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80 Cards in this Set
- Front
- Back
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What should be done for an elderly person concerned about hearing impairment? What screening can be done?
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Elderly patients who admit to hearing impairment should be offered audiometry.
Those who do not admit to hearing impairment should undergo a whispered voice test. Note: Weber and Rhinne is not useful screening test for hearing impairment |
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What type of hearing loss is age related hearing loss?
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Age related hearing loss (presbycusis) is sensorineural
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What are the 2 types of hearing loss? Define each.
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Conductive - sound does not reach the cochlea
Sensorineural - sound is not converted or transmitted via neural signals |
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What investigations should be done for all patients with hypertension?
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CBC, electrolytes, Cr, fasting glucose, lipid profile, ECG, urinalysis
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Causes of secondary hypertension?
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ABCDE
A - aldosteronism, apnea B - bruits, bad kidneys C - cushings, catecholamines, coarctation of the aorta, calcium D - drugs E - endocrine disease (hyperthyroidism, hyperparathyroidism) |
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Red flags for back pain
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BACKPAIN
B - bowel or bladder dysfunction A - anesthesia (saddle) C - constituational symptoms/malignancy K - kronic disease P - parasthesias A - age >50 and mild trauma I - iv drug use N - neuromotor deficits |
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Findings in cauda equina syndrome
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Low back pain, areflexia, lower extremity weakness, fecal incontinence, urinary retention, saddle anesthesia, decreased anal tone
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Describe physical exam for low back pain
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-Neurological exam for L4, L5, S1 helps determine level of spinal involvement
-Peripheral pulses -Straight leg raise (positive if pain <70 degrees, aggravated by dorsiflexion), positive tests indicates sciatica -crossed leg raise (more specific, raising uninvolved leg elicits pain in leg with sciatica) |
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When should an x-ray be done for low back pain?
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-no improvement after 1 month
-fever > 38 degrees -unexplained weight loss -prolonged steroid use -trauma -suspicion of ankylosing spondylitis -history of cancer |
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What is the prognosis for low back pain?
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70% improve in 2 weeks, 90% improve in 6 weeks, 5% chronic
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What are the symptoms of menopause?
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urogenital: atrophy, dryness, incontinence
blood vessels and heart: hot flashes, increased risk of heart disease bones: bone loss, fractures brain: depression, mood swings, memory loss |
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What are the benefits and risks of HRT in menopause?
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Benefits: decreased risk of osteoporosis fractures, colorectal cancer, and menopause symptoms relief
Risks: increased risk of breast cancer, coronary artery disease, stroke, and PE |
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Which etiology of back pain is implied by pain on flexion and extension?
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Pain on flexion - disc origin (back pain) or root compression (leg pain)
Pain on extension - facet origin (back), spinal stenosis (leg) |
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Describe the difference between neurogenic and vascular claudication?
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Neurogenic - walking distance variable, better with change in position, relief in approx. 10 mins
Vascular - set walking distance, better if stop walking, relief in approx. 2 mins, crampy character |
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Describe an approach to back pain
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Is it back dominate or leg dominate?
Back dominate and constant - inflammatory or mechanical Back dominate and intermittent - most likely disc herniation (central or facet joint) Leg dominate and constant - most likely disc herniation (lateral) Leg dominate and intermittent - spinal stenosis |
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Features of osteoarthritis
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-pain with exercise, improved with rest
-morning stiffness <30 mins -deformity, bony enlargement, crepitus, or limitation of movement -affects distal joints of hands, spine, hip and knee |
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What are the radiographic features of OA
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Joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes
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Which joints are commonly affected by OA
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-Hand (DIP, PIP, 1st CMC)
-Hip, knee, -c-spine, l-spine -1st MTP Note: ankle, shoulder, elbow, MCP, rest of wrist uncommon) |
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What are the treatment options for OA
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conservative: weight loss, exercise (OT/PT), assistive devices
pharmacologic: acetaminophen 1st line (max 3.2g/d if healthy liver, 2.6g/d if liver disease), NSAIDs 2nd line, steroid injections, topical NSAID |
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Which patients should undergo early BMD testing (prior to age 65)? At what age?
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Age < 50 - fragility fracture, prolonged use of steroids, hypogonadism, malabsorption syndrome, chronic inflammation, primary hyperparathyroidism
Age 50-64 - fragility fracture after age 40, prolonged use of steroid, parental hip fracture, vertebral fracture, high EtOH or current smoker, low body weight (<60 kg) Age 65+ - all men and women |
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What osteoporosis prevention strategies should be recommended for all individuals ove 50
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Calcium 1200 mg/d, vitamin d 800 iu/d, weight bearing exercise, fall prevention
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What pharmacologic therapy is available for osteoporosis? Who should be treated?
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Antiresorptive therapy: bisphosphonates (alendronate, risedronate, zoledronate), mococlonal antibody (denosumab), and estrogen
Treat all high risk patients (10 year fracture risk > 20% or > 1 prior fragility fracture) |
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Describe approach to describing skin lesions
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SCALD
Size Color - hyper/hypopigmented, erythematous Arrangement - solitary, linear, reticulated, grouped, herpetiform Lesion morphology Distribution - dermatomal, interiginous, symmetrical, follicular |
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3 most common infections associated with vaginal discharge in women
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Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis
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Which STIs have mandatory reporting?
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Chlamydia, gonorrhoea, hepatitis B, HIV, syphilis
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What is the most common reportable STI in Canada?
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Chlamydia trachomatis
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Treatment of Gonorrheae and Chlamydia
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Gonorrhea - cefixime 400 mg, single dose
Chlamydia - azithromycin 1 g, single dose |
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Define sinusitis
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Inflammation of the mucous membranes that make up the nasal cavity and paranasal sinuses or fluid within these cavities
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What are the features of sinusitis
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Maxillary toothache, coloured nasal discharge, no improvement with decongestants, abnormal transillumination, purulent secretions on exam
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What features differentiate bacterial vs viral sinusitis
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Bacterial suggested by symptoms with no improvement after 7 days or worsening after 5-7 days and presence of purulence
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What causes snoring?
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Soft tissue vibration at the back of the nose and throat due to turbulent airflow through narrowed air passages
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How many apneic episodes per hour must a person have to be diagnosed with sleep apnea
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>15 apneic episodes per hour of sleep with arousal recorded
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What treatment is available for obstructive sleep apea?
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Modify: avoid sleeping supine, weight loss, avoid sedatives (EtOH, muscle relaxants, opioids) use inhaled steroids
Primary treatment is CPAP |
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What percent of sore throat is caused by group A strep?
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5-15% of adults and up to 50% of children
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Describe the approach to sore throats using the sore throat score
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Cough absent (1), History of fever > 38 degrees (1), tonsillar exudate (1), swollen or tender anterior nodes (1), age 3-14 yrs (1), age 15-44 yrs (0), age >45 (-1).
If 0 or 1 no culture of antibiotics If 2 or 3 culture all, treat only if positive If 4 or 5 culture all, treat with antibiotics on clinical grounds if patient unwell |
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What should be done if a patient has had recent/ongoing antibiotics and develops diarrhea?
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Send a stool specimen for C. difficile toxin
Start emperic therapy for C. difficile with metronidazole 500 mg PO TID |
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What spirometry criteria must be met for the diagnosis of COPD
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-postbronchodilator FEV1 < 80% predicted
-FEV1/FVC ratio < 0.7 |
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Who should undergo screening for COPD
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-Smokers or ex-smokers 40 yrs of age and older
-Individuals with persistent cough and sputum production or frequent respiratory tract infections |
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How does nicotine replacement therapy work? How effective is it?
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NRT's deliver nicotine, which acts as an agonist at the nicotinic acetylcholine receptor in a lower dose and at a substantially slower rate than cigarettes.
These products roughly double smoking cessation rates. |
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What are the side effects of the nicotine patch?
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Itch at application site, insomnia, and vivid dreams.
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How does a nicotine vaccine work?
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Stimulate the immune system to produce antibodies that bind circulating nicotine and prevent it from crossing the blood brain barrier
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How can the diagnosis of asthma be confirmed?
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Spirometry:
> 12% improvement in FEV1 from baseline 15 minutes after use of a SABA OR >20% spontaneous variability over time in FEV1 values OR positive methacholine challenge |
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Adverse effects of SABA
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Tachycardia, prolonged QT, tremor, anxiety, hyperglycemia, hypokalemia, and hypomagnesemia.
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What is the most effective medication for preventing symptoms and exacerbations of asthma?
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Inhaled corticosteroids are significantly more effective than LABA, leukotriene modifiers, and theophylline.
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Adverse effects of inhaled corticosteroids
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Oral candidiasis (thrush), dysphonia, and reflex cough and bronchospasm.
Reduced growth velocity in first year Changes in bone density and development of cataracts or glaucoma. ICS does not increase risk of asthma. |
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What is the treatment of asthma exacerbation
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-O2 therapy
-SABA -Daily systemic glucocorticoids 3-10 days |
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What questions are important to ask when looking for heart failure in an infant?
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Color, cough, wheeze, dyspnea, palpitations, and diaphoresis during feeding.
Feeding is the most vigorous exercise for an infant. |
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What do S1 and S2 represent?
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S1 represents closure of the atrioventricular valves (tricuspid and mitral).
S2 consists of aortic and pulmonic valve closure |
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What causes splitting of S2?
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Lower resistance in the pulmonary vasculature results in slower closure of the pulmonic valve.
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What is fixed splitting in S2 pathognomonic for?
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Fixed splitting of S2 is pathognomonic for an atrial septal defect.
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Describe Modified Wells Criteria
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Symptoms of DVT (3)
No alternate diagnosis that better explains symptoms (3) Pulse > 100 (1.5) Immbilization > 3 days or surgery in last month (1.5) Prior Hx of PE or DVT (1.5) Hemoptysis (1) Malignancy (1) PE likely if score >4 and unlikely if </= 4. |
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What tests should be ordered for PE based on the Wells score?
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Wells ≤ 4 - PE unlikely, do serum D-dimer. If negative this excludes PE.
Well >4 or positive D-dimer, do CT pulmonary angiogram. |
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Two biggest risk factors for stomach ulcers
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H. pylori infection of gastric mucosa
Chronic use of NSAIDs |
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What are the main causes of lumbar pain made worse with flexion
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Lumbar disc herniation and back strains
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Why does flexion cause pain in lumbar disc herniation?
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The flexion of the lumbar spine at the hip causes traction of the nerve roots which are then compressed against the herniated disc.
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What is the most commonly affected spinal cord level in lumbar disc herniations?
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The vast majority of lumbar disc herniations occur at the L5-S1 disc and usually cause compression of S1 nerve root. Examination of the S1 nerve root is vital in suspected disc herniations.
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What causes the pain associated with back strain
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Initial injury commonly results in a strain (small tear) of one of the supporting lumbar muscles. The Inflamed, swollen muscle will attempt to shorten or spasm.
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What are the common causes of lumbar pain made worse with extension
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Facet joint irritation, spondylolysis, and spinal stenosis.
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Define spondylolisthesis and spondylolysis
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Spondylolisthesis - fracture in the pars interarticularis allows forward slipping of one vertebral body on another
Spondylolysis - fracture of the pars interarticularis |
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What is the treatment of back strain
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Analgesia, early mobilization (no bed rest), and applying superficial heat 3 times a day for 15-20 mins.
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Two deadly causes of back pain
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Cauda equina syndrome and abdominal aortic aneurism
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What is the typical history of a patient with ankylosing spondylitis
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Morning pain and stiffness in a patient < 30 years old
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What is the most common symptom associated with lumbar spinal stenosis
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Neurogenic claudication - discomfort that radiates beyond the spinal area into buttocks and frequently into thigh and lower leg. Made worse with extension.
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Describe the mechanism of action of topical corticosteroids
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Anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive.
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Why must different strengths of steroids be used in different areas of the body?
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Different thickness of the stratum cornium and difference in blood supply the area.
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Describe the features of eczema/atopic dermatitis
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Itchy, dry skin
Usually on flexor surface Skin usually inflamed |
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Describe the treatment of eczema
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Use mild cleanser, moisturize often, cool bathing, avoid triggers
Hydrocortisone cream + calcineurin inhibitors Oral antihistamine |
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Define psoriasis. What is the pathophysiology?
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Psoriasis is an autoimmune disease in which activated t-cells expresses cytokines and this speeds up the growth cycle of skin cells. Normal skin cells mature and fall off the sruface in 28-30 days skin cells in a person with psoriasis mature and move to the sruface in just 3-4 days. It is manifested by cellular hyperproliferation, lack of differentiation, and inflammation.
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What are the diagnostic features of psoriasis?
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Red, scaly plaques that are often itchy.
Plaques commonly located on the elbows, knees, lumbo-sacral area, and scalp. May have nail changes including pitting, onycholysis, oil drop change. May have psoriatic arthritis. |
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Describe treatment of psoriasis
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Dovobet (topical corticosteroids (betamethasone dippropionate) + topical calcipotriol)
Moisturizers, mild cleansers Oral antihistamines Others: topical calcineurin inhibitor, phototherapy, biologics, |
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How is volume status assessed?
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Mucous membranes, skin turgor, orthostatic blood pressure
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Most common causes of chronic kidney disease
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Diabetes, hypertension, and glomerulonephritis.
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Describe the features of vulvovaginal candidiasis
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Thick, whitish discharge that has no odor and the patient complains of significant pruritus of the external and internal genitalia. On physical examination, the vaginal area can be edematous with erythema present.
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Describe the features of trichomonas
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Copious amounts of a thin, frothy, green-yellow or gray malodorous vaginal discharge.
Vaginal soreness or dyspareunia. Cervix has a “strawberry” appearance or redness of the vagina. |
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Describe the features of bacterial vagninosis
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(1) a thin, homogenous vaginal discharge; (2) a vaginal pH more than 4.5; (3) a positive KOH “whiff” test (a fishy odor present after the addition of 10% KOH to a sample of the discharge); and (4) the presence of clue cells in a wet mount preparation
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Length of symptoms of common cold
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Symptoms caused by common cold typically last 1 to 2 weeks.
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Describe the role of vitamin C, echinacea, zinc, and gingseng in the common cold
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Vitamin C - no preventative effect, reduce duration by half day
Echinacea - small preventative effect, no evidence for treatment Zinc - slight reduction in duration Ginseng - small preventative effect (1 cold per year difference) |
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Etiology of croup
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Croup is almost always viral. Parainfluenza virus type 1 and 3 are most commom. Influenza virus, adenovirus, and RSV have also been implicated.
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Clinical features of croup
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Barking seal-like cough, inpiratory stridor, and respiratory distress. Also rhinorrhea and fever.
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Potential complications of PID
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Recurrence of disease, the development of abscess, chronic abdominal pain, infertility, and the increased risk of ectopic pregnancy.
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