0 Family Medicine: 16, 17, 18

Front 1

Primary vs Secondary Skin Lesion: Definition

Back 1

Primary: Uncomplicated lzn representing initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy

Secondary: lesion in which a change has occurred as consequence of progression of disease

Front 2

List and define categories of skin lesions (macule, vesicle, etc)

Back 2

Macule: flat, <1cm
Patch: Macule >1cm

Papule: solid, raised lesion, <1cm
Plaque: papule >1cm

Vesicle: lesion <1cm filled with clear fluid
Bulla; Fluid-filled lesion >1cm in diameter

Front 3

Where does psoriasis appear?

Back 3

Extensor surfaces

Front 4

Where does atopic eczema appear?

Back 4

Flexor surfaces
Behind ears

Front 5

What does it mean when a lesion is an iris lesion?

Back 5

Annular lesion with a second ring "bull's eye"

Front 6

Annual skin cancer screening if a category ___ recommendation.

Back 6

Category I

Front 7

What lesion diameter is a risk for malignancy?

Back 7

6mm+

Front 8

What DRE findings raise suspicion for malignancy?

Back 8

Prostate firm, nodular, asymmetric, or indurated

(BPH = symmetrically firm and enlarged)

Front 9

What is the most common form of skin cancer?

Back 9

Basal Cell Carcinom

Front 10

Basal Cell Carcinoma vs Squamous Cell Carcinoma:
Appearance

Back 10

Basal: plaque-like with waxy, translucent appearance, often with ulceration and telangiectasia. No itching or change in skin color.

SCC: Scaly, pink macular to papular area with erythematous RAISED BASE. Sometimes scale or ulcerated. Borders often irregular and bleed easily. UNLIKE BASAL CELL, heaped-up edges of lesions are FLESHY rather than CLEAR in appearance.

Front 11

When is shave biopsy indicated?

Back 11

When lesion is elevated above surface of skin

Front 12

Under what circumstances should PSA be obtained in setting of BPH?

Back 12

If life expectancy > 10 years
If PSA level will influence BPH treatment (e.g., patient considering treatment with 5-alpha reductase inhibitor)

Front 13

What is the most widely used treatment for cutaneous squamous cell carcinoma?

Back 13

Surgical Incision

Front 14

When is Mohs microscopic surgery indicated?

Back 14

Patients with any non-melanoma skin cancer greater than 2 cms, lesions with indistinct margins, and those close to important structures (eyes, nose, mouth)

Front 15

When is topical 5-FU indicated?

Back 15

SUperficial SCCs and SCC in situ

Front 16

What is the downfall to cryotherapy?

Back 16

Does not permit histologic confirmation of adequacy of treatment margins.

Useful for small, well-defined, low-risk, invasive SCCs and Bowen's dz.

Front 17

BPH:
Medical Management

Back 17

Medical: alpha-antagonists (tamsuolosin, terazosin) decrease syx of LUTS

5-alpha-reductase inhibitors (finasteride) more effective in men w/larger prostates

If severe enough, combine above classes

Sx:
If bladder outlet obstruction creating risk for UTI or lower UTI, consider surgery

Front 18

Tinea capitis:
Treatment

Back 18

ORAL THERAPY (topical tx unable to penetrate hair shaft)

Griseofulvin

Front 19

Tinea unguium:
Treatment

Back 19

Terbinafine 250 mg qd x 12 weeks for toenails, 6 weeks for fingernails

Front 20

How does the composition of a cream differ from an ointment? Lotion?

Back 20

Cream: organic chemicals (oils) and water; can be used in any area, drying effect with continuous use

Ointments: Limited organic compounds consisting of grease (petroleum jelly), with little or no water; desirable for dryer skin. Greater penetration than cream and thus enhanced potency

Lotions/gels: Contain EtOH; most useful in scalp because penetreate easily, leave little residue. Drying effect.

Front 21

What are the strongest steroid creams?
Weakest?

Back 21

Strongest: Betamethasone, Halobetasol

Weakest: Hydrocortisone

Front 22

What are the side effects of steroid creams?

Back 22

Skin atrophy (most common)
Hypopigmentation (more apparent with darker skin tones)
HPA suppression...

Front 23

Where are fractures likely to occur in those with osteoporosis?

Which fractures carries the greatest mortality?

Back 23

Vertebrae
Hip
Distal radius
Proximal humerus

Hip fracture has mortality rate of 20-25%

Front 24

What are the risk factors of osteoporosis?

Back 24

Previous fragility fracture (low impact)
Smoking
Heavy EtOH
Corticosteroid use
Caucasian race
Lower body weight

Front 25

What is the FRAX tool?

Back 25

Tool developed by WHO to calculate risk of fractures; adjusts for gender, ethnicity, and locale

Front 26

How would you interpret the T scores provided on a DEXA scan?

Back 26

0 to -1: Normal
-1 to -2.5: Decreased bone density, or osteopenia
Less than -2.5: Osteoporosis

Note T = standard deviation of average peak bone mass density in a young healthy person

Front 27

What are the USPSTF guidelines for breast cancer screening?

Back 27

Mammogram every 2 years for 50-74

If wish to initiate prior to 50, should be individualized decision

Front 28

What are the ACOD guidelines for Pap smears?

Back 28

Every 2 years from 21-30
Every 3 years from 30-64

Front 29

Is CA-125 level indicated as a screening tool for ovarian cancer?

Back 29

No

Front 30

What are the risk factors for endometrial cancer?

Back 30

Any inc'd exposure to unopposed estrogen:
Unopposed estrogen therapy
Tamoxifen
Obesity
Anovulatory cycles
Estrogen-secreting neoplasms
Early menarche (before 12)
Late menopause (after 52)
Nulliparity

Other factors include:
-HTN
-DM
-Hx breast or colon ca
-Menstrual irregularities
-Age

Front 31

What cancer is smoking protective against?

Back 31

Endometrial

Front 32

What factors are protective against endometrial cancer?

Back 32

Smoking (decreases estrogen exposure)
Oral Contraceptive Use (increases progestin levels, thus providing protection)

Front 33

What is the differential for abnormal uterine bleeding in a postmenopausal woman?

Back 33

Cervical polyps (common in postpartum and perimenopausal women; r/o via pelvic exam)

Endometrial hyperplasia (progresses to cancer in <5% pts)

Endometrial cancer (90% pts with Endometrial Ca have abnl vaginal bleeding)

Proliferative Endometrium: seen in high estrogen states

Iatrogenic causes: anticoags, SSRIs, antipsychotics, steroids, hormones

Genital Tract Pathology

Front 34

What tests/labs should be ordered in a postmenopausal woman with abnormal vaginal bleeding?

Back 34

Transvaginal Ultrasound: most cost-effective test if low risk for endometrial cancer; highly sensitive for detection of endometrial cancer and abnlty

Endometrial biopsy: Gold standard for evaluation of pt with high risk for endometrial cancer. Widely done in outpt setting.

CBC, LFTs: anemia, low PLT, liver abnlts

Thyroid Function Tests: can interfere with HP/Gonadal axis

FSH, LH; Elevated FSH confirms menopause (less inhibin around), elevated LH too

Front 35

How can osteoporosis be prevented?

Back 35

Adults 50 and over should consume 800 IU vitamin D daily
Most adults should consume 1000mg calcium, if over 50, consume 1200 mg

Life-long weight-bearing exercise and muscle strengthening (walking, jogging, Tai-Chi, stair climbing, dancing, tennis)

Limit smoking and excess EtOH

Front 36

What is the treatment of osteoporosis?

Back 36

Bisphosphanates: inhibit bone resorption and reduce bone turnover, increas ebone mineral density. Ex: ALENDRONATE

Parathyroid hormone: Forteo; only if high risk for fracture, given SQ, $$$

Estrogen Replacement Tx: short-term only

Calcitonin: reduces vertebral fractures, but not hip or other fractures

Front 37

What is the benefit of menopause hormone therapy? Concerns?

Back 37

Use for short-term relief of bothersome syx of menopause; improves vasomotor and atrophic symptoms, prevents osteoporosis

Concerns: If given for more than 3 years, risk of breast cancer; unopposed estrogen risks endometrial cancer; beginning after age 60 increases risk of CAD; inc'd risk of stroke after first 1-2 years of use

Use lowest effective dose for shortest possible time

Front 38

What is the best treatment for atrophic vaginitis?

Back 38

Topical estrogen; doesn't even require coverage with progesterone even in women with intact uterus

Available as cream or an E-ring (estrogen-impregnated ring inserted into vagina)

Front 39

For the three types of headaches describe:
Number needed for diagnosis
Character
Associated Symptoms
Length
Aggravated by physical activity

Back 39

Migraine: 5 episodes, pulsating, n/v/photo/phonophobia, unilateral, aura possible
Lasts 4 to 72 hours
Aggravated by phys act

Tension: 10 episodes, photo/phonophobia, pressing headache, bilateral, occipital tenderness, 30 minutes to 7 days
Not aggravated by phys act
(only mild to mod pain)

Cluster: 5 episodes, severe pain, rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, ptosis; orbital/periorbital/temporal
Not agg'd by phys act

Front 40

What are secondary headaches?

Back 40

HAs as a result of another underlying medical or psych diagnosis (ANX, depression)

Front 41

What are the criteria for diagnosis of analgesic rebound headaches?

Back 41

>15 HAs per month
Regular overuse of analgesic for > 3 months
Dev't or worsening of HA during medication overuse

Front 42

What life-threatening diagnoses must be considered with headache?

Back 42

Bacterial meningitis (esp if new rash, abnlt mentation, abnl neuro exam, stiff neck)

Intracranial hemorrhage (recent history of trauma, HTN, abnl neuro exam)

Brain tumor--won't cause pain unuless affects dura mater (brain itself doesn't contain pain fibers)--weight loss, systemic syx, abnl thinking

Front 43

What mental status changes can indicate increased intracranial pressure?

Back 43

Changes in appearance/attitude
Psychomotor behavior
Speech/language
Affect
Attention
Memory
Insight/Judgment

NOTE: LOOK FOR PAPILLEDEMA

Front 44

What medications/substances can trigger headaches?

Back 44

Progesterone
Tobacco
Caffeine
EtOH
Aspartame and phenylalanine (found in diet colas)

Front 45

What two drug are specific to migraine headaches?

Back 45

Sumatriptan
Ergotamine (Ergot alkaloid)

Do not use together!!

Front 46

What prophylactic therapies are available for migraine headaches?

Back 46

Propranolol (good and cheap)
Timolol

Amitriptyline (cheap, excellent drug)

Neurostabilizers:
Divalproex ($$$)--birth defects
Topiramate ($$$)--birth defects