Family Medicine/Internal Medicine

Terms in this set (392)

Blowing diastolic murmur at the left sternal border w/ or w/out a mid-diatolic rumble (Austin-Flint Murmur)

"Austin-Flint" is due to blood flowing back through the aortic valve and hitting the anterior leaflet of the mitral valve

"Duroziez's Sign" is a femoral bruit associated w/ Aortic regurg

Leading cause is mechanical degeneration in U.S.
(previously was rheumatic fever)

BEST TEST to confirm = trans-esophageal echocardiogram

Tx: Valve-replacement (when Austin-Flint sign present)

Physical exam signs in patients with aortic regurgitation include De Musset's sign, Corrigan's pulse, Quincke's pulse and Duroziez's sign. Duroziez's sign refers to a femoral bruit heard while auscultating the femoral artery. It is thought that the sound is produced by blood moving forward during systole and retrograde during diastole in cases of severe aortic regurgitation.

Physical exam in patients with aortic regurgitation presents with a blowing diastolic murmur at the left sternal border with or without a mid-diastolic rumble which is referred to as an Austin-Flint murmur. The Austin-Flint murmur is due to blood flowing backwards through the aortic valve and hitting the anterior leaflet of the mitral valve and is a primary indication for valve replacement.

Corrigan's pulse refers to bounding pulses and Quincke's pulse refers to a pulsating nail bed with elevation of the nail. These two signs are a result of widened pulse pressures that results in hyperdynamic circulation.

De Musset's sign is head bobbing that occurs with the heartbeat.
age-related macular degeneration (ARMD).

two types of ARMD:
1) atrophic/ non-exudative ("dry") ARMD
2) neovascular/ exudative ("wet") ARMD.

Atrophic ARMD makes up 80% of all cases and is the most common cause of vision loss in developed countries.

It is caused by progressive degeneration of the retina and the choroid in the posterior pole due to either atrophy or retinal pigment epithelium detachment.
-painless loss of central vision over years to decades. -peripheral vision remains intact until late stages of disease.

Patients may complain of problems with night vision, difficulty reading or making out faces, and/or metamorphopsia.

Metamorphopsia is a type of visual field defect that causes distorted vision with wavy lines in the central field.

Patients may also report variability in their symptoms where some days their vision is better than others. The main risk factor for ARMD is advanced age, however, other factors include female sex, smoking, family history, cardiovascular disease, and light colored eyes and skin.

Funduscopic examination reveals confluence of drusen (tiny yellow or white accumulations of extracellular material that build up between Bruch's membrane and the retinal pigment epithelium of the eye) with significant pigment changes and accumulation of pigment in the posterior pole. Atrophy of the retinal pigment epithelium and macular fibrosis may also be present.

-quitting smoking
-controlling blood pressure
-combination of vitamins and antioxidants.
--> vitamin A, vitamin E, vitamin C, beta-carotene, zinc, and lutein.
1) Meningococcal vaccination
-inactivated vaccination
-typically administered as one shot
-MC recommendation is in teenagers starting college due to living in closed spaces like dormitories.
-Also recommended in military personnel as well.
-Other indications include patients with: asplenia and complement deficiencies as well as HIV infection patients.

2) Hepatitis A vaccination
-inactivated vaccine
-typically administered as two injections 6 months apart
-typically administered to children--> high likelihood of transmission from children in prior epidemics.
-In adults--> travelers to endemic areas like southeast Asia and Africa.
-Other recommendations include: intravenous drug users and chronic liver disease patients except those with chronic hepatitis B or C infection without liver dysfunction.
(Post-exposure prophylaxis should be offered to all person in close contact with the infected person with no prior vaccination of hepatitis A.)

3) Hepatitis B vaccine
-inactivated vaccine series with 3 injections ( 0 month, 1 month and 6 months).
-hepatitis B titers can be checked prior to administering hepatitis B vaccination series.
-hep B transmission = sexual intercourse and blood or blood contaminated products.
-highly recommended for adults with increased risk of sexual transmission of infections including men who have sex with men, multiple sexual partners, sex partner of a patient with hepatitis B and upon evaluation of any sexually transmitted infection.
-Other indications include all health care workers, co-morbidities (diabetes mellitus, HIV infection, chronic liver disease, end-stage kidney disease), and travelers to countries with endemic hepatitis B.
-hepatitis B vaccination series are recommended for all age groups, since it is one of the leading causes of chronic liver disease and cirrhosis worldwide.

4) Human papillomavirus vaccine (HPV)
-inactivated vaccination administered in a series of 3 injections.
-HPV is the MC sexually transmitted infection in the United states with certain serotypes leading to genital warts and cervical or anal cancer.
-HPV vaccine covers serotypes 6, 11, 16, and 18.
-HPV vaccine is recommended for all females of age 11 to 26 years and males of age 11 to 21 years as well.
-Although this vaccination is highly recommended prior to first sexual intercourse, it is still proven to be effective in individuals with prior intercourse and history of HPV infection due to different serotypes covered by the vaccination.

5) Pneumococcal vaccine
-inactivated vaccination recommended in all adults of age 65 years and older.
-ages 19 - 64 years of age, specific indications include diabetes mellitus, chronic pulmonary disease (asthma and COPD), cigarette smoking, alcoholism, cochlear implant, immunocompromised patients (HIV, multiple myeloma, chronic corticosteroids) and asplenia to list a few.
-Patients who are vaccinated prior to age 65 years, receive a booster dose at age 65 or 5 years after initial vaccination, whichever is later.

6) Varicella vaccine
-live, attenuated vaccination.
-recommended in all persons born after 1980 unless there is a physician documented evidence of either varicella or varicella vaccination.
-live vaccine= contraindicated in pregnancy and used with caution in immunocompromised patients.
1) functional incontinence
This is a form of incontinence characterized by physical or mental barriers to voiding.
psychiatric disorders,
urinary tract infection,
delirium, and
reduced mobility. (post CVA w/ right hemiparesis)

2) Mixed incontinence
This a combination of both stress and urge incontinence. For example, the patient would have leakage with urgency, as well as with stress-producing scenarios (coughing, sneezing, or exertion).

3) Stress incontinence
In this form of incontinence, there is an involuntary loss of urine during a stress maneuver due to weak pelvic floor muscles or insufficient internal urethral sphincter strength. This form is more common in women, though men can develop it after prostate surgery. Nocturnal symptoms are uncommon in stress incontinence and pelvic exam may reveal weak pelvic floor muscle strength or a cystocele. Diagnosis is made by finding evidence of pelvic prolapse. Further, causes of intrinsic sphincter deficiency such as use of alpha-adrenergic antagonists, radiation, or surgical trauma should be considered. If chronic cough is a precipitant, it should be treated. Kegel exercises are often suggested to strength the pelvic floor muscles in the case of mild to moderate stress incontinence. They are often successfully if done diligently, though patients will often become discouraged and give up before maximal benefit can be realized. Pessaries may be of benefit to women with stress incontinence in the presence of bladder or uterine prolapse. Ultimately, surgery offers the highest cure rates, through bladder neck suspension, suburethral slings, or tension-free vaginal tape.

4) Urge incontinence is the most common type of incontinence in geriatric patients and is typically due to detrusor overactivity. In the classic scenario, patients feel an abrupt urge to urinate, but cannot get to the toilet in time. They might also have nocturia. In these patients, pelvic and rectal exams should both be performed. There is no abrupt urge to urinate in this question stem.

5) Overflow incontinence is the unpredictable dribbling of urine or weak urine stream due to underactive bladder and/or outlet obstruction. This is the second most common cause of incontinence in older men. Underactive bladder may be due to medications, specifically calcium channel blockers and anticholinergics, or detrusor denervation, or injury. Outlet obstruction may be due to an enlarged prostate gland, tumors, urethral stricture, or chronic constipation.
1) Akathisia occurs both early and late in antipsychotic drug treatment. It is a subjective feeling of motor restlessness as well as the inability to sit still. This may be manifested by repeated leg crossing, weight-shifting, or stepping in place.

2) Chorea is simply an abnormal involuntary movement disorder, one of group of disorders called dyskinesias. These are quick movements of the feet or hands and take their name from the Greek word for "dance." These movements are often combined with athetosis, which adds twisting and writing movements. Chorea is a primary feature of Huntington's disease and can also be seen in Wilson's disease. Though tardive dyskinesia can present with chorea itself, this patient has lip smacking and head jerking, which is not chorea itself.

3) Dystonias are involuntary contractions of major muscle groups, and are characterized by symptoms such as torticollis, retrocollis, and oculogyric crisis. These are usually rapid in onset and disturbing to most patients. Risk factors for dystonia include young age, male sex, use of cocaine, and history of acute dystonic reaction.

4) Secondary parkinsonism consists of mark-like facies, resting tremor, cogwheel rigidity, shuffling gait, and psychomotor retardation (bradykinesia). Mild parkinsonism is usually not evident unless an examiner observed cogwheel rigidity or diminished arm swing during exam.

5) Tardive dyskinesia (TD) is a hyperkinetic movement disorder that appears with a delayed onset after prolonged use of dopamine receptor blocking agents. TD can present with chorea, athetosis, dystonia, akathisia, stereotyped behaviors and rarely, tremor. The term "tardive" differentiates these dyskinesias from acute dyskinesia, parkinsonism, and akathisia, which appear very soon after exposure to antipsychotic drugs. TD can include a variable mixture of orofacial dyskinesia, athetosis, dystonia, chorea, tics, and facial grimacing. The symptoms involve the mouth, tongue, face, trunk, or extremities. Oral, facial, and lingual dyskinesia are especially conspicuous in elderly patients.

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