family medicine: ROSH Review (set 2)
Non-small cell lung cancer Overview
(most common) - Adenocarcinoma, squamous cell, large cell - Tx depends on staging, may include surgical resection, chemotherapy, or tyrosine kinase inhibitors if positive for ALK or EGFR mutations
Non-small lung cancer subtypes
- Adenocarcinoma - Squamous cell carcinoma - Large cell carcinoma - Adenocarcinoma in situ, formerly bronchioloalveolar cell carcinoma
Small cell lung cancer Overview
- Associated with neuroendocrine and paraneoplastic syndromes - Metastasizes early, tx may include chemo, XRT and whole-brain radiation
Osteoporosis
- Decline in bone mass that results in increased bone fragility and fracture risk - Risk factors: female sex, advancing age, chronic steroid use, alcohol or tobacco use, immobility, family history of fragility fracture - Diagnosis is made by DXA scan: T-score ≤ −2.5 or presence of a fragility fracture - Low bone mineral density: T-score −1.0 to −2.5 - Tx: Lifestyle: calcium, vitamin D, weight-bearing exercise, smoking cessation - First-line pharmacotherapy: bisphosphonatesSecond line: SERMs, recombinant PTH, denosumab - Most common fracture: vertebral body compression fractures
Giardiasis
- History of camping and drinking lake water - Daycare outbreaks - Sudden onset of explosive, foul-smelling, and non-bloody diarrhea - Labs will show flagellated protozoan - Most commonly caused by Giardia duodenalis - Management includes supportive care and antibiotics for symptomatic individuals - Choosing an antibiotic: Individuals ≥ 3 years old — tinidazole Individuals between 1 and 3 years old — nitazoxanide Individuals <12 months old —metronidazole
Hemochromatosis
- Mutation in genes that results in iron overload - PE: liver dysfunction, bronze-colored skin, hypogonadism, arthralgias or arthritis, and cardiomyopathy - Labs: increased ferritin and transferrin saturation > 45% - Diagnosis: MRI or liver biopsy to assess increased iron deposits, HFE genotype - Treatment is phlebotomy - Screen first-degree family members - Hereditary hemochromatosis - autosomal recessive with variable penetrance (HFE gene mutation)
Tension Headache
- Patient presents with bilateral, nonpulsating, band-like pain - PE will show neck muscle tenderness - Most commonly caused by stress - Treatment is NSAIDs (abortive), TCAs (preventive) - Most common type of headache
Cellulitis
- Patient presents with pain, redness, swelling - PE will show tenderness, erythema with poorly demarcated borders, lymphedema - Most commonly caused by group A Streptococcus, Streptococcus pyogenes, or Staphylococcus aureus - Abx selection: uncomplicated, PCN-intolerant, complicated, MRSA
Bacterial Conjunctivitis
- Patient presents with red or pink eye with discharge, usually worse in the morning - PE will show purulent (yellow) discharge and crusting - Most commonly caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, contact lens wearers: Pseudomonas aeruginosa - Treatment is topical antibiotic drops
Macular Degeneration
- Patient will be older - Bilateral, gradual central field vision loss - PEDry (85% of cases): atrophic changes and yellow retinal deposits (drusen spots) Wet: vascular changes - Diagnosis is made by characteristic findings on dilated eye examination - Most common cause of blindness in the older population
Ankylosing spondylitis symptoms
- Signs and symptoms include insidious onset of back pain, night pain, and early morning stiffness. Pain typically improves with activity and is not relieved by rest. Hyperkyphosis may be seen within the first 10 years of disease - Bilateral sacroiliitis is a hallmark of ankylosing spondylitis and occurs early on in the disease. It is usually the earliest radiographic finding. Enthesitis (inflammation at the insertion site of a tendon or ligament on bone) may also be present in ankylosing spondylitis. Other associated conditions include anterior uveitis, peripheral arthritis, temporomandibular joint pain, dactylitis, psoriasis, inflammatory bowel disease, osteopenia, pulmonary disease, and cardiovascular disease (e.g., acute coronary syndrome, thromboembolism, stroke).
Peripheral Artery Disease
- Sx: pain in the affected extremity related to activity (intermittent claudication) - PE: cool extremity with absent or diminished pulses - Dx: ankle-brachial index (ABI) ≤ 0.9 If limb is threatened: contrast arteriography (gold standard) - Caused by atherosclerotic disease - Risk factors: smoking, DM, HTN - Management: risk factor modification, supervised exercise therapy
Ankylosing spondylitis
- chronic inflammatory disease affecting the bones and joints and is associated with HLA-B27 - Men > women - age of onset is around 10-30 years of age
CBilateral screening mammography every 2 years
58-year-old woman who is postmenopausal presents to the clinic for an annual exam. She has no complaints, and physical exam is normal. Family history is positive for diabetes mellitus and hypertension but negative for cancer. Which of the following represents appropriate health maintenance for this patient, according to the U.S. Preventive Services Task Force? ABilateral breast ultrasound every 2 years BBilateral screening mammography and breast ultrasound every 3 years CBilateral screening mammography every 2 years DBilateral screening mammography every year
A Amoxicillin
60-year-old woman presents to your office with a complaint of epigastric pain after eating. She describes the pain as dull, aching, and gnawing. Physical exam reveals mild epigastric tenderness to palpation. Urea breath testing is positive. Which of the following is a component of first-line therapy? AAmoxicillin BAzithromycin CCeftriaxone DRifabutin
CAn increase in both forced expiratory volume and forced vital capacity
A 13-year-old boy presents to his pediatrician for his first sports physical. Physical examination is significant for expiratory wheezes. Pulmonary function and bronchodilator response tests are ordered. The patient's baseline forced expiratory volume in 1 second is 75% of the predicted value, and his forced vital capacity is 3.5 L. Which of the following bronchodilator responses is most consistent with asthma? AA decrease in both forced expiratory volume and forced vital capacity BA decrease in forced expiratory volume and an increase in forced vital capacity CAn increase in both forced expiratory volume and forced vital capacity DNo change in forced expiratory volume or forced vital capacity
D Reduced production of uridine 5'-diphospho-glucuronosyltransferase
A 19-year-old man presents to his primary care provider with recurrent episodes of mild intermittent jaundice. He states these episodes began several years ago and seem to recur when he is stressed. He reports no other symptoms. Physical examination reveals mild scleral icterus and yellowing of the skin. Laboratory testing is significant for a slightly elevated indirect bilirubin. Which of the following best describes the pathophysiology of the most likely diagnosis? ACholestasis BReduced excretory function of hepatocytes CReduced hepatic reuptake of bilirubin conjugates DReduced production of uridine 5'-diphospho-glucuronosyltransferase
AActivated charcoal
A 2-year-old boy who weighs 15 kg presents to the urgent care after his parents caught him eating acetaminophen 1 hour ago. They estimate he ingested between 6 and 10 tablets of acetaminophen 500 mg. The patient appears to be in no acute distress, and his vital signs are within normal limits. Which of the following clinical interventions is best to administer to this patient? AActivated charcoal BGastric lavage CMagnesium citrate DSyrup of ipecac
A A single, erythematous patch with overlying warmth
A 21-year-old man presents to his primary care provider with complaints of right ankle pain for 12 hours. He is a competitive swimmer and has a history of tinea pedis. He has a fever of 102°F and a complete blood count significant for leukocytosis with a left shift. He is not on any medications. Which of the following physical examination findings is most consistent with the suspected diagnosis? A A single, erythematous patch with overlying warmth B Multiple lesions with three concentric zones of color change C Purple, pruritic, polygonal, planar, papular plaques D Raised, purpuric, target-like lesions with two zones of color change
DValproate
A 21-year-old man presents to the emergency department via ambulance after his mother found him seizing early this morning. The patient's mother reports she heard a choking sound coming from her son's room around 4:00 AM. She reports his arms and legs were jerking for at least 1 minute, and he was not responsive. He urinated on himself. In the emergency department, he appears to be postictal, and the oropharynx examination reveals a tongue laceration. Toxicology screen is negative, and finger stick blood glucose is within normal range. Upon further questioning, the patient's mother reports he had a similar episode 2 years ago, but it was determined he did not need any further intervention at that time. Which of the following is the preferred pharmacologic intervention, given the most likely diagnosis? ACarbamazepine BPhenytoin CTopiramate DValproate
DUltrasound
A 25-year-old woman presents to the ED with complaints of abdominal pain and nausea. The patient reports that the pain started about 6 hours ago and has continued to worsen. It started about an hour after the patient had a 15 oz ribeye steak while celebrating her best friend's birthday. Vital signs are as follows: BP 130/85 mm Hg, RR 19 breaths per minute, pulse 95 bpm, and temperature 101.4°F. On physical exam, the patient is ill appearing and unwilling to move around on the exam table due to pain. She has pain in the right upper quadrant that is worse when she inhales and you palpate under the rib cage. Which of the following is the most appropriate diagnostic test? ACholescintigraphy BCT scan CMagnetic resonance cholangiopancreatography DUltrasound
DMoxifloxacin drops
A 25-year-old woman presents to the emergency department with a painful red eye. She wears contact lenses and does not always take them out at night. On exam, her right eye is injected with purulent drainage and a central and round 3 mm corneal opacity. Her visual acuity is decreased, and the opacity takes up fluorescein stain. Which of the following topical agents is the recommended treatment? AAcyclovir drops BErythromycin ointment CLatanoprost drops DMoxifloxacin drops
DPericranial muscle tenderness
A 25-year-old woman presents with complaints of intermittent headache. The patient describes the headache as a band tightening around her head. Headaches are relieved with ibuprofen. Which of the following additional physical exam findings would be present given the most likely diagnosis? AHeadache aggravated by routine physical activity BNasal congestion CNausea and vomiting DPericranial muscle tenderness
A HLA-B27
A 30-year-old man presents to his primary care provider with complaints of gradually worsening shoulder, back, and hip pain for the past 7 years. He states the pain is alleviated by mild activity and does not improve with rest. The pain is most severe at night, and he feels very stiff in the morning. Review of systems is significant for recurrent bouts of acute, unilateral eye pain accompanied by photophobia and blurred vision. Physical examination reveals hyperkyphosis. Radiographs are significant for arthritic changes in the shoulders and hips bilaterally and the presence of syndesmophytes bridging across multiple vertebrae. Which of the following human leukocyte antigen markers is most likely to be positive in this patient? AHLA-B27 BHLA-B51 CHLA-B8 DHLA-DR4
ADull facial expression, dry skin, coarse and brittle hair, and decreased deep tendon reflexes
A 33-year-old woman is found to have a low serum thyroxine level, an elevated thyroid-stimulating hormone level, and a positive thyroid peroxidase antibody on her laboratory findings. Which of the following physical exam findings is classically found in untreated patients with this condition? ADull facial expression, dry skin, coarse and brittle hair, and decreased deep tendon reflexes BIncreased pigmentation of skin, hypotension, and decreased body hair CMoon facies, buffalo hump, truncal obesity, and purple striae DNervousness, hand tremor, ptosis, and tachycardia
A Decreased TSH, elevated T4, elevated T3
A 42-year-old woman presents to her primary care office, reporting symptoms of fatigue, intermittent palpitations, slight tremors, and heat intolerance over the past 3-4 months. Her weight has dropped 20 pounds since her last office visit 4 months ago. The patient notes she has not changed her eating habits and has not been exercising very much lately. On physical exam, her thyroid is diffusely enlarged and there is bilateral exophthalmos present. A full thyroid panel is ordered on her blood work, and she is noted to have a thyroid disorder. Which of the following lab values would be most consistent with this patient's diagnosis? ADecreased TSH, elevated T4, elevated T3 BDecreased TSH, normal T4, elevated T3 CElevated TSH, decreased T4, decreased T3 DElevated TSH, elevated T4, elevated T3
D Giardia lamblia
A 45-year-old man presents to his primary care provider with complaints of foul-smelling diarrhea, malaise, and abdominal pain for 1 week. The patient reports that the symptoms started about 2 weeks after his backpacking trip in the mountains. He does report that several of the other people in his group have experienced similar symptoms. On physical exam, the patient is ill appearing but in no acute distress. Physical exam is unremarkable. What is the most likely diagnosis? AClostridium difficile BCryptosporidium parvum CEntamoeba histolytica DGiardia lamblia
CHereditary hemochromatosis
A 55-year-old man presents to his primary care physician for a physical. He reports it has been a number of years since he has been to the doctor. The patient has no history of adult illness and takes no medication. He says he is drinking three beers most nights of the week. Laboratory values include ALT of 80 U/L, AST of 70 U/L, and alkaline phosphatase of 230 U/L. Liver biopsy is consistent with cirrhosis, and Prussian blue stain shows intense iron staining in the hepatocytes. Serum ferritin is 2,500 ng/L. Which of the following is the most likely diagnosis? AAlcoholic cirrhosis BBeta-thalassemia major CHereditary hemochromatosis DWilson disease
DNeck circumference of 18 inches
A 55-year-old man presents with complaints of daytime sleepiness. The patient denies insomnia or nighttime awakenings. The patient does report that his wife complains about his loud snoring, but that has been going on for years. Which of the following findings would support your suspected diagnosis? ABody mass index 25 kg/m2 BBP 120/80 mm Hg CHemoglobin of 11 g/dL DNeck circumference of 18 inches
C More than four drinks per day
A 56-year-old man presents for a routine physical exam. While taking the history, he reports smoking one pack of cigarettes per day and drinking alcohol daily. Which of the following meets the risk threshold for alcohol-related health risks? A10 drinks per week BAny alcohol consumption that is daily CMore than four drinks per day DTwo drinks per day
BBacterial conjunctivitis
A 6-year-old boy presents to the clinic with right eye redness, yellow-green discharge, and right eye being stuck shut in the mornings. He reports no changes in his vision or eye trauma. On exam, he has injection of the right conjunctiva and yellow discharge in the medial canthus. There is no palpable lymphadenopathy. The left eye is unremarkable. Which of the following is the most likely diagnosis? AAllergic conjunctivitis BBacterial conjunctivitis CInfectious keratitis DViral conjunctivitis
BAcute myeloid leukemia
A 62-year-old man presents to the office with a 2-month history of fatigue, shortness of breath, and intermittent headaches. His physical examination is pertinent for conjunctival pallor, dried blood in the nares, and ecchymosis on the shins and arms. No lymphadenopathy or organomegaly is appreciated. A complete blood count with differential is obtained and reveals pancytopenia. Peripheral smear shows the above cell. What is the most likely diagnosis? AAcute lymphoid leukemia BAcute myeloid leukemia CChronic lymphoid leukemia DChronic myeloid leukemia
BDry age-related macular degeneration
A 62-year-old man presents to the ophthalmology clinic with a gradual onset of decreased visual acuity bilaterally. He describes it as difficulty reading the text on his computer screen and difficulty driving. Dilated eye examination with a slit lamp reveals drusen deposits around the macula. Which of the following is the most likely diagnosis? ACataract BDry age-related macular degeneration CGlaucoma DWet age-related macular degeneration
A Carvedilol
A 65-year-old man with a history of congestive heart failure and hyperlipidemia presents to the office for management of symptoms related to congestive heart failure. He reports dyspnea on exertion. His vital signs are within normal limits. Electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy. A recent echocardiogram reveals an ejection fraction of 40%. His current daily medications include atorvastatin, furosemide, and lisinopril. Which of the following medications would be most appropriate to add to his medication regimen at this time? ACarvedilol BDigoxin CHydralazine DSpironolactone
AAlendronate
A 70-year-old woman reports to her primary care physician with a 2-day history of severe back pain. She picked up a heavy load of laundry just prior to experiencing the back pain. She has a past medical history of rheumatoid arthritis, which has been treated with long-term prednisone use, and a 25 pack-year smoking history. Physical exam reveals a thin woman with moderate kyphosis. She is tender at the level of L1. Lower extremity strength and sensation are intact bilaterally. Her vertebral X-ray is shown above. Which of the following is the first-line treatment of this condition? AAlendronate BEstrogen CRaloxifene DTeriparatide
BPallor with lower extremity elevation
A 70-year-old woman with a history of hypertension and coronary artery disease presents to the office for evaluation of intermittent claudication. Physical examination reveals diminished peripheral pulses. What other physical examination finding would you expect to find? ABrown pigmentation around the ankles BPallor with lower extremity elevation CUlceration at the medial malleolus DWarm lower extremities
AFinasteride
A 75-year-old man with a history of benign prostatic hyperplasia presents with worsening hesitancy, double voiding, and postvoid dribbling. A digital rectal exam reveals a smooth, firm, elastic, and enlarged prostate that has increased in size from a previous evaluation done 6 months ago. Which one of the following medications can reduce the size of the prostate and improve symptoms? AFinasteride BSaw palmetto CTadalafil DTamsulosin
BDelirium
A previously healthy 58-year-old man is admitted to the hospital after an open tibia fracture resulting from a motor vehicle collision. He has no significant past medical history and no known drug allergies. He is given hydrocodone for pain management. On postoperative day 3, his family members tell the nurse the patient has been acting strangely. They report he is periodically confused and unable to remember their names. They noticed the changes began around 2 days ago and worsen around noontime and sundown. The nursing staff has also noticed the patient seems to have sporadic episodes where he becomes inattentive and forgets how to speak English, which is not his first language. Which of the following is the most likely diagnosis? AAlzheimer disease BDelirium CDelusion DSundowning
Alcohol related health risks
According to the National Institute on Alcohol Abuse and Alcoholism, men age < 65 years who consume four or more standard drinks per day meet the threshold for alcohol-related health risks. Standard drinks are defined as a 12-ounce beer, a 5-ounce glass of wine, or 1.5 ounces of 80-proof liquor. Risky alcohol use puts an individual at risk for alcohol-related health issues. Alcohol-related health issues include hypertension, anxiety, depression, gastrointestinal symptoms, electrolyte disturbance, abnormal liver enzymes, macrocytosis, and comorbid substance use disorders. This behavior also places an individual at risk for developing alcohol use disorder. - More than 14 drinks per week is used to define risky alcohol use in men.
Bronchodilator response with asthmatic patients
Bronchodilator response is conducted by spirometry testing before and after administration of a bronchodilator, such as albuterol. A positive response is an increase in FEV1 by ≥ 12% or in FVC by ≥ 12% or ≥ 200 mL. Patients with asthma typically demonstrate a positive bronchodilator response (an increase in both forced expiratory volume and forced vital capacity) with a particularly large increase in FEV1, while patients with COPD, an irreversible airway disease, tend to demonstrate a negative bronchodilator response
Cellulitis symptoms
Cellulitis begins as a single, painful, erythematous patch with poorly demarcated borders and overlying warmth. As the infection progresses, fever, chills, malaise, lymphangitis, and lymphadenopathy may develop. The lesion will begin to expand and may result in septicemia, hypotension, and shock if untreated.
Cellulitis cause & risk factors
Cellulitis is an infection of the dermis and subcutaneous tissue that usually occurs on the lower extremities and is most commonly caused by gram-positive organisms, such as group A streptococci and Staphylococcus aureus. Risk factors for cellulitis include chronic edema, venous insufficiency, lymphatic obstruction, and fissuring of the interdigital spaces secondary to tinea pedis.
treatment for lung cancer
Chest radiography is the most important radiologic study for diagnosis. CT scan of the chest with contrast is useful for staging. Surgical resection is the treatment of choice for patients with limited, nonmetastasized non-small cell carcinoma. Radiation therapy may be an adjunct to surgery. For cases of limited small cell carcinoma, radiation therapy and chemotherapy are used initially. Chemotherapy alone should be used in extensive disease. Surgical resection has limited utility in the treatment of small cell carcinoma.
Jaundice, fever, and right upper quadrant abdominal pain.
Cholangitis What is the Charcot triad?
adenocarcinoma
Cigarette smoking causes the majority of lung cancer, adenocarcinoma is less likely to be associated with smoking. It arises from mucous glands or epithelial cells within or distal to the terminal bronchioles and presents as peripheral nodules or masses
Diagnosing Gilbert Syndrome
Diagnosis can be made by laboratory tests showing repeatedly elevated indirect bilirubin levels in the presence of normal complete blood counts, liver enzymes, and alkaline phosphatase. Definitive diagnosis is made with genetic testing. No treatment is needed for Gilbert syndrome.
diagnosing giardia
Diagnostic options include direct visualization of trophocytes or cysts in a stool sample and an antigen assay. Sensitivity of stool analysis can be difficult and costly as it requires multiple stool analyses and capable laboratory technicians. Antigen assays are cheaper but do not evaluate for any other stool pathogens.
treatment for giardia
First-line treatment for giardiasis in adults is metronidazole 250 mg three times daily for 5 to 7 days or tinidazole 2 grams orally in a single dose. Treatment is also recommended for asymptomatic carriers. Chlorination of water does not inactivate cysts. Filtration with a pore size less than 1 mcm or bringing water to a boil is adequate for wilderness or international travel. For daycare centers or residential care facilities, proper disposal of diapers and frequent hand washing help to prevent transmission.
treatment for tonic clonic epilepsy
For generalized epilepsy: valproate, lamotrigine, and levetiracetam (first-line options) Absence seizures: Ethosuximide Focal seizure disorders: lamotrigine, oxcarbazepine, and phenytoin (first-line options) Carbamazepine and phenytoin can worsen some types of generalized seizures. In addition to pharmacologic therapy, driving restrictions and seizure precautions should be reviewed with the patient.
Cellulitis labs & treatment
Laboratory findings are consistent with infection and include leukocytosis, neutrophilia, left shift, and elevated inflammatory markers. Blood cultures are only positive in a small percentage of patients. A skin biopsy is not typically collected unless the patient is immunocompromised due to the possible presence of an uncommon organism. Treatment for cellulitis is with oral, intramuscular, or intravenous antibiotics that cover Streptococcus and Staphylococcus. Nafcillin, cefazolin, clindamycin, dicloxacillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole are commonly used. Antibiotic therapy should be adjusted if methicillin-resistant Staphylococcus aureus is suspected.
Ankylosing spondylitis Labs & treatment
Laboratory findings often show elevated erythrocyte sedimentation rate. Radiographs of the spine will show the presence of syndesmophytes bridging across multiple vertebrae, giving a bamboo spine appearance. Fusion of the posterior facet joints may also be present. The first-line treatment for ankylosing spondylitis is nonsteroidal anti-inflammatory drugs. Corticosteroids should generally be avoided, as they have minimal impact and may worsen osteopenia. The tumor necrosis factor inhibitors etanercept, adalimumab, or infliximab may be used for patients who do not respond to NSAIDs.
screening for lung cancer
Leading cause of cancer-related death among men and women Screening (USPSTF 2021) - Screen adults age 50-80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years with an annual low dose CT scan - Discontinue screening once the individual has not smoked for 15 years or has a limited life expectancy
Asthma management
Management depends on factors such as asthma classification, level of control, and patient factors (such as age) Treatment options may include SABAs, ICS, combination ICS-formoterol, LAMAs, and LTRAs Step-up or step-down therapy based on asthma control
Acute Myeloid Leukemia (AML)
Most common in adults in their 60s Fever, fatigue, anemia, easy bruising or bleeding, petechiae, bone and joint pain, and persistent or frequent infections PE: hepatosplenomegaly Labs: Auer rods, normocytic, normochromic anemia, blast cells
Corneal Ulcer
Patient will have a history of trauma, incomplete closure, or extended contact lens use PE will show oval ulcer with ragged edges, severe conjunctival inflammation Most commonly caused by Staphylococcus, Pseudomonas( contact lens wearers), Streptococcus pneumoniae Treatment is emergent ophthalmology consult
symptoms of giardia
Patients may then develop a chronic infection characterized by intermittent diarrhea and constipation, greasy, foul-smelling stool, abdominal cramps, flatulence, bloating, nausea, anorexia, and malaise. Weight loss is frequent in chronic disease and may lead to malabsorption and vitamin deficiencies.
chronic lymphoid leukemia
Patients with _________________ have lymphocytosis, fever, weight loss, lymphadenopathy, and organomegaly.
hemoglobin and hematocrit
Patients with an elevated _________________ of unknown cause should be evaluated for obstructive sleep apnea.
lung cancer symptoms/clinical manifestations
Patients with lung cancer generally present with anorexia, weight loss, or asthenia. They may also present with a new or chronic cough, hemoptysis, and nonspecific chest, rib, vertebral, or pelvic pain from metastases. Hoarseness may be present if the recurrent laryngeal nerve is compressed. Other manifestations of lung cancer include superior vena cava syndrome (obstruction of the superior vena cava by a mediastinal tumor), Horner syndrome (facial anhidrosis, ptosis, and miosis), Pancoast tumor (upper extremity weakness due to brachial plexus invasion), and Eaton-Lambert syndrome (proximal muscle weakness or fatigability, diminished deep tendon reflexes, paresthesias).
Tension headache treatment
Prophylactic treatment is recommended for patients with frequent, long-lasting, or disabling headaches. It is recommended for patients with chronic tension-type headache and should be considered in any other patients with frequent, long-lasting, or disabling headaches and when acute treatment fails. Amitriptyline is the recommended first-line treatment to prevent tension-type headache. It is important for patients to identify and avoid headache triggers. Cognitive behavioral therapy, stress management, focused relaxation techniques, and behavioral treatments such as regulation of sleep, exercise, and meals are beneficial for many patients.
Benign Prostatic Hyperplasia (BPH)
Risk factors: advancing age Sx: hesitancy, intermittence or incontinence, frequency or fullness, urgency, nocturia (HI FUN) PE: smooth, firm, mobile prostate without any nodules or indurations Dx: digital rectal exam, UA to rule out alternate causes Caused by stromal and epithelial cell growth in the transitional zone of the prostate Tx: alpha-blockers, 5-reductase inhibitors, surgery (TURP)
Lung Cancer Overview
Risk factors: history of smoking, asbestos exposure Sx: cough, hemoptysis, dyspnea, chest pain, weight loss, back pain, neurologic symptoms (CNS mets, paraneoplastic syndromes like Lambert-Eaton myasthenic syndrome)Pancoast syndrome: tumor in superior sulcus - shoulder pain, Horner syndrome Labs: hypercalcemia (PTHrP or bone mets), hyponatremia (SIADH), exudative effusion Diagnosis: CXR, CT scan, and biopsy to confirm
Ankylosing Spondylitis (Radiographic Axial Spondyloarthritis)
Risk factors: male sex, age < 40 Sx: low back pain that's most severe at night and morning stiffness that improves with exercise PE: limited spinal mobility, decreased lumbar lordosis X-ray: squared vertebral bodies, multiple vertebral fusions (bamboo spine) Labs: increased ESR, positive HLA-B27 Treatment options include NSAIDs, physical therapy, TNF-alpha blockers Associated with: uveitis, aortitis, IBD, psoriasis, apical pulmonary fibrosis Diseases associated with HLA-B27: PAIR Psoriatic arthritis Ankylosing spondylitis Inflammatory bowel disease Reactive arthritis
Obstructive Sleep Apnea
Risk factors: obesity (BMI >30) , male sex, advancing age, allergies Sx: apneic episodes while sleeping, snoring, and daytime sleepiness PE: enlarged tonsils, crowded oropharynx, large neck circumference, hypertension Diagnosis is made by sleep study Treatment is weight loss, CPAP First-line treatment in children is adenotonsillectomy Adverse outcomes: CVA, motor vehicle collisions, pulmonary hypertension, cor pulmonale (right ventricular hypertrophy)
Cholecystitis
Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods, fever PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: U/SGold standard: HIDA Most commonly caused by obstruction by a gallstone Acalculous disease can occur in critically ill Treatment is cholecystectomy, antibiotics; percutaneous cholecystostomy tube in critically ill
Hyperthyroidism
Sx: heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE: hyperreflexia, goiter, exophthalmos, pretibial edema Labs: low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Tx: methimazole or PTU PTU in the first trimester of pregnancy
Mild persistent asthma
Symptoms > 2 days/week but < daily > 3-4 nighttime awakenings/month FEV1 ≥ 80% of predicted
Moderate persistent asthma
Symptoms daily > 1 nighttime awakening/week but not nightly FEV1 60-80% of predicted
Severe persistent asthma
Symptoms throughout the day Nightly awakenings common FEV1 < 60% of predicted
Intermittent Asthma
Symptoms ≤ 2 days/week ≤ 2 nighttime awakenings/month FEV1 > 80% of predicted
T-score in osteopenia & osteoporosis
T-score between −1.0 to −2.5 indicates osteopenia and a score less than −2.5 is diagnostic of osteoporosis.
Pneumococcal Vaccination Recommendations for Adults Aged ≥ 65 Years Prior to January 2022
The 2022 updated guidelines issued by the U.S. Advisory Committee on Immunization Practices (ACIP) regarding pneumococcal vaccination only apply to adults who have never received any pneumococcal vaccine or whose vaccination status is unknown. Prior to January 2022, the ACIP recommended routine vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all healthy adults aged ≥ 65 years. Shared decision-making was recommended to determine whether the 13-valent pneumococcal conjugate vaccine (PCV13) should be given in addition to PPSV23 for adults in this group, who otherwise lack an indication for both vaccines (e.g., an immunocompromising condition). The ACIP still recommends adults who have been getting vaccinated according to the guidelines made before January 2022 to continue with those guidelines rather than switching to the 2022 updated schedule.
screening for breast cancer with normal risk
The U.S. Preventive Services Task Force suggests beginning bilateral screening mammography for women at normal risk of breast cancer at age 50 years and repeating the screening every 2 years until the patient is 74 years old.
False. Ultrasound increases diagnostic yield but also increases false-positive rates and thus is not a recommended screening tool.
True or false: Screening breast ultrasound is recommended for patients with previous breast cancer.
True
True or false: visual, auditory, or somatosensory hallucinations may accompany delirium.
Drinking enough that the blood alcohol concentration levels reach 0.08 g/dL within 2 hours
What is the definition of binge drinking?
100% oxygen
What is the first-line acute treatment for cluster headache?
The liver
What is the main organ responsible for the conversion of T4 to T3?
BPCV20
What is the recommended pneumococcal vaccination for patients aged > 65 years with no other risk factors and no prior history of vaccination? APCV13 BPCV20 CPCV7 DPPSV23
≥ 3 mg/dL
What serum level of bilirubin is associated with jaundice?
- Amoxicillin (metronidazole if PCN allergy) - Omeprazole (PPI) - Clarithromycin
What triple therapy is used to treat H.pylori?
Chlamydial generally occurs between 5-14 days of life, and gonococcal generally occurs between 2-5 days of life.
When do chlamydial and gonococcal neonatal conjunctivitis generally occur?
In the morning on an empty stomach, and the patient should remain upright for 30 minutes afterward.
When should oral bisphosphonates be taken?
Angiotensin receptor-neprilysin inhibitor (ARNI)
Which class does sacubitril-valsartan, a heart failure medication, belong to?
AAdenocarcinoma
Which of the following types of lung cancers is less likely associated with smoking? AAdenocarcinoma BLarge cell carcinoma CSmall cell carcinoma DSquamous cell carcinoma
screening for breast cancer with high risk
Women at increased risk for breast cancer include those who have a first-degree relative with breast cancer, a personal history of radiation therapy to the chest between the ages of 10 and 30 years, an ancestry associated with increased incidence of BRCA1 and BRCA2 mutations, patients with a known hereditary breast or ovarian cancer syndrome, or a personal history of breast, ovarian, tubal, or peritoneal cancer. Patients at high risk for breast cancer should receive annual magnetic resonance imaging of the breasts.
Asthma
__________ is an obstructive airway disease characterized by dyspnea and wheezing. Pulmonary function testing is useful in the diagnosis of asthma and includes spirometry and bronchodilator response. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) may be determined through spirometry. FEV1 is the amount of air that can be forcefully expired in 1 second after maximal inspiration. FVC is the total amount of air that can be expired after maximal inspiration. FEV1/FVC < 0.70 is consistent with obstructive airway conditions, such as asthma and chronic obstructive pulmonary disease (COPD), and bronchodilatory response is a useful test to distinguish between COPD and asthma.
chronic myeloid leukemia
______________ has a triphasic course associated with chronic, accelerated, and blast phases. Many patients are initially asymptomatic before developing symptoms similar to that of acute myeloid leukemia. Chronic myeloid leukemia is associated with the BCR-ABL1 fusion gene that results in the Philadelphia chromosome.
Asthma Overview
airway inflammation + bronchial hyperresponsiveness + reversible airflow obstruction
Viral conjunctivitis
classically presents with eye injection, burning and gritting sensation, and watery or mucoserous drainage. Viral conjunctivitis most often begins unilaterally and then affects the contralateral eye within 24-48 hours. Viral conjunctivitis may cause an enlarged or tender preauricular lymph node. Bacterial conjunctivitis can be distinguished from viral conjunctivitis by its unilateral symptoms, purulent discharge, and absence of preauricular lymphadenopathy.
Entamoeba histolytica
infections are typically asymptomatic. Patients with symptoms develop them over 1 to 3 weeks. They typically present with abdominal pain, diarrhea, and bloody stools but can present with fulminant colitis. Antigen testing is the preferred method, as strains of Entamoeba are visually indistinguishable on stool analysis.
acute lymphoid leukemia (ALL)
is a common malignancy in children. Fever, lymphadenopathy, and organomegaly are common. Lymphoblasts, rather than myeloblasts, are observed.
Wilson disease
is a genetic abnormality leading to impairment of cellular copper transport. Patients typically present between the ages of 5 to 35 years with hepatic dysfunction, neurological symptoms, and psychiatric symptoms. Patients would not have an elevated ferritin level.
Infectious keratitis
is an infection of the cornea that is commonly seen in contact lens wearers. The classic symptoms include eye pain, photophobia, and foreign body sensation. Visual acuity may be decreased. The patient in this vignette had symptoms and signs more consistent with conjunctivitis.
Allergic conjunctivitis
is due to allergens contacting the eye and causing the release of histamine and other chemical mediators by mast cells. Patients typically have bilateral eye redness, watery discharge, and eye itching. Itchiness is the predominant symptom of allergic conjunctivitis. The patient in this vignette had unilateral involvement and yellow drainage, which are suggestive of an infectious etiology rather than allergic conjunctivitis.
Gilbert syndrome
is the most common inherited disorder of bilirubin glucuronidation. It is a benign, autosomal recessive condition characterized by reduced production of uridine 5'-diphospho-glucuronosyltransferase that results in elevated unconjugated, or indirect, bilirubin levels. Patients experience episodic jaundice that may be triggered by periods of stress, illness, physical exertion, hemolysis, fasting, menses, or alcohol use. Physical examination during an acute episode will show scleral icterus and jaundice of the skin.
Cryptosporidium parvum
presents with an acute diarrhea syndrome typically within 7 to 10 days of ingesting the oocysts. The oocysts then release four banana-shaped motolie sporophytes in the small bowel. Symptoms resolve over 10 to 14 days without treatment, and most patients require only supportive care. It is more common in immunocompromised patients. PCR testing is the standard of care for diagnosis, but stool evaluation may reveal oocysts that are 4 to 6 micrometers in diameter.
Alcoholic cirrhosis
presents with liver dysfunction in the setting of long-term alcohol abuse, and the AST to ALT ratio is typically greater than 2.
Clostridium difficile
presents with watery diarrhea, abdominal pain, fever, nausea, and anorexia. It commonly occurs due to antibiotic therapy with fluoroquinolones, clindamycin, cephalosporins, and penicillins. This patient does not have recent antibiotic use.
Beta-thalassemia major
s a severe lifelong anemia that is transfusion-dependent. Symptoms present in late infancy and include pallor, jaundice, dark urine, anemia, and hepatosplenomegaly.
