0 Family Medicine: 10, 11, 12

Front 1

Risk factors for low back pain.

Back 1

Prolonged sitting, desk jobs, truck driving
Deconditioning
Suboptimal lifting/carrying
Obesity (possibly)

Front 2

Causes of low back pain.

Back 2

Strain/sprain (70%)
Age-related DJD in discs 10%
Herniated disc 4%
Osteoporotic fracture 4%
Spinal stenosis 3%

Front 3

What radiologic findings are associated with low back pain?

Back 3

Spondylolysis (defect in pars reticularis)
Disc space narrowing
Spinal instability
Spina bifida occulta

Front 4

What percent of acute low back pain spontaneously resolves?

Back 4

90% within one month

Front 5

Signs and symptoms of low back pain.

Back 5

Low back pain a/w exacerbation when sitting or bending, relief while lying or standing

Other syx:

Front 6

Lumbar flexion:
Normal is ___ degrees
Pain suggests ______

Back 6

Normal is 90 degrees
Pain suggests herniation, osteoarthritis, muscle spasm

Front 7

Lumbar extension:
Normal is ___ degrees
Pain suggests ______

Back 7

Normal is 15 degrees
Pain suggests DJD or spinal stenosis

Front 8

Lateral motion (back):
Normal is ___ degrees
Pain suggests _____

Back 8

Normal is 45 degrees

Pain on same side as bending suggests bone pathology, such as OA or neural compression

Pain on opposite side of bending suggests muscle strain

Front 9

Difficulty with heel walk is associated with ______.

Back 9

L5 disc herniation

Front 10

Difficulty with toe walk is associated with ______.

Back 10

S1 herniation

Front 11

CVA tenderness suggests ______.

Back 11

Pyelonephritis

Front 12

What does SLR suggest if:
-no pain
-tripod sign (lean backwards and support self with outstretched arms)

Back 12

if no pain, then LBP is functional

If tripod sign, LBP is structural

Front 13

What nerve roots are often impinged in low back pain?

Which are associated with the patellar reflex?

Achilles reflex?

Back 13

L4, L5, S1

Patellar: L3, L4

Achilles: L5, S1

Front 14

How are deep tendon reflexes graded?

Back 14

0: No contraction
1+ dec'd but present (hyporeflexic)
2+ normal
3+ increased (hyperreflexic)
4+ clonus: repetitive shortening of muscle after single stimulus

Front 15

Hyperreflexia is a sign of _______.

Back 15

UMN syndrome a/w SPINAL CORD COMPRESSION

Front 16

How is muscle strength rated?

Back 16

0: No movement
1: flicker of movement, can't move limb
2: voluntary movement, can't overcome gravity (can drag hand across table, but not lift it)
3: voluntary movement, can overcome gravity, but not applied resistance
4: voluntary movement, can overcome gravity, and 'some' resistance
5: normal strength

Front 17

Unequal femoral/brachial pulses suggest _____.

Back 17

AAA

Front 18

Decreased rectal tone can indicate _______.

Back 18

Disc herniation and/or cauda equina syndrome

Front 19

How can you tell whether a patient has tight hamstrings or sciatica?

Back 19

Do straight leg raise, if leg goes to less than 80 without pain, dorsiflex foot:
If pain shoots down leg-->sciatica or disc herniation

If not-->tight hamstrings

Front 20

For L4-S1:
Reflex
Pin-Prick Sensation

Back 20

L3: Patellar reflex, lateral thigh
L4: Patellar reflex, medial leg/ankle
L5: Hamstring reflex, lateral leg, dorsum of foot
S1: Achilles reflex, posterior calf, sole of foot, lateral ankle

Front 21

Low back pain with radiation down leg and numbness indicates _______.

Back 21

Disc herniation with nerve involvement

Front 22

Signs and symptoms of ankylosing spondylitis.

How old are patients that present with this?

Back 22

Morning stiffness and achiness over sacroiliac joint and lumber spine.

Seen in pts 15-40 years old.

Front 23

When are x-rays indicated in low back pain?

Back 23

If pain does not improve after 4 to 6 weeks of conservative treatment or
history of trauma
osteoporosis
prolonged steroid use
weight loss of 10 lbs (malignancy)
history of cancer
drug of EtOH abuse

Front 24

When is MRI indicated in low back pain?

Back 24

Neurologic deficit
Radiculopathy
Progressive major motor weakness
Sudden bowel/bladder disturbance (cauda equina compression)
Failed 6 weeks of conservative care

Front 25

What activity level should be suggested to patients with low back pain?

Back 25

Avoid strenuous activities but remain active

Bed rest is NOT more effective than continuation of ADLs; prolonged bed rest may contribute to muscle atrophy, CV deconditioning, etc.

Front 26

Where does gout usually present?

Back 26

Great toe

Front 27

Where does RA usually present?

Back 27

In three or more joints, often including hands and feet

Front 28

Where does osteoarthritis present?

Back 28

Knees, hips, back

Front 29

What does a locking or popping symptom indicate in knee injury?

Back 29

Ligament or menisci injury

Front 30

Fever and joint pain is suggestive of ____________.

Back 30

Septic arthritis

Front 31

What questions are asked in a PHQ-2?

Back 31

During the past month:
Have you been bothered by feeling down, depressed or hopeless?
Have you often been bothered by little interest or pleasure in doing things?

Front 32

How is Lachman's test performed? What does it examine?

Back 32

Lay supine with injured knee raised/flexed, force applied to tibit to move it anteriorly

If excess anterior displacement-->ACL issue

Front 33

What do the anterior and posterior drawer tests assess?

Back 33

ACL and PCL respectively

Front 34

What do the valgus and varus stress tests assess?

Back 34

Valgus (toward groin): MCL
Varus (away from groin): LCL

Front 35

How is McMurray's test performed? What does it examine?

Back 35

Knee is flexed as much as possible, hold heel, grasp knee, and rotate tibia internally (LATERAL MENISCUS) and externally (MEDIAL MENISCUS)

Front 36

What are the three msot helpful findings in diagnosing carpal tunnel?

Back 36

-Symptoms in thumb, 2nd and 3rd digits
-Decreased sensitity to pain (hypalgesia)
-Weak thumb abduction strength

Front 37

Asymmetric arthritis of large joints

Back 37

OA; with stiffness worse after effort

Front 38

Joint stiffness worse in morning

Back 38

RA

Front 39

Joint stiffness worse after effort

Back 39

OA

Front 40

Monoarticular arthritis

Back 40

Gout

Front 41

Contrast joint aspiration of septic arhtritis vs gout/pseudogout:
Fluid Turbidity
WBC
Crystals (be specific)

Back 41

Septic arhtritis:
Opaque, very turbid
Abundant WBCs: 15K-200K
No crystals

Gout/Pseudogout:
Slightly turbid
Moderate amount of WBC 3K-15K
Crystals:
Gout: Monosodium urate
Pseudogout: Calcium pyrophosphate

Front 42

Anterior knee pain
Mild to moderate pain after prolonged sitting

Back 42

Patello-femoral pain syndrome; likely due to overuse injury rather than trauma

Front 43

Lateral knee pain
Pain aggravated with activity
No effusion

Back 43

Iliotibial band tendonitis; likely overuse injury (repetitive knee flexion)

Front 44

Medial joint line pain
Immediate onset of pain/swelling after misstep/collision

Back 44

MCL Sprain

Front 45

Lateral joint line pain
Immediate pain after varus stress

Back 45

LCL sprain

Front 46

Sudden twisting injury
Mild effusion

Back 46

Meniscal tear

Front 47

In gout/pseudogout, which crystals are:
-negatively birefringent
-positively birefringent

Back 47

negative: gout
positive: pseudogout

Front 48

Synovial fluid is clear, straw-colored

Back 48

Simple joint effusion (osteoarthritis, degenerative injury)

Front 49

Synovial fluid is dark, discolored, bloody

Back 49

Hemarthrosis (acute meniscal tear, ACL/PCL tear)

Front 50

Synovial fluid is dark, discolored, with fat globules

Back 50

Hemarthrosis with fat globules-->osteochondral FRACTURE

Front 51

Is x-ray required to diagnose osteoarthritis?

Back 51

No; knee x-rays are insensitive for detecting early OA and do not correlate well with degree of syx

Front 52

Radiographic features of osteoarthritis

Back 52

Joint space narrowing (best predicts disease progression)
Subchondral sclerosis (hardening of tissue beneath cartilage)
Osteophytes (bone spurs--bony projections arising from joint)
Subchondral cysts (fluid filled sacs in bone marrow)

Front 53

What imaging modality is preferred for diagnosis of meniscal or ligamentous damage?

Back 53

MRI

Front 54

Management of OA

Back 54

Category A:
Water/land based exercise, aerobic walking
NSAIDs, acetaminophen (reduce pain)--Tylenol is first choice
Ultram (older pts with mod to severe pain)
Steroid injections (short term)

Category B:
Hyaluronic acid injections (mixed evidence)
Glucosamine (mixed evidence; some pain relief)
Chondroitin (doesn't decrease pain)
Acupuncture (weak evidence)
S-adenosylmethionine (SAM-e)

Front 55

What is the goal of OA management?

Back 55

Maintain function, not be pain free.

Front 56

When is a nerve conduction velocity study indicated for Carpal tunnel?

Back 56

If syx fail to improve w/conservative tx, motor dysfn, thenar atrophy

Front 57

Colorectal cancer screening:
Age eligibility

Back 57

50-75

Front 58

Lipid disorder screening:
Age eligibility

Back 58

Women 40(?) years and older if at inc'd risk CHD
Men 35 years and older

Front 59

Hypertension screening:
Age eligibility

Back 59

18+

Front 60

According to the USPSTF who should undergo abdominal ultrasound for AAA assessment?

Back 60

One-time u/s in men 65-75 w/hx smoking

DO NOT SCREEN FOR AAA IN WOMEN

Front 61

Who should receive a zoster vaccine?

Back 61

60+

Front 62

Who should receive a pneumococcal vaccine?

Back 62

65+

Front 63

What is the most common sexually transmitted bacterial infection in the US?

Back 63

Chlamydia

Front 64

Who should be screened for chlamydia?

Back 64

Category A:
All sexually active non-pregnant women 24+
Non pregnant women 25+ at inc'd risk

Category B:
All pregnant women 24+
Pregnant women 25+ w/inc'd risk (h/o chlamydia or STI, new/multiple sex partners, inconsistent condom use)

DO NOT SCREEN WOMEN 25+ WITHOUT INC'D RISK, REGARDLESS OF PRENANCY STATUS--positive test more likely to be FP than TP

Front 65

What are the characteristics of a good screening test? Include characteristics of the condition at hand.

Back 65

High sens/spec
High prevalence in population
Latent stage of dz when pts asyx
Effective tx

Front 66

Which vaccines are live, attenuated? When can patients get pregnant after these vaccines?

Back 66

MMR, should wait 3 months before conceiving

Front 67

With regard to women considering pregnancy, who should receive a pneumococcal vaccine?

Back 67

High risk--cocheal implants, asplenia

Front 68

Connexin-26 is associated with ___________.

Back 68

Nonsyndromic hearing loss

Front 69

What hereditary diseases should be screened for in preconception counseling?

Back 69

Ethnic wise:
Sickle Cell
Thalassemia
Tay-Sachs

Family history wise:
Cystic Fibrosis
Nonsyndromic hearing loss (connexin-26)

Front 70

Which infectious diseases should be screened for/counseled in preconception counseling?

Back 70

HIV
Syphilis
HBV
Rubella, Varicella
Toxoplasmosis--avoid cat litter, garden soil, raw meat
CMV, parvovirus B19--frequent hand washing

Front 71

Which hypertension drugs should be avoided in pregnancy?

Back 71

ACEI, ARBs, Thiazides

Front 72

Which anxiety drug should be avoided in pregnancy?

Back 72

Benzodiazepines

Front 73

Which blood thinner is contraindicated in pregnancy? Substitute?

Back 73

Warfarin!

Use heparin instead (in setting of DVT)

Front 74

What is the folic acid recommendation for pregnancy?

Back 74

Folic acid 1mg qd

Front 75

Why is bleeding in early pregnancy considered normal?

Back 75

Because could be result of invasion of trophoblast into decidua (implantation bleed)--some adolescents mistake this for a menses, leading to delay in diagnosis of pregnancy and potential misdating of pregnancy.

Front 76

What is Naegele's Rule for calculating delivery date?

Back 76

Take first day of last menstrual period
Add 1 year
Subtract 3 months
Add 1 week

Front 77

What will the patient experience during a medical termination of pregnancy?

Back 77

First pill taken in doctor's office, pt feels nothing

Second pill taken at home, usually one or two days later; within couple of hours, cramping and heavy bleeding occur for few horus

Follow-up in 1 week

Front 78

Abortion is legal up to ____ weeks of pregnancy.

Back 78

22 weeks

Front 79

What contributes to half of all miscarriages in the first trimester?

Back 79

Chromosomal abnlts;
Note about 1/3 of pregnancies end in miscarriage
87% of women who miscarry have subsequent normal pregnancies and births

Front 80

When is first trimester bleeding considered emergent?

Back 80

Tachycardia, hypotension

Front 81

What questions should be asked to obtain an obstetric/gynecologic/menstrual history?

Back 81

When did you begin having periods?
How long do they usually last?
When was your last normal menstrual period?
Is it unusual for you to miss a period?

Front 82

What is Chadwick's sign?

Back 82

Bluish-purple hue in cervix and vaginal walls caused by hyperemia

Front 83

What is ectropion?

Back 83

When central part of cervix appears red from mucus producing endocervical epithelium protruding through cervical os onto face of cervix; common in women taking OCPs

Front 84

What is an inevitable abortion?

Back 84

Dilated cervical os

Front 85

What is an incomplete abortion?

Back 85

Some but not all of intrauterine contents (or products of conception) expelled

Front 86

What is a missed abortion?

Back 86

Fetal demise without cervical dilatation and/or uterine activity (often found incidentally on u/s)

Front 87

What is a septic abortion?

Back 87

Intrauterine infection (abdominal tenderness and fever present)

Front 88

What is a complete abortion?

Back 88

Products of conception have been completely expelled from uterus.

Front 89

What is a threatened abortion?

Back 89

Simply a pregnancy complicated by bleeding before 20 weeks gestation (a "catch-all" descriptive diagnosis)

Front 90

What are hCG levels like in a molar pregnancy?

Back 90

>100,000

Front 91

What is measured in determining rubella immunity?

If a pregnant woman is not immune to rubella, what is the management?

Back 91

Presence of IgG Abs

If not immune, receive POSTPARTUM immunization

Front 92

Who should receive RhoGAM?

Back 92

Rh D negative women

Front 93

What tests should be ordered in the setting of first trimester bleeding?

Back 93

CBC
-WBC will allow detect infection
Wet Mount Prep for Gonorrhea, Chlamydia, Trichomonas
-All STIs can cause vaginal bleeding
-Culture should not be obtained as it is very expensive
-Chlamydia cultures only used in forensic investigation (rape, child abuse)

Type and Screen

Quantitative beta-hCG

Front 94

When in pregnancy is hCG secreted?

Back 94

day 7 post-ovulation

Front 95

Describe the rate of increase of beta-hCG with pregnancy.

Back 95

On expected date of menses: >=100
Doubles every other day for 6-7 weeks
Conclusive pregnancy by transvaginal u/s 1500-1800
By transabdominal u/s >5000

In ectopic gestations and spontaneous abortions, hCG levels lower than normal and increase at less than normal rates

Front 96

When are progesterone levels useful in pregnancy management?

Back 96

Levels <5 associated with evolving miscarriage or ectopic pregnancy

Levels >25 associated with sustainable intrauterine pregnancy

Levels between 5 and 25 have minimal diagnostic value

Front 97

Can ultrasounds rule out ectopic pregnancy?

Back 97

No

Front 98

How does accuracy of estimated due date change with the timing of ultrasounds?

Back 98

First trimester: +/- 1 week
Second trimester: +/- 2 weeks
Third Trimester: +/- 3 weeks

Front 99

Medical management of spontaneous abortion.

Back 99

Intrauterine contents not expected to be seen until bega-hCG >1500; so serial reading is needed (every 48-72 hrs)

Front 100

Medical management of inevitable abortion.

Back 100

Watchful waiting with precautions regarding unusual amounts of bleeding or pain, or fever is effective in over 75% of cases

Process can take up to 1 month and can be complicated by sadness, grief, guilt, and can delay emotional closure

Can also undergo D&C should patient elect
Can also use misoprostol (vaginal administration)--takes 3-4 days