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417 Cards in this Set
- Front
- Back
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A patient falls. What are some things that you want to know?
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Was is a mechanical fall or a "syncopal" fall (did they black out)?
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In for boards:
Bug: infectious presentation Strep: ?, Staph: ? In actual practice: Bug: infectious presentation Strep: ?, Staph: ? |
In for boards:
Bug: infectious presentation Strep: Cellulitis, Staph: Abscess In actual practice: Bug: infectious presentation Strep: Cellulitis, Staph: Abscess OR Cellulitis |
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What do you do with anything that is swollen?
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Elevate it! Note in the plan
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Patients with COPD: what should you ask them about their breathing?
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Did they notice any wheezing?
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What are some "good numbers to remember" for the diseases below?
1. Diabetes 2. Asthma 3. CHF |
1. Diabetes: Hb A1c
2. Asthma: peak flow 3. CHF: Ejection Fraction |
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What is the "gold standard" for temporal arteritis?
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A biopsy.
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Why can a biopsy of temporal arteritis come back as a false negative sometimes?
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Because the arteritis is intermittent along the artery.
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When you are describing the lung on physical exam, what are the first thing that you comment on?
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Don't jump right to the abnormal lung sounds. Comment about
- Chest wall expansion - Air entry - Chest wall abnormalities |
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Patient with COPD: essential question to ask about PMH.
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Have you ever been hospitalized for your COPD before? Did you have to be intubated? Put on a ventilator? When was your last ER visit?
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How do you determine if the difference between edema and extra adipose tissue?
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Is the swelling old or new?
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Chest pain questions:
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How long does it take the chest pain to go away when it comes on? Sweating? Palpitations? Come on with exertion?
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What is one way to evaluate a swollen finger?
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Compare it to the other fingers!
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How do you evaluate wounds on physical diagnosis?
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Place, size, edges (sloping vs. smooth), color,
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What are the different stages of wounds?
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Stage I: skin broken
Stage II: Stage III: muscle involved Stage IV: bone involved Description of this is important for determining if the wound needs to be debrided or not |
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What is something that you should put in your plan for a patient with liver/kidney failure?
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"Dose according to liver/kidney failure"
"Avoid drugs that are excreted by the kidney/liver." |
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Something to assess about a patient's general well-being upon examination.
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Whether the patient speaks in full sentences or not.
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If you have a hernia, what is one important question to note? Why is it important to auscultate?
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Is the hernia reducible or irreducible? Important to ausculate to see if you can hear bowel sounds.
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What constitutes a positive Murphy's Sign?
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Upon expiration, place your hand under the patient's right costal margin. Then ask them to breathe in. If the patient feels pain then this is part of a positive Murphy's Sign. The other part is doing the test on the left hand side and seeing no hypersensitivity upon inspiration. These two things constitute a positive Murphy's Sign.
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Approximately how long would it take for a patient with a blood alcohol level of 300 to drop to normal levels?
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About 24-30 hours.
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Where should you start palpating when feeling for the liver?
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Start really LOW and work your way up.
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When should you be applying pressure when palpating the liver?
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When the patient is expiring. Let up pressure when the patient is inhaling.
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Which way does the diaphragm move on inspiration?
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Down. The lungs expand and the diaphragm/liver moves down.
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Maneuver for examining aortic regurgitation?
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Have the patient lean forward. Ascultate the 2nd and 3rd left intercostal spaces with the stethescope diaphragm.
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Best position to hear mitral disease?
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Left decubitus position. Listen very lightly with the BELL listening for S3, S4, diastolic rumble.
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If someone says "I have 3 drinks a day" you should ask what?
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What types of alcohol do you prefer?
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What is a type of gait characterized by favoring certain motions to avoid pain?
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An antalgic gait.
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If a patient has nausea and vomiting, what is the safest immediate course of action as far as their status is concerned?
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Make them NPO --> look at some labs and buy some time.
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How long do you usually have before symptoms come on if you ignore diabetes?
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About 10 to 15 years.
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If you see that someone is on prednesone, what is a question that you absolutely need to find out?
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Why is this patient on prednisone?
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What are some questions that you should ask patients with thyroid issues?
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1. Determine if the patient is euthyroid, hypothyroid, or hyperthyroid.
2. Assessment of risk factors. - Exposure to ionizing radiation. - Family history 3. Assessment of symptoms of mass effect. - Difficulty swallowing, hoarseness of voice, SOB when lying flat. - Determine the rate of growth of the nodule or goiter (e.g, has your collar size changed) |
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What are some things that you should look for on physical exam in a patient with thyroid issues?
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Vitals: HR, Weight
HEENT: Lid lag, proptosis, conjunctival irritation, loss of lateral 1/3 of eyebrows. Neck: Thyroid: size, texture, nodules, bruits, Pemberton's Sign. CV: Tachycardia, bradycardia, Lungs: Rales Neuro: Motor strength, reflexes, tremors Skin: Moist/dry, brittle hair, vitiligo. Psych: Affect, speech patterns. |
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What is Pemberton's Sign? What is it indicative of?
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The development of:
- facial flushing - elevation of jugular venous pressure - inspiratory stridor upon raising both arms above the head simultaneously Indicates SVC syndrome secondary to thyroid goiter or tumor. |
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If TSH is ___, then the patient would proceed to what to determine what?
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If the TSH is LOW, then the patient would proceed to a RADIOACTIVE IODINE UPTAKE (because there is a low risk of malignancy)
If the RAIU scan shows increased uptake, then you proceed with hyperthyroid workup. If the RAIU scan is low or normal, then you do ultrasound --> fine needle aspiration. |
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If the TSH is ______ or ____, then the patient should proceed to ultrasound and possibly fine needle aspiration.
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If the TSH is NORMAL or HIGH, then the patient should proceed to ultrasound and possibly fine needle aspiration.
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Trousseau's Sign
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Inflate BP cuff at a point greater than the systolic blood pressure and hold it there for three minutes. In the absence of blood flow, the patient's hypocalcemia will cause spasm of the hand and forearm muscles (obstetrician's hand)
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Chvostek's Sign
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tap facial nerve anterior to ear --> contraction of ipsilateral facial muscle.
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What does POLYuria mean?
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It means increase in the AMOUNT of urine, not the frequency
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Fever
Flank pain Which is more indicative of pyelonephritis? |
Fever is seen more often than CVA tenderness!
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A woman who notices blood in her urine. What is a question that you need to ask?
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Is she menstruating?
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"Pus always suggests __(bug)__"
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"Pus always suggests S. aureus"
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What type of infection is associated with wrestling?
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"Herpes gladitorum" herpes simplex from wrestling mats.
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Folliculits, furuncles, carbuncles --> ?
Cellulitis --> ? |
Folliculits, furuncles, carbuncles --> S. aureus
Cellulitis --> 95% GAStrep |
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Descriptive term for the appearance of the skin in:
Graves disease Inflammatory breast cancer Pseudoxanthoma elasticum |
peau d'orange or "skin of an orange"
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Beta hemolytic strep loves _____.
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Beta hemolytic strep loves EDEMA.
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Basic data concerning bites by pets
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1% of all ED visits
Children > adults Frequency: dog bites > cat bites Infection: cat bites (35%) > dog bites (10%) |
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Cat bite with immediate sx: what organism?
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Pasturella multicoda
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Cellulits: offending bug, treatment
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95% strep, 5% staph
Cefazolin, nafcillin, or vancomycin |
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Cat bite: ABX
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Ampicillin (every 4-6 hrs)
Ceftriaxone (daily) |
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Dog bite: ABX
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Augmentin (Dogmentin)
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What should you do rule out GAS necrotizing fascitis?
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Look for crepitus (only 1/3 sensitive)
Get a plain film and look for gas |
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Penetrating injury --> worried about what bug --> type of infection --> what surgical procedure would you do?
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Penetrating injury --> beta hemolytic strep --> cellulitis --> debridement
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Crushing trauma --> worried about what bug --> type of infection --> what surgical procedure would you do?
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Crushing trauma --> Clostridia --> myositis --> amputation
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Foot care advice for diabetics
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Look at your feet everyday.
If you can't because of retinopathy, have someone else look at your feet for you. If you are inflexible, get a mirror |
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Do most tumors cause fever?
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No, not really
Tumors that do: Lymphomas, renal cell carcinoma, and any tumor in the liver |
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What are the tumors that cause fever?
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Lymphomas, renal cell carcinoma, and any tumor in the liver.
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What makes for a good sputum culture?
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Lots of PMNs, not a lot of squamous cells, lancet shaped cells inside PMNs
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How should you go about getting a sputum sample?
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You should watch the patient give it!
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How can you differentiate between a pleural effusion vs. consolidation?
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Usually can differentiate by ultrasound or CT
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"If you are standing around discussing an x-ray for more than 3 minutes, it's time to get a CT scan." Dr. Glew
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***
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"If a patient's racial identity is ot relevant to issues, don't include it in the opening, include it in the social history." Dr. Glew
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***
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How much does a CT scan cost?
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$1500 - $2000
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GERD can cause coughing and wheezing
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***
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What are some states that can present with a natural left shift?
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Steroid use, pregnancy
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Post auricular adenopathy
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Mononucleosis
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Dose of ACEi and cough
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Cough increases with dose, esp at 40-60 mg/day
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Extremely important study of diabetes: DCCT (Diabetes Control and Complications Trial) NEJM 1993: 329: 977-986
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***
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BMI =
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Weight in kg / (height in meters)^2
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What are the odds of an American having diabetes in 2010?
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1 in 3
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Diabetes control: metformin vs. exercise
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Meformin reduced complications by 30%, exercise reduced by 60%!
Exercising 30 minutes a day was the most effective |
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What are the units used to measure serum glucose in the EU? How do you convert?
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mmol/L.
To convert from mg/dL, divide by 18 g/mol. |
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What is a way that you can distinguish between an insulin overdose vs. an insulinoma?
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Insulin overdose: will see no C-peptide
Insulinoma: will see increased C-peptide |
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What tissues in the body don't need insulin?
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Brain, heart, erythrocytes
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"Insulin is like the key that unlocks the door and lets glucose into your body." - Dr. Mordes
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***
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Above what level does your serum glucose need to be before you are seeing glucose in the urine?
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Above 180 mg/dL
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Why do we say that a fasting glucose level of 126 mg/dL is diagnostic for diabetes? Why this number?
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Because it is based on the European system
7.0 mmol/L = 126 mg/dL 126/18 = 7.0 |
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Post-prandial glucose levels are the first to be elevated
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***
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As of December 2009, what Hb A1c is diagnostic for diabetes?
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> or = to 6.5%
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How long do RBC stick around?
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about 3 months
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Community acquired pneumonia: onset
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Usually acute
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"cough of a few weeks" = pneumonia?
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Not usually, usually is more acute. Might suspect TB
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"afebrile" = pneumonia?
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no, usually presents with fever
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pneumonia: weight loss
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Don't usually see weight loss with pneumonia.
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Factors that should prompt consideration of TB in the DDx
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1. Hx of postive tuberculin test or disease.
2. Contact with known or suspected tuberculosis case 3. Presence of fibrotic lung lesions or upper lobe scars compatible with inactive TB 4. Immigration from countries with high risk for TB. |
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What is vitamin B6 used for in the treatment of TB?
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Used to decrease the amount of neuropathy associated with INH.
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Upper lobe infiltrate on CXR + foreign born, what do you do?
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Isolation w/ N95 mask, order smears.
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A pt says that they have an allergy to local anesthetics. One time after injection they becames sweaty and tachycardic. What is going on?
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This is most likely not a true allergy, but is a normal reaction to epinepherine that is included in the local anesthetic solution. Could also be a hypersensitivity reaction to the preservative (often PABA, methylparaben, propylparaben)
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How do you locate the femoral nerve?
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It is at the level of the inguinal ligament. Intentionally touch the nerve with the needle to create a paresthesia. DO NOT inject anesthetic into the nerve, this is very painful.
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How do you locate the sciatic nerve to do an injection?
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Hook needle up to nerve stimulator and try to evoke motor activity
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Where is a good place to inject to block the brachial plexus?
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Just superior to the clavicle where it passes over the first rib.
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How do people with a blood sugar of 120-160 feel?
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Fine, no sx usually. But definite increase in AE from diabetes.
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Dr Mordes on diabetes: "For what you need, you ain't got enough."
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***
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Dr. Mordes: "People with diabetes, not 'a diabetic'"
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***
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Steps to placing an IV catheter.
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1. Get all the equipment you need.
2. Bevel up 3. Shallow angle in 4. Hold needle thingy in place and slide catheter in. 5. Take needle thingy out 6. Take touriquet off. 6. Place tape sticky side up under the butterfly and then wrap around (don't cover puncture site). 7. Put saline flush syringe on. Pull back to get air out. Then flush by putting air in. |
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Steps to intubate
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1. Get all the equipment that you need, make sure that laryngeoscope light works.
2. Put middle finger in between teeth then use thumb and index fingers to scissor mouth open. 3. Put blade in on right side with blade at a right angle to sweep tongue out of the way. 4. MAC blades are designed so that the tip goes in the velicula (in between the epiglottis and the tongue). Miller blades are used to go on top of the epiglottis and physically move it away (more helpful in kids). 5. Pull up and out at an angle (don't ratchet back or you will break teeth!) to visualize vocal chords. 6. Keep looking at the chords and have someone pass the endotracheal tube to you. 7. Insert the tube up until 23 or so. Inserting too deeply will cause the tube to go into the main stem bronchi. 8. Inflate the balloon. 9 Connect the bag 10. All set! |
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How much do insulin pumps cost?
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3000-5000 dollars!
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Which requires ATP: cardiac contraction or relaxation?
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Relaxation!
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A drug's lipid solubility correlates well with its what?
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Its average amount of adverse effects.
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Why should you not discontinue beta-blockers abruptly?
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It can cause a hyperadrenergic state.
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Nitrates for angina are very lipid soluble so they can be given:
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transdermally! Also sublingually to avoid the liver.
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How do nitrates relieve angina?
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Nitrates work by increasing pulse pressure and LVEDP. They cause peripheral dilation, but they don't expressly dilate the stenosis. Nitrates work via NO.
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Nitrates should not be taken with what other drug?
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Viagra! Can cause too much hypotension.
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675. IMS (Immediate Memory Span)
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Most of us only have 7 digits +/- 2. This is why phone numbers are not 10 digits long!
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People with HTN and meds
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have a lower risk of becoming demented than those that do not
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Common thing that people do that increases the risk of getting Alzheimer's
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Smoking!
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"Doughy" abdomen
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Tuberculous peritonitis
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Viridians strep NOT strep viridians
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***
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A good way to remember to get lab data to patients
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Have them call you later
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"I'd rather be bitten by a dog's anus than by a human mouth."
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Dr. Glew
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Foot puncture wound
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P. aeruginosa
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Medicaid will not pay for
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home ABX
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Culture negative pyarthrosis
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Suspect Lyme
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Don't pierce cartiledge!
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Not a great blood supply. Hard to cure if it gets infected
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Never start parenteral IV without
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blood cultures
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anemia + neuropathy of posterior columns
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B12 (folate deficiency does not do this!)
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Too many egg whites can cause...
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a biotin deficiency!
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People affected by fava beans are usually from what part of the world?
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Meditteranean!
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vLow citrulline, ornithine =
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Urea cycle disorder
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Allopurinol is not
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an acute txt for gout
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presents 10 years earlier than the diagnosis of Huntington's
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Depression
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One of the only infections that can give you lymphocytosis
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Pertussis
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If someone has had HA x 6 mo, then it is probably not
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temporal arteritis.
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Jaw claudication after eating
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temporal arteritis.
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Aspirin and acetaminophen are good for HA, but have to
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Take them early!
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Equal, nutrisweet contains this
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Aspartame
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Stop chewing sugarless gum =
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headache due to sudden lack of aspartame
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Temporal focal meningoencephalitis
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Herpes encephalitis (get them on acyclovir!)
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Herpes encephalitis: tx
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Acyclovir
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Herpes encephalitis has a predeliction for which lobes
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Temporal
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A normal EEG does not rule out
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seizure
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Mental status exam
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Can ask about sports, TV, etc.
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If stool osmolarity is >400 then
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diluted with urine
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If stool osmolarity is < 290 then
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diluted with H2O
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Nearly 30% of all deaths from CAD are attributable to
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smoking
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Smoking is protective for
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Parkinson's!
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Head pain in the elderly
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Think Giant Cell Arteritis
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Patient who can't see straight ahead needs
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the most urgent care
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ROS for macular degeneration
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"Any warpage or distortion?"
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The shoulder can come out of socket after a stroke
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Often pec major is the only muscle working, and holds arm to the body.
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If arm hurts after stroke
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Put in pocket
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Dressing with hemiparesis: which arm goes in first?
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The bad arm!
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amoxicillin + EBV = ?, amoxicillin + CMV = ?
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amox + EBV = rash, amox + CMV = no rash
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Uncommon to have _______ _____ as a child in the tropics
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Chicken Pox
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Smallpox scabs are infectious for how long?
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"Forever" . Worry about smallpox in mummies!
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Causes terrible back pain
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Endocarditis! Smallpox!
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Why should you foam after removing gloves?
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Because there can be microperforations
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To get max antiseptic effect from alcohol wipes
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Let alcohol dry on skin
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Everyone over the age of __ aspirates once a night
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45
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Osteomyelitis of the vertebrae/disk begins on the
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anterior side
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Tumors of the vertebrae start in the
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body of the vertebra
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What happens if a vertebral disk is destroyed?
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The vertebrae will fuse on its own
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c/c tetra and doxy: excretion
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Tetra: renally excreted, doxy: hepatic/fecal
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Corticosteriods stabilize the
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BBB
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How many neurons do you lose in a minute in stroke
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1000000
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tPA is
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neurotoxic!
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Men have a ___ higher risk of stroke than women
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19%
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Af Amer are ___ as likely as whites to have stroke
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2x
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Most powerful risk factor modifier in stroke
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HTN
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If you have a second concussion within a week of having the first it could be
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catastrophic
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If you have TIA you inc the risk of
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MI
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White dot in the retinal vessels
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Hollenhorst (cholesterol) plaque
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Hemorrhagic stroke vs. ischemic stroke
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Hemorrhagic stroke will usually do much better.
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What can you put on the brain to induce seizure?
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Penicillin!
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"Deserve 1 imaging study"
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Pts with migraine
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Sunset sign
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Aqueductal stenosis
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Wilson's disease: diet
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No lobster! Too much copper!
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Largest tumors in the body come from the
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Ovaries!
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Spotty periods after menarchy because
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GnRH periodicity not well established
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Any time there is no FSH
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Females lose follicles
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What do OTC "ovulation indicators" look at?
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At urinary LH
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HCG given to infertility pts to
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mimic LH and tigger ovulation
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Peaking of HCG correllates with peaking of
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nausea
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Possibly preg pt with enlarged uterus and open cervix =
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bad
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99% of ectopic pregs are in the
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fallopian tubes
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Scopolamine vs diphenhydramine: amnesia
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Scop does cause amnesia, diphen does not
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Peripheral circulating DA can cause
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HypoTN, nausea
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What happens when you pet a dog
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Both yours and the dogs oxytocin go up!
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Ok to say to a psych patient
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"It doesn't make sense to me, but...ok"
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"Soft signs" you see in schizophrenia
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Tap on forehead --> will blink repeatedly. Stroke along the side of the mouth --> rooting response?
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Seroquel (quetiapine) can help you...
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sleep, and gain weight
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Meds for alzheimer's allow grandparents to
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remember their grandparent's names for 3 extra months (that's all)
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Most middle aged men should take ____ once a day for protective CV effects
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Aspirin
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Migraines are NOT caused by ..... Instead they are thought to be caused by....
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...vasodilation of the vessels of the meninges. ...probably due to dysfunction of 5-HT receptors
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What is the cause of St. Anthony's fire? What was the ancient treatment?
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Ergot (grows on rotting rye). Was to make a pilgrimage. Worked because you eneded up eating the grain of a different region.
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What if sumitriptan doesn't work for migraine?
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Then you might want to reconsider your diagnosis
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Most data on pregnancy and radiation exposure comes from
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Hiroshima and Nagasaki
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Hallucinations while going to sleep and while waking up
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Hypnogogic hallucinations, usually not pathological
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Grief bereavement
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"Not going to feel better for two years"
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the "Tie Sign"
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For mania. Pt might be manic if starts making comments about someone's tie. a half-joke
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Depression eval, what lab test should you check?
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TSH
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what percentage of MS patients are depressed?
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50% This is much more than with other neurodegenerative disorders, so we think there is something inherent to the disease that makes depression more common.
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L-sided stroke --> ?, R-sided stroke --> ?
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L-sided stroke --> depression, R-sided stroke --> mania
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People that are depressed have "heart rate variability"
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***
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People that cut themselves are more likely to
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complete suicide. Also those that take more than 70 pills
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An emotional plea is effective sometimes
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***
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Physicians and suicide
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Attempt less often, complete more often
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How many grams of EtOH is in 1 beer?
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10 g
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|
|
Excessive phone calling correllates well with
|
Mania
|
|
|
If pt has ascities and fever
|
Check to see if the ascities is infected!
|
|
|
ECRP can cause
|
Pancreatitis!
|
|
|
Natural remedy for hepatitis
|
Milkthistle
|
|
|
Bereavement: worse for men or women?
|
Men
|
|
|
Diarrhea was thought to be
|
An excessive form of the desire to giving to others.
|
|
|
Agoraphobia often made better by
|
Having a sympathetic companion along with the person.
|
|
|
Extinction
|
Decrease undesired behavior by ignoring it.
|
|
|
2 issues with extinction
|
Have to be able to deal with escalation of the event
have to be able to provide "non contingent" attention. |
|
|
"try to avoid using benzos in your medical practice"
|
Dr. Hobart
|
|
|
Mitral value prolapse: panic attack
|
Inc risk of panic attack
|
|
|
Alcohol: panic attacks
|
Alcohol use can cause worse panic attacks.
|
|
|
Caffiene : panic attacks
|
Some people can have caffiene induced panic attacks
|
|
|
Self help for panic attacks
|
Exercise, especially w other people. . Regular sleep, getting up at reg hours.
|
|
|
Age of children : anxiety in mother
|
Age of children may bring back memories of when parents were abused.
|
|
|
Benzo : alcohol
|
Act on the same receptors.
|
|
|
MA is one of the worst states in divertion of prescribed meds
|
Dr. Barton
|
|
|
Alcohol, barbituates, benzos, others (methaqualone "qualudes")
|
All have potential cross reactivity
|
|
|
Opiod withdrawl
|
Not life threatening
drug craving hyperalgesia, mydriasis N/V ab cramps insom, anxiety F, sweating piloerection |
|
|
Legally drunk
|
0.08%. 0.15 or 0.2% if tolerant
|
|
|
Most persons prescribed opiods for chronic pain do not become abusers.
|
***
|
|
|
Diacetylmorphine
|
Heroin.
|
|
|
Opiod detox meds
|
Clonidine for autonomic signs
otreotide for gi symptoms may be followed by naltrexone therapy. |
|
|
Suboxone
|
Naloxone is in to prevent shooting it up. Will precipitate withdrawl.
Suboxone = naloxone + buprenorphine |
|
|
One of the biggest problems with buprenorhine
|
Acute pain is very difficult to manage.
|
|
|
Why is methadone less abuseable than heroin?
|
It is very long acting, much less rush and assoc craving
|
|
|
Cns depressant withdrawl
|
Craving, irritability insomnia, tachycardia, htn, hallucinations
|
|
|
Disulfram
|
Don't take nyquil! Contains alcohol.
|
|
|
Naltrexone oral vs IM
|
Oral = pennies per day
IM = hundreds of dollars a month. |
|
|
Two forms of cocaine
|
Hydrochloride salt: inhaled IV
Alkaloidal base: crack, smoked. Faster high. |
|
|
Cocaine withdrawl
|
Craving, sleepy, unhappy, depressed, bradycardia
mild compared to opiod withdrawl |
|
|
Amphetemes
|
Have appetite suppression affects, become refractory to this in about 2 weeks.
|
|
|
Dronabinol
|
Medicinal marijuana! Elderly people don't like associated affects.
|
|
|
Marajuana wihtdrawl
|
Insomnia, restlessness, nausea. Almost imperceptible.
Not an analgesic, but may be affective in atypical pain syndromes |
|
|
Two types of psychadelics
|
5-HT2 agonists: LSD, etc.
NMDA antagonists: Ketamine, PCP No withdrawl |
|
|
Sharpies contain
|
Toluene! Can get high off of this.
|
|
|
Inhalants
|
Most are non halogenated alkanes, cause arr, sz. Brain damage, liver, kidney damage
|
|
|
Nicotine withdrawl
|
Insom, irr, anx, wt gain
can use bupropion (Xyban), varenecline (wmost effective, wt gain) |
|
|
People and animals HATE how DA blockers make them feel
|
Unless they are being txtd for hallucinations
|
|
|
Inhalant withdrawl
|
Cns depressants: sz, irritability, major problems are irreversible organ damage.
|
|
|
Is an addict in pain
|
Some clinicians will inject a syringe of saline3 ethical?
never tell what it is and what the dose is: ask "how did this help" If not comfortable in prescribing huge loads of opiods for acute on chronic pain, get a pain consult. |
|
|
Putting a lemon in your mouth
|
Autoerotic asphyxiation. Makes you wake up before you die.
|
|
|
A good way of explaining androgen insensitivity to a child.
|
You are a girl because all the cells of your body only respond to "girl" hormones.
|
|
|
A Samoan third gender type
|
Fa-afafine
|
|
|
Reconstructed penises
|
Doesn't grow, need multiple surgeries.
|
|
|
Conversion therapy for homosexuality
|
Doesn't work.
|
|
|
If you can go up and down a flight of stairs without arrhythmias
|
then you can return to sexual activity
|
|
|
If have arrhythmias
|
Don't drink, eat heavy meals, or be with strange partners
|
|
|
Frequentcy of oral sex
|
Increases with educational level!
|
|
|
If a patient wants to practice oral sex on a male
|
Dr rogoff suggests using a dairy queen ice cream
|
|
|
Vagina is analagous
|
To the scrotum. Not so much innervation.
|
|
|
Dealing with vaginismus
|
Instruct them to use tapered candles. Put it until you feel comfortable, then move to a larger size.
|
|
|
Squeeze (Sieman's) technique
|
Squeeze both sides of glands. Count 1, 2, 3. To delay premature ejaculation.
|
|
|
Masturbation correlates with
|
Increased education
|
|
|
Most comfortable position for people with abdominal issues.
|
Rear entry.
|
|
|
Good position for men with premature ejaculation.
|
Woman on top.
|
|
|
What if you are in the delivery room and you can't tell the sex of the baby?
|
Don't just make your best guess. Talk about good things and ease parents into "it looks like the genitals are not developed yet"
|
|
|
Toddlers in the bed
|
If you are a single parent and you let your toddler stay in bed with you and you get a new partner, you will have to "evict" the newborn.
|
|
|
Nudity with children
|
It's ok if you are ok with it. If you are uncomfortable with it, they will notice.
|
|
|
Primal scene with kids
|
Kids think that mommy and daddy are having a fight! Tell kid that everyone loves each other.
|
|
|
High spinal cord injury
|
Flaccid high and spastic lower. Increased erections?
|
|
|
SSRI
|
Anorgasmia -> loss of libido. "bathed in seratoin," become insensitive to serotonin
|
|
|
Pt is 12-13 weeks preg and has PID...
|
Probably not... May have C or G but progesterone in preg keeps cervical mucus thick
|
|
|
Perihepatic adhesions between liver and diaphragm (Fitz-Hugh-Curtis syndrome)
|
HIGHLY indicative of prior PID!
|
|
|
Increased susceptiblity to UTIs during preg due to
|
Inc progesterone slows motility of the smooth muscle of the urinary tract leading to Inc risk of infection.
|
|
|
Screening tests at pregnancy
|
HBV, syphilis, rubella, GC/CT, GBS, should offer HIV to All women. As needed: evaluation for HCV, HSV, varicella. HIV: w txt can go from 25% -> <1%
|
|
|
How does pregnancy affect women with HIV?
|
Does not affect the progression of the disease.
|
|
|
What is the worst thing that a preg woman with HIV can do?
|
Stop her meds because she is preg! Viral loads will go up, Inc risk of transmission.
|
|
|
WITS study
|
Women and Infant Transmission Study. Giving meds to dec transmission of HIV from mom to baby. Zidovudine!
|
|
|
Increased risk of vaginal prolapse
|
Use of forceps
|
|
|
Pushing in labor for over 2 hours
|
Too long, at risk for pelvic floor trauma.
|
|
|
Reversible causes of incontinence in the elderly
|
Delirium
Infection Atrophic urethritis & vaginitis Pharmacological causes Psychological causes Excessive fluid secretion Restricted mobility Stool impaction |
|
|
C/c female vs male brains
|
Female brains are about 5% smaller. The brain grows independently from the body - people with bigger bodies don't usually have bigger brains.
|
|
|
Neonates and elderly have low stomach acid...
|
...some drugs need acid to be absorbed. Ketoconazole is one. If pt is taking a PPI, take ketoconazole with coke (acid)!
|
|
|
Cholestyramine binds to...
|
....many other drugs
|
|
|
Absorption of fluoroquinolones inhibited by...
|
...divalent cations. Bind and chelate out.
|
|
|
Duration of effect controlled by what
|
Half life AND absorption
|
|
|
10 of morphine orally is...
|
...3 given IV
|
|
|
Procardia XL (nifedipine)
|
May see tablet shell in stool
|
|
|
Don't crush enteric coated drugs
|
They get really smushy and can't through a feeding tube.
|
|
|
Clindamycin liquid, Claritin liquid
|
Taste terrible!
|
|
|
Warfarin + TMP-Sulfa =
|
BAD INR will shoot up
|
|
|
Child with guttate psoriasis - check for
|
Previous strep A infection
|
|
|
DDx for nail pitting
|
1. Psoriasis
2. Alopecia areata |
|
|
Difference bet tinea corporis and pityriasis rosea
|
Herald patch of pityriasis rosea: scale is on the inside of annular ring. Tinea corporis: scale is on the outside of the annular ring.
|
|
|
Most important DDx for PItyriasis rosea
|
Secondary syphilis
|
|
|
Pityriasis rosea treat
|
Can give erythromycin even though thought to be a viral disease!
|
|
|
Lichen planus is itchy, but...
|
...pts don't seem to itch plaques!
|
|
|
Oral lichen planus is assoc w...
|
...hepatitis C!
|
|
|
History of ezcema
|
593 Aetius, "boiling out or over"
|
|
|
What is atopy?
|
Tendency toward hayfever, allergic rhinitis, asthma or atopic dermatitis.
|
|
|
What is the atopic march?
|
Atopic derm --> asthma --> allergic rhinits
|
|
|
Severe atopic dermatitis in infants is usually due to...
|
...a food allergy
|
|
|
T or F: a child can have atopic dermatitis without being itchy.
|
False. AD = itching
|
|
|
Atopic dermatitis saying
|
"the itch that rashes, rather than a rash that itches"
|
|
|
Neomycin and bacitracin can cause...
|
...allergic contact dermatitis in children.
|
|
|
Timecourse of initial exposure and contact dermatitis
|
7-10 days bc no tcell memory yet
|
|
|
Dermatitis below umbilicus
|
Allergy to nickel in jeans button!
|
|
|
Wheals =
|
Hives
|
|
|
If you circle a "wheal" in a pt w urticaria, will the lesion be in the same location tmw?
|
No, lesions are very migratory. Helps with dx.
|
|
|
2 big offenders for anaphylaxis w urtcaria
|
Peanuts, latex
|
|
|
Foods that cross react with latex
|
Bananas, kiwi, avocados, chesnuts! Avoid if have latex allergy!
|
|
|
Most common complaint that PTA have that present to a PCP.
|
Back pain and musculoskeletal issues.
|
|
|
What is the normal range of motion of the knee?
|
There is no normal. Examine the pts uninvoled knee to see what normal is for that pt. Usually 130-135
|
|
|
Knee "locking"
|
Means that you can't extend knee. To pts may mean many things. One of the mos common presenting sx of meniscal tear.
|
|
|
What is the difference between a fracture and a break?
|
There is no difference!
|
|
|
To classify a fracture
|
Which bone?
Where in the bone is the fracture? Displaced or not? Fracture pattern? Comminuted? (lots of little pieces) open or closed? (if open go directly to OR) Does the fracture involve the articular surface? |
|
|
Callus is a...
|
...good thing! Highly vascularized new bone formation.
|
|
|
Moron is...
|
...a made up word that was originally used bc it was thought to be inoffensive. Bc it had no previous meaning! But didn't work...
|
|
|
Children: questions to evalulate developmental function
|
"how does she indicate wants and needs?"
"What kinds of things does she like to play with?" |
|
|
"intellectually disabled"
|
1. Significantly subaverage intellectual function.
2. Deficits in adaptive behavior. 3. Occuring during developmental period (before age 18) if you get in a car crash at 17 years in 364 days - you may qualify for an intellecual disability. |
|
|
Potty training happens when?
|
Most trained by 3 or 4 years.
|
|
|
Sedated "coma end of things" vs. Seizing: which neurotranmitters?
|
GABA is coma. Glutamate is the seizing end of things.
Only one enzyme that really governs GABA/glutamate balance. Barbituates, benzos lean you toward the GABA end of things. |
|
|
Mydriasis
|
MyDriasis = Dilated
|
|
|
Don't cause pipping pupils
|
Meperidine, propoxyphene, diphenoxylate/atropine, and pentazocine, sometimes tramadol
|
|
|
Effect of respiratory rate
Benzo: Ethanol: Barbituates: Opiods: |
Benzo: unchanged
Ethanol: unchanged Barbituates: dec Opiods: dec |
|
|
C/c maculopapular rash vs. Palpable purpura
|
Mp rash is blanchable pp is not
|
|
|
Scabies how many mites?
|
Usually about 12 mites! Unless norweigen scabies = thousands of mites.
|
|
|
Koebner phenomenon
|
Think psoriasis
|
|
|
Remembering decimal points
|
Always lead and never trail
|
|
|
2006 report found unnecessary polypharmacy in
|
15-20% of patients on 4-6 patients
|
|
|
The five rights of writing prescriptions
|
Patient
dose route time medications |
|
|
Becareful about using corticosteroids with eczema because
|
A fungal infection can look like Eczema. Giving steroids with fungal infection can make feel better but problem worse.
|
|
|
If pts with psoriasis stop corticosteroids
|
The psoriasis comes right back. Can use calcipotriene to prevent remission.
|
|
|
Usually give methotrexate with
|
Folate to prevent bone marrow side effects.
|
|
|
Phototherapy for psoriasis
|
"narrow band" around 312 nm
|
|
|
-cept
-mab -umab / -ximab |
Signifies receptor analogs. Work by binding-up cytokines.
-mab signifies monoclonal antibody against receptor. These work by blocking the cytokine receptors on lymphocytes. (-umab indicates human abs, -ximab indicates animal abs) |
|
|
Doctor has to have a special registration for what dermatological med?
|
Isotretionoin (accutane). Have to do IPLEDGE. One month off accutane and you are safe to get pregnant again.
|
|
|
If you have dryness between your toes, there is something else going on.
|
First require pts to treat tinea pedis with topical. Then work on the onychomycosis. If don't do this then infxn of nails recurrs from tinea pedis. Don't need new shoes. 6 wk treatment for fingernails, 12 wk treatment for toenails. Generally safe, now don't really check any labs before prescribing.
|
|
|
Herpes zoster often causes skin to be tender before breakout
|
If treat with acyclovir or valacyclovir early enough, can prevent post herpetic neuropathy.
|
|
|
Permethrin (Elimite)
|
For scabies or head lice. Need to prescribe permethrin TWICE so that can eradicate both scabies bugs and eggs. Need to rx two doses seven days apart. If wait too long then hatch and then lay eggs. If too soon then permethrin won't be able to kill eggs.
|
|
|
ADHD correlates with
|
Maternal smoking!
|
|
|
ODD (oppositional defiant disorder) often responds to same meds as...
|
...ADHD drugs
|
|
|
Sugar in kids.
|
Does not cause hyperactivity.
|
|
|
Appetite suppression with methylphenidate
|
Have a big breakfast before you take your methylphenidate.
|
|
|
Drug holidays with methylphenidate?
|
Not recommended to stop on weekends, summer. Can have cardiac symptoms.
|
|
|
Pregnant women are the most at risk for intimate partner violence.
|
"During pregnancy and the first year of a child's life a woman is more likely to die from a domestic homicide than any other cause of death. " Chang 2005
|
|
|
Getting the partner out of the room.
|
You have control to say: "I need to examine your wife alone."
|
|
|
Ways to frame questions about domestic violence
|
Many patients I see are coping with an abusive relationship, so I start by asking about it directly.
Follow lead in with specifics: "At any time has a partner hit, kicked, or otherwise hurt or frightened you?" "Do you have guns at home? Where's the ammunition?" |
|
|
Patient tells you about domestic violence.
|
"I believe you. We can help you."
|
|
|
Batterer/perpetrator: what is not useful
|
Couples counseling is not only not useful but can escalate the violence.
Anger management txt does not get to the core issue |
|
|
Most at risk for domestic violence when...
|
...when victim is trying to leave! So just leaving is often not possible. It's more like you need to totally escape.
|
|
|
You have to report domestic violence to the police. T or F?
|
False.
|
|
|
You don't get a severe myopathy from
|
Any type of vasculitis ?
|
|
|
If ALT or AST is elevated for no reason
|
Could be a myositis!
|
|
|
Don't do an EMG on all limbs...
|
...save one limb for a muscle biopsy. Usually thigh.
|
|
|
Corporal punishment is not abuse if...
|
...no marks are left
|
|
|
Exposure of sexual material to children is...
|
...sexual abuse
|
|
|
Exposure of fetus to substances during pregancy
|
Automatically neglect
|
|
|
Spanking
|
Isn't a very effective way of parenting, but hasn't been shown to be particularly detrimental.
|
|
|
Section 51A
Section 12 |
51A: for abused children. MA gives more power to the state. If you "have reasonable cause to believe" that there is abuse, you must immediately report orally or written report within 48 hours.
No mandated reporter has ever been convicted for not reporting. Not reporting = one thousand dollars Reporting frivolously = one thousand dollars. DCF has to decide to investigate or not. If investigate then have to substantiate or not. The threshold for what has been substantiated has risen with hard economic times. 12: when you send someone to the ED for psych eval. |
|
|
If you really want to know what is going on with the patient
|
Ask the nurses before they sign out in the morning!
|
|
|
Ask for feedback directly
|
Tell me three things I can approve on.
|
|
|
What patIents want FP quote
|
Affabilty availability ability in that order
|
|
|
Don't sit on the same aide as the attendings at
|
Surgical grand rounds
|
|
|
Muscle spasm of the back
|
Usually causes generalized back pain with diffuse burning pain not past knee. Radiculopathy presents with shooting pains past knee.
|
|
|
Remember that ibuprofen + diabetes
|
Not so great because the patient might have renal involvement.
|
|
|
For lower back pain
|
Get a diagnosis! Osteoarthris, etc.
|
|
|
With radiculopathy
|
Vibratory would be first to go.
|
|
|
Colon cancer
|
Prevents more with constipation more than diarrhea
|
|
|
Some people get a low grade fever with
|
Dehydration
|
|
|
What viruses are associated with symmetrical arthritis
|
Parvovirus and HCV, HBV, HAV in acute phase
|
|
|
If have HCV you can't use what med for RA
|
methotrexate
|
|
|
Cryoglobulinemia is assoc with
|
RF factor and HCV
|
|
|
Of someone comes into your office with all the sx of RA with positive RF
|
Must be present for at least 6 weeks
|
|
|
Chinese pharmaceuticals
|
Often have all kinds of other meds thrown in
|
|
|
The percentage of people taking cam therapies
|
50%
|
|
|
Regulation of dietary supplements
|
Dietary supplement health and education act ( DSHEA 1994)
Orrin Hatch and herbal factories in Utah. Lobbies got DHEA passed. Gave manufacturer the responsibiltiy. Also Food, Drug, and Cosmetic Act is what gives the FDA it's power. But doesn't apply to dietary supplement, becuase it's not food. FDA can't investigate unless there is direct proof of harm. |
|
|
Ayurvdic medications
|
Frequently cause arsenic, lead, mercury
|
|
|
Homeopathic dilution
|
24x 60% chance that there is 1 molecule of remedy in the bottle
|
|
|
Echinacea is more potent in
|
Germany. Regulated in Germany. More potent.
|
|
|
St johns wort and transplant
|
Induces intestinal. CYP3A4 can lead to decreased tacrolimus and cyclosporine concentration.
|
|
|
Brazilian weight loss remedy
|
Contains lead
|
|
|
Spice toxicity
|
Contains lead. Usually from little Indian markets in India. Also herbal teas.
|
|
|
Medical foods
|
Not required to be regulated, review, or approved! But there is a drug insert.
|
|
|
Remember, if you want to fight big pharma, going to supplements
|
Often the supplement companies are owned by big pharma!
|
|
|
Malar rash vs acne rosea
|
Acne rosea does not spare the nasolabial folds.
|
|
|
Lupus in Latin
|
Means wolf. Malar rash looks like wolf
|
|
|
Toxic rape seed oil in Spain in 1970s. Polyvinyl exposure. Gadolinium exposure.
|
Scleroderma!
|
|
|
Skin biopsy in scleroderma
|
Don't really need to do. If do it, do in inconspicuous area.
|
|
|
Most specific antibody for lupus?
|
Sm abs. About 30% of pts have this but it is specific for lupus.
|
|
|
A major side effect of anti-TNFs
|
Reactivation of TB! Reactivation of hep B in chronic carriers.
|
|
|
Lethargic
obtunded stuporous |
LethArgic - wake up when call
obtunded - wake up when shake stuporous - need painful stimuli to wake |
|
|
Serious recurrent symptoms reported by only one person
|
Suspect munchausen's by proxy
|
|
|
Munchausen's by proxy
|
Don't confront! The parent with run with the child.
Need to alert dcf to be present when confront. |
|
|
Older patients with parnoid ideation
|
May just be that they can't hear, so they think that everyone is whispering about them!
|
|
|
Delirium vs. Dementia
|
Delirium
1. Sudden onset 2. Fluctuating level of arousal. Can go from somnolence to agitation. Dementia usually doesn't vary. |
|
|
IOP has significant
|
Diurnal variation!
|
|
|
People with cutting in central areas.
|
More indicative of psychosis.
|
|
|
A white t-shirt has an SPF of
|
SPF 10
|
|
|
What does a dermatologist say about sunlight and vitamin D?
|
Just get it from a dietary supplement!
|
|
|
Even though psoriasis is very itchy, you don't see
|
Eosinophils!
|
|
|
If can completely extend your elbow
|
There is no excess in the joint
|
|
|
Gout vs. Pseudogout can you see on x-Ray?
|
Can see calcium pyrophosphate of pseudogout.
|
|
|
What kind of biopsy do you do with a melanoma?
|
Excisional biopsy. NOT a shave biopsy - need to see whole depth.
|
|
|
Identifying an ixodes tick
|
Have BLACK legs
|
|
|
Helpful practice for those with personality disorder
|
Tell pts to "check it out" and to ask people about their emotions/ what they meant.
|
|
|
The 11th step of alcoholics anonymous
|
Meditation and prayer
|
|
|
Diabetic acidosis vs. Alcoholism acidosis
|
Alcohol inhibits gluconeogenesis and so alcoholism ketoacidosis presents with hypoglycemia
|
|
|
TG excess and chylomicrons vs. VLDL
|
TG excess comes from diet --> chylomicrons
from liver--> VLDL refrigerator test VLDL more milky and with plasma. Chylomicrons float to the top. |
|
|
Minocylene can cause
|
Drug induced lupus. Get antihistone antibody screen
|
|
|
Heavy menses with hyper thyroid or hypo thyroid?
|
HYPOthyroidism !
|
|
|
Rule of twos with WBCs
|
0-200 normal
200-2000 non inflammatory 2000 and above is inflammatory |
|
|
Presdnisone and mood
|
Can cause restlessness and a racing mind.
|
|
|
When blood glucose fluctuates
|
Vision can become blurry because of water coming in and out of the lens of the eye. People think that prescription is changing.
|
|
|
Ankylosing spondylitis management tips
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Sleep on back, not curled up. Do back extention exercises.
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Criteria For inflammatory back pain vs. Mechanical
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1. Age of onset is under 40 years
2. Insidious onset 3. Duration greater than 3 months 4. Association with morning stiffness (>1 hr) 5. Improvement with exercise |
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Table for memorizing types of insulin
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Peak/Duration
Glargine: none/>24 hours NPH: 6/12 Regular: 3/6 Lispro, Aspart: 0.5/3 everything is approx half of that above it. |
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Delusional disorders are characterized by
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Defined by an "encapsulated" delusion. Pt usually otherwise fine. Characteristically only one delusion. Doesn't usually have visual hallucinations.
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Lewy body dementia
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Characterized by visual hallucinations. Pt otherwise fine. ?
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How to approach energy healing
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Do you pray? Do you mind if I say a little prayer for your leg?
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EKG Changes with pericarditis
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Pericarditis can trigger ST elevation "All over the place" - Dr. Cuenoud
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Cold sweat happens because
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The pt has a vagal reaction and the body is compensating to the hypotension by activating the sympathetic system
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Anteroseptal MI: which leads?
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V1 - V2
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Anterior MI: which leads?
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V2 - V5
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Anterolateral MI: which leads?
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V5, V6
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ST depression is sometimes falsely positive, but
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ST elevation is rarely falsely positive
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Ca blockers are good for ____ but not good for _____
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Not good for MI
Good for esophageal spasm |
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What is a person's mortality rate if they have chest pain for more than 1 hour and recieve no intervention?
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30-40% mortality
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Does a pt with angina have a normal EKG?
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Yes when there is no pain and "maybe" when there is pain.
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What are the eight steps to evaluating an EKG?
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1) Rhythm
2) Rate 3) Nature of PR 4) Duration of PR 5) Duration of QRS 6) Duration of QT 7) T wave 8) Other |
