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Family Medicine EOR Exam Topic List

Terms in this set (403)

URGENT CARE (4%)

Respiratory failure/arrest

Deteriorating mental status/unconscious patient

Allergic reaction/anaphylaxis

peptic ulcer disease

Burns (degrees)

1st -- minor damage/epidermis -- ERYTHEMA

2nd- Partial-thickness- painful
superficial/Papillary dermis-- BLISTERS
deep/reticular dermis -- RUPTURED blisters

3rd -Full/destroy-dermal appendages - no* sensation
white, leathery, charred

4th -- muscle, bone

5th -- loss of a body part

What is the most common type of burn?

Treatment for chemical burns:

white phosphorus -- 1% copper sulfate/calcium gluconate
acid burns -- lavage x30min

Manage burn shock by aggressive fluid* resuscitation -- Parkland formula:

% burn area x body wight (kg) x4ml/hr= total amount of fluid needed x24hrs

half -first 8 hrs/ Ringer's lactate** solution /measure UO

Additional tx for burn pts:

NG tube -- for gastric distention
Foley catheter -- UO at least 0.5 ml/kg/hr -- adult
escharotomy -- compartment syndrome/ventilation diff
Sulfadiazine -- topical burn ointment
deep burns/full-thickness -- autography

Complications of burns:

gastric/duodenal ulcers -- "Curling ulcers"
*** injection
chronic healing -- malignant -- SCC -- "Marjolin ulcer"

What is the most common cause of third (3rd) trimester bleeding?

Abruptio placentae ***

-- premature separation of placenta AFTER 20 weeks // PAINFUL

Risk factors are known for the development of Abruptio placentae (9):

Trauma, smoking, HTN, decrease folic acid, cocaine**, alcohol (>14 drinks/week), uterine anomalies, high parity, previous abruption (re-occur 10-17%), advance age

What is the most common type of abruption/less severe?

EXTERNAL abruption -- bleeding occurs

Management of Abruptio placentae:

Delivery - C-sec* -- definitive tx
Blood type, cross match, and coagulation studies

? Placenta previa:

No digital exam *** -- covers the cervical os
Painless bleeding -- before 20 weeks
dx: US tx: watchful wait/c-sec

Bites/stings: human

Eikenella corrodens -- tx: Augmentin

Bites/stings: spider (2)

brown recluse - Loxosceles reclusa -- infarct of skin/rapid blood coag./sinking macule/pale gray/ halo LARGE -- tx: would cleansing & analgesia

black widows -- neurological -- tx: Diazepam & calcium gluconate

Foreign body aspiration s&s:

* choking, coughing, unexplained wheezing/hemoptysis

asphyxia - obstructing, PNA - toxic, ARDS - gastric asp.

Diagnostic studies for FBA:

Expiratory X-ray -- regional hyperinflation -- check valve effect

Tx: Heimlich maneuver -- lifesaving
Bronch -- dx; tx -- culture --PNA

Cardiac failure/arrest

V-tach -- T-fib -- asystoly
tx: CPR

Fractures/dislocations:
examples of directions

transverse -- R angle to the axis of the bone

spiral -- twisted -- torsion

oblique -- between horizontal & vertical

comminuted -- splintered & crushed

segmental - double

Imaging studies for fx/dislocations:

Plain-film radiograph -- both - AP and lateral (90degrees)

radionucleotide bone scan -- stress fx -athletes/ osteopenia, wight bearing

CT *** -- best -- carpal bones, elbow, tibial plateau// pelvic, facial, itra-articular fx

MRI -- hip fx **

How do you treat: Open fx, intra-articular fx, femur fx, fx's tibia, fibula in adults?

analgesics, immobilization, EMERGENT referral to Ortho

Define Open fx; How do you tx?

bleeding **

tx: debrided/irrigated -OR -within 4-8hrs

IV antibiotics - 1st, 2nd cephalosporins & aminoglycosides -- x48 hrs (after fx, + after OR) -- TETANUS status **

Define intra-articular fx; how do you tx?

fx line enters a JOINT cavity

tx: open tx -restore and maintain articular congruity
stable -- active ROM

Tx of femur fx:

femoral neck fx -- percutaneous screws/hemiarthroplasty

femoral shaft fx -- intramedullary rods/plates

intertrochanteric fx -- sliding hip screw fix// or long gamma nail

*** SIGNIFICANT HEMORRHAGE

define fx of the tibia and fibula in adults; tx?

ligamental, meniscal, and vascular injuries

tx: simple -- closed reduction, cast; complicated/unstable -- open reduction with internal fixation (ORIF)

Fx in children:

physis, or growth plate -- injury of attached ligaments

swelling/tenderness; Salter-harris -- growth place fx

Salter-Harris classification of fractures:

I - fx through epiphyseal plate
II - methaphyseal fx
III - through the epiphysis into the articular surface
IV - fx through -distal metaphysis, epiphyseal plate, and epiphysis
V - impaction** of epiphyseal plate

Two types of incomplete fx:

Torus fx & Greenstick fx

Define Torus fracture (aka buckle fx); Tx?

one side of the cortex buckles** as a result of a compression injury -- falling on an outstretched hand

tx: 4-6 weeks in a cast

Define Green stick fx; Tx?

long bones -- when bowing* causes a break in one side of the cortex

tx: <15 degrees -- long arm or leg cast -- 4-6 weeks
> 15 degrees -- referral to an ortho surgeon

What is dislocation?

total loss of congruity -- between the articular surfaces of the joint

Most common sites of dislocation are:

Anterior shoulder
Posterior hip -- osteonecrosis of femoral head
Posterior elbow

Treatment of dislocations:

assess neurovascular status -- tx Closed reduction**

reduce spontaneously -- immobolization 2-4 weeks follow by ROM

if fx or interposed soft tissues -- open reduction/internal fixation

assess the neurovascular status pre- and post-, get postreduction radiographs

Diff between Sprains/strains:

sPrains -- collagenous tissues -- Ligament or tendon

sTain -- injury to the Bone-Tendon unit @ myotendinous junction or the muscle

Sprains or strains injury often follows a sudden stretch; it can lead to AVULSION of Tendon:

mallet finger avulsion or stretch of the terminal extensor tendon -- tx: extensor splinting x6 weeks

It can also lead to Ligamentous sprain:

stretch of the anterior talofibular ligament (ATL) -- common ankle sprain**

Tx for both strains and sprains:

supportive therapy: RICES -- rest, ice, compression, elevation, and support/bracing

What is the most common type of fx in children and adolescents?

Fx clavicle **
caused by fall on an outstretched arm

tx: kids - figured-of-eight sling -4-6weeks
adults -- sling -6 weeks

Shoulder dislocation:

fall on outstretched arm - aBduction/extension
Anterior** shoulder

Dx and Tx of shoulder dislocation:

Dx: AP view and transthoracic "Y" view
humeral head deformities= Hill-Sachs lesions - recurrent dislocations

Tx: reduction, immobilization= sling/swath - Velpeau sling**; <40yo -- therapy after 3 weeks; >40 - after 1 week

Humeral head* fractures:

proximal humerus -- OLDER pt w/osteoporsis/ F
Neer classification -- ecchymosis x 24-48hrs/pain -greater tuberosity

early mobilization -pendulum excises -- prevent frozen shoulder

Humeral shaft* fx:

MVC, fall, penetration injury, gunshot wounds
*** radial n. damage

Dx and Tx for humeral shaft tx:

dx: AP and lateral x-ray -- elbow and shoulder

tx: coaptation splint --
hanging cast, Sarmiento brace, or OR

Supracondylar humerus fx:

all on the outstretched hand with HYPEREXTENSION of the elbow

** brachial a. -- most spastic artery -- Valkamann ischemic contractures // varus=gunstock or valgus deformities

Fracture and dislocations of the hand:

boxer's fx
colles fx
gamekeeper's thumb

Explain Boxer's fx; Tx?

metacarpal neck of the 4th or 5th finger
loss of the prominence of the knuckle

bunch to another's humans mouth -- tx with antibiotics -Eikenella corrodens

tx: 25-30 degrees --ulnar splint f/o in 1-2 w

What is the most common injury of the wrist?tx?

Colles fx ***

fall onto the dorsiflexed hand --- "silver fork" deformity
distal radius fx with dorsal angulation

tx: cast

diff collers fx vs. smith fx:

Explain Gamekeeper's thumb; tx?

sprain or tear of the ulnar collateral ligament of the thumb; laxity -- weakness of pinch

tx: complete rupture --surgery; partial -- thumb spica cast

What is the most common fracture of the elbow in adults?

radial head fx** --- fall outstretched hand

Explain radial head injuries:

subluxation of the radial head -- kids 4yo -- "nursemaid's elbow" -- excessive longitudinal traction

How do you dx radial head injury?tx?

AP/lateral films -- displacement of anterior "fat pat" and presence of a posterior fat pat -- hemarthrosis

tx: "screwing" action - place the radial head back within the annular ligament

What bone is most commonly fx carpal bone?

scaphoid (navicular) fx***

Clinical features of scaphoid fx; tx?

can lead to avascular necrosis; pain over anatomic snuffbox

X-ray -- can be negative - re-peat 2-3 w// Bone scan or MRI *** should be order

tx: long-arm spica cast -- referral to ortho; 1mm - ORIF

Myocardial infarction

12 lead EKG;
STEMI -- ST elevation in 2 leads

II, III, aVF - RCA

Tx for MI -STEMI:

Aspirin & clopidogrel
coronary angio and PCI -- 90min
thrombolytic therapy -- 3 hrs

Hypertensive crisis

HTN urgencies -- 220/125-- reduce BP within hours -- not to rapidly -- tx: sodium nitroprusside; if MI - niroglycerin or BB

HTN emergencies -- diastolic >130-- reduce within 1 hr ** -end-organ damage, optic-disc edema=papilledema

What dz is the leading cause of death in hospitalized pt?

What is the initial* dx test for Pulmonary embolus; How do you tx?

spiral CT ** (replace V/Q scan)
Pulmonary angio -- definitive

tx: heparin; low-molecular-weigh heparin or warfrin after acute face - 3months

Clinical features of Pneumothorax?dx, tx?

ipsilateral chest pain; decreased tactile fremitus
dx: expiratory CXR

tx: <15% -resolve spont; large - chest tube;
CXR every 24hrs

In whom Orbital cellulitis is common?

kids 7-12yo; associated with sinusitis, dental infections..

Causes of Orbital cellulitis?

Strep pneumo, H. flu, Gram -, MRSA

Orbital cellulitis clinical features; dx, tx?

ptosis, purulent d/c, conjunctivitis, sluggish pupillary response
dx: CT** -- broad infiltration of the orbital soft tissue

tx: medical emergency! hospitalization, IV nafcillin & metronidazole// surgical drainage if reoccur

Ingesting harmful substances (poisonings)

What poison produce garlic breath?

arsenic and organophosphates

Anticholinergic OD causes:

Tricyclic antidepressants OD:

prolonged QRS complex

Tx for poison OD:

airway
activated charcoal -- GI decontamination**

Antidote for acetaminoophen:

Antidote for Aspirin (salicylates):

activated charcoal, whole-bowel irrigation, physostigmine

Antidote for Organophosphates (chlorthio, diazinon):

decontamination of skin, atropine + pralidoxime

Antidote for Iron:

evoke emesis, gastric lavage, whole-bowel irr,
*Desferoxamine, Dialysis

Dermatitis -- eczema:

dermatitis - ex-; eczema - endogoenous

acute - well-demarcated erythema; chronic -plaque, satellite papules

dx: patch test
tx: burrow's solution, topical corticosteroids

dermatitis -- seborrhea:

infants -cradle cap; adult- dandruff
yellow-greasy look

tx: baby shampoo/ketoconazole; selenium/zinc

Nummular eczema:

pruritic inflammatory dz - young, old
fall/winter, coin-shaped plaques - extremities

tx: moisturizers or topical steroids

>40 yo with actopic hx
tapioca-like, vesicles/clusters

tx: burrow's solution, bullae-drained but kept intact, topical collodion

Lichen simplex chronicus

lichenification --long-term atopic dermatitis -- repetitive scratching/rubbing

well-circulated plaque

tx: stop the itch-scratch cycle; dressing/topical steroids, tar, anti-histamine

4P's: purple, polygonal, pruritic, papule; Wickham striae=white lines

hair-scarring alopecia; nail -longitudinal splintering

lab: biopsy*, immunoflurescence; check Hep C
tx: topical steroids, cyclosporine mouthwash

Pityriasis rosea

herald patch follow by Christmas tree; teenagers
hx:URI, rash
tx: self-limited

genetic, HIV - resistant tx
epidermal cell turnover - fast
"silvery scales" Auspitz sign - bleeding

tx: topical corticosteroids/ vitamin D, calcipotriene, coal tar/salicylic acid - dressing

Erythema multiforme

induced by drugs - sulfa.. pt <20yo;

tx: avoid substance; control herpes outbreaks- acyclovir

Stevens-Johnson syndrome/Toxic epidermal necrolysis

mucocutanous/ flaccid blisters-Nikilsky sing -- drug reaction - sulfa, aminopenicillins..
tx: burn unit

Bullous pemphigoid

autoimmune dz; - Nikolsky sing - dot rupture easily

dx:biopsy tx: systemic Prednisone, azathiprine

adolescents/males
"comadones"

tx: mild - retinoids, azelaic acid; more severe - tetracycline; isotretinoin

F 30-50; telangiectasis, flushing

tx: reduce triggers-alcohol, hot beverages; metroindazole**

Actinic keratosis

cumulative exposure to the sun - fair skin ppl
thickened lesions progress very slow to -- SCC; cutaneous horn

tx: liquid nitrogen

Seborrheic keratosis

benign plaque; brown or black; velvety, warty surface --"stack on", older ppl

tx: liquid nitrogen

dx: microscope/nits
tx: prevention*, permethrin, pyrethrins, malathion -1st-line tx

tx: 1% lindane or 5% permethrin cream -- 8hrs -- repeat in 7 days

brown recluse - Loxosceles reclusa --tx: analgetics
black widows - neuro -- tx: diazepam and calcium gluconate

Basal cell carcinoma

tx: mohs mirographic surgery

Kaposi's sarcoma

superficial spreading **
nails - acral lentiginous
tx: refer to derm/surgeon

loss of hair;
androgenetic alopecia - male/genetic - tx: minoxidil solution
alopecia areata -- unknown - exclamation point hairs; scalp - tatalis, body -uviversalis -- tx: systemic steroids

Condyloma acuminatum

Molluscum contagiosum

poxvirus
tx: self limited; curettage-1st line;

HPV 16-18 - CA
condylomata - genital
tx: spontaneous regression; salicylic acid

vaccine females -9-26yo

H. flu, Strep, staph
swollen, hot, tender

tx: oral penicillinase-resistant penicillin -- dicloxacillin* or cephalosporin; if pt allergic - erythromycin

Acanthosis nigricans

obesity, insulin resistance
tx: no ; addressing underlying dz

Hidradenitis suppurativa

female - axillary dz; male -anogenital dz
obesity; abscess, fibrosis..
tx: intralesional triamcinolone, I&D

Lipomas/epithelial inclusion cysts

benign; fat cells; tx:surgical ecision - cosmetic

"black spot"; pregnancy
dx: wood's lamp - hyperpigmented macules
tx: 3% hydroquinone solution + 0.025% tretinoin gel

Pilonidal disease

Pressure ulcers

stage I - erythema
stage II - necrosis, superficial/partial thickness
stage II - deep/full thickness - but not through fascia
stage IV - muscle/bone

food/drug allergies
wheals size pencil eraser
tx: acute - H1 antihistamine - diphenhydramine

associated with thyroid dz, pernicious anemia, DM, Addison dz, or idiopathic
tx: sunscreens, cosmetics; psych distressing

S. qureus; pseudomonas - hot tub
pseudofolliculitis barbae= razor bumps

tx: compresses, topical clindamycin/erythromycin;

Tinea infections

Trihophyton rubrum
dx: KOH prep
tx: antifungal creams BID x4 weeks;
nail - oral griseofulvin x3 months

Tinea versicolor

Malassezia furfur
dx: KOH - hyphae/spore -"spaghetti and meatballs"
tx: selenium sulfide shampoo x15min - 7 days

Pharyngitis/tonsillitis

viral than bacterial; group B-hemolytic strep
fever >38, tender anterior cervical adenopathy, lack* of cough, exudate -- Centor criteria

dx: rapid strep sccreen
tx: IM penicillin -compliance issues; oral penicillin (erythromycin - if allergic)

Acute/chronic Sinusitis

tx: NSAIDs -pain; saline washes, steam;
antibiotics only for -- 10-14days symptoms

Aphthous ulcers

painful, round ulcer -yellow-gray center; red-halos
buccal/labial mucosa

chronic inflammation of lid margins; cause:seborrhea, staph/strep
scurf & collarettes

tx: baby shampoo on catton-tipped swabs

viral Conjunctivitis

adenovirus; highly contagious**
swimming pools - epidemic keratoconjunctivitis

*erythema, copious watery discharge
tx: eye lavage with normal saline BID x7-14 days/vasoconstrictor-antihistamine drops

bacterial conjunctivitis:

strep pneumonia -- development keratitis
chlamydia (mocopurulent/follicular) & neisseria -sex/delivery
* copious purulent discharge "glued"
dx: PMNs
tx: drops - sulfa, fluoroquiinolones, aminoglycosides

lacrimal gland caused by obstruction
cause: staph..
tx: warm compresses and antibiotics

s. aureus; contagious
tx: warm compresses x 24hrs

acute severe* vertigo, hearing loss -days to weeks
hearing loss may/not resolve
tx: vestibluar suppressants

viral follows URI; bacterial - M.cat, H.flu
hoarseness**
tx: vocal res; if bacterial - erythromycin

cause: pseudomonas, proteus, fungi

tx: otic drops - aminoglycoside or fluoroquinolone +/- corticosteroids, avoid moisture

cause: strep pneum., H. influ, M. cat, Strep pyogenes
tx: amoxicillin

Tympanic membrane perforation

from otitis media or trauma

tx: resolve on their own; sometimes surgical repair of TM; ossicular chain - persistent hearing loss

avoid water

eyelid everts* - advanced age, trauma, infection or pasly of facial n.

lid and lashes are turned in secondary to scar tissue or a spasm -- orbicularis oculi muscle

Tx for ec/entropion

surgical repair - if causes trauma "trichiasis", excessive tearing, exposure keratitis, cosmetic

Corneal abrasion

minor trauma - fingernails, contact lens, eyelashes, small foreign body

dx: record visual acuity before exam; slit-lamp or fluorescein stain

tx: topic anesthetic -just for exam; saline, gentramicin* or sulfa; patching only for L >5-10mm x 24hrs

trauma, contact lens, poor lipid apposition -- circumcorneal injection and watery to purulent discharge

dx: dense corneal infiltrate w/epithelial defect; "Dendritic" lesion - herpis keratitis

tx:referred to an opthalmologist

increased intraocular P; optic n. damage -- impediment flow - canal of Schelemm - anterior chamber

Open-angle glaucoma

more common*/chronic
>40yo pt, AA, fam hx, DM

peripheral vision loss; increased cup-to-disc ratio; ocular HTN

tx: B-blockers; prostaglandin-like medications

Angle-clouse glaucoma

emergency -- complete closure of the angle
painful eye; loss of vision

circumlimbal injection, steamy cornea, fixed mid-dilated pupil; N&V

tx: IV carbonic anhydrase inhibitor - acetazolamide, topical BB, and osmotic diuretics- mannitol
mydratics*

Macular degeneration

age related or secondary to - drugs -chloroquine or phenothiazine

irreversible central* vision loss

drusen deposits -- Bruch membrane -- hemorrhage/fibrosis

Metamorphopsia -- Amsler grid**

tx: not effective tx; early - laser therapy

increased intracranial P -- malignant HTN, hemorragic strokes, SDH, pseudotumor cerebri

disc swollen, blurred, obliteration of the vessels
tx: therapy for the underlying cause

slowly growing thickening of the bulbar conjunctiva

highly vascular, triangular mass -- toward cornea

tx: excision -- if interferes with vision

Retinal detachment

flapping in the vitreous humor - "rugae"
superior temoral* retinal

"curtain being drawn over the eye from TOP to the bottom" floaters or flashing lights

tx: emergency -- pt supine head turned to side of detachment; laser surgery

Retinal vascular occlusion; ARTERY

artery -- emergency - emboli - poor prognosis

painless vision loss; "box-carring", cherry red spot, blindness
tx: vessel dilation/paracentesis

Retinal vascular occlusion; VEIN

secondary to thrombotic event; risk:DM, polycythemia, leukemia
"blood and thunder: retina; dilated veins, hemorrhages, edema, exudates
tx: neovascularization -- injection VEGF inhibitors

hypertensive -- diffuse arteriolar narrowing, copper/silver wiring, AV nicking- atherosclerosis

diabetic -- leading cause BLINDNESS** -- yearly dilated ophthalmoscopic exam;
hard exudate , venous dilation..

tx: glucose, BP control, laser phtocoagulation, vitrectomy

Ménière disease

vertigo - min to hrs; lower range hearing loss, tinnitus*, one-sided aural pressure

tx: low-sodium diet and diuretics - Acetazolamide

Allergic rhinitis

IgE -- pollen, molds, dust..
atopic dz hx; "bluish discoloration below the eyes", allergic salute

tx: avoid allergens; antihistamines, cromolyn sodium

** anterior -Kiesselbach plexus
risk- nose picking

posterior - Woodruff --HTN, atherosclerosis

tx: Anterior -- pressure sitting position leading forward -lessen swallowing of blood

Samter triad -- hx nasal polyps, asthma, aspirin

tx: 3m -topical corticosteroids

Peritonsillar abscess

"hot potato" voice, deviation of uvula
tx: aspiration, I&D, amoxicillin

dx: FEV1/FVC: <75%; 10% increase in FEV1 after bronchodilator

tx: B-adrenergic agonist- rescue; inhaled croticosteroids --chronic use

caused by viruses: rhinovirus, coronavirus, RSV

inflammation of the airway, cough
dx: sputum color does not* predictive; no labs; CXR - NEGATIVE

tx: hydration, expectorants, analgesics, b-agonist, cough suppressants (not for kids)

dx: FEV1/FVC ratio decrease; CBC -polycythemia

Tx: smoking cessation - Most important **, O2 of PaO2<55

** primary cause of mortality from infectious dz
S. pneumorniae

tx: macrolide -- clarithromycin, azithromycin or doxy --OUT pt

mycoplasma pneumoniae
tx: erythromycin or doxy

tetracycline (for chlamydia)

Hospital-acqquired PNA:

S. aureus; pseudomonas

tx: ceftriaxone, rep fluoroquinolone, imipenem

PNA HIV related:

Strep **, penumocystis jirovieci

tx: Trimethoprim-sulfa = Bactrim

dx: cxr - Ghon & Ranke complexes
biopsy -- caseating granulomas - nacrotizing granulomas

tx: isolation, INH, RIF, PZA, EMB 2m; follow by 4m

Bronchogenic carcinoma** - leading cause of CA deaths; risk - smoking

SCLC "oat cell" - spread early -- central bronchi/metastasize

NSCLS -- slow -- SCC -hemoptysis; Adenocarcinoma* - mucous glads; Large CC - does not fit -- tx: SURGERY

Sleep disorders

Tobacco use/dependence

diuretics; Thiazide -1st line; loop - renal

B-Adrenergic antagonist -- young/white pts

ACE inhibitors -- DM, CKD (young/white pts)

Angiotension II receptor-blocking agents -- no cough

Calcium channel blockers -- blacks and elderly

aldosterone receptor antagonists -- spironolactone

prostatic hyperplsia

alpha- adrenergic antagonist

fenoldopam (dopamine-1 receptor)

during pregnancy

Coronary artery disease

tx: IV fluids, O2, NTG 0.4mg every 5min x3 doses, bed rest

Peripheral vascular disease

atherosclerosis -- CVA
Leriche syndorme -erectal dysfunction
tx: d/c tabacco; BB, ACE inhi, statins

A-fib**
tx: >48hrs -- tx: heparin or enoxaparin -- rate control 3-4 weeks; cardioversion

HF -- digoixin, amio, dronedarone
no HF - metoprolol or esmolol

viral ** tx: steroids, NSAIDs
bacterial - Strep viridans; IV users - S. aureus , post valve surgery - gram-/fungi -- tx: Gentromycin with ceftriaxone or vanco

Hypertriglyceridemia

Congestive heart failure

tx: ACE inhibitors

Valvular disease

AS -- Left side heart;
dyspnea, fatigue, decreased exercise tolerance
tx: surgical repair, PCI -ballon
meds - diuretics, vasodilator, digoxin/ BB

GASTROINTESTINAL

colonic polyps can cause:

iron anemia -- bleeding polyps

types of colonic polyps:

hyperplastic polyps -- low risk
tubular polyps -- carry risk --follow up x5years

*** villous polyps -- high-risk of malignancy -- follow up colonoscopy 3y

Family members of those with familial polyposis syndrome should be eval:

every 1 to 2 years
beginning @ 10-12yo

Colorectal cancer

>50yo; HNPCC or Lynch syndrome - high risk; familial polyposis - 100% risk

Prognosis of colorectal CA:

Dukes A/Stage I -- mucosa - good

Duke C/Stage III - +lymph // D/IV - metastases -- 5 y --5%

Clinical features of colorectal CA; Right vs. Left lesions:

Right-- chronic blood loss -Iron def

Left -- circumferential -- change of bowel habits

Diagnostic studies & tx for Colorectal CA:

occult blood in the stool -- screen >40yo
colonoscopy -->50yo; 10y earlier fam hx

tx: surgical resection + chemo-stage III
radiation - rectal tumors

Anal fissure; most common location? symptoms?

Posterior midline**

severe tearing pain on defecation -- hematochezia-- bright red blood; stool/tissue

Tx for anal fissures:

bulking agents & increase fluid-avoid straining;

Sitz baths - acute pain;
silver nitrate/genital violet -- healing

Peptic ulcer disease; most common cause? Primary clinical features? gastric ulcer vs duodenal ulcer?

H.pylori ** associated to malignancy

abdominal pain or discomfort;
gastric - worse after food/wight loss
duodenal - better after food

PUD & bleeding:

melena ***
** most common cause of nonhemorrhagic GI bleed

dx: Endoscopy

tx: stop irritating factors-smoking, NSAIDs, Etoh;
PPI w/ clarithromycin + amoxicillin + metronidazole -- 2-4 weeks

Prophylactic tx for pt with hx of PUD who require daily NSAIDs use:

misoprostol or PPI

List diff causes of Gastritis (inflammation of stomach):

autoimmune -pernicious anemia - Type A - BODY of the stomach

H. pylori - Type B - ANTRUM/body -- adenocarcinoma

NSAIDs, stress, Etoh

Gastritis dx; tx:

dx: endoscopy with biopsy

tx: removal of causative factor: NSAIDS, alcohol..

What is Gastroenteritis?

stomach flu; VIRAL- norovirus, rotavirus; watery diarrhea

define Diarrhea; tx:

3 or more liquid/semiliquid stools DAILY for @ least 2-3 days

hx of ALL current meds*

dx: WBC in stool - inflammatory process
tx: supportive

define Secondary diarrhea; what does it indicate?

large volume without inflammation;
Pancreatic insufficiency --bacterial toxins/laxative use

Tx for C-diff diarrea:

metronidazole, vanco, fidaxomicin

Define constipation; when do you worry; tx?

decrease stool volume; increase firmness

**pt >50yo -- new-onset -- colon CA

tx: increase in fiber (10-20 g/day); fluid -(1.5/2L day); exercise;
>2 weeks - investigate

Pancreatitis; most common cause? clinical features?

cholelithiasis or alcohol abuse

epigastric pain radiating to the back; lessens when pt leans forward; N&V

Hemorrhagic pancreatitis:

bleeding into the flanks=Grey Turner sign;
umbilical area = Cullen sign

Pancreatitis dx; tx?

dx: Elevated LIPASE** X3fold; amylase
ranson criteria - poor prognosis
tx: stop oral intake, IV fluid/hyperlimentation; opioid; antibiotic

Inflammatory bowel disease; Crohn vs. UC:

Crohn dz -regional -mouth to anus; Transmural; fistulas TX: oral corticosteroids=PREDNISONE

UC -- distal-proximal-cont; Mucosal surface; bloody-puss filled; colon CA; TX: aminosalicylates/steroids;Surgery-cure

What is the most common cause of Appendicitis? dx;tx?

fecalith**
McBurney point; Psoas sign

dx: leukocytosis; CT
tx: appendecotomy

Gastrointestinal bleeding

Stages of internal hemorrhoids*:

Stage I - confined to the anal canal - bleed with defection

Stage II -protrude -reduce spontaneously --bleeding/mucus*

Stage III - require manual reduction -- pain/discomfort

Stage IV - chronically protruding/risk strangulation

Treatment for hemorrhoids:

Stage I &II -- high-fiber diet/increase fluids; Bulk laxatives

higher stages -- suppositories w/anesthetic/astringent properties

Stage IV -- SURGERY (injection, rubber band ligation/slerotherapy)

Bowel obstruction; small vs. large;

small -- adhesions or hernias
large - neoplasm

Bowel obstruction clinical features; dx; tx?

high pitched abdominal sounds

dx: dehydration/electrolyte imbalance;
x-ray- air-fluid levels/dilated loops

tx: NPO, NG sxn, IV fluids, monitoring
mechanical obstruction -- urgent surgery

Viral hepatitis; clinical features; dx; tx?

tea-color urine, vague abdominal discomfort

dx: aminotransferase elevated; bilirubin >3; HBsAg -ongoing infection; anti-HBs -acute hepatitis

tx: supportive

liver cancer**; + pruritus -- primary sclerosing cholangtitis

Cholecystitis/cholelithiasis

cholelithiasis- gallstones

Cholecystitis - obstruction of the bile duct-colicky epigastric RUQ pain, right shoulder; after fat meal

cholelithiasis dx; tx?

dx: HIDA scan/ ERCP; bilirubin levels increase; leukocytosis

tx: surgery

irreversible fibrosis/nodular liver
alcohol**
dx: labs-minimal abnormal; anemia, AST
tx: abstinence form alcohol

Giardiasis and other parasitic infections

flagellate protozoan Giardia lamblia

* foul-smelling, greasy stools
tx: Metronidazole

acid reflex; tx: large -surgery

Gastroesophageal reflux disease

dx: hx heartburn/regurgitation; endoscopy

tx: H2 blockers - cimetidine; PPI**-omeprazole -- first-line M/S - AM

Irritable bowel syndrome; dx;tx?

functional dz/psych; ** most common cause of chronic abdominal pain
dx: labs normal tx: reassurance

rare; immunocompromised pt
Candida sp, CMV..

** odynophagia-painful swallowing; or dysphagia=difficulty swallowing

Esophagitis dx; tx?

endoscopy; CMV/HIV - large, deep ulcers; HSV -shallow ulcers; Candidal -white plaques

** cytology/culture- endoscopic brushing -defefinitive

tx: CMV -IV ganciclovir; HSV- acyclovir; Candida -fluconazole or ketoconazole

Inguinal Hernias

indirect** = passage of intestine through the internal inguinal ring down the inguanal canal-srotum

direct = external Hessselbach triangle
tx: surgery

bladder infection; coliform bacteria -E-coli

dx: pyuria, bacteriuri, hematuria; culture +

tx: fluoroquinolone or nitrofurantoin x3-5 days;
resistant -- trimethoprim-sulf

kidney infection; DM & elderly women

Dx: CBC left shift UA: WBC cast

tx: fluoroquinolone or trimethoprim-sulfa -- 1-2 weeks**

Glomerulonephritis
(inflammatory proteins in the glomerular membrane)

kids** 2-12yo

hematuria -- tea/cola urine**
edema face/HTN

dx: ANO-titer - Strep infection; UA: >3RBC

tx: steroids & immunosuppressive drugs

Nephrolithiasis

** calcium
upper ureter = anterior abd
lower part = ipsilateral groin, testicle/libia

dx: heliacal (spiral) CT
tx: <5mm - pass spontaneously
>10mm -- not likely to pass - Ureteral stent or percutaneous nephrostomy***

Benign prostatic hypertrophy

60-65 yo male; LUTS -45
Dx: PSA slightly elevated; DRE -enlarged prostate

tx: watchful/wait; alpha-adrenergic agonists -prazosin

Gram -; chronic pelvic pain syndrome

dx: sudden fever, chills.. UA -pyuria; e-coli

tx: Cipro 500mg BID or Levo 500mg Daily -- 2-6* weeks //culture urine in 1 week

<35- chlamydia --tx: ceftriaxone 25omg IM + doxy BID x7days

>35 e-coli --tx: cipro 500mg BID x10-14 days

heavy lifting/trauma/sexual
enlarged scrotal mass

** Prehn sign

screen every women <26yo; new sex partner x60days; >2 partners

vaginal discharge

dx: cervical swap; UA -men
tx: ceftriaxone IM ** tx chlamydia as well

most common STI in US**

tx: Azithromycin or Doxy
no sex 7 days!!

-With discharge␣think gonorrhea or chlamydia

Reactive arthritis; Urethral carcinoma Men: balanitis
Women: candidiasis, cystitis

pospubertal males -- mumps
testicular swelling, unilateral;fever, tachycardia

dx: UA, cultures, US** - r/o mass
tx: mumps --ice and analgesia

Testicular cancer

*** seminomatous
* painless solid testicular swelling/para-aortic lymph node

dx: scrotal US - suspicious intratesticular echogenic focus

tx: Stage I - radiation therapy; IIc/III - chemo

MUSCULOSKELETAL SYSTEM/ RHEUMATOLOGY

Acute and chronic lower back pain

**prolapsed intervertebral disk and low back strain

Costochondritis

Bursitis/tendonitis

subacromial; prepatellar/subpatellar= housemaid's knee

tx: precipitating factors, rest, NSAIDs, and steroid injections

Rheumatoid arthritis

Reactive arthritis

pannus

dx: ESR, CRP -elevated; RA and anti-CCP

tx: methortrexate** (DMARDs), NSAIDs

pain WORSE THROUGHOUT the day
DIP= Heberden nodes
PIP= Bouchard nodules

dx: osteophytes
tx: acetaminophen **

**podagra - attack of the MPJ of the great toe

chalky deposits of urate crystals

How do you dx, tx Gout?

dx: joint fluid analysis - rod-shaped negatively birefringent urate crystals
radiograph - small, punched out lesions and interosseous tophi

tx: elevation/rest; decrease purines/alcohol intake
**NSAIDs - indomethacin 25-50mg TID

Systemic lupus erythematosus

AA women;
dx: Smiths antigen, double-stander DNA* ; ANA*

tx: exercise and sun protection; NSAIDs, antimalarials=hydroxychloroquine

dx: DEXA

tx: bisphosphonate -- empty stomach -sit upright x3omin

central pain above/below the waist that is bilateral and axial for x 3 months

dx: no labs; T-cell subsets

tx: SSRIs; Pregabalin (Lyrica) **

Plantar fasciitis

runners/overweight pts
miro tear in the plantar fascia @ calcaneal;
pain with first step AM
inflexible achilles tendes

Plantar fasciitis; dx; tx?

dx: radiology -normal/or calcaneal fx/bone spur
MRI - calcifications of the plantar fascia

tx: 6-12m - PT -stretching of the plantar fascia - massage with tennis ball

Overuse syndrome

REPRODUCTIVE SYSTEM

primary - 2 y of menarche - no* patho
secondary - endometriosis, fibroids..

dx: primary -- basis of hx and PE
secondary -- target possible PELVIC* patho

dx: start NSAIDs just before the expected menses --continue 2-3days; secondary - tx underlying cause

Dysfunctional uterine bleeding

uterine bleeding -absence of anatomic lesion -- cause hormonal **

dx: HCG -1st r/o pregnancy; Progestin trial - bleeding stop - anovulatory cycles

tx: oral contraceptives

Bacterial Vaginitis

fish odor/bubbly gray discharge;

dx: Wet prep: clue wells, alkaline pH; Whiff test

tx: metronidazole or clinda cream

Trichomoniasis:

purulent discharge, strawberry cervix

dx: Wet prep: trichomonads

tx: 1 dose metronidazole

Yeast vaginitis:

candida albicans
cottage cheese discharge

dx: KOH wet prep
tx: 1 dose butoconazole or fluconazole

Atrophic vaginitis:

thinning/shrinking of tissues/decrease estrogen

dx: - wet prep
tx: estrogen replacement therapy

Pelvic inflammatory disease

dx: DNA probes** -- for gonorrhea and chlamydia
tx: mild -- out pt antibiotics, IUD removal
severe --IV antibiotics

fibrocystic changes - cysts, papillomatosis..

suspected cysts -- fine needle aspiration - straw-color fluid
tx: no tx, supportive bra

2nd most common benign breast disorder; black women:

fibroadenomas -- round, firm, smooth, mobile;
<25yo -- biopsy

** infiltrating ductal carcinomas
Upper outer quadrant -- immobile mass

dx: mammography ** best screening tool
tx: lumpectomy (I-IIB -cure);
tamoxifen -postmenapasal women

Grading of prolapse:

1= descent between normal position and ischial spines
2= hymen
3= within* hymen
4= through* hymen

Tx for cystocle/retocele:

pelvic floor exercises, vaginal pressaries, surgery

dx: FSH>30
tx: exercise,
combined hormone rep. therapy - increase risk cardiovascular dz, breast CA

Intrauterine pregnancy

** fallopian tube
occlusion 2nd to adhesions

dx: hCG titer >1,500 - should show baby -- if not than it's ectopic

tx: methotrexate** - hCG <5,000; mas<3.5 cm;

oral hormonal - most effective **

Cervical cancer

HPV 16,18, 31,33 --CIN

CIN -1 -- moderate dysp; CIN 2- severe dys; --20's
CIS - carcinoma in situ -- 25-35
CA->40

Cervical CA dx; tx:

dx: pap smear, liquid-based specimen -- 3 years before sex; or age 21

abnormal cytology -- colposcopy & biopsy **
tx: electrocautery or cryocautery

Gardasil or Cervarix -- 11-12yo-- x3 over 6months

avaible to all women 9-26yo

Spontaneous abortion

termination of pregnancy BEFORE 20 weeks; ** chromosomal abnormalities

tx: no longer viable - uterus must be emptied; if pregnancy early - managed expectantly - allow the products to pass

Differential
** Neuro: acoustic neuroma, TIA, stroke, Parkinson's, neuropathy, migraine

Cardiac arrhythmia --#1 cause!

Seizure disorders

status epilepticus ->5min

tx: IV Diazepam or lorazepam

loading dose of -- phenytoin

In generalized NONCONVULSIVE seizures, EEG typically shows:

generalized bilaterally synchronous and symmetric 3-Hz spike-and-wave activity

Generalized Convulsive, Simple/Complex partial seizures typically are treated with:

carbamazepine, phenytoin, and valproic acid

What two medications used for Generalized nonconvulsive=absence seizures?

valproic acid or ethosuximide

Transient ischemic attack

few min- resolve completely/no infarction
1/3 will have stroke in 5 y

dx: noninvasive transcranial Doppler and duplex ultrasound; conventional angiography** - definitive

tx: prophylactic antiplatelet therapy -- aspirin; prophylactic antiplatelet therapy -- aspirin

Cerebral vascular accident

risk factor: HTN;
type: ischemic;

dx: CT; LP -hemorragic

tx: thrombolytic therapy x3hrs

Alzheimer's disease

patho: intracellular neurofibrillatory tangles and extracellular neuritic plaques

tx: delay dz - Acetylcholinesterase inhibitors= tacrine; severe dz= Memantine (NMDA)

Parkinson's disease

patho: substantia nigra--deficiency of the neurotransmitter dopamine

micrographia* - diff hand writing; "pill-rolling"; slow shuffling gait, cogwheel rigidity

tx: Levodopa (cardidopa +); arrest -selegiline

Essential tremor/ (aka familial tremor)

hands, head; manual skills/speech
enhancement with emotional stress relieved with alcohol

dx: No other abnor.; Refer to neurology to r/o

Tx: Propranolol*

Right side; pregnant, DM;
CN 7 ; forehead +face

dx: clinical
tx: lubrication eye drops -- prevent corneal drying/ oral prednisone

Headaches: tension**

most common;
tx: simple analgesics -- aspirin, acetaminophen, or NSAIDs

tx: 100% oxygen; sumatriptan (IM)

prophylactic: verapamil ***

tx: triptan* - cumtriptan;
isometheptene

micro: STIC
macro: folate, B12 def

Sideroblastic anemia:

lead toxicity, Etoh -- iron accumulation -mitochondria

dx: hct 20-30%, lead= basophilic stippling of RBCs

tx: chelation therapy; transfusion

asian
alpha - HgH dz -hydrops fetalis
beta=Cooley

Thalassemia dx, tx:

dx: electrophoresis*
tx: Folic acid

(avoid iron, oxidative drugs)

most common**
GI bleed; PUD, NSAIDs
Pica, Plummer-Vinson syndrome

Iron Anemia dx; tx:

dx: ferritin <20**

tx: ferrous sulfate 325mg TID per day- on empty stomach; vitamin C -absorption

Chronic inflammation:

neopastic dz; autoimmune -- rheumatoid arthritis, lupus;

dx: elevated CRP or Westergren ESR
tx: underlying cause

Folic acid def anemia:

poor dietary intake; meds=phenytoin, trim-sulfa
*sore tongue -glossitis

Folic acid def anemia dx, tx?

dx: macro-oval and hyperseg. polymorphonuclear** cells

Howell-jolley bodies -nuclear DNA
folate <150

tx: 1mg/day folic acid (oral)

B12 def anemia:

pernicious anemia --lack of intrinsic factor

dx; hyperseg neutrophils -6 lobes; increased LHD/indirect bilirubin;
B12 low, Schilling test ***

tx: B12 1,000 IM monthly - lifelong

dx: Heinz body-denatured hemoglobin

tx: self-liminted; oxidative drugs/fava beans avoid

Leukemia; acute

tx: induction chemo

more common; deoynucleotidyl transferase

Leukemia; chronic

most common**

dx: clonal malignancy of B lymphocytes; isolated lymph >20,000; Smudge cells

tx: palliative :(

hiladelphia chromosome; myeloprolife dz

tx: Imatinib mesylate=Gleevec **

Thrombocytopenia

low plates -- 100,000-15
50,000 -- petechiae, nose, gums bleed

tx: ITP - resolves spont. -- corticosteroids/splenectomy

TTP & HUS - plasma exchange

Clotting disorders

vWD -- most common - lack factor 8

Hodgkin & non-Hadgkin

Reed-Sternberg cells ;

Epstein-barr virus;pain after alcohol

tx: chemo

non-Hodgkin dz:

B-cell lymphoma; enlarged nodes

tx: radiation alone

genetic; JAK2 mutation;
increased RBCs # and volume

secondary cause: chronic hypoxia, smoking, renal tumors

Polycythemia; dx, tx?

dx: hematocrit -54%, thrombocytoisis, epo decrease

tx: phlebotomy

Diabetes mellitus; type II

dx: random glucose > 200
fasting glucose >126, HbA1C >6.5

tx: metformin - reduces hepatic glucose producation; Cr >1.5; lac acidosis

thiazolidinediones = pioglitazone

without risk of hypoglycemia
contraindicated in CHF pt, liver dz

bladder CA :(

alpha-Glucosidase inhib =acarbose

blocking the enzyme -- GI symptoms

DPP-4 inhib = saxagliptin

stimulate insule sec; pencreatitis/urticarai/agioedema:(

Adrenal insufficiency

Addison disease **
autoimmune - adrenal cortex
hyperpigmentation

dx: hyperkalemia; 8am low cortisol; elevated ACTH >200

tx: corticosteroids and mineralocorticoids

Cushing's disease

ACTH excess -- anterior* pituitary microadenoma

dx: overnight dexamethasone suppression test -<5 -no;
24-hour urine collection for cortisol/Cr
Somatostatin**/MRI

tx: transphenoidal selective resection

Hyperthyroidism

** Graves dz;

toxic mutinodular goiter -secondary

Hyperthyroidism; dx; tx?

dx: low TSH; peroxidase/thyroglobulin antibody +, RAIU - increase reuptake

tx: B-blocker -- propranolol; PTU -prego; MMI

elderly; iodine-def; DM

** Hashimoto thyroiditis
secondary - Sheehan syndrome

clinical features: myxedema, iron def, Down pt

Hypothyroidism; dx; tx?

dx: elevated TSH

tx: Levothyroxine 25-200 mg daily;
T4 - needs increase in 3rd trimester of pregnancy

INFECTIOUS DISEASES

Epstein-Barr virus
"kissing dz"
splenomegaly, "pseudocroup"

Mononucleosis; Dx; tx?

dx: granulocytopenia - darker, vaculolated stain; heterophile antibodies, screening mono - usually + 4 weeks

false + sphilis test - VDRL -10%

tx: nonaspirin antipyretics; avoid contact sports

Lyme disease; cause? stages?

borrelia burgdorferi -- ixodides tick

stage 1 -- erythema migrans "bull's eye"
stage 2-- pericarditis, aseptic meningitis, bells palsy
stage 3 -- join pain // acrodermatitis chronicum atrophicans - blueish-red - europe

Lyme disease dx; tx?

dx: immunofluorescent assy or ELISA;
Western blot - confirm

tx: Doxycycline

dx: two -- ELISA test + Western blot

orthomyxovirus
type A**
Reye syndrome -- fatty liver with encephalopathy

dx: leukopenia, proteinuria; CXR -diffuse infiltrates

tx: zanamir inhalation= Relenza; oseltamivir=Temiflu x48hrs

enterica" --food/water
enteric=typhoid fever

"pea soup" diarrea/hemorrhage

tx: ceftriaxone or fluoroquionolones -not for kids/pregos

What is the most common form of Salmonellosis?

Gastroenteritis ***

tx: self-liminted;
sick-cell pt -tx: TMP-SMX

blood and MUCUS stools

dx: leukocytes, RBC; culture
sigmoidoscopy- inflamed engorged mucosa, punctate lesions/uleras

tx: fluid; TMP-SMX

PSYCHIATRY/BEHAVIORAL SCIENCE

tx: 4-6 weeks; >6m effect
SSRIs fluoxetine, paroxetine, sertraline

side effects: GI upset, headache, sex dysfunction

Generalized anxiety disorder

tx: SSRIs, sNRIs, buspirone

benzos- short-term;
behavioral and insight-oriented therapy

tx: acute - benzo -alprazolam or larazepam

SSRIs -- paroxetine, fluoxetine, venlafaxine, sertraline

most common dz**
agoraphobia - places, malls

tx: SSRIs -- paroxetine;
B-blokers -propranolol -- tremors

Post traumatic stress disorder

tx: SSRIs - sertaline, paroxetine
short - Benzos

trazodone - benzos

less than 85% of expected weight for heigh; BMI<17.5

tx: family member *
nutritional state; hospitalization if - more 20% below body wight

SSRIs -fluoxetine

Substance abuse disorders

alcoholist -- tx: 12-step program AA; Al-Anon-family

alcohol withdrawal - benzo - diazepam=Valium; antipsychotic -haloperidol

opioid - naloxone

nicotine - bupropion or varenicline

marijuana -- haloperidol

Domestic violence

optons and allowed to decide which path to take

70% greater risk of being killed by leaving abusive partner

bacterial meningitis

strep pneumonia, Neisseria men; Group B-babies

dx: LP; CT before LP
WBC elevated, protein high 100-500; glucose low

tx: Adults >55, Etoh, -- ampicillin + cefotaxime + vanco

treatment for PAD

which medication can cause 2nd degree mobitz 1 weinkebach

pt is tx for hypertension and suffered from an acute MI, which med is contraindicated

nocturnal dyspnea, S4

left ventricular diastolic heart failure

orthohypotension physiology

decreased venous return

Pt c/o cold pain, what is the next best diagnostic step

decreased venous return

new onset Afib after drinking lots of alcohol

cardiovert within 48 hours

test that would indicate emphysema

FEV1/FVC <0.7 after bronchodilation

low CBC
MCV=10
low serum ferritin

aplastic anemia?

unilateral ovarian swelling
uterus with masses

cervical cancer is most commonly caused by

condyloma lata secondary to HPV

scentless vaginal discharge with no clue cells on smear

mastitis etiology

painless hematuria

renal cell carcinoma

which race increases the risk for prostate cancer

african american

blood diarrhea and tenesmus

treatment for c. diff

celiac vs IBS test to order

H pylori gastritis treatment

clarithromycin, amoxicillin, PPI x 14 days

pt has history of celiac disease. which skin manifestation may present

dermatitis herpetiformis

ipsilateral UE numbness

non-gonococcal vs gonococcal

arthralgia differentiates gonococcal from non-gonococcal

stress fracture in young female runner

pt has an acute gout attack, what treatment is c/i?

Pt c/o lower back pain that's relieved when leaning forward

spinal stenosis

bitemporal hemianopsia

pituitary tumor

absent seizure on EEC

spike and wave form

vision changes for 36 hours, afferent pupillary defect, change in color vision

pregnant hyperthyroidism treatment

most commonly result in patient with goiter

most common side effect of glyburide/glipizide

use lidocaine to kill

5 y.o unilateral green nasal discharge

otitis externa etiology

kissing tonsils treatment

rash on cheeks and back of baby

treatment for impetigo

bactriban topical

treatment for longterm GAD

treatment used for mood stabilizer

pt on tartan and takes ibuprofen, what risk

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