Clinical Scenarios
What is considered normal fetal heart rate?
110-160 bpm for baseline
First-line prophylactic migraine medications?
*Beta-blockers: Metoprolol (47.5-200 mg) Propranolol (20-160mg) Timolol (10-30mg) Neurostabilizers: Divalproex sodium (500-1500mg) Topiramate (25-200mg)
Child presents with a cough, fever >38C, sputum production, and crackles on lung exam. What is the diagnosis?
Bacterial Pneumonia Caused by streptococcus pneumoniae
What are the symptoms of right parietal infarct? (5)
Left hemiplegia, may attempt to read while holding books upside down, inattention to areas of the room, denial of stroke disability, left facial weakness
A 28-year-old, G2P1 female delivers a 6lb 7oz baby boy at 39 weeks gestation. At one minute, baby has blue extremities and a pink body, his arms and legs are flexed. HR is 118 bpm and he is coughing and crying vigorously. What would his APGAR score be at one minute?
8
Patient presents with fever, headaches, toothache, facial pain, mucopurulent nasal discharge, and has not improved with OTC decongestants. What is your diagnosis?
Acute Sinusitis
Lower back pain with morning stiffness and achiness over the sacroiliac joint and lumbar spine, Diagnosis?
Ankylosing Spondylitis
Hoarseness, epigastric discomfort with lying down, laryngitis, discomfort after large meals, and bitter taste are all typical symptoms of what disease?
GERD
When evaluating a person with a possible stroke, when is it acceptable to administer t-PA?
If onset of neurologic symptoms was <3 hours prior to presentation also, emergent CT head does not show an intracranial bleed, an early acute infarct, or a brain mass
What 2 medications are given to manage allergic rhinitis?
Oral antihistamine (cetirizine) Inhaled Nasal Coritcosteroid (fluticasone)
First line treatment for migraine headaches? (2)
Sumatriptan (imitrex) Ergot Alkaloids (ergostat)
Patient presents with a tightening, bilateral headache that does not worsen with activity. No nausea but they are sensitive to light. Diagnosis?
Tension Headache - need 10 to diagnose Last 30min to 7 days
Patient presents with low-grade fever, rhinorrhea, sneezing, nasal congestion and cough of up to one week. What is the diagnosis?
Upper Respiratory Infection (no wheezing or lower lung findings)
What test has the best predictive value for DVT?
Venous Doppler
What is first-line therapy for H.pylori?
"Triple therapy" for 10-14 days: - PPI standard dose twice daily - Amoxicillin 1 gram twice daily - Clarithromycin 500 mg twice daily "Quadruple therapy" for 10-14 days: - PPI standard dose once or twice daily (OR ranitidine 150 mg twice daily) - Metronidazole 250 mg 4 times daily - Tetracycline 500 mg 4 times daily - Bismuth subsalicylate 525mg 4 times daily
What do you prescribe for treatment of GABHS pharyngitis in a child with NKDA?
*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 G IM if potential noncompliance. Amoxicillin liquid - 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) - 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 - reserved for patients with penicillin allergy. Azithromycin or clarithromycin may have fewer gastrointestinal side effects than erythromycin.
What are the four cardiovascular or cerebrovascular mechanisms of TIAs or possible stroke?
1. Embolic 2. Thrombotic 3. Cardiogenic 4. Hemorrhagic
What are the 7 cardinal movements of labor?
1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion
How is orthostatic hypotension defined?
1) A drop in systolic blood pressure of ≥ 20 2) drop in diastolic blood pressure of ≥ 10 - when changing position from supine to standing - accompanied by feelings of dizziness or light-headedness
What are the 3 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 >/= 126 mg/dL. 3) hemoglobin A1C >/= 6.5%.
What are the AHA recommendations for prevention of a first stroke? (3)
1) Adjusted-dose warfarin (target INR, 2.0-3.0) - all patients w/ nonvalvular AF 2) Antiplatelet therapy with aspirin 3) Dual-antiplatelet therapy with clopidogrel and aspirin - high risk patients
What are the most common causes of vertigo in primary practice?
1) Benign Paroxysmal Positional Vertigo 2) Vestibular Neuritis - post URI 3) Acute Labyrinthitis
What are the AHA recommendations for prevention of stroke in patients with stroke history? (2)
1) For patients with ischemic stroke or TIA with paroxysmal (intermittent) or permanent AF - Anticoagulation warfarin (target INR, 2.5) 2) patients unable to take oral anticoagulants - Aspirin alone
What vaccinations are given at 4 months?
2nd dose of Hib, DTaP, IPV, Rotavirus, PCV
How long should anticoagulation last for a patient after their first DVT?
3 months unless due to cancer
James is brought in by his mother and father today for a well-child visit. His mother had a normal term pregnancy and uncomplicated spontaneous vaginal delivery. 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. At what developmental age is James?
3 years
What is the first line treatment of pneumonia in children ages 3mos - 5years? Ages 5 years to adolescence?
3mos-5yrs: Amoxicillin b/c covers strep pneumoniae 5yrs & up: azithromycin (macrolides) b/c covers atypical organisms
What vaccinations are given at 6 months?
3rd dose of Hep B, Hib, DTaP, IPV, Rotavirus, PCV Start annual influenza vaccinations
A 72-year-old woman with a 30-year history of type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and 5 units of insulin aspart with meals. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is true regarding diabetic retinopathy?
40% of people with severe diabetes requiring insulin have retinopathy five years after diagnosis
Mr Gill is a 27-year-old male who presents to his primary care physician with post-prandial epigastric burning. The burning is episodic, without associated hematemesis, dysphagia, or odynophagia. In the past, he has episodically used an OTC chewable calcium carbonate to provide relief. Over the past month, he has had to increase the frequency of its use to four times daily. His blood pressure is 120/81 mm Hg, heart rate at 75/min and regular. Physical exam reveals only minimal epigastric tenderness on palpation but is otherwise normal. Which of the following is the most appropriate next step in management?
8 week trial of pantoprazole
A 61-year-old male with a history significant for COPD presents to the emergency department for shortness of breath. Upon exam you see a thin male with perspiration on his forehead. He is having a difficult time answering questions because "he just can't catch his breath." You order an arterial blood gas on the patient. The results are pH 7.22 (7.34-7.44) PaCO2 81 mmHg (35-45 mmHg) PaO2 55 mmHg (75-100 mmHg) . The best next step is:
Begin mechanical ventilation
Patient presents with cough of more than 5 days and usually purulent sputum. Diagnosis?
Acute Bronchitis Usually viral (URI if less than 5 days)
A 52-year-old female presents for her third visit this year for productive cough. She has a 34-pack year history but has weaned down to only five cigarettes per day since she began to notice a cough. With her smoking history, you are concerned about the possibility of COPD. The gold standard for diagnosis of COPD shows:
FEV1/FVC ratio of <70% of predicted
Sally is a generally healthy 27-year-old female graduate student who presented to your office twelve weeks ago with episodic post-prandial epigastric burning. This had been bothering her for nearly six months but she had been busy with her thesis and was unable to find the time necessary for an appointment. She reported this year has been particularly stressful, with limited time resulting in increased consumption of coffee and take-out fast food. At that time, she began an eight-week trial of omeprazole. She returns now with no improvement of her symptoms. She discontinued the omeprazole one month ago because she ran out of the medication. She has no additional symptoms and physical exam is unremarkable. Which of the following is the most appropriate next step in her management?
Administer a urea breath test
What is generally considered to be most helpful in distinguishing between COPD and asthma?
Air-flow obstruction in asthma is reversible, but in COPD it is not.
Patient presents with sore throat, sneezing, itchy and watery eyes, clear rhinorrhea, post-nasal drip, and no fever. Diagnosis?
Allergic rhinitis/pharyngitis
A 7-year-old boy is brought to your clinic with a fever of 102-103° F (38.9-39.4° C) for the last three days. He is up-to-date on all vaccinations and has no significant medical history. His mother notes that he has not had a cough but is eating and drinking less because "it hurts to swallow." On examination of his neck you notice tender cervical lymphadenopathy bilaterally, and auscultation of his back shows clear lung sounds on both sides. His oropharyngeal exam shows erythematous throat, but no tonsillar exudates. What is the next best step?
Amoxicillin therapy - b/c scores at least 4 - rapid strep test if score is 2-3 McIsaac Decision rule allows you to calculate the need for various interventions in a patient who presents with signs/symptoms of strep throat. One point is assigned each for fever greater than 38.0 degrees Celsius, absence of cough, tonsillar exudates, cervical lymphadenopathy, and age less than 15-years-old. One point is removed for age older than 45-years-old.
Mr. Jones is a 67-year-old male brought into your office because he's been having "dizzy spells where he almost passes out" for a week. Your records indicate a history of back pain and diabetes. Upon further questioning, Mr. Jones says he sometimes feels like he's going to pass out and gets short of breath after walking about half a block. He's never felt this way before. His back has also been really bothering him for the past several week so he's been taking ibuprofen "all the time." His temperature is 98.6, blood pressure 105/65, heart rate 110, and respiratory rate 18. On physical exam, you note conjunctival pallor and cold extremities. His cardiopulmonary exam is unremarkable and his abdomen is mildly tender, non-distended. As you think through your differential diagnosis and tests to order, which of the following best describes the likely etiology of his symptoms?
Anemia Mr. Jones is likely bleeding from his stomach from taking too many NSAIDs for his back pain resulting in a gastritis or ulcer. The resulting blood loss and anemia leads to decreased preload and episodes of presyncope when his cardiac output is unable to keep pace with the increase in metabolic needs. As a result, his brain is inadequately perfused.
What is recommended as first-line therapy for secondary prevention of noncardioembolic TIA or noncardioembolic stroke?
Aspirin
What is the #1 cause of wheezing? Can you name 6 other causes?
Asthma COPD, CHF, foreign body aspiration, bronchitis, postnasal drip, PE
A 40-year-old male presents to the clinic with dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He denies fever, but does report some continued shortness of breath. He is a smoker but only smokes 1-2 cigarettes a day for about six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis?
Asthma (aspirin-induced) Do pulmonary function testing.
What are 8 common causes of chronic (>8 weeks) cough?
Asthma, GERD, postnasal drip, medications, tobacco, COPD, bronchitis, post-infection
When should diabetes screening be started?
At age 45 for all patients. In overweight or obese patients with additional risk factors.
Young adult presents with cough, fever, headache, pleuritic chest pain, vague abdominal pain, vomiting, diarrhea, pharyngitis, and otalgia/otitis. Diagnosis?
Atypical Pneumonia Mycoplasma or Chlamydia pneumoniae
What are the three most common complications of influenza?
Bacterial Pneumonia Bronchitis Otitis Media (can also cause neurologic complications, i.e. meningitis)
What lab studies should be ordered at an initial pregnancy visit? (6)
Blood type/Rh status, Chlamydia screening (urine or swab), HIV test, urinalysis, Hep B surface antigen, hemoglobin/hematocrit
Cognitive impairment, weight loss or other systemic symptoms, abnormal neurologic examination. Diagnosis?
Brain Tumor
What anticipatory guidance should be given at 23 weeks pregnant?
Breastfeeding Car seats Contraception
What is bronchiolitis? What age group does it affect?
Bronchiole infection caused by RSV and progresses to wheezing, cough, dyspnea, and cyanosis. Young children with the peak at 6 months of age. Infants require supportive treatment including oxygen if hypoxic.
What lab tests should be included in an initial work-up for fatigue?
CBC, ESR, serum glucose, TSH, iron studies with ferritin
Patient presents with increased AP diameter of the chest, decreased diaphragmatic excursion, wheezing, and prolonged expiratory phase. Diagnosis?
COPD
Why is it important to distinguish between cardioembolic etiologies of stroke versus atherothrombotic?
Cardioembolic etiologies require treatment with oral anticoagulant therapy For patients with a cardioembolic cause, place on coumadin therapy. For patients with an atherothrombotic stroke, place on an anti-platelet agent.
A 63-year-old male with a past medical history significant for hypertension, COPD, and tobacco dependence is accompanied by his wife to a hospital follow-up clinic appointment. She is very concerned about her husband's recent hospitalization for a COPD exacerbation and asks what can be done to improve her husband's health. Which of the following holds the greatest long-term health benefit for our patient:
Cessation of tobacco products
What is the test of choice to confirm a diagnosis of pneumonia?
Chest Xray
Patient presents with 12 weeks of nasal congestion, mucopurulent drainage, facial pain/pressure, and decreased sense of smell. What is your diagnosis?
Chronic Sinusitis
Patient presents with severe pain around one eye accompanied with lacrimation, rhinorrhea, or facial sweating. Diagnosis?
Cluster Headache - need 5 to diagnose Last 15-180 minutes
You are seeing a 55-year-old female patient for follow-up who you met two weeks ago at her physical exam. Her review of systems and physical exam were only significant for fatigue. Her blood work shows iron deficiency anemia. She is post-menopausal x 2 years with no significant past medical history or family history but a 10 pack per year smoking history. Prior to establishing with you she hadn't seen a doctor since she was 18 years old. Which of the following would be the most appropriate next step in diagnosis?
Colonoscopy
Lower back pain worse with sitting or bending, increased pain with coughing and sneezing, pain radiating down the leg, paresthesias, and foot drop. Diagnosis?
Disc Herniation
Ms. Kovacs is a first time mother you are seeing on postpartum day two in the hospital, with her newborn son Christopher. Her pregnancy was uncomplicated and Christopher was born full-term via spontaneous vaginal delivery with no complications and a birth weight 7 lbs (3178 grams). Ms. Kovacs is getting ready to be discharged home today but is concerned because the baby now weighs 6.8 lbs (3087 grams) and she hasn't been able to produce milk every time Christopher wants to feed. Upon receiving your recommendations, she has been attempting to breastfeed with good technique every two to three hours with strong latching and vigorous suckling. Mom is still concerned her baby isn't getting enough to eat. Which of the following would be the most appropriate advice for mom?
Continue to attempt breastfeeding
Ms. Jones is a first time mother who brings in her 5-day-old son Tommy for his first scheduled newborn visit. Upon reviewing Tommy's hospital records you note that mom's pregnancy was uncomplicated and that Tommy was born full term via spontaneous vaginal delivery and his birth weight was average for gestational age at 3000 grams. Per your discussion with mom, she has been breastfeeding successfully with good technique every two to three hours on demand since delivery. Tommy's physical exam is normal and largely unchanged from the hospital; he is at the 70th percentile for height and head circumference, but his weight has decreased to 2750 grams. Mom is very concerned by this weight loss and wants to know what she should do. You should recommend:
Continuing breast feeding with same frequency and return to clinic in 5-7 days
Mr. Roberts is a 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension who presents lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of symptoms he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. Vital signs are temperature 100.2 F, blood pressure 135/75, pulse 76/min, and respiratory rate 15/min. Given this history, which of the following physical exam maneuvers are most helpful in making the diagnosis? (2)
Costovertebral angle percussion (pyelonephritis) Digital rectal exam (prostatitis)
What determines if you should do a rapid strep test on a sore throat?
Criteria: Modified Centor Score Give one point for each positive response: Tonsillar exudate or erythema Anterior cervical adenopathy Cough absent Fever present: Age 3 to 14 years: +1 point Age 15 to 45 years: 0 points Age over 45 years: -1 point Score 4-5: treat with antibiotics Score 2-3: do strep test
Lower back pain that radiates down the leg and numbness. Diagnosis?
Disc Herniation (nerve involvement)
Lower back pain that improves in supine position. Diagnosis? (2)
Disc Herniation Spinal Stenosis
A 45-year-old female presents to your office complaining of left calf pain and swelling. She reports first noticing the pain after her yoga class earlier in the week. She denies having any chest pain or shortness of breath. She has no significant PMH. Her physical exam is significant for tenderness to palpation over the left calf. No edema or redness is present. The circumference of her left calf is 10 cm and the circumference of her right calf is 9 cm. What is the most appropriate next step in diagnosis?
D-dimer
What would be at the top of your differential for unilateral leg swelling? Bilateral leg swelling?
DVT, cellulitis, or lymphedema PAD or venous insufficiency
A 21-year-old G1P0 African-American female present to clinic as a new patient to establish prenatal care. What is the most important benefit of group prenatal care for this patient?
Decreases the likelihood of preterm delivery
What are the top 5 differential diagnoses for fatigue?
Depression Obstructive Sleep Apnea Anemia Occult Malignancy Coronary Artery Disease
A 55-year-old man presents to your office complaining of pain and stiffness in his knees. He used to play basketball three times a week with his friends but stopped about seven months ago because he was finding it difficult to keep up. His PMH is significant for hypertension, hyperlipidemia, and obesity. His BMI is 32. On exam, he is afebrile. There is no erythema or effusion of his knee joints but there is crepitus on movement of each joint. His range of motion of the knees is full. His x-rays show narrowed joint spaces and subchondral calcification. What is the most appropriate initial counseling for this patient?
Develop a weight loss plan with the patient
What tests would you order in a patient you think may have PUD or functional dyspepsia? (3)
Digital rectal exam with guaiac test (FOBT) H pylori IgG serology CBC
A 35-year-old female with a history of headaches presents to your office with a headache that is not responsive to 400 mg Ibuprofen TID or 500 mg Tylenol TID. Upon gathering further history you find that in the past her headaches were controlled with these medications but recently have been worse with this same treatment. She complains of 4-5 headaches weekly that are often present on awakening. Which of the following is the best treatment for her disorder?
Discontinue use of Ibuprofen and Tylenol
What do you do if goal INR is overshot?
Discontinue warfarin, give Vitamin K 5 mg orally.
What are appropriate therapeutic choices for a patient with peripheral vertigo? (4)
Diuretics Epley maneuvers (BPPV) Vestibular rehabilitation exercises Vestibular suppressant medications
Ms. Wicket is a 30-year-old woman establishing with you as a new patient. Her past medical history is significant for hypothyroidism for which she has been without treatment for five years. She currently takes no medication and has no surgical or family history. She is single, with no children, drinks alcohol socially, and does not use tobacco or other recreational drugs. The only records she has are from blood work that she had done last month significant for a very elevated thyroid stimulating hormone (TSH). What constellation of symptoms would you expect her to be positive for on your review of systems?
Dry skin, sensitivity to cold, constipation, and fatigue
An otherwise healthy 58-year-old woman presents in your office with a cough, sore throat and fevers. Which of the following physical exam findings would most lead you to treat with antibiotics?
Dullness to percussion and crackles on lung exam consistent with community-acquired pneumonia
How do you decrease maternal blood loss during a delivery?
Early clamping of the umbilical cord Active management of third stage of labor by giving oxytocin to aid placental detachment post-delivery
What lung exam findings indicate lung consolidation (5)?
Egophony increased tactile fremitus dullness to percussion crackles whispered pectriloquy
How do you treat a patient with symptoms of GERD, PUD, or gastritis who does not have red flag symptoms?
Empiric treatment with a PPI or histamine-2 antagonist Lifestyle modifications PPI test (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.
Child appears ill and has fever > 103 F. Symptoms include inspiratory stridor, "hot potato" (muffled) voice, dysphagia, drooling, and sits in a "tripod" position, Diagnosis?
Epiglottitis - due to Haemophilus influenzae type B
Ms. Smith is a 35-year-old female with no past medical history who presents with dizziness for the past week. She says these episodes of dizziness in which the room feels as though it is spinning last for a minute or two at most but cannot seem to identify what is causing them. She denies any change in diet, headaches or recent illness. Her father passed away from a stroke at the age of 60 but she denies any other significant past medical history. Her physical exam is unremarkable and you are unable to elicit nystagmus with a head thrust maneuver. You then have the patient turn her head 45 degrees to the right and quickly lay down supine with her head over the table. When you turn her head to the side, she starts to feel dizzy and her eyes dart back and forth. What is your next step?
Epley maneuver
A 24-year-old G1P0 white female at 38 weeks gestation presents to ED complaining of strong lower abdominal contractions that are 10 minutes apart for the last hour. Subsequent cervical examination demonstrates that she is 2cm dilated. FHT are 140 and NST is non-reactive with early decelerations. What is the most appropriate management of this patient?
Expectant management Patient is currently not in active labor. Active labor is defined as cervical dilation >4 cm in the presence of contractions. Contractions are normally 3-5 minutes apart. Fetus is not in distress at this time. Early decelerations are indicative of head compression and are not especially concerning.
A 32-year-old African American female at 35 weeks gestation (G2P1) presents to the clinic with headache and RUQ abdominal pain. BP was 172/121 on examination while seated. No visual changes noted. Edema is present in the hands, bilaterally. Urine dipstick demonstrated 4+ protein. FHT are 117. What is the best treatment for this condition?
Expeditied delivery of premature fetus
A 31-year-old female, G1P0 at 26 weeks gestation, presents to the clinic for her gestational diabetes screening. Her pregnancy has been uncomplicated. Vital signs are stable. Which of the following would require a follow up three-hour glucose tolerance test?
Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 158 mg/dL Screening for gestational diabetes is usually performed between 24 and 28 weeks gestation, using a fasting glucose and a one-hour glucose following a 50g glucose load. If the fasting glucose is greater than 126 mg/dL, OR the one-hour glucose is greater than 130mg/dL (90% sensitivity) or 140mg/dL (80% sensitivity), then the patient is considered to have a positive result. In the case of a positive one-hour glucose, the patient should undergo a three-hour GTT with a 100g glucose load.
What are the 6 red flags for serious illness or neurologic impairment with lower back pain?
Fever Unexplained weight loss Pain at night Bowel or bladder incontinence Neurologic symptoms Saddle anesthesia
What are characteristic symptoms of influenza?
Fever, cough, myalgia, sore throat
A 56-year-old Spanish-speaking male presents to your office for a six-month follow-up visit for DM type 2 diagnosed at his previous visit with a HbA1C of 7.0%. At that visit, you discussed dietary modification including eliminating carbohydrates like rice from his diet. You also emphasized the importance of exercise and recommended he join a gym. On repeat testing of HbA1C today, you find that his HbA1C has increased to 7.5%. What might you do differently when counseling the patient at this visit?
Find out from the patient whether barriers exist to his adherence to your previous suggestions
What vaccinations are given at 2 months?
Hep B, Hib, DTaP, IPV, Rotavirus, PCV
What are 7 comorbid conditions that needs to be controlled in order to improve asthma symptoms?
High BMI, GERD, chronic sinusitis, uncontrolled allergic rhinitis, stress, depression, obstructive sleep apnea
A 65-year-old male with known type 2 diabetes mellitus presents to the emergency department with altered mental status. The patient experienced no known head trauma. His vitals are BP 90/74, HR 102, RR 16, Temperature 38.1 C. His mucous membranes appear very dry and he is started on IV fluids. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis?
Hyperosmolar hyperglycemic state (HHS)
Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain, which began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which of additional physical exam finding would be consistent with this man's level of disc herniation?
Hypoactive ankle tendon reflex The clinical signs presented by this patient—difficulty with heel walk and the abnormal strength of ankle plantar flexion—is consistent with nerve root impingement at the level of L5. A hypoactive ankle tendon reflex is also consistent with a nerve root impingement at this level.
You are seeing a 55-year-old established male patient of yours in the office for his yearly physical. He has a past medical history significant for hypertension and hyperlipidemia with no significant family history. He has no complaints and your review of systems and physical exam are all within normal limits. However, he would like you to write him an order for a PSA test because a friend of his recently passed away from prostate cancer. What would be the best response to this patient's request concerning checking PSA and prostate cancer?
I can see that you are concerned about having prostate cancer. PSA screening in asymptomatic men is not recommended, but I would be happy to discuss this with you.
Sudden onset of headache, severe headache, recent trauma, elevated blood pressure. Diagnosis?
Intracranial Hemorrhage
What are milestones of normal development that you might expect to see in a four-week-old infant? (6)
Increased alertness and responsiveness Move hands to mouth and eye range. Diminishment of jerky upper extremity motions. Can pick up head and move from one side to other when lying prone. Increased ability to focus on faces and show preference for human faces. Hearing maturation; beginning to turn head toward familiar sounds.
What are indicators that an antibiotic would be helpful for a patient with a diagnosis of an acute exacerbation of COPD?
Increased dyspnea Increased phlegm production Change in sputum colour
Patient presents with high fever (102-104F), chills, myalgia, headache, upper and lower respiratory tract symptoms. Diagnosis?
Influenza
What vaccines are recommended for patients with diabetes?
Influenza Vaccine Pneumovax Hep B vaccine
What vaccinations should pregnant women receive and when should they be given?
Influenza vaccine - any time during pregnancy Rhogam vaccine - at 28 weeks if mom Rh-
What medications should be prescribed for suspected asthma?
Inhaled Bronchodilator (albuterol) Inhaled Corticosteroid (standard asthma medications)
What two medications are given for asthma and why?
Inhaled Corticosteroid - maintenance medication to control inflammation Albuterol - bronchodilator for quick-acting rescue
A 65-year-old truck driver presents to your office complaining of right calf redness and swelling. He reports that he has had these symptoms off and on for some time but noticed that the redness and swelling on the right has worsened over the past few days and he also noticed fevers and chills. His PMH is significant for DM type 2, COPD, and heart failure. He has a 25 pack-year smoking history. His physical exam shows a temperature of 101.1, 2+ pitting edema of his calves bilaterally, and dry, flaking skin over both calves. His right foot shows interdigital maceration and he has redness, warmth, and tenderness just inferior to the knee. When measuring the circumference of his right leg, you note that it is 12cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in this patient's care?
Initiate treatment with antibiotics
Male presents with bright red blood per rectum and fatigue. Diagnoses? (3)
Iron Deficient Anemia due to: Colorectal Carcinoma Bleeding Diverticuli Colon Polyps
A 61-year-old female has recently been diagnosed with type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1c was 8.9%. Her BP has been 150/92 and 154/96 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. You diagnose her with hypertension and consider adding which of the following medications?
Lisinopril ACE inhibitors are the first line antihypertensive medications in patients with diabetes mellitus because of their renoprotective properties.
A 9-year-old boy who moved to the United States from Canada one year ago presents to your clinic with a three day history of fever, sore throat, and muscle aches. He lives at home with his parents who practice strict vegetarianism, and he does not eat meat of any kind. He is up to date on all vaccinations, and review of his medical records indicates that he has had several episodes of otitis media in the last five years. He was hospitalized twice in the past, once for a splenic rupture sustained in a MVA, and the second time two weeks ago where he was diagnosed with Kawasaki's disease. You suspect a viral infection and order the appropriate tests. Which of the following is the greatest risk factor for complications of your suspected diagnosis in this patient?
Long-term aspirin therapy (from Kawasaki) Risk factors for complications of Influenza are children <5, COPD, conditions that affect the ability to handle respiratory secretions/increased risk of aspiration, CHD, metabolic conditions, Chronic Renal Disease, immunosuppression, and long term aspirin therapy.
In the secondary prevention of ischemic stroke, when using Aspirin alone as anti-platelet therapy, what dose is recommended (high or low); and on what basis?
Low dose aspirin; confers equivalent benefit to high dose, and less bleeding risk
A 65-year-old truck driver presents to your office complaining of right calf pain and swelling. He has recently returned from a four-day cross-country trip after which he had onset of his current symptoms. The patient reports that the week prior to his four-day trip, he was mostly in bed recovering from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25 pack-year smoking history. He denies having any chest pain or SOB. His physical exam shows 2+ pitting edema of his right leg. When measuring the circumference of his right leg, you note that it is 14cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in diagnosis?
Lower extremity Doppler
What are the three most common causes of lower back pain?
Lumbar Strain Disc Herniation Degenerative Joint Disease
Mr. Jones is a 67-year-old male brought into your office because he's been having "dizzy spells and room spinning" for the past two days that are intermittent. Your records indicate a history of back pain, diabetes and hypertension. Upon further questioning, Mr. Jones cannot identify when these spells come on and nothing seems to relieve them. His temperature is 98.6, blood pressure 165/95, heart rate 78, and respiratory rate 18. On physical exam, you notice a slight nystagmus. You ask him to focus on your nose but the nystagmus continues. What is the next best step to confirm a stroke?
MRI
Headache with fever, mental status changes, or stiff neck. Diagnosis?
Meningitis
A patient newly diagnosed with DM II has made a plan to work on diet and exercise. Her A1c is found to be 8.9%. What is the best medicine to start at this time?
Metformin
What do you prescribe a patient with symptomatic bacterial vaginosis?
Metronidazole, 500 mg twice per day for 1 week
Patient presents with severe, unilateral, throbbing headache that gets worse with activity. They also complain of nausea and sensitivity to light. Diagnosis?
Migraine Headache - need 5 to diagnose Last 4-72 hours
Patient presents with fever, pharyngitis, and lymphadenopathy. Diagnosis?
Mononucleosis - posterior cervical lymphadenopathy - suspect after negative strep test - monospot test negative until 7 days post start
A 68-year-old male with a past medical history significant for hypertension and diabetes presents to your office with a three month history of headaches. He describes a pain that has occasionally awoken him from sleep and is often worse in the morning. He denies any weakness or changes in vision. His exam shows 4+ reflexes in the right upper and lower extremities but is otherwise normal. What is the best next step in management for this patient?
Neuroimaging
What are the 5 most common manifestations of end-organ damage due to diabetes?
Neuropathy Nephropathy Cerebrovascular Disease Coronary Heart Disease Retinopathy
What are the 9 recommended tests for the initial emergency evaluation of a patient with suspected acute ischemic stroke?
Noncontrast brain CT or brain MRI Serum electrolytes/renal function test ECG Markers of cardiac ischemia Complete blood count w/ platelet count Prothrombin time / INR Activated partial thromboplastin time Oxygen saturation Chest radiography
A patient presents complaining of one week of upper respiratory symptoms including nasal congestion and drainage. On the day the symptoms began he had a low-grade fever that has now resolved. His nasal congestion persisted and he has had yellow nasal drainage for five days with associated mild headaches. On exam he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight amount of yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinuses What would your treatment plan for the patient in this hypothetical situation be?
Observation and reassurance. It is more likely to be a viral rhinosinusitis if the duration of symptoms is less than ten days and they are not worsening. In this case, you can continue to observe the patient and reassure him that antibiotics are not necessary at this time. Ask the patient to return if he develops fever or worsening symptoms. In the event that antibiotics are offered, narrow spectrum antibiotics such as amoxicillin or trimethoprim-Sulfamethoxazole be used initially for most uncomplicated cases.
A 24-year-old female presents to the clinic complaining of nausea and headache for the last week. She denies any fever, changes in bowel movements, or sinus symptoms. She is sexually active with one partner, and admits to not being consistent with her birth control pills. She does not remember the date of her last menstrual period, and reports a history of irregular menstrual cycles. She has not taken a home pregnancy test. Her vital signs reveal a blood pressure of 124/76 mmHg, a pulse of 78/min, respirations of 20/min, temperature of 98.1o F (taken orally), and an oxygen saturation of 98% on room air. The first most appropriate step in management is to:
Obtain a urine hCG.
Mr. Rodriguez is a 32-year-old male who presents with three months of post-prandial epigastric burning. He reports no relief with antacid therapy. He has no allergies and no significant past medical history. He denies any hematemesis, odynophagia, dysphagia, hoarseness, or sore throat. Physical exam is unremarkable other than epigastric tenderness. H. pylori IgG serology is positive. Which of the following treatment regimens will most likely be successful in treating Mr. Rodriquez?
Omeprazole twice daily, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily
Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and recently completed a six-month steroid taper. She presents to her primary care physician after two weeks of lower lumbar back pain. She does not recall any trauma but began to feel a sharp pain after bending over to pick up laundry. The pain radiates bilaterally into her anterior abdomen. She has found no relief with over the counter NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2 region. There are no neurologic deficits and reflexes are intact. Which of the following is the most appropriate next step in management?
Order a plain x-ray
What is appropriate treatment for an acute DVT? (3)
Outpatient initiation of rivaroxaban alone Inpatient admission with administration of unfrationated heparin overlapping with the initiation of warfarin Outpatient initiation of low molecular weight heparin (LMWH) overlapping with the initiation of warfarin
A 28-year-old male comes to the Emergency Department with shortness of breath, cough and wheezing for the last 4 hours. He states that he was diagnosed with asthma recently, and is currently using inhaled corticosteroid with a long acting B2-agonist daily to control his symptoms. His RR is 34/min; Temp: 98.8 degrees F; O2sat: 88%; BP: 130/85 mmHg. What treatment should be given to this patient first?
Oxygen
What are the 6 P's of limb threatening injury (compartment syndrome)?
Pain Pallor Pulselessness Paresthesia Perishing Cold Paralysis
What are absolute contraindications to a digital cervical examination?
Patient report of vaginal bleeding with an undocumented placental location (or a known low-lying placenta or placenta previa.) - could worsen bleeding Patient report of leaking vaginal fluid with known prematurity (or known preterm premature rupture of membranes - PPROM.) - could introduce bacteria and infection
Patient initially has runny nose, low-grade fever, and mild cough. Most symptoms resolve but cough worsens and lasts >14 days. Diagnosis?
Pertussis - whooping cough
Ms. Smith is a first time mother who brings in her 3-day-old Caucasian daughter Michelle for her scheduled newborn visit. Upon reviewing Michelle's hospital records you note that mom's pregnancy was uncomplicated and that Michelle was born full-term via spontaneous vaginal delivery with no complications and her birth weight was average for gestational age. Per your discussion with mom, she initially tried breastfeeding immediately postpartum but has since been feeding Michelle an adequate amount of regular baby formula with good technique. On today's exam she is at the 80th percentile for height, weight, and head circumference. Her physical exam is largely unchanged from the hospital except for prominent bilateral scleral icterus and a hint of yellow skin to the head and upper chest with no change in skin over the abdomen or distal extremities. The baby is active and suckles well. What is the most likely diagnosis based upon the presentation and course of Michelle's jaundice?
Physiologic Jaundice of the Newborn
A 36-year-old female, G3P2 at 21 weeks gestation, returns to clinic for an ultrasound. She currently smokes a half pack of cigarettes per day. Her last two children were delivered by cesarean section. She reports no vaginal bleeding, no urinary symptoms, and no fluid leaking. She states her baby moves "all the time." Her vitals reveal a blood pressure of 130/74 mmHg, a temperature of 98.3o F, a pulse of 82, a respiration rate of 18, and a pulse oximetry of 98%. The ultrasound reveals no fetal abnormalities, but the location of the placenta is partially covering the cervical os. The diagnosis and treatment plan is:
Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution
A 67-year-old female with an 80 pack year smoking history presents to an urgent care for worsening shortness of breath. She also reports her chronic cough is more frequent and is producing greenish mucous throughout the day. She is using her inhaler every two hours and has been taking an antibiotic left over from a previous sinus infection. On exam there is a whistling noise when she exhales. What other treatment should you consider at this time?
Prednisone
A 15-year-old female with a history of allergic rhinitis presents to the clinic with a five day history of productive cough and wheezing that is worse at night. She denies any shortness of breath, chest pain, or fever. The patient states that she has had similar symptoms in the past, especially when seasons change. The only reported past medical history is atopic dermatitis which is well-controlled with an over-the-counter steroid cream. What is the best next step?
Prescribe a short acting beta agonist inhaler with a short course of oral steroids Because the patient is symptomatic and wheezing, she needs to be treated with a medication to control her symptoms and treat her exacerbation.
What options are available for postpartum contraception?
Progestin-only pills, injectable progestin (Depo-Provera), and progestin implant Do not use combined oral contraceptives because they are known to suppress milk production in the early postpartum period.
What test is diagnostic for COPD?
Pulmonary function testing (PFT) is the gold standard. In pulmonary function testing, either a FEV1/FVC ratio less than the 5th percentile, or less than 70%, confirms a diagnosis of COPD
A 68-year-old male with COPD requiring 2L of oxygen at nighttime presents to clinic complaining of increasing lower extremity edema over the past few weeks. He also thinks his nighttime cough might be worse. The mechanism of disease behind the most likely complication is:
Pulmonary hypertension causing right heart failure
A 48-year-old female with no smoking history comes to the emergency department with complaints of sore throat for the last two days. She does not have a thermometer at home, but states she has been feeling hot and her children have also been out from school for a fever and sore throat. Her children are now staying with their father who she is separated from, and he notified her yesterday that they were on antibiotics for their symptoms. She was holding off coming to the doctor because she wasn't coughing or having any problems with swallowing until breakfast this morning. You note that she has a fever of 38.6 degrees Celsius measured by the nurse, and on physical exam you observe an erythematous throat with exudate, and bilateral cervical lymphadenopathy. What is the next best step?
Rapid Strep Test
What are red flag symptoms for intracranial pathology? (10)
Rapidly increasing frequency Abrupt onset Marked change in pattern History of poor coordination Focal neurologic signs or symptoms Awakens the patient from sleep Worsened with use of Valsalva's maneuver Persistent headache following head trauma New onset of headache in a person age 35 History of cancer or HIV
Working at your clinic, you receive a call from a patient of yours, Mr Smith, a 45-year-old male who was seen three days ago complaining of lower back pain. At that time he had no history of trauma, pain that improved while lying down and no neurologic deficits. He works as a truck driver. He was treated conservatively along with pharmacologic intervention with NSAIDs and muscle relaxants. He calls your office now due to only minimal improvement. And although his symptoms have not changed, he is frustrated with the slow progress, needs to get back to work as soon as possible, and is concerned this might be "something serious." Which of the following is the most appropriate next step in management?
Reassure him and schedule a follow-up appointment in a few days
Ms. Jones is a 35-year-old female with a significant past medical history of SLE who had been on NSAID therapy for the previous three months presented four weeks ago with heartburn. At that time, she reported episodic, mealtime epigastric burning radiating to the throat for the past few months. She has had no surgeries. Serologic testing for H. pylori IgG was reported to be positive a few days after her visit and she was begun on triple therapy. She now returns to the office for follow up. Today she denies any epigastric burning or tenderness. Physical exam is not significant. Which of the following is an accepted indication for performing repeat testing at this visit for H. pylori eradication?
Restarting of chronic NSAID therapy for SLE
Patient presents with fever, difficulty swallowing, neck or ear pain, muffled "hot potato" voice, and asymmetric tonsillar enlargement and/or deviation of the uvula. Diagnosis?
Retropharyngeal abscess - patient appears ill - managed emergently
Ms Smith is a 38-year-old female with a significant past medical history of hypercholesterolemia who presents to her primary care physician after 4 weeks of episodic epigastric discomfort. She reports a recurrent ache-like sensation in the epigastric region occurring about 10 minutes after eating and lasting for several hours. The pain does not appear to be associated with any particular food. She denies any odynophagia or dysphagia. Ms Smith is a smoker, with a 30-pack year history. You are concerned about peptic ulcer disease. Which additional history finding would increase your level of concern?
Return symptoms despite consistent use of antacids
Patient presents with a punctate, erythematous, blanching, sandpaper-like rash on the neck, groin, and axillae, and 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). Diagnosis?
Scarlet Fever - complication of GABHS Pharyngitis (strep throat)
When should women be screened for gestational diabetes and how?
Screening should be performed at 24-28 weeks with a one-hour glucose tolerance test.
What are the top 5 differential diagnoses for dizziness/lightheadedness with focal neurologic findings?
Seizure Stroke Transient Ischemic Attack Coronary Artery Disease Medication Side Effect
An 18-year-old non-smoking male comes to the clinic with cough, chest tightness, and difficulty breathing. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough primarily at night since he was 4 years old. He has no past surgical history and no recent travel. On physical exam, you notice the patient appears in mild distress, has hunched shoulders, is using accessory muscles during respiration, and is only able to talk in two to three word sentences. His vitals are: Pulse 125/min, O2 sat 88%, BP 100/70 mmHg. On auscultation, you hear wheezing on inspiration and expiration throughout both lungs. You also notice a prolonged expiratory phase. What is the most likely diagnosis?
Severe asthma exacerbation
A 20-year-old female G1P0 at 37 weeks gestation presents to the emergency department with the complaint of a headache that has not gone away, despite taking acetaminophen 3 hours ago. She reports no visual changes, but admits to feeling nauseous and having stomach pain that she attributed to having a "bad case of heartburn." She states she went to her primary care physician that morning, and her blood pressure was elevated. She states she was asked to do a 24-hour urine collection when she left the clinic, but has not been able to use the restroom. Her vitals reveal a blood pressure of 182/106, a pulse of 92, a temperature of 98.2o F, a respiration rate of 20, and a pulse oximetry of 97%. What is the diagnosis and the best course of management?
Severe gestational hypertension - admitting the patient to the hospital, with administration of magnesium-sulfate, workup for preeclampsia, followed by possible induction or cesarean section
Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely?
Spasm of paraspinous muscles
What is the best test to confirm a diagnosis of asthma?
Spirometry, both with and without bronchodilation
Lower aching back and posterior thigh discomfort that increases with activity or bending. Diagnosis?
Spondylolisthesis
What are the three steps of DM II management?
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.
Patient presents with fever, sore throat, and tender cervical lymphadenopathy. Diagnosis?
Strep Throat (Group A beta hemolytic strep pharyngitis)
Mr. Jones is a 67-year-old male brought into your office because he's been having "dizzy spells and room spinning" for the past two days that are intermittent. Your records indicate a history of back pain, diabetes and hypertension. Upon further questioning, Mr. Jones cannot identify when these spells come on and nothing seems to relieve them. His temperature is 98.6, blood pressure 165/95, heart rate 78, and respiratory rate 18. On physical exam, you notice a slight nystagmus. You ask him to focus on your nose but the nystagmus continues. What is the most likely cause of his "dizzy spells"?
Stroke the acute onset of symptoms, nystagmus that changes direction and nystagmus that does not resolve with gaze fixation are consistent with a central lesion as opposed to a peripheral lesion
What is evidence that a woman may be in active labor?
Strong regular contractions that are difficult to walk or talk through. Cervical exam with greater than 4 cm of dilation Cervical change in the setting of regular contractions
How do you determine due date of pregnancy?
Subtract 3 months and add 7 days from start of last menstrual period. (Naegle's Rule)
A 13-year-old girl comes to your clinic stating she has been having fever and chills for three days, and aching muscles for the last two days. She states she has also had a mild cough, but is not having any difficulty with breathing. She is up to date on vaccines and her only other medical history is having her tonsils and adenoids removed last year. On physical exam, you find her temperature to be 102.6 degrees F, pulse 96, and her BP to be 115/84. She has clear rhinorrhea and her oropharynx is mildly erythematous. The rest of her physical exam is normal, and a rapid strep test in the office is negative. What is the next best step in management?
Suspect influenza. Since this patient is presenting outside of the 48-hour window, she should be treated supportively with rest, hydration, and ibuprofen or Tylenol for pain/fever.
It is November and you are working in a small, rural, emergency department serving a community who is currently going through a flu epidemic. Your next patient is a 4-year-old boy who was brought in by his mother for a sore throat and fever that started two nights ago. She says he has a mild cough, and is complaining of headaches as well. Since last night, he has had a decreased appetite and hasn't been his normal, active self. She also wants you to know that he is allergic to eggs and latex, and uses an inhaler once a month for asthma like symptoms. On physical exam you note an erythematous throat, clear rhinorrhea, and rhonchi on auscultation. A rapid strep test was performed in the office and is negative. His last well child check was 14 months ago, and his mother says she knows he is due for another but her schedule has been too busy. What is the next best step in management?
Tamiflu (oseltamivir phosphate) can be prescribed in patients who show signs of flu like symptoms without further testing in communities with known flu outbreaks. Tamiflu can reduce symptoms of the flu, and is recommended only in patients who are still within a 48 hour window since symptoms began.
What is the disease course for influenza?
The fever that comes with influenza lasts for three to five days. The cough and feeling tired can last longer; some people will have a cough and still feel tired about two weeks after they were initially sick.
A 60-year-old Hispanic female presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes 1-2 glasses of wine per week. Her vitals are BP 130/70, HR 70/min. Her BMI is 30 kg/m2. Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows: random blood glucose of 205 mg/dL Creatinine 0.8 mg/dL, TSH 2.1 U/L. What test is needed to diagnose diabetes mellitus?
The random blood glucose is sufficient Diabetes can be diagnosed with either an HbA1c >6.5%, a fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l), a plasma glucose ≥ 200 mg/dL (11/1 mmol/l) 2 hours after a 75 g glucose load, or symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dL (11.1 mmol/l).
Mr. and Mrs. Thomas are first time parents who have brought their 5-day-old newborn son into your office for his first visit. Mom's pregnancy, baby birth, and today's physical exam are all normal. Both parents are sharing the duties of feeding, cleaning, holding, and watching their son without any problems. When Mrs. Thomas steps out of the room to use the restroom, Mr. Thomas asks to speak with you privately. He wants to know if you can prescribe some antidepressant medication for his wife because since giving birth she hasn't been the same. She has been having mood swings multiple times a day, he has found her crying in bed at night after putting their son in his crib, and she gets very irritated and yells at her parents any time they try to help with the baby. What would be the most appropriate advice to give Mr. Thomas?
This behavior is very common and normal within the first two weeks postpartum and should resolve
What are the causes of postpartum hemorrhage?
Tone - uterine atony Trauma - perineal or cervical lacerations Tissue - retained in uterus Thrombin - bleeding disorder (4 T's)
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. Diagnosis?
Traumatic brain injury (concussion)
What determines when a 3hr GTT is abnormal, allowing you to diagnose Gestational Diabetes?
Two or more of the four glucose measurements exceed the cutoffs.
You are on call over the weekend for the pediatric clinic and a concerned mother calls in. She has three children at home, her youngest being 5-weeks-old. She's very busy and about to leave town on Monday to visit relatives out of state. She tells you that for the last week her two oldest children have had a cough, runny nose, and one or two fevers as high as 101.2 F, but these symptoms have improved in both children with Tylenol. Her youngest child is now having the same symptoms and has a temperature of 100.5 F. Because they're about to go out of town, mom wants to know if you can call in something stronger like an antibiotic so her youngest can feel better sooner. What do you recommend mom should do for her youngest child:
Urge mom to bring her child to the nearest Emergency Department While the baby may well have the same viral URI given the likely exposure to her older siblings with similar symptoms, a 5-week-old with a fever should be evaluated for possible sepsis.
What is the test of choice to confirm a diagnosis of pulmonary embolism?
Ventilation-Perfusion scan
Patient presents with mild fever, barking cough, inspiratory stridor, and hoarse voice. Diagnosis? Bonus: What is seen on Xray?
Viral Croup Steeple sign - narrowing of the trachea as it joins to the larynx due to a narrowed column of subglottic air.
Child presents with chills, fever, dry, nonproductive cough, and GI symptoms or arthralgias. Diagnosis?
Viral Pneumonia Influenza, RSV, adenovirus, rhinovirus
What are the top two diagnoses for pediatric fever, sore throat, cough, & rash?
Viral pharyngitis Group A Beta-hemolytic Streptococcus pharyngitis
What should be assessed at the 10 week prenatal follow up?
Weight, blood pressure, measurement of fundal height, auscultation of fetal heart tones
When should vaccines be withheld?
When a patient has a moderate to severe illness including high fever, otitis, diarrhea, and vomiting. Give when no longer acutely ill.
You are working in a free clinic for patients who are uninsured and mostly from a very low socioeconomic class. You're seeing a 45-year-old patient whose only complaint is intermittent headaches and a family history significant for a brother who recently died at the age of 47 due to colon cancer. The patient states that he is concerned about developing colon cancer like his brother and wants to know if he should be screened; however, he cannot afford a colonoscopy. Your county has a government-funded colonoscopy screening program for patient who are asymptomatic and 50 years old. For the time being, what testing could you recommend to your patient based on his means as a secondary screening method for colon cancer?
Yearly fecal occult blood testing
Lower back pain worse with sitting and movement. Diagnosis? (3)
lumbar strain disc herniation degenerative arthritis (mechanical causes)
Pregnant woman presents with visual disturbances, severe headache, right upper quadrant or epigastric pain, nausea, vomiting, decreased urine output. Diagnosis?
severe preeclampsia
At two weeks of age, infants' weight should be:
at birth weight
What vaccinations do children receive between 4-6yo?
booster of DTaP, IPV, MMR, and varicella
What is the optimal range for blood glucose?
fasting blood glucose should be 80 -120 mg/dl postprandial blood glucose between 1-2 hours after a meal should be < 180 mg/dl
In a previously normotensive pregnant woman at or after 20 weeks of gestation, the presence of persistent systolic blood pressure of ≥140 mmHg and/or a diastolic blood pressure of ≥90 mmHg, without proteinuria is defined as?
gestational hypertension
Samantha and Joe bring in their newly adopted 5-year-old son, Matthew to your office with the chief complaint of sore throat. He was born in the United States and was neglected by his biological parents. Samantha and Joe believe Matthew lived in an old building and ate mostly non-nutritious meals. They are unsure if his immunizations are up to date. Upon physical exam his T= 101, HR=80, RR=19, BP= 95/63. He has anterior cervical lymphadenopathy, tonsillar exudates and palatal petechiae. What is the most appropriate next step in the management of this patient?
give immunizations at well child visit and screen for lead toxicity
When is neuroimaging indicated for patients with vertigo? (2)
nystagmus that changes direction and that does not inhibit with focus normal head thrust test in the face of constant and new vertigo
12-year-old Jennifer is brought to the emergency room by her mother with a fever of 104.1 and difficulty breathing. She was seen by her family medicine doctor this morning who advised them to report to the emergency room immediately. Jennifer also has dysphagia and neck pain. Physical exam shows T=104.0, HR=85, RR=15, BP: 110/70. She speaks in a muffled voice and appears in severe distress. She has asymmetric tonsillar enlargement and deviation of the uvula to the right side. Laboratory studies: WBC: 14, Hgb: 12. Which of the following is the most likely diagnosis?
peri-tonsillar abscess
In a pregnant woman, the presence of persistent systolic blood pressure of ≥ 140 mmHg and/or a diastolic blood pressure of ≥ 90 mmHg, with proteinuria of 0.3 grams or greater in a 24-hour urine specimen is defined as?
preeclampsia
What are the symptoms of viral (nonstreptococcal) pharyngitis?
rhinorrhea, cough, oral ulcers, absence of high grade fever
What 4 criteria would define preeclampsia as severe?
severe hypertension of at least 160 mmHg systolic or 110 mmHg diastolic right-upper-quadrant pain or a doubling of serum transaminases platelet count < 100 > 1.1 mg/dL pulmonary edema
Timmy, a five-year-old boy with a past medical history of eczema is brought to your office today for a well-child visit. His caregiver reports no concerns since his last visit and that he is adjusting well to kindergarten. You instruct Timmy to look straight ahead at the clock on the wall and you then cover his left eye. You notice that his right eye moves inward upon this request. When you cover his right eye, you notice that his left eye remains in a forward position. Which of the following is the most likely diagnosis?
strabismus of the right eye
A 27-year old female, G2P1, returns to the clinic for her second prenatal visit. Her labs reveal that her blood type is A Rh-. She states she has done research online, and is concerned that this pregnancy will result in her baby dying if it has a different blood type than her own. To reassure the patient, you explain that her team of health care providers will:
treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum.
