50 terms

AAFP Board Review Questions - GEN MED 2

GEN MED - PART 2
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VENOUS ULCERS
- #1 cause
- physical exam findings
- tx regimen
ETIOLOGY: venous stasis, 80%
PE: shallow, erregular, over bony prominence (medial malleolus)

TX
1) - compression therapy (standard of care)
contraindicated in PAD and HF pts
- leg elevation (standard of care) at least 30 mins TID

2) platelet aggregation inhibitors:
- Pentoxyfilline (Trental)
- aspirin, 325 mg
Normal pulmonary capillary wedge pressure (PCWP) values
8-10

- if hypotensive and normal PCWP = hypovolemia
- if hypotensive and high PCWP = heart failure
Recommended type of feeding in acute pancreatitis
Total enteral > total parenteral > D5

- no specific method of total enteral feeding is recomended over the other (NG vs. NJ vs. PEG, etc)
Pneumococcal vaccine recommendation in adults
- SINGLE DOSE for EVERYONE at AGE 65

< 65 YOA with CHRONIC DISEASE risk factors
- one dose BEFORE AGE 65 then one dose 5 YEARS LATER or at the AGE OF 65, WHICHEVER IS LATER.
Pulmonary solitary nodule characteristic that is concerning for malignancy:
- size
- border
- risk factor in patient's history
SIZE: > or equal to 8 mm
BORDER: irregular border
HX: any history of smoking!

- KIM: recommendations for screening chest CT for any patient who has smoked over 100 cigarettes in their lifetime.
Common cause of hypotension and oliguria in the ICU, not improved with IVF.
- work-up?
- adrenal insufficiency: drop in cortisol levels can occur with severe inflammatory response and critical illness --> hypotension, oliguria, tachycardia.

- w/u: cortisol levels after cosyntropin stimulation test
Bridging therapy recommendations for Lovenox and Coumadin
- when to stop bridging?
- Bridge for: at least 5 days with INR > 2.0 for at least 24 hours .
- Can stop bridge if INR has been > 2.0 for at least 24 hours during the five day period.
HSP
- age of onset
- classical physical exam finding
- laboratory findings (CBC, spp)
- systemic general manifestation
AGE: < 20
PE: * palpable pruritic purpura *
LABS: * NO thrombocytopenia * --> only purpura without low platelet levels
SX: renal failure --> bx shows IgA deposits
Natural supplement found to be helpful in treatment of IBS
peppermint oil
Pseudotumor cerebri classical presentation of symptoms
- Dx?
- Headaches
- transient vision LOSS --> pappilledema
- pulsatile tinnitus

Dx: normal CT, high opening pressure on LP

* migraine-like headache with transient vision loss and tinnitus
* KIM typical patient: young obese female *
Why must actinic keratosis be removed?
They are precursors to squamous cell carcinoma
DOFC for social performance anxiety
propranolol
#1 neuromuscular disorder of childhood
- clinical presentation
- work-up
Duchenne muscular dystrophy
- SX: gait abnormality by age 4-5 or delayed walking.
- W/U: elevated CK levels
Need muscle biopsy for final diagnosis
PAD
- ABI value for diagnoses
< 0.7
PAD medical management (after control of risk factors)
- 1st line: Aspirin
- 2nd: Plavix
- 3rd: ciloastazol
What is always in the differential for sudden onset AMS changes or behavioral changes (agression, etc) in the elderly?
Hypoxia!
- get an ABG!!
- also sepsis (CBC) and metabolic abnormalities (metabolic panel)
C diff treatment
PO Flagyl or PO vancomycin
- may need to repeat dose
Osteoporosis screening recommendations in men
all men > 70 yoa need a DEXA scan
Management of acute ascites
- grade 1
- grade 2
- grade 3
GRADE 1 (seen only with US)
- salt restriction
- spironolactone (first)
- lasix (2nd)

GRADE 2 (starting to be seen with naked eye)
- same as above

GRADE 3 (grossly seen with naked eye)
- large bore abdominal pericentesis
Differentiate ACUTE ANGLE GLAUCOMA and RETINAL ARTERY OCCLUSION based on the following:
- onset of symptoms
- presence of pain
- exam of external eye
- fundoscopic exam
ACUTE NARROW ANGLE GLAUCOMA
- painful
- acute
- red eye
- normal fundoscopic exam

RETINAL ARTERY OCCLUSION
- painless
- over a few seconds
- normal external eye
- cherry red spot
Common risk factor for frozen shoulder syndrome
Diabetes
How can Frozen Shoulder syndrome and Rotator Cuff Tear be differentiated?
Rotator Cuff Tear
- decreased active ROM
- normal passive ROM

Frozen Shoulder
- decreased active ROM
- decreased passive ROM
Recommended anti-platelet therapy after cardiac stenting
DRUGS (always dual therapy!)
- Aspirin 325
- Plavix 75 mg or Effient (prasugrel)
What are the different types of cardiac stents?
- minimum length of antiplatelet therapy based on type of stents.
TYPES
- bare-metal
- sirolimus-eluting
- drug-eluting

LENGTH
- Bare-metal = 1 month
- Sirolimus-eluting = 3 months
- Drug-eluting = 6 mo (1 year is target)
Drug of first choice for pregnancy induced hepatic cholestasis
Ursodiol
- not cholestyramine, this is second choice
Treatment of choice for pertussis
- what are the stages of perstussis?
- what is the purpose of pertussis tx?
Azithromycin
- STAGES:
catarrhal (most infectious) --> paroxysmal (wooping cough) --> convalencent (recovery period)
- PURPOSE OF TX
reduces transmission to others but has no effect on current symptoms.
Anti-depression meds and weight gain:
- anti-depressive (all classes) more likely for weight gain
- anti-depressive (all classes) least likely for weight gain
- SSRI more likely for weight gain
- SSRI least likely for weight gain
MORE WEIGHT GAIN
- all classes: mirtazapine (remeron)
- ssri: paroxetine (paxil)

LEAST WEIGHT GAIN
- all classes: bupropion (wellbutrin)
- ssri: fluoxetine (prozac)
For the following vesicular conditions, states the cause/etiology:
1. anterior mouth oral ulcers without fevers
2. anterior mouth oral ulcers with low fevers
3. general oral ulcers, periorbital and genital ulcers
4. posterior pharynx oral ulcers with fevers
5. ulcers on tip of finger
6. ulcers on anterior mouth, hand and feet
1) aphthous ulcers
2) herpetic ulcers of hsv-1
3) bechet's syndrome
4) Herpangina (etiology: cocksackie & echovirus)
5) herpetic whitlow
6) Hand-Foot-Mouth disease by cocksackie
Management of Rosacea
MILD CASES
- topical metrogel
- sunscreen

MODERATE/SEVERE + EYE INVOLVEMENT
- PO flagyl
- PO doxy
- PO tetracycline
Diabetic foot infection treatment of choice
1st) no MRSA: Keflex or Augmentin

2nd) for MRSA tx: clinda, doxy, bactrim
Vertebral Compression Fractures
- #1 cause in > 55 yoa
- #1 cause in < 50-55 yo
> 55 YOA: osteoporosis

< 50-55 yoa: rule out malignancy/bone mets!
- specially with a history of minimal trauma
Tx of vertebral compression fractures
- mild to moderate
- severe
MILD TO MODERATE
- decreased activity until pain improves for up to 2 weeks
- pain control
- PT

SEVERE (when pain persists > 2 weeks of conservative tx)
- vertebroplasty referral
Differential diagnosis for exercise-induced asthma that does not improve with albuterol tx
- How are they differentiated?
Vocal cord dysfunction
- differentiated via PFTs

ASTHMA: normal inspiration, flat expiration
VC DYSFUNX: flat inspiration, normal expiration
New onset HTN > age of 50 + worsening renal function after ACE-I = ??
Bilateral renal artery stenosis

* a worsening renal function after starting ACE-I for HTN is classic for bilateral renal artery stenosis *
When using d-dimer for PE diagnosis, what is important to KIM about the negative predictive value (aka: the significance of a negative value)?
- If the patient is low or moderate risk, then a normal d-dimer rules out PE.

- If the patient is high risk, then a normal d-dimer does not rule out PE and the patient needs CTA.
Common cause of restless leg syndrome.
- target goal of treatment
Anemia!
- Continue iron supplement until ferritin levels > 50
Approach to a patient with heparin-induce-thrombocytopenia and presence of DVT/PE.
- DC heparin and start heparin anticoagulant.
- KIM that heparin is used to prevent clot formation. Once clot is formed, heparin has no use.
Tx of chronic primary insomnia
Cognitive behavioral therapy
Describe the FADIR and FABER testing for hip pain
- What medical condition of the hip are they indicative of?
FADIR: pain with flexion, adduction, internal rotation
- femoroacetabular impingement

FABER: pain with flexion, abduction, external rotation
- osteoarthritis of the hip
Classical triad for seratonin syndrome
- What are the most common meds associated with seratonin syndrome?
- Tx
AMS, autonomic instability, neuromuscular hyperactivity
- i.e. clonus, diahrrea, fevers, muscle rigidity

Combination of SSRI and...
- cyclobenzaprine (flexeril)
- ultram (tramadol)
- MAOI
- metoclopramide (Reglan)
- odansetron (Zofran)
- triptans
- dextramethorphan

TX
- If mild without autonomic instability: remove med, outpatient f/u
- If severe with autonomic instability: inpatient, tx with Benzo
Drug of first choice for elderly with HTN
HCTZ.
- with or without ACE-I
Work-up for adrenal insufficiency
First: 8 am serum cortisol
Second: ACTH (cosyntropin) stimulation test
Management of PVCs
- frequent vs. infrequent
FREQUENT: > 30 PVCs per hour or 3 or more consecutive ones
- worsening CAD untill proven otherwise in patients with risk factors.
- workup with stress test, echo or Holter

INFREQUENT
- manage conservatively if asymptomatic
What is the "fat pad sign"?
"Fat Pad Sign" is seen on elbow xray.
- Indicates a non-displaced fracture
Effect of metformin on cardiovascular events of DM type 2
only drug proven to reduce risk of cardiovascular events in diabetics.
Screening method for primary hyperaldosteronism
- how will patients initially present?
morning serum aldosterone:createning ratio
- Sx: HTN + hypokalemia
Describe necessary liver enzyme changes for discontinuation of a statin
AST and ALT more than 3x upper limit of normal.
- continue patient on statin therapy otherwise as benefits outweigh the risk.
Markers of active Hep B infection in a patient with chornic Hep B.
- elevated LFTs
- detectable HBeAg (not Ab)
- high levels of HBV DNA (> 200,000)
Most common causes of hyperthyroidism
- laboratory wise, how are they differentiated?
LOW TSH, HIGH T4, HIGH IODINE UPTAKE
- Grave's disease (#1)
- toxic multinodular goiter
- thyroid adenoma

LOW TSH, HIGH T4, LOW IODINE UPTAKE
- thyroiditis
Tx approach to the most common common causes of hyperthyroidism
THYROIDITIS: will present with tender thyroid
- Prednisone & propranolol
- symptomatic management (no meds)
- self limiting within a few weeks
- questionable viral involvement

ALL OTHERS:
- meds, radioactive iodine uptake, medical management