptable after initiating use. ACE inhibitor cough is common in 15 - 20% of patients due to bradykinin production. Angioedema is a serious side effect to monitor in patients. Avoid in pregnant women (Category C drugs).

What are the symptoms of hypothyroidism?

Weight gain, cold intolerance, pedal edema, heavy periods, and fatigue all arise from slowed metabolism. Fatigue is common to both hyper and hypothyroidism.

What is the main weight loss medication approved by the FDA?

Weight loss medications approved by the FDA include orlistat (Alli, Xenical) a nonprescription medication which acts by inhibiting absorption of dietary fats. Treatment guidelines suggest two to four years of treatment. Orlistat may be considered as initial therapy due to its excellent cardiovascular safety profile. It is also recommended for patients with diabetes in whom additional weight loss is recommended after use of metformin and dietary/lifestyle changes. Gastrointestinal side effects may limits its use, but usually decrease over time.

What is the classic description of Colic?

Wessel definition - Rule of Three Unexplained paroxysmal bouts of fussing and crying that lasts at least three hours a day, at least three times a week, for longer than three weeks.

Do you xray every child with suspected pneumonia?

When community-acquired pneumonia is suspected, a chest x-ray is only indicated if the child is hypoxic or isn't responding to treatment. Note: all children that are admitted to the hospital for pneumonia should have a PA and lateral chest x-ray.

Why is good dental care especially important in diabetics?

When diabetes is not controlled properly, high glucose levels in saliva may help bacteria that attack tooth enamel thrive. Going to the dentist and brushing your teeth helps remove decay-causing plaque which can result in cavities and gum disease. It is also important to go to the dentist regularly because gum diseases and fungal infections appear to be more frequent and more severe among diabetics due to immunosupression. Additionally, periodantal disease can increase the risk of heart trouble.

What features of low back pain are classic for disc herniation?

When disc herniation is suspected, a very important historical point is the position of comfort or worsening of symptoms. Classically, disc herniation is associated with exacerbation when sitting or bending; and relief while lying or standing. Other symptoms of disc herniation include: increased pain with coughing and sneezing pain radiating down the leg and sometimes the foot paresthesias muscle weakness, such as foot drop

What risks does placenta previa pose?

When the placenta attaches low in the uterus, it can cover the cervical os, which can lead to excessive bleeding at or prior to delivery, jeopardizing the health of the fetus. While bleeding from placenta previa can occur at any time, bleeding more often occurs later in pregnancy, either late in the second or in the third trimester. With the advent of ultrasound, it is usually diagnosed before a woman has any bleeding.

What is the most accurate way to date a pregnancy?

When used for dating, ultrasound is most accurate during early pregnancy and should be performed as early as possible (and no later than 20 weeks).

How is the modified straight leg raise test done? What are abnormal findings? And what is their significance?

While continuing to talk to the patient, raise each leg by extending the knee from 90 degrees to straight. If the pain is functional, the action is possible without difficulty. If the pain is due to structural disease, the patient will instinctively exhibit the "tripod sign" by leaning backward and supporting himself with his outstretched arms on the exam table.

What are the recommendations on screening for skin CA?

While skin cancer is the most common type of cancer, the USPSTF is currently reviewing guidelines regarding screening. Presently, the draft statement states that current evidence is insufficient to assess if there is more harm or benefit to visual skin cancer screening in adults. The USPSTF is also currently evaluating if there is any benefit in providing behavioral counseling for skin cancer prevention.

What are the risks associated with hormone replacement therapy in postmenopausal women?

While the particular risks for groups of women are still being defined, recent reviews of the available evidence have provided some key practice recommendations including: Combined estrogen and progestogen use beyond three years increases the risk of breast cancer. Use of unopposed systemic estrogen in women with a uterus increases endometrial cancer risk. Beginning HT after age 60 increases the risk of coronary artery disease. HT increases the risk of stroke at least for the first one to two years of use. HT for menopausal symptoms should use the lowest effective doses for the shortest possible times.

What are the salient features of endometrial hyperplasia?

With or without atypia can cause bleeding. Simple hyperplasia progresses to cancer in less than 5% of patients; atypical complex hyperplasia is a premalignant lesion that has a 25% probability of progressing to cancer. Therefore, careful monitoring and treatment is important with this disorder.

Who gets screened for lipid disorders?

Women 20-45 if increased risk for coronary heart disease.

What are the ACS recommendations for BRCA screening?

Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered. Women age 45 to 54 should get mammograms every year. Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening

Why is the incidence of poor outcomes in CVD increasing for women when it is decreasing for men?

Women are less aggressively treated than men and have worse outcomes. The fact that women are usually older at presentation than men and that women tend to wait longer before seeking treatment may be part of the reason. Women are also less likely to participate in cardiac rehabilitation. Unfortunately, one study showed that in ambulatory care setting, women were less likely to be treated with a beta-blocker, aspirin or a statin even after having a heart attack. Effective early diagnostic strategies for diagnosing CHD earlier in women are critical, as 40 percent of initial cardiac events in women are fatal.

What are the risk factors for aneuploidy in pregnancy?

Women at higher risk for a fetus with aneuploidy (an abnormal number of chromosomes) include: Positive maternal serum screen Age > or = 35 at delivery (singleton fetus) Age > or = 32 at delivery (twins or higher multiples) Fetus with identified abnormalities on ultrasound Women with a previously affected pregnancy Known chromosomal translocation, inversion, or aneuploidy in either parent

What are the cervical CA screening guidelines for women > age 65? Who is exempt from cervical CA screening?

Women older than 65 years who have had adequate screening within the last ten years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing. Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening. Exempt if total hysterectomy for benign reasons

When can genetic testing be done on the fetus and what are the risks?

Women who are at increased risk for fetal anomalies should be offered prenatal screening and diagnosis by amniocentesis or chorionic villus sampling. Amniocentesis involves the insertion of a thin, long needle through the belly and into the uterus to withdraw a sample of amniotic fluid for testing. This test may be performed beginning at about 15 weeks and carries an approximately 1/300 to 1/500 risk of causing spontaneous abortion.Chorionic villus sampling (CVS) involves biopsy of a small amount of placental tissue via the vagina and cervix. CVS can be performed earlier, at about 10-13 weeks' gestation, but has a higher risk of causing spontaneous abortion (1-3%) as well as limb defects (1:3000 to 1:1000).

What is the risk of gest HTN and preeclampsia?

Women with severe gestational hypertension and mild or severe preeclampsia have an increased risk of pregnancy complications including: preterm delivery, small for gestational age infants, and placental abruption. Women with mild gestational hypertension have not been shown to carry similar risks, so making the distinction between these entities is important.

What is Xanthelasma?

Xanthelasma are yellowish plaques that occur most commonly near the inner canthus of the eyelid, more often on the upper lid than the lower lid. Xanthelasma palpebrarum is the most common cutaneous xanthoma.

How do you perform a quick assessment of a child's (age 5) ability in verbal, general knowledge, and motor function?

You turn to Althea and ask her to name four colors around the room. She is able to answer without difficulty. You give her a pencil and paper and ask her to draw a person. You are pleased that her drawing is quite complex and has at least six body parts. You ask her to copy a square and a triangle. You notice that she is able to hold the pencil correctly. You ask her to stand up and to skip, hop, and stand on one foot, which she does with no difficulty. Lastly, you ask her if she has any pets. "I have a dog named Rufus." She is able to tell you a short story about her dog and she has good articulation, with complete sentences and correct tenses and pronouns.

Can a woman get pregnant before menarche?

Young women who have not yet menstruated, but are sexually active, may be at risk for pregnancy because ovulation can occasionally occur before the first menstrual period.

What approach is most effective in treating major depression?

a biopsychosocial approach (meds, CBT, and exercise) Elderly have lower rates of spontaneous remission with depression

What is Tramadol?

a centrally acting analgesic with effects on the μ-opioid receptor that also stimulates release of serotonin and inhibits reuptake of norepinephrine, may be a good choice, given its effectiveness in alleviating moderate to severe pain and its lower abuse potential than other more potent opiod agonists, though it still carries some risk.

What is Reiter's Syndrome?

a medical condition typically affecting young men, characterized by arthritis, conjunctivitis, and urethritis, and caused by an unknown pathogen, possibly a chlamydia. The infection usually occurs days to weeks before the onset of joint pain. In some cases a preceding infection may only be identified with laboratory testing. Symptoms include joint pain and stiffness, most commonly in the knees, ankles, and feet. In a type of reactive arthritis called Reiter's syndrome, there may be discomfort during urination as well as eye inflammation. If needed, treatment includes anti-inflammatory medication or steroids.

What thickness of the endometrium on TVUS is reassuring against CA?

a thickness of 4 mm or less is reassuring that the patient does NOT have endometrial cancer. Greater than 4mm is either proliferative endometrium, endometrial hyperplasia, or endometrial cancer. Biopsy is indicated.

What are the components of metabolic syndrome?

abdominal obesity, dyslipidemia, hypertension, and insulin resistance with or without impaired glucose tolerance.

At what age do pts qualify for the Zoster vaccine?

age 60

What is the advantage of using liquid-based system over the conventional Pap smear technology?

allows for later testing of the sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal

Syncope can occur with initiation of what class of drugs?

alpha blockers

Any patient presenting with insomnia should also be screened for what other psychiatric disorders?

anxiety and depression

What does conservative therapy for low back pain consist of?

aspirin/NSAID and/or muscle relaxants heat/cold

What non-migraine specific medications are available to treat migraine HAs?

aspirin/butalbital/caffeine Fiorinal acetaminophen/butalbital/caffeine Esgic, Fioricet, Phrenilin (lacks caffeine) acetaminophen/dichloralphenazone Midrin (discontinued in the US) acetaminophen/aspirin/caffeine Excedrin

What medications can be used to help someone with smoking cessation? And how effective are they?

bupropion (Wellbutrin, Zyban, Budeprion) or varenicline (Chantix) Somewhat effective (quit rate at 12 months 1.5-3 times the placebo quit rate)

What blood glucose targets are recommended to patients with diabetes?

fasting blood glucose should be 80 -120 mg/dl postprandial blood glucose between 1-2 hours after a meal should be < 180 mg/dl

What are the red flags of low back pain?

fever unexplained weight loss pain at night bowel or bladder incontinence neurologic symptoms (saddle paresthesia, etc)

What conditions are often comorbid with asthma and, if treated, may improve asthma control?

gastroesophageal reflux disease (GERD) obesity or overweight obstructive sleep apnea rhinitis or sinusitis stress and depression

What are some common side effects of NSAIDS?

gastrointestinal upset decreasing the effectiveness of hypertension medications increasing the effect of sulfonylureas

What is the presentation of hepatitis?

hepatitis is very important to recognize and diagnose as it can be contagious and some forms of hepatitis can lead to liver cancer. Patients usually present with nausea, vomiting, diarrhea, light colored stools, and/or dark urine which is often described as cola- or tea-colored. Patients generally have fever and yellow discoloration of their eyes, skin and mucus membranes (jaundice). Patients may have abdominal pain, loss of appetite, and malaise.

What endocrine disease may atypically present in the elderly, causing insomnia?

hyperthyroidism (consider testing if other etiologies not obvious)

How often should a lipid panel be checked?

in all adults over 21 every 4-6 years

How effective are condoms against pregnancy?

is a sheath rolled onto the penile shaft (male type; effectiveness against pregnancy 85-98%) or inserted into the vagina (female type; effectiveness against pregnancy 75-95%) just before intercourse. These are safe, protect against sexually transmissible infections (STIs) and are widely available.

What are some of the most popular diets today?

low-carbohydrate, high-protein, high-fat diet (Atkins) high-carbohydrate, low-fat diet (Pritikin) high in fruits, vegetables, whole grains, nuts, beans, seeds, and monosaturated fats (Mediterranean diet) high-protein, low-carbohydrate, fat-controlled diet (South Beach, Zone, ...) high-fiber, low-fat, vegetarian diet (Ornish) grapefruit or raw food diet (single food or food group) pre-packaged diet (Jenny Craig, NurtriSystems, Weight Watchers, ...) very low calorie or fasting diet

What are the most Frequent Causes of Death for a 55-Year-Old Male in the US?

malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis

What is the American Cancer Society (ACS) and the American Urology Association (AUA) recommendation for prostate CA screening?

men ages 55 - 69 thinking about having prostate cancer screening should make informed decisions based on available information, discussion with their doctor, and their own views on the benefits and side effects of prostate cancer screening and treatment.

What is the evidence justifying the yearly physical exam?

more than half of preventive services (e.g. ordering screening mammography or colonoscopy) are done at non-preventive care visits. No evidence-based guidelines recommend routine annual exams for all adults. Many patients expect auscultation of the heart and other components of physical exam as part of the periodic exam, even if not recommended by scientific evidence of benefit. Patients also expect "routine" laboratory tests. Physicians often meet these expectations, despite no evidence that they improve patient outcomes. For example, a screening urinalysis is done at 25% of preventive visits.

What are some possible side effect of chronic inhaled corticosteroid use?

osteoporosis, adrenal suppression, growth suppression, dermal thinning, hypertension, Cushing's syndrome, cataracts, increased emotional lability, psychosis, peptic ulcer disease, atherosclerosis, aseptic necrosis of the bone, diabetes mellitus, and myopathy

restless leg syndrome/periodic leg movements/REM sleep behavior disorder are together classified as what?

parasomnias

What is the most reliable indicator of possible compartment syndrome on physical exam?

paresthesias most reliable (pain out of proportion often first sign to present)

In what condition does the patient experience involuntary leg movements when falling asleep or during sleep, respectively?

periodic leg movement (falling asleep) and REM sleep behavior disorder (during sleep)

What are the risks of gestational diabetes?

preeclampsia fetal macrosomia (large babies who also may have a disproportionately large trunk to head ratio, increasing risks for shoulder dystocia in labor) birth trauma need for operative delivery neonatal mortality newborn complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, and others)

What are the different types of primary headaches?

primary headache include migraine, tension type, and autonomic cephalalgias such as cluster headaches

What are serious, less common causes of persistent cough?

pulmonary conditions such as bronchogenic carcinoma of the lung, sarcoidosis and tuberculosis. cardiac conditions such as congestive heart failure.

What is the USPSTF recommendation for prostate CA screening?

recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA based screening in average risk males results in little or no reduction in prostate cancer related deaths and is associated with harms related to tests, procedures and treatment of the condition, some of which may be unnecessary.

What are some major independent risk factors for CVD?

sedentary lifestyle stress premature family history excess alcohol use and many more (e.g. obesity, poor diet, low selenium levels, high homocysteine levels, etc.) Tobacco use

What are some identifiable causes of HTN?

sleep apnea, chronic kidney disease, primary aldosteronism, renovascular disease, pheochromocytoma, coarctation of the aorta, and thyroid or parathyroid disease. A review of all medications, including over-the-counter and complementary medications is crucial. Some common prescription medications like birth control pills, amphetamines, thyroid medications, steroids, and certain anti-depressants may elevate blood pressure. Some common over-the-counter medications can also elevate blood pressure, such as: pseudoephedrine, appetite suppressants, or NSAIDS. Some herbal remedies may elevate blood pressure such as ma huang, bitter orange, ginkgo, ginseng, licorice, and St. John's wort. As noted above, cocaine and ketamine use, narcotic withdrawal, excessive alcohol intake and smoking can also elevate blood pressure.

How do most physicians incorporate the PHQ-2 and -4 into their practices?

some family medicine practices now use the PHQ-2 as the first step of a 2-step screening process. Patients who score 2 or more are then asked to complete the full PHQ-9.

What medications may reduce the risk of BRCA in at-risk women?

tamoxifen or raloxifene.

What are the components of a diabetic foot exam?

testing for loss of protective sensation Sensory testing, according to the ADA, should be conducted with a 10-gram monofilament PLUS any one of the following: vibration using 128-Hz tuning fork pinprick sensation ankle reflexes (Achilles necessary, but patellar not needed) Assessment of pedal pulses (dorsalis pedis and posterior tibial arteries). Assessing the arterial supply to the lower limbs and feet is essential in evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healing and amputation in diabetes patients. Inspection. Skin changes such as hair loss and temperature changes may signal vascular insufficiency. Since foot ulceration is usually caused by breaks in the skin due to accidental trauma or poorly-fitted footwear, at each visit the patient's feet should be inspected for breaks in the skin, pressure calluses that precede ulceration, existing ulceration and infection, and bony abnormalities that lead to abnormal pressure distribution and ulceration. The patient's footwear should also be inspected for abnormal patterns of wear and appropriate sizing.

Can you screen for alcohol abuse based solely on the amount of alcohol consumption?

the American Society of Addiction Medicine has developed standards for a positive screen based on the number of drinks ingested per week. Consumption of more than 14 drinks per week or more than 4 drinks per occasion for men, and more than 7 drinks per week or more than 3 drinks per occasion for women is considered a positive screen.

Does the actual embryonic age match up well with the estimated gestational age?

the actual embryonic age (e.g., the age of the fetus since the date of conception) will typically be approximately two weeks less than the clinically calculated EGA based upon the LNMP.

What is the recommendation for the pneumococcal vaccine in pts who have previously received the PPSV23 vaccine?

the newest recommendations for adults aged 65 years or older who received PPSV23 previously say to administer PCV13 at least 1 year after the dose of PPSV23

In a pt with breast lump, what findings on PE increase the likelihood of malignancy?

the presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular borders increases the likelihood of malignancy.

What is meant by "pre-diabetes"? And why is it important to identify individuals who have pre-diabetes?

the presence of either impaired fasting glucose-IFG (fasting glucose 100-125 mg/dl) or impaired glucose tolerance-IGT (2 hr values of oral glucose tolerance testing 140-199 mg/dl). New evidence shows that damage to end-organs is already occurring during pre-diabetes and that progression to diabetes can be delayed or prevented with lifestyle modification and to a lesser degree with medication. The Diabetes Prevention Program (DPP) was a randomized, 5-year study to evaluate intensive lifestyle modification (education, coaching in diet and exercise, etc.) versus diet/exercise information along with 850 mg of metformin twice a day. The study population included 3200 participants with impaired glucose tolerance. Intensive lifestyle modification produced a 58% reduction in risk for type 2 diabetes, or a delay of about 11 years. The metformin group showed a less impressive 31% risk reduction.

What migraine specific medications can be given to abort migraines?

triptans - dizziness, sleepiness, nausea, fatigue, paresthesia, throat tightness/closure, chest pressure ergot alkaloids ergotamine (Ergostat), ergotamine/caffeine (Cafergot), dihydroergotamine (DHE) -severe reactions possible; MI, ventricular tachyarrhythmias, stroke, hypertension, nausea, vomiting, diarrhea, dry mouth, rash

high total body fat is a risk factor for what?

type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease

What are the most common causes of persistent cough?

upper airway cough syndrome (UACS - previously called postnasal drip) vocal cord dysfunction asthma gastroesophageal reflux disease (GERD) cough due to medications such as angiotensin-converting enzyme inhibitors (ACE-inhibitors) tobacco-related cough post-infectious cough chronic obstructive pulmonary disease (especially the chronic bronchitis type) non-asthmatic eosinophilic bronchitis.

Which risk groups need to have more frequent screening for cervical cancer?

women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971).

Do you always take b/l BP measurements when following HTN?

you only need one measurement on one arm for ongoing monitoring, as you are no longer screening for hypertension or an aortic anomaly.