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AAFP Board Review Questions - GEN MED

AAFP board review questions - General Medicine 1- 18
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Laboratory work-up for male hypogonadism
1. total testosterone levels. If abnormal....
2. free testosterone levels (more $$). If abnormal....
3. LH and FSH to distinguish between primary and secondary.
Treatment for Plantar Fasciitis
1. OTC heel inserts with plantar fascia stretching exercises
2. NSAIDS
- steroid injections are only used when the above regimen is not sufficient.
Most commonly injured knee tendon.
- testing maneuver
ACL (anterior cruciate ligament)
- test with Lachman's
How are MM and MGUS best differentiated without bone marrow biopsy?
Clinically - both will have M spike in electrophoresis
- MM will have end-organ damage: renal failure, skeleton lesions, hypercalcemia.
- MGUS will be asymptomatic
What is the best way to determine if MGUS has progressed to MM?
Clinically!
- look for evidence of end-organ damage and symptoms.
- no need for bone marrow biopsy which is too invasive.
Polymyalgia Rheumatica
- clinical presentation/sx
- lab work-up for dx
- tx
SX: proximal joint stiffness at shoulders and pelvis
W/U: - high ESR
- normal CPK, aldolase and muscle biopsy (to differentiate from myositis)
TX: highly responsive to PO steroids
What is Refeeding Syndrome?
- what patients are at risk?
- pathophysiology
- complications
- methods of prevention
- DEF: syndrome that occurs once parenteral feeding is started in a severely starved patient, leading to severe complications.
- AT RISK: patient's below 70% of ideal body weight (anorexia nervosa, chronic alcoholics who haven't eaten, chemo pts...)
- PATHOPHYS: once parenteral feeding is started, glucose levels rapidly rise which lead to higher insulin secretion from pancreas. Insulin will drive phosphate (and potassium and magnesium) into cells and hypophosphatemia will prevent proper phosphorylation, including ATP production -> hypoxia -> myocardial dysfunction --> respiratory failure.
- PREVENTION: correct all electrolytes prior to starting parenteral nutrition
Side effect of inhaled steroids
- prevention of side effect
- ORAL CANDIDIASIS
- sore throat
- weak voice

PREVENTION: rinse mouth after each use or use a valve-holding-chamber with MDI for better direct delivery.
Most common cause of chronic hoarseness.
- when is further work-up needed?
- what is the next step in work-up?
- #1 cause is chronic viral laryngitis or URI.
- further workup is needed if it has been present for > 3 months
- Laryngoscopy is modality of choice.
Most common cause of R heart failure in adults.
L heart failure.
Melanosis coli cause
- chronic senna and other laxative use
Pulmonary Function Test (PFTs) are also known as...
Spirometry.
Classical clinical presentation suggesting orbital etiology of eye pain
pain with eye movement with no redness
- requires a stat CT of the head.
Colorectal CA screening recommendations for positive family history
Start at age 40 or 10 years before earliest relative diagnosed (whichever comes first!!)
- then every 5 years
Drugs associated with drug-induced pleurisy
The same drugs causing drug-incuded Lupus: HIPP
- hydralazine
- INH
- procainamide
- quinidine

** always rule out other causes of pleurities: pneumonia, PE, cardiac etiology to name a few
Drugs contraindicated in WPW
- why are they contrainidicated?
- tx of WPW
- CCB, adenosine & digoxin --> atrial fibrillation
- Tx: procainamide is the recommended tx
What type of drugs require TB screening prior to starting it for antu-immune conditions?
TNF inhibitors "-ab"
Describe the characteristics (key words) of the following gait pattern banormlaities:
- Parkinson's
- Motor neuropathy
- cerebellar degeneration
- visual impairment
PARKINSON'S: short steps and shuffling
MOTOR NEUROPATHY: steppage gait from foot drop with hyperflexion of hips and knees
CEREBELLAR: wide, staggering
VISUAL IMPAIRMENT: abducted arms and legs, "walking on ice"
Method for screen of gait abnormalities in elderly
Up and Go test:
- ask patient to stand up from chair without using arms, walk 3 meters, turn and sit back down on chair
- < 10 sec = normal
- > 20 sec = severe gait abnormality
- 11-19 = moderate gait abnormality
Daily baby aspirin recommendations in healthy men and women
- in non-healthy
MEN
- ages 45-79 without risk for GI bleed

WOMEN
- ages 55-79 without risk of GI bleed

ALL PTS WITH DIABETES (along with folate)
Protocol for further testing in a 1-year old with anemia
Treat with iron.
- no need to order further testing.
- improvement of Hg levels with Fe will be enough for a diagnosis
Altitude Sickness
- elevation at risk
- symptoms
- tx/prevention
- ALTITUDE: at risk > ~ 8,000 ft (or 25,000 m)
- SX: nausea, vomitting, headaches, fatigue --> pulmonary edema --> cerebral edema
- TX: 1) Acetazolamide or 2) dexamethasone
** acetazolamide is contraindicated in sulfa allergy.
Natural remedy of chronic venous insufficiency
- pathophys/mode of action
- ffor what patients is it recommended?
Extract of horse chestnut seeds
- extract only! actual seeds are poisonous.

PPATHOPHYS: sstimulates prostaglandis, cauing venocconstriction.
- rrecommended ffor patients that cannot tolerate mmechanical compression or have contra-indication, i.e PAD.
* ideal for patients that hhave contraindication to compressionn stockings!! *
#1 cause of erythema multiforme
Herpes Simplex Virus infection (> 50% of cases)
- the other 50% are usually idiopathic
- few cases can have many other etiologies
Describe ways to ask patient about 4 METS of exertion.
- vacuum an entire house without symptoms
- go up 2 flights of stairs, or one flight carrying large laundry basket
- mowing entire yard
What is important to determine when doing pre-operative testing for non-cardiac non-emergent surgery in a patient without specific risk factors?
If patient is able to perform 4 METS of exertion without symptoms.
- if not... --> dipyridamole-thallium stress test
Complications associated with long-term PPI therapy
- decreased VIT B12 absorption
- decreased CALCIUM absorption
- increased C. DIFF COLITIS risk
- increased COMMUNITY ACQUIRED PNEUMONIA risk
Recommendations for endometrial biopsy to rule out endometrial CA in abnormal vaginal bleeding
ANY abnormal vaginal bleeding in a patient over the age of 35 requires an endometrial biopsy.
Atrial flutter therapy in a...
- hemodinamically unstable patient
- hemodinamically stable patient
UNSTABLE... immediate cardioversion

STABLE.... digoxin or verapamil
What is equivalent to a 24-hr urine protein collection?
- describe results
early morning urine protein/createnine ratio
- If < 0.15 = negative, normal
- If > 0.7 = hhigh, likely above 300 mg in 24 hr
-- If 0.15 to 0.7 = need f/u with 24 hr protein

* can be used as ""rule out" screening test when 24 urine collection is not abel to be performed *
Antidepressant with SE of weight gain and little impact on insomnia
Remeron
Target hemoglobin levels for patients with anemia of chronic disease secondary to CKD
10-12
** hemoglobin at normal levels have been associated with increase heart failure and negative cardiovascular outcomes
Cut off age for SIDS concern and more concern for other causes of suffocation
6 months
- peak in 2-4 months
Lifestyle recommendation changes for frequent calcium oxalate renal stones (4 recs)
- low sodium
- low protein
- high potassium citrate (increases urinary pH and citrate formation)
- increased fluids
At what createnine levels is metformin contraindicated?
- what is the only PO medication indicated in patients with CKD?
Men: > 1.4
Women: > 1.5

- Glypizide
How can diabetes be diagnosed?
- fasting blood sugar > 125 x 2
- random glucose > 200 with classic DM symptoms
Differentiate spinal stenosis and herniated disc symptomatically
SPINAL STENOSIS
- back pain improved with sitting (flexion), worse with standing (extension)

DISC HERNIATION
- improved with standing (extension), worse with sitting (flexion)
Outpatient MRSA recommended tx (antibiotic choice)
In preferred choice:
- doxy
- clinda
- mtx/smx
Vitamind D supplementation recommendation for infants - adolescents
400 IU per day.
- even if baby is formula fed, you must supplement bc not enough in formula.
- supplement specifically if baby breast fed
SPONTANEOUS PNEUMOTHORAX
- pathophysiology
- types of patients affected
- treatment protocol
- chances of recurrence
PATHOPHYS
- subcutaneous bullae

PATIENTS
- young (< 40), tall, without lung diease

TX
- If < 20% with only mild symptoms... monitor and repeat CXR in 1-2 days
- If > 20% or moderate-severe symptoms... chest tube placement.

RECURRENCE
- good chance of recurring within next 2 years
Cardiac complication of high dose methadone use
Torsades with QT prolongation
RHEUMATOID ARTHRITIS
- laboratory work-up
- initial tx
WORK-UP
- CBC
- ESR, CRP,
- RF
- anti-citrullinated antibody

--> xray to look for erosions once diagnosed

TX
- reffer once diagnosed --> DMARD tx
- NSAIDS and steroids for acute exacerbation
PCP in HIV
- CD4 levels for tx
- tx
- recommendations for steroids
CD4: < 200
TX: IV bactrim (for acute), PO bactrim (for prophylaxis)
STEROIDS: If PO2 < 70... steroids!
Scaphoid fracture
- clinical presentation
- management
SX: fall with outstretched hand with tenderness at anatomical snuff box
- if xray is clean but + snuff box tenderness, fracture just the same (xray may be normal at first)

TX
- proximal 1/3 --> ortho referral
- distal 1/3 --> thumb-spica cast, repeat xray in 12 weeks to look for union
Blackbox Warning of Thiolidazones (Actos - pioglitazone).
HEART FAILURE black box warning.
- Also contraindicated in liver failure
Pediatric fluoride supplementation recommendation:
- age water supplementation should be started
- age toothpaste supplementation should be started
- amount of fluoride recommended
- type of water recommended
AGE H20 SUPPLEMENTATION
- starting at 6 months

AGE TOOTHPASTE SUPPLEMENTATION
- starting at 2 years
* supplementing before 2 years may lead to teeth fluorosis bc of high levels *

AMOUNT RECOMMENDED
- 0.6 mg/L to 1.0 mg/L

TYPES
- tap water in the US is ok
- Nursery Water bottled water
Allergic Rhinitis treatment protocol
INITIAL THERAPY
- intranasal steroids is treatment of first choice

SECOND THERAPY
1) oral antihistamines if intranasal steroids failed
2) add intranasal antihistamine
3) add oral leukotriene receptor antagonist
4) add intranasal cromolyn
At what levels must isolated blood pressure elevation be treated in the emergency setting?
Only on HYPERTENSIVE EMERGENCIES: > 180/110.
- any isolated blood pressure increased below that, just repeat it at a later time.

* same approach for hypertensive urgency: only treat emergently if patient symptomatic or if BP > 180/110 = hypertensive emergency *
Role of steroids in treatment of bronchiolitis
No evidence to suggest improvement.
- Treatement for RSV is supportive only with bronchodialators
Define Thrombocytopenia
- threshold for symptoms
- level of purpura manifestation
- level of concern for bleeding with minimal trauma
- level of concern for spontaneous bleeding

* platelet transfusion is indicated at what level? *
Thrombocytopenia = plat < 150,000
- symtpms will start when platelets < 50 K
- purpura/petechiae: < 30 K
- minimal trauma: < 10 K
- spontaneous bleed: < 5 K

* platelet transfusion: when < 10,000 *
Emergent causes of thrombocytopenia
- ITP (autoimmune-induced)
- TTP (can lead to HUS, renal and neuro manifestation)
- HELLP
- HIT (heparin induced)
- DIC
Bisphosphonates proven to reduce HIP FRACTURES.
- Others proven to reduce VERTEBRAL fractures
HIP:
- Alendronate (Fosamax)
- Risedronate
- Zoledronic acid

VERTEBRAL
- all others
PCOS management
- fertility desired
- fertility not desired
FERTILITY DESIRED
- Metformin
- Clomiphene
* metformin induces more ovulation than clomiphene *

FERTILITY NOT DESIRED
- OCPs
- aldactone (for hirsutism)
- metformin (for glucose control)