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AAFP Board Review Questions - GEN MED 3

AAFP board review
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Is IBS usually associated with or without abdominal pain?
With.
Diagnostic modality of choice for septic arthritis
Ultrasound of the joint
- will indicate effusion which can be emergently aspirated
Define secondary amenorrhea
lack of menses for at least 3 months
What is the female athlete triad?
Amenorrhea, osteoporosis, eating disorder
What is the osteoporosis Z and T score?
Z score < -2
T score < -2.5
#1 cause of resistant otitis media in children
penicillin resistant Strep. pneumo.
Characteristics of a benign solitary lung lesion
- malignant lung lesion?
BENIGN
- solid appearance, < 5 mm, concentric calcification, doubling time < 1 month (KIM cancers don't grow fast)

MALIGNANT
- "ground glass" appearance, > 10 mm, no calcification, doubling time 1 month to 1 year
#1 cause of chronic cough
GERD
Management of Synthroid doses in pregnancy
- increase it by 30-50% during 4-6 wga
- metabolic changes in pregnancy lead to extra need of synthroid
What medications have shown improvement in morbidity and mortality of heart failure patients? (i.e. what meds must ALL HF patients be on?)
MUST AT ALL TIMES
- ACE-I
- Beta blocker

SYMPTOMATIC HF
- spiranolactone
Rear facing car seat requirements
12 months AND 20 lbs
Meds that decrease M&M in CAD patients
ACE-I
Beta blockers
Aspirin

* all CAD patients must be on above meds *
Most common presenting symptoms of Hodgkin's lymphoma?
- what are the "B cell "?
Painless lymphadenopathy
- B-symptoms: night sweats, unexplained fever, weight loss
What is the minimum age requirement for children using OTC "cold" medications?
2
- FDA recommends against cold OTC meds for children under the age of 2
Diet recommendation for patients with gout
reduce protein intake!
Excisional procedure for presumptive melanoma lesion
Excisional biopsy with a 1 mm margin
First line management for GAD
Cognitive Behavioral Therapy - before meds!
What are the only SSRIs FDA approved for general anxiety disorder?
- What is a good choice for short term control instead of benzos?
Paroxetine (Prozac)
Escitalopram (Lexapro)
Duloxetine (Cymbalta)
Venlafaxine (Effexor)

KIM: Vistaril is a good choice for anxiety that is non-habitual and fast acting, instead of benzos.
- has been FDA approved for anxiety.
AAA screening guidelines
- When is surgical repair recommended?
Males (men only!) in between 65-75 who have ever smoked
- Surgery if above or equal to 5.5 cm
What is the PO to IV conversion of morphine?
IV dose should be 1/3 of the PO dose
Treatment of acute SVT
1st: vagal maneuver
2nd: Adenosine 6 mg
3rd: Adenosine 12 mg
4th: cardioversion
How can vitamin D deficiency present?
-Classic symptoms of osteomalacia
- Unspecified symptoms of general body aches, chronic fatigue, arthritis, low back pain, depression
Work-up for vitamin D deficiency:
- what type of vitamin D level is ordered?
- cut off value for deficiency & insufficiency
- order 25-hydroxyvitamin D levels
- Insufficiency: 20-30
- Deficiency: < 20
Daily recommended amount of vitamin D for adults
~ cholecalciferol (D3) 800 IU daily from all sources
Management of vitamin D deficiency
- ergocalciferol (D2) 50,000 units weekly x 8 weeks
- recheck 25-hydroxyvitamin D level
- may repeat for another 8 weeks if not normalized > 30
- if normal, maintain with 800-1,000 IU of cholecalciferol (vit D3)
Describe the Ottowa Rules indicating need for ankle radiograph after trauma
1. unable to bear weight for 4 steps
2. bony tenderness of medial and lateral malleolus
3. bony tenderness of posterior 6 cm of either malleoli
4. tenderness at base of 5th metatarsal
Recommendation for prophylaxis of traveller's diahrrea
- not routinely recommended!
- recommended only for:
1 immunocompromised
2. trips where diahrrea may be very socially impacting (i.e. important business trip*

Tx: Rifaximin
Once a patient is diagnosed with heart failure, what is the first critical thing that needs to be determined?
- Diastolic vs. systolic!
* echo is critical! *
What are the meds that decrease mortaility in heart failure?
ACE-I
Beta blockers

- Diuretics only in acute exacerbations
- Spironolactone only if BP not well controlled
When is ACTIVATED CHARCOAL recommended as tx for acute medication OD?
Drug of first choice if:
- within 1 hour of ingestion
- not lithium or iron
- not enteric coated or extended release
Gestational DM accu checks goal
Fasting: < 100
1 hr post prandial: < 140
Initial therapy recommendation for depression in adolescents and children
Cognitive Behavior Therapy
- Not meds!
Define STEMI in an EKG
- Def: ST segment elevation of 0.1 mV in two contiguous limb leads
What is the recommendation for FNA of a thyroid nodule?
A normal or hypofunctioning thyroid (normal TSH/high TSH) nodule of > 1 cm in an ultrasound.
Describe the average DURATION AND PEAK of the following LONG-ACTING insulins:
- Lantus
- Levemir
- NPH (humulin)
- glargine/Lantus: 24 hours / NO PEAK
- determin/Levemir: 6 - 23 hours / 8 hours peak
- NPH: ~ 12 hours / 8 hours peak
Describe the average DURATION AND PEAK of the following SHORT-ACTING insulines:
- aspart (novolog)
- lispro (humalog)
- regular
- Novolog: ~3-5 hours
- Humalog: ~ 3-5 hours
- Regular: ~ 5-8 hours
What type of medicines cause dystonic reactions/DYSTONIA?
- How is acute dystonia treated?
DA blocker: prochlorperazine, metoclopramide, anti-psychotics
- tx with benztropine or diphenhydramine.
What are the contra-indications to IO administration of IV meds?
there are none!
- all patients of all ages can have IO access. All meds given IV can also be given IO.
How do the following classes of DM medications work?
- biguanides (metformin)
- glitazones (pioglitazone/Actos)
- sulfonylurea (glipizede/Glucotrol)
- DPP-4 (gliptins/Januvia)
- Amylin analogs (pramlintide/Symlin)
- Biguanides: increase insulin sensitivity
- glitazones: increase insulin sensitivity
- sulfonylureas: stimulate pancreatic insulin excretion
- DPP-4: slow down breakdown of sugars
- Amylin: delay gastric emptying
What is the technical medical diagnosis given to the cause of amenorrhea in female athletes?
- describe LH and FSH levels
Hypothalamic amenorrhea
- low LH and FSH levels
Tx of hirsutism in patients:
- with amenorrhea
- without amenorrhea/regular cycle
With amenorrhea/PCOS
- OCPs
- metformin
- aldactone

Without amenorrhea/no PCOS
- OCPs + aldactone
Describe calcium supplement therapy in patients with osteoporosis
- dosing
- carbonate vs. citrate
Dosing: 1,200 mg per day
- must be taken in 500 mg BID-TID

Carbonate: cheap, needs acid and meal for absorption
Citrate: expensive, can be taken on an empty stomach

- do not take them with other medicines! Can decrease absorption.
Vitamin D goal levels in women
30 ng/ml of 25-hydroxyvitamin D
Bisphosphanates MOA?
What is a rare but severe side effect of bisphosphanates?
- MOA: inhibit osteoclastic activity
- osteonecrosis of the jaw!
Raloxifene MOA
- contraindication
- for which patient is it best indicated?
- MOA: selective estrogen receptor modulator
Agonist activity on bones and lipids, antagonist on breast and uterus
- contra-indication: h/o VTE
- recommended for patients with vasomotor sx (it improves them) and high risk for breast cancer (decreases it)
What are the two classes of drugs used to tx BPH?
- MOA
- Differentiate them in terms of onset of action for relief of symptoms.
- side effects
1. Alpha blockers (doxazosin, tamsulosin)
- MOA: relax smooth muscle of prostate gland for acute relief of symptoms
- TIMING: acts fast to improve symptoms, but do not decrease size of prostate
- SE: orthostatic hypotension - worse with ED drugs, hypotension

2. 5-alpha reductase inhibitors (finasteride, dutasteride)
- inhibits prostate growth
- do not provide immediate symptom relief - takes 6 months -, but shrink size of prostate for more of a curative impact.
- SE: ED, decreased libido, decreases PSA levels - double levels when monitoring for prostate cancer
Criteria for SOMATIZATION DISORDER
- 2 GI symptoms
- 1 neurological
- 1 sexual
- 4 pain complaints
Why is BUN/Cr ratio not frequently used in children to evaluate for renal abnormalities?
Because Cr vary by age!!
What are the 3 most common types of dementia?
- Alzeheimer's
- Vascular
- Lewy Body
How will Alzeheimer dementia present?
SLOW and PROGRESSIVE deterioration with involvement in memory, speech, personality and executive function.
How will Vascualr dementia present?
SUDDEN STEPWISE DETEREORATION in cognitive function with cardiovascular risk factors - DM, CAD, HTN.
- more sudden than Alzeheimer
How will Lewy Body dementia present?
* triad*: DEMENTIA plus PARKINSONISM and VISUAL HALLUCINATIONS
What is the recommended drug of therapy for dementia?
Acetylcholinesterase inhibitors
- donepezil (Aricept)
- galantamine, rivastigmine

NMDA Receptor Antagonist
- Mementine (Namenda)

* Aricept > Namenda for clinical improvement *
Describe the AUA recommendation for prostate cancer screening in the following population:
- younger than 40
- 40-54 yoa
- 55-69 yoa
- > 70
< 40 yoa
- harm >> benefit; recs against screening

40-54
- if no risk factor harm > benefits; recs against screening
- consider high risk factor (AA, family hx)

55-69
- shared decision making!
- consider benefits over harm, mortality from other diseases,
- benefits > harm with shared decision making

- > 70 yoa
- harm >> benefits