Family Medicine - Part 1

Front 1

Definition of Metabolic Syndrome

Back 1

Central Obesity - Men ≥ 94 cm, Women ≥ 80 cm
Plus any TWO of the following four factors:
TG level: ≥ 1.7 mmol/L
HDL-C - Men < 1.0 mmol/L, Women <1.3 mmol/L
Blood Pressure ≥ 130/85 mmHg
Fasting Blood Glucose ≥ 5.6 mmol/L

Front 2

When to start screening full fasting lipid profile? How often?

Back 2

Screen males over age 40 and females over age 50 (or who are menopausal) OR any adults with additional CAD risk factors (e.g. obesity, DM, etc.)
Screen every 1-3 years.

Front 3

What are secondary causes of dyslipidemia?

Back 3

Hypothyroidism, chronic kidney disease, DM, nephrotic syndrome, liver disease.

Front 4

What is the primary target of therapy in a patient with dyslipidemia?

Back 4

LDL-C levels are the primary target.
An alternate primary target is ApoB (not used widely yet).

Front 5

When do you initiate treatment and what are the primary targets of treatment based on patient's 10 year risk category?

Back 5

High risk (>20% 10-yr risk of CAD or Hx of DM or any atherosclerotic disease): consider treatment in all patients, LDL-C target < 2 mmol/L or > 50% decrease

Moderate risk (11-19%): treat if LDL-C > 3.5 mmol/L or TC/HDL-C ratio > 5.0, LDL-C target < 2.0 mmol/L or > 50% decrease

Low risk ( ≤10%): treat if LDL-C ≥ 5.0 mmol/L, target of ≥50% decrease in LDL-C

Front 6

What are the main side effects of statin therapy?

Back 6

Myopathy and hepatotoxicity. Others include rash, pruritis, GI symptoms, rhabdomyolysis.
Monitor ALT, AST, CK at baseline then 6 wks later for signs of transaminitis or myositis.
Must follow LFTs and evaluate fasting lipids q6-12 m.

Front 7

What therapy is recommended for isolated hypertriglyceridemia?

Back 7

Principle therapy is lifestyle modification becuase isolated hypertriglyceridemia does not increase your cardiovascular risk.
Drug therapy: Nicotinic acid or fibrates.

Front 8

What is the 1st line monotherapy for increased LDL-C?

List drug names a doses.

Back 8

HMG CoA reductase inhibitor (statin)

atorvastatin (Lipitor) 10-80 mg/d
fluvastatin (Lescol) 20-80 mg/d
rosuvastatin (Crestor) 5-40 mg/d
simvastatin ( Zocor) 10-80 mg/d

Front 9

What is the mechanism of action of statins?

Back 9

Inhibits cholesterol biosynthesis, decreases LDL synthesis, increases LDL clearance, modest increase in HDL, limited decrease in VLDL.

Front 10

5 A's for patients willing to quit smoking

Back 10

Ask if patient smokes
Advise patient to quit
Assess willingness to quit
Assist in quit attempt
Arrange follow up

Front 11

List options for nicotine replacement therapy

Back 11

Nicotine gum, nicotine patch, and nicotine inhaler.

Front 12

Describe mechanism of action, side effects, dosage and contraindications to Bupropion.

Back 12

Mechanism: Inhibits re-uptake of dopamine and/or norepinephrine.
Side effects: insomnia and dry mouth.
Dosage: 150 mg qAM x 3 d, then 150 mg bid x 7-12 wks. Continue to smoke for first 1-2 wks of treatment and then stop completely.
Contraindications: Seizure disorder, eating disorder, MAOI use in past 14 days, simultaneous use of buproprion (Wellbutrin) for depression.

Front 13

Describe mechanism of action, side effects, dosage, and contraindications to Varenicline.

Back 13

Mechanism: partial nicotinic receptor agonist, and partial nicotinic receptor competitive antagonist.
Side effects: nausea, vomiting, constipation, headache, dream disorder, and insomnia.
Dosage: 0.5 mg qAM x 3d, then 0.5 mg bid x 4 d, continue 1 mg BID x 12 wks.
Continue to smoke for first wk of treatment and then stop completely.
Contraindication: caution with pre-existing psychiatric condition.

Front 14

Investigations to order in alcoholic patients

Back 14

GGT and MCV for baseline and follow up monitoring
AST, ALT (usually AST:ALT ratio approaches 2:1 in an alcoholic)
CBC (anemia, thrombocytopenia), INR (decreased clotting factors produced by liver)

Front 15

Adverse medical consequences of problem drinking

Back 15

GI: gastritis, dyspepsia, pancreatitis, liver dz, bleeds,
Cardiac: hypertension, alcoholic cardiomyopathy
Neurologic: Wenicke-Korsakoff syndrome, peripheral neuropathy
Hematologic: anemia, coagulopathies

Front 16

What are the Ottawa ankle rules?

Back 16

x-rays of the ankle should be performed if there is bony tenderness of the posterior edge or tip of the distal 6 cm of either the medial or lateral malleolus, or if the patient is unable to bear weight immediately or when examined

Front 17

What are the 3 ligaments on the lateral aspect of the ankle? Which is most commonly injured?

Back 17

1. anterior talofibular ligament
2. calcaneofibular ligament
3. posterior talofibular ligament
The ATFL is the most commonly injured ligament, followed by the CFL.

Front 18

What are the Ottawa knee rules?

Back 18

Perform a knee x-ray on patients with a knee injury who have any one of the following five criteria: (1) age 55 years or older, (2) isolated patella tenderness, (3) tenderness of the head of the fibula, (4) inability to flex the knee to 90°, and (5) inability to bear weight for four steps immedi- ately and in the examination room (regardless of limping)

Front 19

How do you determine the likelihood of cancer in a skin lesion?

Back 19

ABCDE - asymmetrical, boarder irregularity, color irregularity, diameter > 5mm, and evolving or changing over time.
Lesions that exhibit any of the ABCDE signs should be excised.

Front 20

What are the characteristic features of basal cell carcinoma? What is the primary treatment?

Back 20

Basal cell carcinomas are the most common of all cancers. They typically appear as pearly papules, often with a central ulceration or with multiple telangiectasias. Patients typically present with a growing lesion and some- times complain that it bleeds or itches. The primary treatment is excision.

Front 21

What are the characteristic features of squamous cell carcinoma? What is the primary treatment?

Back 21

Squamous cell carcinomas are often irregularly shaped plaques or nodules with raised borders. They are frequently scaly, ulcerated, and bleed easily. Complete excision is the treatment of choice.

Front 22

Define microscopic hematuria.

Back 22

The presence of 3 or more red blood cells per
HPF on two or more properly collected urinalyses.

Front 23

List 5 urologic causes of hematuria.

Back 23

Urologic causes of hematuria include tumors, calculi, infections, trauma, and benign prostatic hyperplasia (BPH).

Front 24

Eosinophils in urine suggests what type of renal disease?

Back 24

Interstitial nephritis, often caused by analgesics or other drugs, is suggested by the presence of eosinophils in the urine.

Front 25

What is the most common cause of non iatrogenic hyperthyroidism? What is the pathophysiology of this disorder? What is the primary treatment?

Back 25

Graves disease is an autoimmune disorder caused by antibodies directed against the TSH receptor on the thyroid gland initiating the production and release of thyroid hormone. Graves disease is treated symptomatically with antithyroid drugs (propylthiouracil and methimazole) and/or β-blockers. Definitive treatment is radioactive iodine.

Front 26

What is thyroid storm?

Back 26

Thyroid storm is an acute hypermetabolic state associated with the sudden release of large amounts of thyroid hormone into circulation, leading to autonomic instability and central nervous system dysfunction such as altered mental status, coma, or seizures.

Front 27

What percent of Graves patients have exophthalmos?

Back 27

Approximately 50% of patients with Graves disease have exophthalmos.

Front 28

What is the preferred treatment of Graves disease in adolescents?

Back 28

Antithyroid drugs are the preferred treatment of adolescents because they may go into spontaneous remission after 6 to 18 months of therapy.

Front 29

How do you treat thyroid storm?

Back 29

Thyroid storm is treated with administration of high doses of PTU and β-blockers (to control tachycardia and other peripheral symptoms of thyrotoxicosis). Hydrocortisone is given to prevent possible adrenal crisis.

Front 30

What is the most common noniatrogenic cause of hypothyroidism?

Back 30

The most common noniatrogenic condition causing hypothyroidism is Hashimoto thyroiditis, an autoimmune thyroiditis.

Front 31

What investigations should be performed when the diagnosis of primary hypothyroid is made if the thyroid is normal on physical exam?

Back 31

Once the diagnosis of primary hypothyroidism is made, further imaging or serologic testing is unnecessary if the thyroid gland is normal on physical examination.

Front 32

What is the treatment of hypothyroidism?

Back 32

Most healthy adults with hypothyroidism require about 1.7 μg/kg of thyroid hormone replacement daily, with requirements falling to about 1 μg/kg for the elderly. Dose is increased slowly every 4-6 weeks until TSH normalizes.

Front 33

Which thyroid nodules require biopsy?

Back 33

Nonfunctioning nodules measuring greater than 1 cm by examination or ultrasonography require biopsy via fine-needle aspiration.

Front 34

What are signs that could confirm the rupture of membranes?

Back 34

Visualization of amniotic fluid leaking from the cervix; the presence of pooling of amniotic fluid in the posterior vaginal fornix; demonstration of a pH above 6.5 in fluid collected from the vagina using Nitrazine paper; or visualization of “ferning” on a sample of fluid on an air-dried microscope slide.

Front 35

What is the recommended antibiotic prophylaxis for GBS colonization during labor?

Back 35

Penicillin 5 million units IV loading dose followed by 2.5 million units IV every 4 hours; alternative treatments include IV ampicillin, cephalothin, erythromycin, clindamycin, and vancomycin.

Front 36

What factors effect the progression of labour?

Back 36

Power, passenger, passage.

Front 37

What are the important considerations when interpreting fetal heart rate data?

Back 37

Base-line heart rate - 110 to 160 beats/min is considered normal.
Variability - is regulated by the balance of sympathetic and parasympathetic control of the sinoatrial node. Fetal acidemia secondary to hypoxemia can impair CNS function and reduce variability.
Periodic heart rate changes - the accelerations and decelerations from the baseline heart rate that occur, often related to uterine contractions. An acceleration is an increase in the fetal heart rate of 15 beats/min or more for 15 seconds or longer and is a reassuring finding.

Front 38

What is the significane of early, late, and variable decelerations in fetal heart rate?

Back 38

Early - fetal heart rate decline coincides with a contraction onset. Fast return to baseline. Thought to be due to compression of fetal head (increased vagal tone).
Late - gradual reduction in the fetal heart rate that starts at or after the peak of a contraction and has a gradual return to the base-line. Late decelerations are a manifestation of uteroplacental insufficiency and fetal hypoxia.
Variable - abrupt decrease in fetal heart rate, usually followed by an abrupt return to baseline that occurs variably in its timing, relative to a contraction. Are considered to be due to umbilical cord compression during contractions.

Front 39

Using an anatomical approach what are the big 3 causes of hypercalcemia.

Back 39

Increase in calcium resorption from bone, decreased renal excretion of calcium, or an increase in calcium absorption from the gastrointestinal tract.

Front 40

What physical symptoms are associated with hypercalcemia?

Back 40

"Stones, bones, psychic groans, abdominal moans"
Also shortened QT interval and arrhythmias.

Front 41

What is the first step in investigating hypercalcemia?

Back 41

Rule out offending medications (eg. thiazide or lithium).
Measure serum PTH level. If elevated suspect a benign adenoma of one of the parathyroid glands. If low suspect PTH-rP and search for malignancy.

Front 42

Causes of geriatric hearing loss

Back 42

Presbycusis (#1, aged related, sensorineural), noise-induced hearing loss, cerumen impaction, otosclerosis, and central auditory processing disorder

Front 43

What factors contribute to falls in the elderly?

Back 43

Age related postural changes, alterations in visual ability, certain medications, and diseases affecting muscle strength and coordination.

Front 44

Describe a rapid screen for dementia

Back 44

“Clock draw” and the “three-item recall” is a rapid and fairly reliable office-based screening for dementia. When patients fail either of these screening tests, further test- ing with the MMSE should be performed.

Front 45

Describe a rapid screen for geriatric depression

Back 45

A simple two-question screen:
1. Have you felt down/depressed/hopeless in the last 2 weeks?
2. Have you felt little interest or pleasure in doing things? Positive responses can be followed up with a Geriatric Depression Scale

Front 46

Drug of choice for isolated hypertension

Back 46

Thiazide diuretic

Front 47

2 greatest risk factors for stroke

Back 47

Hypertension and Atrial Fibrillation

Front 48

Risk factors for osteoporosis

Back 48

Older age, female gender, white or Asian race, low calcium intake, smoking, excessive alcohol use, and chronic glucocorticoid use

Front 49

Immunizations recommended in the elderly

Back 49

1. Annual influenza vaccination
2. Pneumococcal immunization (x1)
3. Tetanus and diphtheria booster (x1)
4. Herpes zoster (at age 60 or older) (x1)

Front 50

What is the rate of survival to discharge in patients who undergo in hospital CPR

Back 50

15%

Front 51

What is the most likely cause of sore throat with cough and rhinorrhea?

Back 51

Viral.

Front 52

What findings are associated with group A Strep infection?

Back 52

Findings frequently associated with GAS infections include an abrupt onset of sore throat and fever, tonsillar and/or palatal petechiae, tender cervical adenopathy, and absence of cough.

Front 53

How is the diagnosis of GAS pharyngitis made? How are these results interpreted?

Back 53

GAS is diagnosed via rapid antigen testing or throat culture. Rapid antigen tests can be conducted in a few minutes. RA tests are highly specific but have a lower sensitivity than throat culture. A positive rapid antigen test would prompt antibiotic treatment; a negative test should be followed by a throat culture.

Front 54

Most common bacterial pathogens in AOM

Back 54

S. pneumoniae, H. influenzae, and M. catarrhalis

Front 55

What initial investigations should be ordered on a patient with ACS?

Back 55

1. CBC, lytes, urea, creatinine, PT/PTT/INR, glucose,
2. ECG
3. troponin I - stat and every 6 to 10 hrs x3
4. CXR
5. O2 saturation

Front 56

Describe the effect of morphine in ACS

Back 56

Morphine can achieve adequate analgesia which decreases levels of circulating catecholamines, thus reducing myocardial oxygen consumption.

Front 57

Describe the NYHA functional classification of angina

Back 57

Class I—Angina only with unusually strenuous activity
Class II—Angina with slightly more prolonged or slightly more vigorous activity than usual
Class III—Angina with usual daily activity
Class IV—Angina at rest

Front 58

Describe post infarction treatment

Back 58

-ACEi (not CCB), beta-blocker, ASA, long acting nitrates (if recurrent angina), statin
-Stress test (+ test = referral for angiography)

Front 59

Signs of atherosclerotic disease on physical exam

Back 59

1. bruit on auscultation
2. diminished peripheral pulses

Front 60

Describe the chest pain in pericarditis

Back 60

Increases with respiration (pleuritic) and decreases when sitting forward

Front 61

Differential Diagnosis of abdominal pain

Back 61

GI - PUD, pancreatitis, IBD, appendicitis, gastroenteritis, IBS, diverticular disease, bilary tract disease
Urinary tract - UTI, renal calculi
Gyne PID, ectopic, endometriosis
CV - CAD, AAA, ischemic bowel
other - toxin, foreign body, psychogenic

Front 62

Red flags in abdominal pain

Back 62

Severe pain, signs of shock, peritoneal signs, abdominal distention

Front 63

What structures are referred to the foregut, midgut, and hindgut?

Back 63

Epigastric (foregut) - distal esophagus, stomach, proximal duodenum, bilary tree, pancrease, liver
Periumbilical (midgut) - distal duodenum to proximal 2/3 of transverse colon
Hypogastric (hindgut) - distal 1/3 of transverse colon to rectosigmoid region

Front 64

Describe etiology of allergies

Back 64

Increased IgE levels to certain allergens -> cross linking of IgE causes excessive degranulation of mast cells -> release of inflammatory mediators (eg. histamine) and cytokines -> local inflammatory reaction

Front 65

Management of allergic rhinitis

Back 65

1. Oral antihistamines (eg. Reactine, Claritin) - 1st line for mild symptoms
2. Intranasal steroids - for moderate/severe or persistent symptoms (need > 1 mo to see results)
3. Intranasal decongestants (use must be less than < 5 d to avoid rebound decongestion)

Front 66

Define primary amenorrhea

Back 66

Absence of menstruation by 14 without secondary sex characteristics
OR
Absence of menstruation by 16 with secondary sex characteristics

Front 67

Etiology of primary amenorrhea

Back 67

Turner's syndrome, constitutional delay of growth and puberty, Kallman syndrome (pituitary failure), androgen insensitivity syndrome, Mullerian agenesis, imperforate hymen, secondary amenorrhea.

Front 68

Define secondary amenorrhea

Back 68

Absence of menstruation for 3 months or 3 cycle lengths

Front 69

Tests for initial workup of amenorrhea

Back 69

-B-HCG, TSH, prolactin, LH, FSH
-progesterone challenge to access estrogen status
-karyotype
-U/S to confirm anatomy, identify PCOS

Front 70

Etiology of secondary amenorrhea

Back 70

Pregnancy, hypothyroidism, hyperprolactinoma, medications, PCOS, premature ovarian failure, anorexia/bulimia nervosa, CNS tumor, chronic illness

Front 71

List 3 screening questions for anxiety

Back 71

Do you tend to be an anxious or nervous person?
Have you felt unusually worried about things recently?
Has this worrying affected your life? How?

Front 72

What organic causes should be ruled out in a patient presenting with anxiety

Back 72

post MI, arrhythmias, hyperthyroidism, diabetes, pheochromocytoma, asthma, COPD, drugs

Front 73

What are the pharmacologic treatments for generalized anxiety disorder?

Back 73

1st line - Escitalopram (SSRI), paroxetine (SSRI), sertraline/Zoloft (SSRI, venlafaxine (SNRI)
2nd line - benzodiazepine, buproprion XL

Front 74

Define asthma

Back 74

Chronic but reversible airway inflammation leading to acute obstructive symptoms characterized by periodic attacks of wheezing, shortness of breath, chest tightness, and coughing.
Attacks are due to airway hyper-responsiveness to triggers/antigen leading to bronchoconstriction, mucous plugs, and inflammation

Front 75

Define COPD

Back 75

Chronic, progressive, expiratory lung disease characterized by limited airflow due to emphysema and chronic bronchitis

Front 76

Describe treatment of COPD

Back 76

1. SABA prn (salbutamol)
2. SABA prn + LAAC (tiotropium) or LABA (salmeterol)
3. SABA prn + LAAC + low-dose combine ICS/LABA

Front 77

Describe treatment of asthma

Back 77

1. SABA prn (salbutamol)
2. SABA prn + low dose ICS
3. SABA prn + medium/high dose ICS or low-dose ICS plus LABA, LT modifier, or long acting theophylline
4. SABA prn + medium/high dose ICS + either LABA, LT modifier, or long acting theophylline
5. As above + immunotherpy

Front 78

What are the signs that asthma is poorly controlled?

Back 78

Daytime symptoms 4 or more times/wk (SABA use 4x/wk or more)
Night symptoms 1x/week or more
Asthma related absence from school or work
Exercise induced asthma

Front 79

What is the most important side effect of SABA?

Back 79

Hypokalemia