0 Family Medicine: 4, 5, 6

Front 1

Compartment Syndrome:
Causes
Presentation
Treatment

Back 1

Rising pressure in muscle compartment impairs perfusion to compartment; can be due to fractures, crush injuries, burns, arterial injuries

Presentation: 6Ps
Pain (hallmark)
Pallor
Pulselessness
Paresthesias (most reliable sign)
Poikilothermia (inability to regulate body temperature)
Paralysis

Treatment: Emergent decompression via fasciotomy

Front 2

What urinalysis abnormalities are indicative of UTI?

Back 2

Leukocyte esterase
Nitrites

Front 3

What is the most common mechanism of injury for ankle sprain?

Back 3

Plantarflexion and inversion

Front 4

What is the most common mechanism of injury for MEDIAL ankle sprain?

Back 4

Forced eversion and dorsiflexion (less common than lateral sprains)

Front 5

History of a snap or tear is diagnostically significant in acute ____ injury.

Back 5

Knee, not ankle

Front 6

With regard to weightbearing, what sign is most suspicious for severe injury?

Back 6

A patient who seeks help immediately and is non-weightbearing is more likely to have a severe injury than one who presents a few days after incident and is fully weightbearing

Front 7

Which leg should be examined first when a patient comes in with injured leg?

Back 7

uninjured leg before injured leg

Front 8

What ligament is most likely to be injured in acute ankle injury?
What test allows for its assessment?

Back 8

Talofibular

Assess via anterior drawer test; if ligament is torn, talus will subluxate anteriorly

Front 9

Which ligament does the inversion test assess?

Back 9

Calacaneofibular ligament; if ankle does not appear lax on inversion, ligament is intact.

Front 10

Which ankle ligament is least likely to be injured?

Back 10

Medial ligament

Front 11

How are ankle sprains graded (I-III)?

Back 11

Grade I: Stretching and/or small tear of ligament: slight to no fnal loss, mild tenderness, mild swelling, usually no ecchymosis, no mechanical instability

Grade II: Incomplete tear, moderate functional impairment, difficulty bearing weight, tenderness over involved structures, mild to mod pain, mild to mod swelling, ecchymosis common; moderate instability (stretching of joint with stress, but definite stopping point

Grade III: complete tear and loss of integrity of ligament; inability to bear weight (unable to take four steps independently), severe swelling (greater than 4 cm about fibula), ecchymosis present, mechanical instability (significant stretching of joint with stress without stopping point)

Front 12

What is the most common acute ankle injury?

Back 12

Lateral ankle inversion sprain caused by combination of plantarflexion and inversion

Front 13

Differential for acute ankle injury

Back 13

Sprain
Peroneal tendon tear (usually due to inversion injury or repetitive trauma)
Talar dome fracture (may occur with ankle sprain, initial x-rays may miss; repeat imaging required is syx persist to detect avascular necrosis)
Fibular fracture: due to falls, athletic injury, high velocity mechanism (MVA), inability to walk
Tendonitits (usually posterior tibialis tendon)
Subtalar injury: often due to high-energy injury

Front 14

Draw ankle diagram with relevant tendons.

Back 14

Front 15

According to the Ottawa Rules, when are radiographs of the ankle needed?
Of the foot?

Back 15

Radiographs of ankle needed if:
There is pain in malleolar zone AND either:
-bony tenderness along distal 6cm of posterior edge of malleolus OR
-Inability to bear with both immediately and in ED

Radiographs of foot needed if:
-Pain in midfoot region AND
-Bony tenderness in either navicular bone or base of fifth metatarsal OR
-Inability to bear weight both immediately and in ED

Front 16

What is the RICE mnemonic for ankle sprain treatment?

Back 16

Rest for first 72 hours only; not moving ankle for longer period of time can cause dec'd range of motion

Ice several times throughout day for 10 minutes at a time to reduce swelling/pain

Compression with tape, elastic wrap, or semi-rigid ankle support (latter leads to quicker return to sports and work and less instability of ankle)

Elevation to reduce swelling

Front 17

What anti-inflammatory medication can be given for acute ankle pain?

Back 17

Ibuprofen 400-600 mg 2 to 3 times a day PRN

Front 18

What ankle exercises should be recommended to patients with acute ankle injury?

Back 18

Ankle inversion, eversion, plantarflexion, dorsiflexion

Calf-stretching, single-leg balancing

Front 19

How can patients avoid potential re-injury?

Back 19

Avoid flip-flops or sandals and activities such as soccer until re-evaluation (usually 1 week)

Front 20

Treatment for dysuria.

Back 20

Bactrim or cipro if treating community with known high uropathogen resistance to TMP-SMX

Front 21

How do the signs and symptoms of hyperthyroidism differ by age?

Back 21

If under 50:
96% of pts present with tachycardia
96% increased sweating
92% heat intolerance
84% present with fatigue
84% tremor
50% with weight loss
(also experience hyperreflexia, diarrhea, light tremors)

If pts over 70:
71% tachycardia
56% fatigue
Weight loss, atrial fibrillation
Other typical syx are absent

Front 22

Why do patients with hyperthyroidism experience:
Tachycardia
Weight Loss
Exercise Intolerance and Fatigue

Back 22

Inc'd heart rate and cardiac output due to inc'd peripheral O2 needs and inc'd cardiac contractility (due to elevated T4)

Weight loss due to increased calorigenesis (heat produced by consumption of food), inc'd gut motility and associated hyperdefecation and malabsorption

Exercise intolerance and fatigue contributed to by O2 consumption and CO2 production, respiratory muscle weakness

Front 23

Describe the hypothalamic-pituitary axis with regard to thyroid function.

Back 23

Hypothalamus releases TRH
Pituitary releases TSH
Thyroid releases T3/T4

T4/T3 exert negative feedback by controlling release of TRH/TSH

Front 24

What is the main cause of hyperthyroidism?
Pathophys?
Triggers?

Back 24

Graves' Disease (toxic diffuse goiter);
Antibodies act at TSH receptor and stimulates gland to secerete excess T4/T3

Females 5-10 x more likely to have it than males

Triggered by stressful life events, high iodine intake, recent pregnancy

Front 25

What physical exam finding is found in Graves' disease but not in other etiologies of hyperthyroidism?

Back 25

Bruit/thrill seecondary to increased vascularity of thyroid

Pretibial myxedema secondary to increased deposition of hyaluronic acid in dermis/subcutis

Exophthalmus (can be bilateral or unilateral)--up to 10% manifest when pt is euthyroid or even hypothyroid

Front 26

What symptom of Graves' will not resolve with radioactive iodine?

Back 26

Proptosis

Front 27

Based on age, which patients tend to have solitary/multinodular toxic thyroid goiters?

Back 27

Younger patients (under 40) tend to have solitary toxic nodular goiter

Older patients (over 40) tend to have multinodular toxic goiters

Front 28

What causes hyperthyroidism after viral illness or pregnancy?

Back 28

Thyroiditis; typically short term

Front 29

What are the 2 main causes of excess iodine consumption? Effects?

Back 29

Diet or amiodarone; may induce hyperthyroidism

Front 30

Causes of thyroid goiter (enlarged thyroid gland).

Back 30

Lack of iodine (most common cause worldwide)
Hashimoto's (causes hypothy)
Graves
Nodules
Cancer
Pregnancy
Thyroiditis

Front 31

Signs and symptoms of hypothyroidism.

Back 31

Weight gain
Cold intolerance
Pedal edema
Heavy periods
Fatigue (common in both hyper and hypothy)

Front 32

Why is anemia on differential for palpitations?

Back 32

Causes tachycardia via hypovolemia

Anemia can also cause dyspnea on exertion because of lack of O2 carrying capacity

Common in women with heavy periods

Front 33

What lab value differentiates hypothyroidism from hyperthyroidism?

Back 33

TSH

Front 34

Diagnose:
High TSH
Low T4

Back 34

Hypothyroidism

Front 35

Diagnose:
Mildly elevated TSH
Normal T4

Back 35

Subclinical hypothyroidism

Front 36

Diagnose:
Normal TSH
Increased T4

Back 36

Pituitary adenoma (TSH-producing) or T4 resistance

Front 37

Diagnose:
Decreased TSH
Increased T4

Back 37

Thyrotoxicosis (hyperthyroidism)

Front 38

Diagnose:
Decreased TSH
Decreased T4

Back 38

Central (or pituitary) hypothyroidism (TSH and/or TRH deficiency)

Front 39

Diagnose:
Decreased TSH
Normal T4
Increased T3

Back 39

T3 toxicosis

Front 40

What are the cutoffs for a high vs low radioactive iodine uptake in a patient with suspected hyperthyroidism?
What do these values indicate?

Back 40

High RAIU (>30%): Graves if diffuse uptake, goiter, TRH-secreting pituitary tumor, HCG-secreting tumor

Low RAIU: <15%; subacute thyroiditis (gland leaking excess hormone, so uptake low bc more T4 not synthesized), silent thyroiditis, iodine induced, exogenous L-thyroxine, struma ovarii, amiodarone

Front 41

What antibody is detected in Graves' disease?

Back 41

Thyroid peroxidase antibodies present in 70-80% of Graves' pts

Front 42

Management of hyperthyroidism.
(Treatment and labs)

Back 42

Propranolol for syx relief of adrenergic symptoms (tachycardia, tremor, heat intolerance)
Pts with Graves' should be referred to opthalmologist

Oral radioactive iodine (single dose) destroys overactive thyroid cells over few months; patients eventually become hypothyroid; must obtain pregnancy test!

Check TSH every 2-3 months until stabilized; and every 6 mos thereafter.

Alert pt to syx of hypothyroidism in advance

Front 43

Management of hypothyroidism.

Back 43

Levothyroxine; adjust dose until patient feels normal and TSH is in normal range. Can be managed with 1-2 blood tests a year. usually stays about same.

Increase dose slowly; aim for dose of 1.5-1.8mcg per kg

Front 44

Criteria for diagnosis of diabetes.

Back 44

1. HBA1c > 6.5% (do not have to be fasting)
2. Fasting glucose >126
3. Oral Glucose Tolerance Test (more sensitive, but difficult to do and poorly reproducible)
4. Random glucose >200 + syx of hyperglycemia

Unless there are obvious syx of hyperglycemia, methods 1-3 should be confirmed by repeat testing

Front 45

Who should be screened for diabetes according to the American Diabetes Association?

Back 45

Those with BMI over 25 and one or more of the following:
Habitual physical inactivity
Minority (even Asian/Pacific Islander)
First-degree relative with DM
Previously dx'd impaired fasting glucose (100-125) or impaired OGTT (2-hour glucose 140-199)
HTN (BP>140/90)
HDL <35 or TG >250
Hx gestational DM, baby >9lbs
PCOS
Acanthosis nigricans
Hx CVD

IN ABSENSE of above risk factors, screening should begin at 45 years of age; if normal, repeat every three years

Front 46

Who should be screened for diabetes according to the USPSTF?

Back 46

Asyx adults with sustained BP (treated or untreated) greater than 135/80

Front 47

How is prevalence of neuropathy determined (physical exam finding)?

Back 47

Loss of ankle jerk reflexes

Front 48

What is fatalismo?

Back 48

Holding to belief that control over one's diabetes is external to self, Latino patients may express that nothing can be done to improve their DM or health. "It is out of my hands" or "Everyone has to die from something"

Front 49

Type 1 vs Type 2 DM:
Diabetic Ketoacidosis or Hyperglycemia Hyperosmolar State
Serum pH
Ketones (+/-)
Serum glucose level

Back 49

DM I:
DKA
pH <7.30
Ketones +
Glucose >250

DM II:
Hyperglycemia hyperosmolar state
pH >7.30
Ketones -
Glucose >600

Front 50

Microvascular vs Macrovascular Complications (examples)

Back 50

MIcrovascular: retinopathy, nephropathy, neuropathy

Macrovascular: CHD, cerebrovascular dz, peripheral artery disease)

Front 51

What are the components of a comprehensive diabetic foot exam?

Back 51

Test for loss of protective sensation (monofilament plus vibration, pinprick, ankle reflexes)

Pedal pulses (dorsalis pedia and posterior tibial arteries); evaluates peripheral vascular dz--strongest risk factor for delayed ulcer healing and amputation in diabetes patients

Inspection for breaks in skin, pressure calluses that precede ulceration, existing ulceration and infection, bony abnlts, hair loss, temp changes; examine footwear for abnlr patterns of wear and appropriate sizing

Front 52

What does HbA1c value reflect?
How often should it be performed?

Back 52

Reflects plasma glucose concentrations over 4-12 week period

Perform at diagnosis and at least twice a year in pts who are stable and <7%

Front 53

Most diabetic patients will die from ___________.

Back 53

Cardiovascular disease

Front 54

Why should B12 levels be measured in diabetics?

Back 54

Metformin can cause asymptomatic subnormal levels of B12; only perform if pt exhibits neuropathy

Front 55

When should TSH be performed in diabetics?

Back 55

If patient has DM1

Front 56

What labs should be ordered at baseline DM visit?

Back 56

HbA1c
EKG
Spot urine albumin:creatinine ratio
Fasting Lipid Profile (dyslipidemia can complicate management of DM)

Front 57

What is the 1st treat treatment algorithm for DM II?

Back 57

1) Diagnosis: If HbA1c >6.5%: lifestyle changes plus metformin

2) Assessment: If HbA1c >8%: continue lifestyle changes and metformin; add sulfonylurea (Glyburide, Glipizide, Glimepiride) or basal insulin (glargine, detemir, NPH)

3. Reassessment: If HbA1c >8: continue lifestyle changes and meformin, add basal insulin or intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia.

Can move on to step 4, but this is 2nd tier (fewer well-validated studies support this approach):
Adding rapid-acting insulin with meals
Thiazolidinediones--Glitazones (Actos) or rosiglitazone (Avandia) for those who can't tolerate GI f/x of metformin or have hypoglycemia w/sulfonylureas
GLP-1 analogs: exenatide, liraglutide
Etc.

Front 58

What is the target for HbA1c? Why?

Back 58

HbA1c under 7% prevents microvascular disease (retinopathy and nephropathy)

However, blood pressure and lipid control demonstrate more improvement of CV risk than intensive glycemic control.

Front 59

Goal for fasting blood glucose?
Postprandial glucose?

Back 59

80-120 fasting
<180 postprandial

Front 60

What are the preferred HTN drugs for diabetics?

Back 60

If BP >140/90
ACE inhibitor, ARB, beta blocker, or CCB; plus lifestyle change (reduce CV events and risk)

Front 61

What are the LDL goals in patients with diabetes?

Back 61

If no known CVD, <100 mg/dl
if known CVD using statin, <70 mg/dl

Front 62

When should aspirin therapy be used in patients with diabetes?

Back 62

history of CVD or at moderate/high risk of CVD

Common dose is 81mg qd

No e/o use of ASA in pts under 30; contraindicated in pts <21 bc of Reye's

If have CVD and an ASA allergy, use clopidogrel 75 mg qd

Front 63

Advise all patient that smoke to ______.

Back 63

Quit, not just cut back!

Front 64

What risk does smoking pose in patients with diabetes?

Back 64

higher risk of premature development of microvascular complications and CVD. Smoking is most important modifiable cause of premature death.

Front 65

Recommended eye care for diabetics.

Back 65

yearly dilated ophtahlmoscopic exam as many pts w/retinopathy may not complain of syx

Front 66

What immunizations are recommended for diabetics?

Back 66

Annual vaccination for influenza
Pneumococcal vaccine for diabetics > 2 years; one-time revaccination for patients over 64 if received first dose more than 5 years ago

Should also receive revaccination if have nephrotic syndrome, chronic renal disease, or are immunocompromised