0 Family Medicine: 31, 32, 33

Front 1

What are the modifiable and non-modifiable risk factors for coronary artery disease?

Back 1

Modifiable:
DM
HTN
(DM + HTN causes atherosclerosis and remodeling of blood vessels)
Sedentary lifestyle, obesity
Tobacco use
Abnormal lipid levels

Non-modifiable:
Older age; men >45, women>55
Male gender
FMH CVD at young age in first degree relative

Other:
HDL<40

Front 2

What is the leading cause of death in the United States?

Back 2

Coronary Artery Disease, specifically MI

Front 3

When does diastolic heart failure physiologically occur?

Back 3

LV function preserved but symptoms of heart failure present
LV develops abnormaily of filling, becoming stiff and noncompliant as disease progresses
Then there's inc'd pulmonary vessel pressure during exercise, inc'd fill pressure, and LA pressure and size increase-->congestion

At this point exercise intolerance increases and clinical signs of failure (DOE!!!) appear, also pulmonary congestion, hepatic congestion, and peripheral edema

40% of pts with CHF have preserved systolic function--may have better prognosis than those w/systolic dysfunction

Front 4

What testing is required to rule out arrhythmia?

Back 4

Extended cardiac monitoring

Front 5

Etiology of non-ischemic cardiomyopathy.

Back 5

Idiopathic
Infections (viral)
Toxic (EtOH)
Infiltrative (sarcoidosis)

-Dilated, hypertrophic, arrhythmogenic right ventricular dysplasia (ARVD), restrictive

Front 6

Who is at risk of pulmonary embolism?

Back 6

Those with h/o malignancy, hypercoagulable state, recent surgery, or prolonged immobility

Note: would not result in pulmonary edema or related lung findings

Front 7

What tests should be ordered for a patient with acute onset SOB?

Back 7

CXR: r/o other contributing causes of dyspnea, ex: cardiomegaly, central vascular congestion and hilar fullness, pleural effusions (appears as blunting of costophrenic angles), Kerley B lines (represent fluid in lungs)

EKG: look out for T wave inversions (may indicate prior injury or acute ischemia), ST elevations

Echo/Doppler to assess blood flow through valves/chambers; measure size of chambers, thickness of walls, size of cavity, measure EJECTION FRACTION

Front 8

What is the ejection fraction cutoff for diastolic dysfunction?

Back 8

EF >45% along with syx of heart failure indicate diastolic dysfunction

Front 9

Who should undergo exercise tolerance testing as an initial diagnostic test?

Which tests are more specific than ETT?

Back 9

Patients with intermediate risk for suspected CAD

Exception: baseline EKG is not not interpretable (WPW, paced heart rhythm, left bundle branch block, or more than 1mm of ST depression at baseline)

Negative predictive value of ETT is not very good

Both stress echo and nuclear stress testing are more specific (and sensitive) than ETT; choice of which of these tests ordered depends on regional practice patterns and availability

Front 10

What is the diagnostic utility of brain natriuretic peptide?

Back 10

Can differentiate heart failure from non-cardiac conditions in patients with dyspnea (it's released in response to excessive stretching of heart)

Front 11

BP management in setting of CAD.

Back 11

ACE inhibitor--first choice in pts w/DM, HTN, and albuminuria

Reduce risk of subsequent coronary events in pts w/high CVD risk

Front 12

What is the recommendation for A1C levels in diabetics?

Back 12

Several guidelines recommend reduction of A1C to under 7%

However, studies show that intensive glucose control have not demonstrated reductions in CV events or mortality
There's inconsistent improvement in microvascular complications, including nephropathy
And there are inc'd AEs, including weight gain, fluid retention, and symptomatic hypoglycemia

Front 13

DM management in setting of CAD.

Back 13

Metformin--use of insulin mitigates (makes less severe) metformin advantage of not causing weight gain

Front 14

BP recommendation for those with diabetes.

Back 14

Under 130/80

Front 15

What are CAD equivalents?

Back 15

Atherosclerotic stroke
Peripheral vascular dz
Carotid stenosis
Renal artery stenosis
Diabetes

Front 16

What is the LDL guideline for those with CAD? Those with CAD equivalents?

Back 16

CAD, CAD equivalents LDL <100
CAD _ ongoing risk factors (DM, ongoing tobacco use)<70

Front 17

How does aspirin recommendation differ for primary prevention in women vs men?

Back 17

Recommendation for ASA in women is to prevent stroke

ASA for men is to prevent CAD

ASA is not contraindicated for women at risk of CAD.

Front 18

Medical management of new onset CHF.

Back 18

Send patient directly to ER via ambulance; admitting directly to floor may lead to unacceptable delay in care, as floor nurses have too many patients to manage initial work-up and stabilization of an acutely ill patient

Need urgent stabilization, likely with IV furosemide

Front 19

Which diabetes drugs are contraindicated in heart failure?

Back 19

Thiozoladinediones, ex: rosiglitazone, pioglitazone

Front 20

What is primary dysmenorrhea?
Etiology?

Back 20

Onset of painful menses w/o pelvic pathology (as opposed to secondary dysmenorrhea, which is a result of pelvic pathology)

A/w increase amount of PROSTAGLANDINS

Most commonly occurs in women in teens and twenties; 20-95% of women affected; 10-15% syx severe enough to miss school/work

Classically begins 1-2 years after menarche, decreases as women have more children, birth control use and timing can impact syx

Front 21

What are risk factors for dysmenorrhea?

Back 21

Depression, anxiety (esp in adolescents)
Smoking
Early onset of menarche
Overall lower state of health or other social stressors (not lower SES)

Front 22

What is menorrhagia?

Back 22

Blood loss more than 80 mL (difficult to quantify)

Menses lasting longer than 7 days is most likely menorrhagia

(Note: many women either over or underestimate blood loss; pad/tampon count difficult due to variability in absorption of different pads and how much blood a woman has on pad prior to changing)

Front 23

What is metrorrhagia?

Back 23

Irregular and frequent bleeding, not necessarily heavy

Menstrual cycles typically last 21-35 days

Front 24

What is premenstrual syndrome?

Back 24

Breast soreness, weight gain, bloating, diarrhea, constipation, fatigue

Irritability, easy crying, eating more then rest of month

must r/o depresion

Front 25

What is premenstrual dysphoric disorder?

Back 25

More severe than premenstrual syndrome, symptoms have to significantly impair a woman's life

Front 26

How should a uterus feel? What would be concerning?

Back 26

Smooth in contour around entire surface area, mobile

Concerning: Serosal or large mucosal fibroids causing a 'knobby' feel; non-mobile in endometriosis

Front 27

What does the cervix/vagina look like if endometriosis is present?

Back 27

May be blue-ish

Front 28

Uterine fibroids are three times more common in _______.

Back 28

African American women

Front 29

Risk factors for uterine fibroids.

Back 29

Dec'd with OCP, increasing parity, and smoking

Inc'd with early menarche, FMH fibroids, inc'd EtOH

Front 30

Symptoms of uterine fibroids.

Back 30

Menorrhagia, secondary anemia, dysmenorrhea, pressure symptoms (inc'd urinary frequency), potential difficulty achieving pregnancy

Front 31

Symptoms of chronic pelvic inflammatory disease.

Back 31

Lower abdominal pain, usually UNRELATED to menses.

Menorrhagia seen in 1/3 of women with PID, esp subclinical dz that isn't treated early.

Front 32

What is adenomyosis?
Symptoms?

Back 32

Uterine thickening; occurs more frequently in parous than nonparous women.

U/S may demonstrate heterogeneously boggy uterus. MRI more specific for diagnosis.

60% of women complain of menorrhagia
Some urinary or GI syx secondary to size and mass effect on bladder/rectum

Front 33

What is cervical stenosis?
Symptoms?

Back 33

Congenital or acquired (related to cryotherapy or loop electrosurgical excision procedure)

Front 34

How does the presentation of endometriosis differ from that of leiomyoma?

Back 34

Women with endometriosis present with dyspareunia; rare in women with leiomyoma

May also have bowel or bladder syx that cycle with menses, fatigue, abnl vaginal bleeding, and some effect on fertility

Will note pain in cul-de-sac, immobile and retroflexed uterus, pain with uterine motion

Front 35

Who is inflammatory bowel disease commonly misdiagnosed as a gynecologic problem?

Back 35

Constipation and diarrhea are potential syx a/w premenstrual syndrome

Note: abnl vaginal bleeding isn't a typical symptom of inflammatory bowel dz

Front 36

What studies should be ordered for dysmenorrhea?

Back 36

**Pelvic ultrasound (one view on abdomen, one inside vagina)
CBC: Fe def anemia (augments fatigue)
Pregnancy test (in every woman of reproductive age w/any changes in bleeding pattern or amount)

Thyroid: fatigue and bowel syx overlap

Front 37

Management of dysmenorrhea secondary to leiomyoma.

Back 37

Ibuprofen--decreases effect of prostaglandins

Mirena intrauterine device (best option for tx fibroids in women hoping to maintain fertility) ; can decrease overall uterine volume (doesn't decrease size of fibroids, though)

Combined OCPs when dysmenorrhea related to anovulation; not proven to reduce menstrual flow

Hysterectomy (definitive surgical option)

Myomectomy (surgical removal of leiomyoma and not entire uterus)

Front 38

How long can an IUD be left in?

Back 38

5 years; it's progestin only
May have some irregular bleeding at beginning but most women stop bleeding by a year

Front 39

How long does Depo-Prover last? AEs?

Back 39

12 weeks

AEs:
Bone density loss after several years of loss; may take 9-18 months for woman to regain regular menses after last injection

Potential weight gain

Front 40

When is hysterectomy indicated?

Back 40

Uterus 14-16 weeks in size or greater ± symptoms
Any leiomyoma growing rapidly regardless of rest of uterine exam
Any time pt has failed other management

Front 41

What is paragard IUD?

Back 41

Birth control without hormones; made of copper

Inc'd risk of dysmenorrhea and menorrhagias just from IUD

Not a treatment for leiomyomas

Front 42

Medical management of premenstrual syndrome.

Back 42

SSRI; start 14 days prior to menses (luteal phase) an continue until menses start

Front 43

What is pre-syncope?
Etiology?

Back 43

Feeling light-headed or faint, as opposed to actually passing out.

Etiology: inadequate cerebral perfusion

Front 44

Treatment for thyroid storm.

Back 44

Beta blockers
Treatment for hyperthyroidism

Front 45

Treatment for atrial fibrillation.

Back 45

Rate control via pharmacologic or electric cardioversion or use of CCB, beta blockers, digoxin

Front 46

What is disequilibrium?
Etiology?

Back 46

Feeling of being off balance

Etiology:
Cerebellar degeneration
Tx: underlying etiology and balance rehabilitation physical therapy

Front 47

What drug is known to result in vertigo?

Back 47

Aminoglycoside toxicity (-mycin)

Front 48

How is peripheral nystagmus inhibited and intensified?

Back 48

Inhibited by fixation on a point
INtensifies when fixation is withdrawn

Front 49

Utility of the head thrust test in vertigo.

Back 49

Demonstrates peripheral lesion

When you face your pt and ask them to focus on your nose, eyes fixed on nose even if you move his head suddenly to the side.

If there's a peripheral lesion in vestibular system, vestibular ocular reflex will be disrupted and eyes will move with head and saccade back to center when head moved in direction of lesion.

A normal head thrust test in the presence of vertigo means the peripheral vestibular system is intact and that the lesion is central

Front 50

Utility of the Dix-Hallpike maneuver.

Back 50

Turn pt's head to 45 degrees and quickly lay him down supine with head over end of exam table.

Turn head to side, should reporudce syx of dizziness and nystagmus. If present, nystagmus will have fast component in direction of pathology.

Front 51

What is peripheral vertigo?
Examples?
Physical exam findings.

Back 51

Caused by problems with inner ear or vestibular system.

Ex: Meniere's, vestibular neuritis, BPPV

Positive head thrust
Unidirectional nystagmus that doesn't change direction

Nystagmus that resolves with gaze fixation

Front 52

What is central vertigo?
Examples?
Physical exam findings.

Back 52

Tends to be more serious than peripheral vertigo.

Arises from central nervous system.
Ex: Stroke (cerebellar infarct), TIA< vestibular migraine

Normal head thrust
Nystagmus changes direction
Nystagmus does not resolve w/gaze fixation

Diagnose with MRI

Front 53

What is the most common cause of vertigo?
Pathophys?
Diagnosis?

Back 53

Benign paroxysmal positional vertigo
Calcium carbonate debris in semicircular canals

Confirm dx w/Dixx-Hallpike

Treat with Epley maneuver

Front 54

Presentation of cerebellar infarct.

Back 54

Disequilibrium; uncommon cause of vertigo

Front 55

Presentation of Meniere's disease.
Treatment?

Back 55

Unilateral hearing loss
Tinnitus
Vertigo

Treat with diuretics and low salt diet; should decrease endolymphtic pressure and abate syx

Front 56

What is vestibular neuritis?

Back 56

Commonly a/w recent URI
Results when viral infection of inner ear causes inflammation of vestibular branch of CN VIII

Labyrinthitis occurs when infection affects both branches of nerve resulting in tinnitus and/or hearing loss as well as vertigo

Front 57

When is an MRI indicated for assessment of vertigo?

Back 57

If suggestion of central lesion on physical exam

Front 58

For otitis media when should antibiotics be given?
Watchful waiting?
When should antibiotics NOT be given?

Back 58

Give Abx if under 6 mos old

Watchful waiting if between 6 mos and 2 years--depending on certainty of diagnosis, social supports, clinical picture

DON'T tx w/Abx if child over 2 years old with uncomplicated acute otitis media (Abx optional)

Front 59

Treatment for uncomplicated maxillary sinusitis

Back 59

Do not treat with abx

Front 60

Treatment for streptococcal pharyngitis

Back 60

PCN to shorten course of dz

Front 61

Treatment for bronchitis

Back 61

Watchful waiting

Antibiotics can have a modest effect on length and severity of syx in acute bronchitis; however, most people will recover w/o abx treatment. Don't contribute to resistance.

Front 62

Treatment for upper respiratory infection

Back 62

Don't give ABx

Front 63

What anti-emetics can be used in vertigo?

Back 63

Meclizine, dimenhydrinate

Avoid in elderly bc of sedation