Family Medicine - Part 2

Front 1

Define benign prostatic hyperplasia

Back 1

Hyperplasia of the stroma and epithelium in the periurethral transition zone

Front 2

Differential diagnosis for BPH

Back 2

Prostate cancer, urethral obstruction, bladder neck obstruction, neurogenic bladder, cystitis, prostatitis

Front 3

Investigations for patient presenting with BPH

Back 3

DRE (size symmetry, nodularity, texture)
Urinalysis for microscopic hematuria
Serum PSA (<4 ng/mL normal, >10 ng/mL abnormal)
Creatinine, BUN, post void residual U/S
voiding diary

Front 4

Describe the symptoms of BPH

Back 4

FUNWISE - frequency, urgency, nocturia, weak stream, intermittency, straining, emptying feeling incomplete

Front 5

Which medications should be avoided or monitored in patients with BPH?

Back 5

Antihistamines, diuretics, antidepressants, decongestants

Front 6

Describe the treatment of BPH

Back 6

Mild-moderate symptoms - fluid restriction, pelvic floor exercises, bladder retraining, medication change
Moderate-severe symptoms (1) α-receptor antagonists (eg. tamsulosin/Flomax) relax smooth muscle (2) 5-α reductase inhibitor (eg. finasteride/Proscar) only for patients with demonstrated prostate enlargement due to BPH, inhibits enzyme responsible for conversion of testosterone to DHT thus reducing growth of prostate

Front 7

Define acute bronchitis

Back 7

Acute infection of the tracheobronchial tree causing inflammation leading to bronchial edema and mucus formation

Front 8

Describe the etiology of acute bronchitis

Back 8

80% viral: rhinovirus, coronavirus, adenovirus, influenza, parainfluenza, RSV
20% bacterial: M. pneumoniae, C. pneumoniae, S. pneumoniae

Front 9

When is a CXR indicated in acute bronchitis?

Back 9

Cough > 3 weeks, abnormal vital signs, localized chest findings, CHF

Front 10

What is the differential diagnosis of acute bronchitis

Back 10

URTI, asthma, sinusitis, pneumonia, bronchiolitis, pertusis

Front 11

What is the management of acute bronchitis

Back 11

Primary prevention: hand washing, smoking cessation
Symptomatic relief: rest, fluids, humidity, analgesics and antitussives as required
Note: Probably viral so no antibiotics unless elderly, co-morbidities, or suspected pneumonia

Front 12

What features help differentiate between bacterial and viral causes?

Back 12

Bacterial infections give a higher fever, excessive amounts of purulent sputum production and may be associated with COPD.

Front 13

List the cardiac and pulmonary DDx for chest pain

Back 13

Cardiac - angina*, MI*, pericarditis*, myocarditis, aortic dissection*, endocarditis
Pulmonary - pneumonia, pneumothorax*, PE*, pulmonary htn, lung Ca

Front 14

List the GI, MSK/neuro, and psycholgic DDx for chest pain

Back 14

GI - GERD, PUD, esophageal spasm, cholecystitis, perforated viscus*, hepatitis
MSK/neuro - costochondritis, intercostal strain, arthritis, rib fracture, herpes zoster
Psych - anxiety, panic, depression

Front 15

Describe the effects and mechanism of action of nitroglycerin

Back 15

-nitroglycerin is a type of nitrate
-nitrates are converted to nitric oxide in the mitochondria, nitric oxide is a potent natural vasodilator
-at low doses nitroglycerin dilates veins more than arteries (decrease preload)
-at higher doses it also dilates arteries (decrease afterload)

Front 16

Describe the treatment algorithm for stable ischemic heart disease

Back 16

1. lifestyle modification and manage comorbid disorders
2. ASA 81 mg PO OD, β-blocker for all post-MI or HF, ACEi for patients > 55 or with any coincident indication, statin for patients with coronary artery disease
3. β-blocker for all, sublingual nitrate for prophylaxis and acute symptom relief
4. long acting nitrate +/- CCB
Note: move to next step if symptoms persist.

Front 17

Define the common cold

Back 17

Viral URTI with inflammation
aka acute rhinitis or URTI

Front 18

Etiologies of the common cold

Back 18

Rhinovirus (30-35%), coronavirus, adenovirus, RSV, influenza, parainfluenza, coxsackie virus

Front 19

Incubation period, duration, and method of transmission of the common cold?

Back 19

Incubation: 1-5 days
Symptoms peak 1-3 days and usually subside within 1 week
Transmission: person-person contact via secretions or droplet

Front 20

Symptoms of the common cold

Back 20

Local: nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough
General: malaise, myalgias, mild fever

Front 21

Compare and contrast cold vs flu

Back 21

Flu - sudden onset, higher fever, severe, exhaustion, worse cough, no sore throat, no runny nose, achy, chills, decreased appetite
Cold - slow onset, no fever, mild exhaustion, +/- cough, sore throat, runny nose, less headache, no chills, normal appetite

Front 22

What are the absolute contraindications for OCP use

Back 22

Pregnancy, undiagnosed vaginal bleeding, thromboembolic disorder, cerebrovascular or coronary artery disease, breast/uterine tumor, impaired liver function, congenital hypertriglyceridemia, smoker > 35 yrs old, migraines with focal neurological signs, uncontrolled htn

Front 23

Differential diagnosis of cough

Back 23

Upper airway cough syndrome (postnasal drip)
Asthma
GERD
Non-asthmatic eosinophilic bronchitis
ACEi

Front 24

Investigations to rule out reversible causes of dementia

Back 24

CBC, electrolytes, creatinine, liver enzymes, B12, TSH, glucose, serum Ca, folate,

Front 25

Describe pharmacologic therapy for dementia

Back 25

NMDA receptor anatgonists and cholinesterase inhibitors slow rate of cognitive decline

Front 26

Quick screening questions for depression

Back 26

Are you depressed?
Have you lost interest or pleasure in things you usually like to do?
Do you have problems sleeping?

Front 27

What should be ruled out before the diagnosis of depression is made

Back 27

Early dementia, hyper/hypothyroidism, DM, liver failure, renal failure, vitamin def, anemia, medication side effect, mono, menopause, cancer

Front 28

List criteria for depression

Back 28

MSIGECAPS - depressed mood, increased/deceased sleep, decreased interest, guilt, decreased energy, decreased concentration, increased/decreased appetite, psychomotor agitation, suicidal ideation
Need 5/9 including anehonia and depressed mood for > 2 weeks.

Front 29

Describe common medications and doses for depression

Back 29

sertraline (Zoloft) - 50-200 mg PO OD
fluoxetine (Prozac) - 20-80 mg PO qAM, first line for teens
bupropion (Wellbutrin) - 100-400mg PO qAM, less side effects

Front 30

Describe the diagnostic criteria for DM

Back 30

One of the following on 2 occasions:
-random BG > 11.1 mmol/L with symptoms
-fasting BG > 7.0 mmol/L
-2h post 75 g OGTT > 11.1 mmol/L
-HbA1c >6.5%

Front 31

What screening should be done for DM

Back 31

Fasting blood glucose in everyone >40 q3yrs
More frequent and earlier if risk factors

Front 32

What are the goals of DM treatment for fasting glucose, postprandial, HbA1c, BP, and LDL

Back 32

-fasting or preprandial glucose 4-7 mmol/L, inadequate if > 10 mmol/L
-2h postprandial glucose 5-10 mmol/L
-HbA1c < 7.0%, inadequate if > 8.4%
-BP < 130/80
-LDL < 2.0 mmol/L

Front 33

What are the long term complications of DM

Back 33

microvascular: retinopathy, nephropathy, neuropathy
macrovascular: CAD, CVD, PVD

Front 34

Describe the initial management of hyperglycemia in type 2 DM

Back 34

1. if A1c < 9 % wait 3 mo to see what effect lifestyle intervention (nutrition and exercise) has on A1c
2. If A1c > 9% initiate metformin immediately +/- another agent or insulin
3. If symptomatic hyperglycemia or metabolic decompensation initiate insulin +/- metformin

Front 35

What agents can be used if DM targets are not met with metformin

Back 35

α-glucosidase inhibitor, DPP-4 inhibitor, insulin, insulin secretagogue, TZD

Front 36

What other medications should be considered for patients with diabetes

Back 36

-ACEi for all htn diabetics and those with microalbuminuria (30-300mg albumin in 24 h)
-ASA for all diabetics without contraindications
-statins to attain LDL < 2.0 mmol/L

Front 37

What features of diarrhea make it more likely to be bacterial vs viral?

Back 37

Fever and bloody stools increase probability of bacterial infection

Front 38

Differential diagnosis of chronic diarrhea

Back 38

Drugs (laxitives, antibiotics), infection (bacteria, parasite), inflammation (IBD, diverticulitis), neoplasia, malabsorption/maldigestion, IBS, idiopathic

Front 39

Describe nonspecfic treatment for diarrhea

Back 39

-antidiarrheal opiates (loperamide/Imodium) - most effective
-increase fibre
-fluids

Front 40

Which bugs are tested for on stool C & S

Back 40

Campylobacter, Salmonella, Shigella, E. coli

Front 41

What are the indications for antibiotic therapy in acute diarrhea

Back 41

-septicemia
-fever with fecal blood or leukocytes
-always: Shigella, V. cholerae, C. difficile, travellers diarrhea, E.coli, Giardia,
-maybe: Salmonella, Yersina, Camplobacter
-always treat Salmonella typhi

Front 42

Routine bone density screening is recommended for

Back 42

Women aged 65 and over, and younger women with risk factors

Front 43

What is the difference between vertigo and nonvertiginous dizziness?

Back 43

Vertigo (vestibular) - world seems to revolve around individual or individual has the sensation of revolving in space
Nonvertiginous - feel light-headed, giddy, dazed, mentally confused, or disoriented

Front 44

Describe an approach and DDx for vertigo

Back 44

Vertigo can be central (15%) or peripheral (85%)
Central - brainstem or cerebellar -> tumour, stroke, drugs, MS
Peripheral - inner ear or vestibular nerve -> idiopathic, meniere's, BPPV, acoustic neuroma, trauma, drugs labrynthitis

Front 45

What should be included in the basic workup of hypertension

Back 45

Creatinine, electrolytes, urinalysis, ECG, fasting glucose, lipids,
Note: currently there is insufficient evidence for or against routine testing of microalbuminuria.

Front 46

What lifestyle changes effect blood pressure and what results can be expected from these changes?

Back 46

DASH diet - decrease by approx. 10 mm Hg
Aerobic exercise, reduce EtOH by 3 drinks, reduce weight by 10 lbs, reduce sodium to 2.4g/d - decrease by approx. 5 mm Hg
Note: stopping smoking doesn't decrease blood pressure but it decrease CV risk.

Front 47

What are the blood pressure targets for patients with and w/o diabetes

Back 47

Without diabetes <140/90
With diabetes <130/80

Front 48

How often should patients with uncontrolled blood pressure be assessed?

Back 48

Every 2 months

Front 49

What combinations of antihypertensives are not recommended?

Back 49

ACEi + ARB should not be used.
ACEi + CCB is preferable over ACEi + thiazide.
Beta-blocker + ACEi/ARB should not be used unless there is a secondary indication for using the beta-blocker.

Front 50

When should a patient be referred to a hypertension specialist?

Back 50

If blood pressure is still not controlled after treatment with 3 antihypertensives.

Front 51

Which patient group is beta-blockers inappropriate? ACEi?

Back 51

Beta-blockers not recommended for patients > 60 yrs old.
ACEi not recommended for black patients.

Front 52

What is the first line monotherapy for htn in a diabetic and isolated htn?

Back 52

Diabetic - ACEi or ARB 1st line. Add CCB if need 2nd drug.
Isolated - thiazide diuretic 1st line but ACEi, BB, CCB, ARB all appropriate.

Front 53

What is the therapy for htn in patients with coronary artery disease, recent MI, heart failure, LVH, and past stroke or TIA.

Back 53

Coronary artery disease - ACEi or ARB, beta-blocker for patients with stable angina.
Recent MI - ACEi + beta-blocker.
Heart failure - ACEi + beta-blocker +/- aldosterone antagonists.
Past stroke - ACEi +/- diuretic.

Front 54

What is the treatment of hypertension in non-diabetic chronic kidney disease patients? What is the treatment target?

Back 54

Target <140/90
Non-diabetic CKD - ACEi if there is proteinuria. Carefully monitor K

Front 55

What is the name and dose of thiazide type diuretics.

Back 55

Chlorthalidone - 12.5-50 mg OD
Hydrochlorothiazide - 12.5-50 mg OD

Front 56

What are some of the side effects of thiazide-type diuretics?

Back 56

Hyperuricemia, hypokalemia, hypomagnesemia, hyperglycemia, hyponatremia, hypercalcemia, hypercholesterolemia

Front 57

What is the dose of loop diuretics?

Back 57

furosemide - 20-160 mg bid

Front 58

What are common names and doses of ACEi?

Back 58

Enalapril - 2.5-40 mg in 1 or 2 doses
Ramipril - 1.25-20 mg in 1 or 2 doses

Front 59

What are the side effects of ACEi?

Back 59

Cough, hypotension, rash, acute renal failure, angioedema, hyperkalemia

Front 60

What are common names and doses of CCB?

Back 60

Amlodipine - 2.5-10 mg OD
Verapamil - 120-480 mg in 1 or 2 doses
Diltiazem - 120-540 mg OD

Front 61

What are the common side effects of CCB?

Back 61

Dizziness, headache, edema.
Amlodipine - flushing, tachycardia, rash
Verapamil/Diltiazem - AV block, bradycardia, HF

Front 62

What are common beta-blocker names and doses?

Back 62

Atenolol - 25-100 mg in 1 or 2 doses
Metoprolol - 50-200 mg in 1 or 2 doses
Propranolol - 40-240 mg in 2 doses
Labetalol - 200-1200 mg in 2 doses

Front 63

What are the side effects of beta-blockers?

Back 63

Fatigue, depression, bradycardia, erectile dysfunction, decreased exercise tolerance, heart failure

Front 64

In which patients is use a beta-blocker for hypertension indicated?

Back 64

Migraine, angina, post MI, heart failure.

Front 65

What are 2 quick screening questions for domestic violence?

Back 65

1. In general how would you describe your relationship? - Lot of tension, some tension, or no tension.
2. Do you and your partner work out arguements with...? - Great difficulty, some difficulty, or no difficulty.
Lot of tension or great difficulty make intimate partner violence exposure likely.
Also "Do you feel safe at home?"

Front 66

DDx for dyspepsia

Back 66

Common: peptic ulcer disease, gastroesophageal reflex disease, gastritis, functional
Others: cholelithiasis, IBD, esophageal or gastric cancer, pancreatitis, pancreatic cancer, Zollinger-Ellison syndrome

Front 67

Define cholelithiasis and choledocholithiasis

Back 67

Cholelithiasis refers to the presence of gallstones in the gallbladder.
Choledocholithiasis refers to stones within the common bile duct.

Front 68

What investigations should be ordered for dyspepsia?

Back 68

Testing for H. pylori with urea breath test, endoscopy (preferred) or upper GI series. a

Front 69

DDx of dyspnea

Back 69

Pulmonary - COPD, asthma, pneumothorax, pneumonia, restrictive lung disease
Cardiac - CHF, CAD, MI, cardiomyopathy, valve dysfunction, pericarditis, arrhythmia, hypertrophy
Other - neuromuscular, metabolic, anxiety, panic attack, trauma, pain,

Front 70

When do you treat UTI? What investigations can/should be ordered?

Back 70

When history and physical consistent with UTI treat empirically.
Urinalysis/dipstick: positive for nitrites or leukocytes
Urine R & M: pyuria, bacteriuria, hematuria
Urine C & S

Front 71

Which patients should be considered for prophylactic antibiotics for UTI?

Back 71

Patients with >3 UTI's per year

Front 72

What is the name of the area affected by anterior and posterior epistaxis?

Back 72

Anterior: Little's area/Kiesselbach's plexus
Posterior: Woodruff's plexus/sphenopalatine artery

Front 73

What is the treatment of anterior epistaxis?

Back 73

Forward lean with direct pressure.
Silver nitrate
Gelfoam/Hemostat
Nasal packing with vaseline gauze
Cotton soaked with vasoconstrictor and anesthetic
I

Front 74

Common etiologies of erectile dysfunction?

Back 74

Organic: vascular (90%) (arterial insufficency, atherosclerosis), endocrine (low T, diabetes), medications (clonidine, anti-htn, SSRI)
Psychogenic (10%)

Front 75

What investigations should be done in a patient with new ED?

Back 75

fasting glucose, HbA1c, lipids,
testosterone, prolactin, LH
TSH, CBC, urinalysis

Front 76

What is the pharmacologic treatment of erectile dysfunction? What are the side effects?

Back 76

Phosphodiesterase type 5 inhibitors:
sildenafil (Viagra) 25-100mg/dose
tadalafil (Cialis) 5-20mg/dose
Side effects include flushing, headache, indigestion.
Take 0.5-4 hours prior to intercourse.

Front 77

What are red flags for fatigue?

Back 77

Fever, night sweats, weight loss, neurologic deficits, ill appearing.

Front 78

DDx for fatigue

Back 78

Depression, anemia, hypothyroidism, diabetes, substance abuse, sleep disorder, life stresses, drugs

Front 79

DDx for fever

Back 79

Infection
Cancer - leukemia, lymphoma, other malignancies
Medications
IBD, collagen vascular disease, DVT

Front 80

DDx of joint pain

Back 80

Non-articular: bursitis, tendonitis, fibromyalgia, polymyalgia rheumatica
Inflammatory articular
seropositive: RA, SLE, scleroderma, polymyositis,
seronegative: ankylosing spondylitis, IBD, psoriatic arthritis, reactive arthritis
crystal: gout, pseudogout
infectious: gonococcal, non-gonococcal
degenerative: osteoarthritis
other: metabolic, hemophiliac, trauma

Front 81

What are the features of a migraine?

Back 81

POUND
Pulsatile quality
Over 4-72 hours
Unilateral
Nausea and vomiting
Disabling intensity

Front 82

What is the treatment of acute migraine?

Back 82

1. acetaminophen, ASA, +/- caffeine
2. NSAIDs
3. 5HT agonists (triptans), ergotamine, +/- antiemetic

Front 83

What is the prophylactic therapy for migraine?

Back 83

1. beta-blocker
2. TCAs
3. anticonvulsants

Front 84

DDx of headache

Back 84

Primary - tension, migraine, cluster
Secondary - Meningeal irritation, increased ICP, temporal arteritis, subarachnoid hemorrhage

Front 85

What are the characteristics of cluster headache?

Back 85

<3 h at a time
sudden, unilateral, severe, usually around eye
constant, aching, stabbing
Patient often paces
May see red watery eye, rhinorrhea, ptosis
frequently awakens patient

Front 86

Acute treatment of cluster headache

Back 86

High flow O2
Sumatriptan (nasal or injection)

Front 87

Prophylactic therapy for cluster headache

Back 87

Verapamil, lithium, prednisolone

Front 88

Red flags for headache

Back 88

Sudden onset severe headache, worst headache ever, new headache after age 50, headache present on awakening, impaired mental status, fever, neck stiffness, seizures, focal neurologic signs, jaw claudication, scalp tenderness