Family Medicine Shelf

Front 1

Abdominal Pain and diarrhea
-in children, GI origin
-MC (1)
-Severe (4)

Back 1

MC
-Gastroenteritis
Severe
-Intussusception
-Dysentery
-Appendicitis
-Hernia

Front 2

Abdominal Pain and diarrhea
-in children, GU origin
-MC (1)
-Severe (1)

Back 2

MC
-UTI in females
Severe
-UTI in males

Front 3

Abdominal Pain and diarrhea
-in children, MSK origin
-MC (1)
-Severe (2)

Back 3

MC
-Abdominal wall trauma
Severe
-Visceral injury
-Child abuse

Front 4

Abdominal Pain and diarrhea
-in children, Non-abdominal origin
-MC (2)
-Severe (3)

Back 4

MC
-Psychogenic (school phobia)
-Pneumonia (lower lung)
Severe
-Depression
-Lead poisoning
-Strep throat

Front 5

Abdominal Pain and diarrhea
-in Adults, GI origin
-MC (9)
-Severe (5)

Back 5

MC
-idiopathic
-Irritable bowel syndrome (IBS)
-Gastroenteritis
-PUD
-Cholelithiasis
-Pancreatitis
-Hepatitis
-Diverticulosis
-Inflammatory bowel dz (IBD)
Severe
-Appendicitis
-GI obstruction/perforation/bleeding
-Cholecystitis/cholangitis
-Diverticulitis w/ perforation
-Mesenteric thrombosis

Front 6

Abdominal Pain and diarrhea
-in Adults, GU origin
-MC (3)
-Severe (2)

Back 6

MC
-cystitis
-pyelonephritis
-urolithiasis
Severe
-GU obstruction (acute or chronic)
-GU malignancy

Front 7

Abdominal Pain and diarrhea
-in Adults, GYN origin
-MC (3)
-Severe (2)

Back 7

MC
-Dysmenorrhea
-Ovarian cyst
-PID
Severe
-Ectopic
-Tubal/pelvic abscess

Front 8

Abdominal Pain and diarrhea
-in Adults, MSK origin
-MC (3)
-Severe (3)

Back 8

MC
-hernia
-abdominal wall trauma
-osteoporotic fracture
Severe
-strangulated hernia
-visceral injury
-PE

Front 9

Abdominal Pain and diarrhea
-in Adults, Non-abdominal origin
-MC (4)
-Severe (2)

Back 9

MC
-Pneumonia (lower lung fields)
-Pleuritic pain
-Herpes zoster
-Depression
Severe
-MI
-AAA

Front 10

What % of abdominal pain complaints in primary care subside without a definitive dx being reached?

Back 10

40-50%

Front 11

Triage, by means of history and physical examination, patients that may have an acute
“surgical” abdomen.

Back 11

Somewhat more likely to be “surgical" if:
History:
Acute onset, trauma, no prior abdominal complaints. Pain severity may or may not
help differentiate "surgical" from “non-surgical” abdomen.
Physical Exam:
Vital signs: especially fever, low B.P., high pulse
Appearance:
Lying in one position (hurts to move or cough due to peritoneal irritation).
Abdominal Exam:
Distention or obstructive signs; tenderness to percussion or rebound, esp. if
localized (perforation or peritoneal irritation); blood on gastric aspirate or rectal
exam; include pelvic exam in women
Lab:
Normal urinalysis; acute anemia or left shift on CBC; include HCG in Women
Diagnostic Test:
Discuss with the students the relative sensitivity of various radiographic imaging
studies for the diagnosis of acute appendicitis.
 Abdominal plain films (low sensitivity and specificity)
 Ultrasound (sensitivity 75-90%, specificity 86-100%)
 Spiral CT (sensitivity 90-100%, specificity 91-99%)

Front 12

Construct a plan to manage the potentially surgical abdomen by timely observation and
appropriate consultation.

Back 12

Consult surgeon early if any positive findings, above; co-manage with repeat exams,
judicious pain meds, repeat CBC's (increasing WBC’s?, decreasing hct?); start IV, type
and cross-match blood p.r.n.; keep patient n.p.o.

Front 13

Construct a stepped approach to the management of patients with gastroesophageal
reflux disease, based upon evidence based medicine as well as cost effectiveness

Back 13

A. Lifestyle modification - (elevated head of bed 6 inches, decrease fat intake, stop
smoking, decrease weight, avoid large meals or aggravating foods avoid, avoid
recumbency for three hours post-prandially.)
B. Antacid or H2-blocker - as needed.
C. Scheduled dose of H2-blocker, proton pump inhibitor, and/or a prokinetic agent,
e.g., metoclopramide (Reglan) for 8-12 weeks. Consider endoscopy if severe or
no response.
D. Maintain therapy with H2-blocker or proton pump inhibitor.
E. Surgical intervention for refractory cases.

Front 14

List and evaluate four tests for H. pylori.
***Which test is 1st line?

Back 14

-Serology (whole blood or serum serology is cost effective initial approach in
symptomatic and at risk symptomatic patients; should confirm the test with a
different method if pre-test probability is low.
-C13 or C14 Urea Breath Test (UBT). The sensitivity and specificity of UBT is
approximately 88 to 95 and 95 to 100 percent, respectively. False positive results
are uncommon. To prevent false negative results, the patient should be off
antibiotics for at least four weeks and off proton pump inhibitors for at least two
weeks.
-Stool Antigen (if patient not on PPI or taking bismuth).
-Endoscopic Gastric Biopsy (reserved for patients undergoing EGD).

Front 15

List two causes of peptic ulcer disease and discuss treatment options.

Back 15

-NSAID use - avoid NSAIDS. Treat with H2-blockers or proton pump inhibitor. Treat
H.pylori if present (see below).
-H.pylori - combined treatment with omeprazole, bismuth, metronidazole,
clarithromycin and/or amoxicillin. Several regimens available using 2-3 of the above
drugs for 1-2 weeks duration (e.g., lansoprazole 30mg + amoxicillin 1gm +
clarithromycin 500mg all bid X 14 days).

Front 16

Define diarrhea

Back 16

Patient (subjective) definition is best: i.e., an increase in frequency and/or decrease
in consistency of stools; but quantify by further questioning.

Front 17

Differentiate chronic from acute diarrhea.

Back 17

>2 weeks = chronic. (compare with cough 
>4 weeks = chronic)

Front 18

List symptoms that help differentiate viral from bacterial acute diarrhea.

Back 18

Viral is more likely associated with vomiting, watery diarrhea; and no fever, no blood
or pus in the stool.

Front 19

Discuss rehydration in the treatment of dehydration due to acute diarrhea.

Back 19

Oral rehydration therapy (ORT); in children, also continue calorie intake (especially
starches) with no major change in diet; ORT can be initiated and evaluated in the
primary care office (to prevent hospitalization)

Front 20

Compare and contrast the characteristics of inflammatory (caused by invasive
organisms that disrupt the mucosal lining) vs. non-inflammatory diarrhea (caused
by organisms that stimulate excessive intestinal secretions.)

Back 20

INFLAMMATORY
-Clinical- bloody, small volume, LLQ cramping, may be febrile and toxic
-Site- Colon
-Causes- Shigella, some Salmonella, Helicobacter jejune, Yersinia, invasive or hemorrhagic E. coli, Campylobacter, C. diff, Ameoba histolytica
-Fecal leukocytes- positive
-Further Dx evaluation- indicated
NON-INFLAMMATORY
-Clinical- large volume, watery, may have nausea, vomiting, and cramps
-Site- Small intestine
-Causes- Viruses, vibrio, enterotoxigenic E coli (ETEC) and other enterotoxin producing bacteria, Giardia, Cryptosporidium, cyclospora, Norwalk, Rotavirus, drugs
-Fecal Leukocytes- Neg
-Further Dx eval- if severely volume depleted or toxic, or if lasts > 2 weeks

Front 21

List some serious/life threatening causes of diarrhea in adults vs children

Back 21

CHILDREN
-MC- viral, bacterial
-Severe- intussusception (currant jelly stools), IBD
ADULTS
-MC- viral, lactose intolerance
-Severe:
-C diff
-IBD
-colorectal cancer
-obstruction
-HIV
-typhoid
-ischemic bowel
-eating disorder

Front 22

Name the most common organism causing traveler's diarrhea.

Back 22

E. coli (various pathogenic mechanisms – mostly ETEC)

Front 23

Understand the evidence behind the use of probiotics and the treatment/prevention
of antibiotic-induced diarrhea.

Back 23

Probiotics that contain species of Lactobacillus or Saccharomyces decrease the
likelihood of diarrhea from antibiotics in children or adults (absolute risk reduction:
3 to 23 percent; NNT: 10). Tell patients to look for these products in the "diarrhea
section" of the pharmacy. A typical dosage is 5 to 10 billion viable organisms
administered three to four times a day. The probiotics should be separated from
the antibiotics by a couple of hours. (Level of Evidence: 1a)

Front 24

Name a vaccine now available to reduce the disease burden of infectious
diarrhea.

Back 24

Rotavirus is the leading recognized cause of diarrhea-related illness and death
among infants and young children. Every year, rotavirus is associated with 25
million clinic visits, 2 million hospitalizations, and more than 600,000 deaths
worldwide among children younger than five years of age. Earlier vaccines were
withdrawn because of association with intussusceptions. Two oral doses of the
new live attenuated G1P[8] HRV vaccine were highly efficacious in protecting
infants against severe rotavirus gastroenteritis, significantly reduced the rate of
severe gastroenteritis from any cause, and were not associated with an increased
risk of intussusception.

Front 25

Distinguish, by history and physical examination, low back pain secondary to systemic
disease from back pain due to regional musculoskeletal origins, utilizing age, sex, and
occupational risk criteria in their clinical reasoning.

Back 25

Fever, weight loss, loss of appetite, elevated sed rate, anemia, elevated alkaline
phosphatase, and lymphadenopathy, elevated PSA.

Front 26

Distinguish typical symptoms and signs of complicated (disc/nerve root involvement)
from those typical of uncomplicated (muscular/mechanical) low back pain.

Back 26

Signs of nerve root involvement, such as: dermatomal radiation, positive SLR test, and
other neurological changes.

Front 27

Differentiate the diagnoses of back pain that are:
a. most common or likely
b. most serious/ high pay off
-children vs adults

Back 27

1) Children
MC
-Acute low back strain
-Exercise/sport injury
Serious
-SCFE
-Discitis
2) Adults
MC
-MSK injury
-Disc dz
-Cervical strain
-Compression fracture
-Spinal stenosis
-Ergonomic stress secondary to work
Serious
-Cauda equina syndrom
-Discitis
-Potts dz
-Abscess/infection
-Cancer
-AAA

Front 28

Formulate appropriate plan of management of patients with low back pain which
incorporates an awareness of the patient's occupation, home situation, and minimal use of
pharmacologic agents.

Back 28

Usually includes bed rest on firm mattress or “bed board” and ice massage the first few
days followed by heat, anti-inflammatories, non-narcotic analgesics, and gradual
increase in activity. Discussion of weight loss in patients whose weight is greater than
recommended for height. Early physical therapy. Consider ergonomic evaluation
referral.

Front 29

Integrate the role of exercise, physical therapy, weight loss, and other modalities into the
management of the acute and chronic back pain patient.

Back 29

Back and abdomen exercises increase strength and flexibility of back and hamstring
muscles.

Front 30

Discuss the rationale for “clinical practice guideline” by agencies such as the Agency
for Healthcare Research and Quality (AHRQ), and apply these guidelines to the
following cases:
a) A 40-year-old man with 2 days of lumbar back pain after lifting his television set.
He complains of pain in the right lower back area. He smokes and has no other
significant history. On physical exam the only significant finding is a positive
straight leg test. What is the next step in this patient’s management?

Back 30

This man has musculoskeletal low back pain without neurological defect. Imaging
studies, such as a plain film would not be appropriate. Conservative treatment with
anti-inflammatory medicines and back exercise is appropriate. If the pain does not
resolve in four weeks consider further work-up.

Front 31

Discuss the rationale for “clinical practice guideline” by agencies such as the Agency
for Healthcare Research and Quality (AHRQ), and apply these guidelines to the
following cases:
An 8-year-old boy brought in by his mom after a fall from the monkey bars. He
has pain in the mid-thoracic spine and no other complaints. On physical exam, he
has a great deal of pain with palpation of the mid-thoracic spine. His neurological
and physical exams are normal. What is the next step in the management of this
patient?

Back 31

Imaging studies (radiograph of thoracic spine) are indicated because of this
patient’s age and the likelihood of spinal fracture.

Front 32

Discuss the rationale for “clinical practice guideline” by agencies such as the Agency
for Healthcare Research and Quality (AHRQ), and apply these guidelines to the
following cases:
A 65-year-old woman with three months-worsening back pain in the lumbar area.
She is obese but has lost 20 pounds without trying in the last month. She has not
seen a doctor in several years because she has had no health care coverage. She
recently qualified for Medicare. Her past medical history is significant for intermittent
low back pain over the last 30 years. On physical exam she is an obese female with
exquisite tenderness on palpation of the lumber spine. What is the next step in the
management of this patient?

Back 32

Imaging studies, starting with lumbar spine films are indicated for this patient
because of her age. Diagnostic tests such as a CBC and ESR are also indicated.
Please note, because of the lack of insurance she has not been able to obtain
routine preventive services. The patient has breast cancer with metastases to her
spine. She had never had a mammogram.

Front 33

List the components of a referral to physical therapy for back pain:

Back 33

What: low back pain, mid-back pain
Severity: mild, moderate, severe
Stage: acute, chronic, sub-acute-reoccurring X (# years)
Nature: (if known) inflammatory, trauma, cumulative stress (work related).
May include components of treatment:
 Ergonomics
 Posture/body mechanics
 Patient education; lifting, pushing, pulling
 Assist with pain management
 Manual therapy
Give your contact information for follow up, include imaging studies if relevant.

Front 34

KNEE PAIN
A. Localize (with the patient in the optimum position for each finding) the point
tenderness, ligamentous laxity, or fluid, in a knee that has:
-Effusion
-Meniscus injury
-Collateral ligament sprain
-Cruciate ligament tear/sprain
-Anserine Bursitis
-Osgood-Schlatter's
-Ileo-tibial band syndrome
-Baker's cyst

Back 34

1) Lying down:
-Effusion
“Milk” any fluid in the supra-patellar extension into the joint space proper, then ballot
and also observe for para-patellar fullness.
-Meniscus injury
Check for joint line tenderness; positive McMurray and Lachman tests; and/or possible
“locking”.
-Collateral ligament(s)sprain
Realize that medial ligament sprain is most common knee injury. With knee in 20-30
degrees of flexion, check for laxity on valgus stress (varus stress if lateral ligament).
2) Sitting on table
-Cruciate ligament tear/sprain
Assess for positive “drawer” sign: ACL= + anterior sign;
PCL= + posterior sign.
-Anserine bursitis
Check for point tender 3-4 cm below plateau on anterior-medial tibia, where hamstring
reflections insert in a “goose foot” pattern (pes anserinus = “goose foot”).
3) Standing:
-Osgood-Schlatter’s “disease”
Tender apophysis of calcifying tibial tubercle that usually occurs in early-teen male (joint
not involved).
-Ileo-tibial band syndrome
This is a linear tenderness superior to fibular head and lateral femoral condyle (no
laxity or fluid).
-Baker’s cyst
This is a 2-4cm round cystic mass in popliteal fossa. Fluid is often “reducible” into joint
space in prone position. Mass is not inflamed and may not be tender.

Front 35

Discuss common knee injures, their mechanism, symptoms signs and special tests
and initial therapy
-ACL tear

Back 35

Mechanism: landing from a jump, pivoting or decelerating suddenly, fixed foot and
valgus stress
Symptoms: audible pop heard or felt, pain, tense swelling minutes after injury, feels
unstable (bones shifting or giving away)
Signs: effusion (if acute), limited ROM due to effusion or other internal derangement), j
oint line tenderness if accompanying meniscal damage.
Special Tests: Lachman’s, Anterior Drawer, pivot shift
X-ray usually nondiagnostic; MRI sensitive and specific.
Initial Therapy: braces and crutches, early PT, analgesia usually with NSAIDs, consider
surgical repair

Front 36

Discuss common knee injures, their mechanism, symptoms signs and special tests
and initial therapy
-Meniscus tear

Back 36

Mechanism: twisting injury or deep squat though patient may not recall a specific injury
Symptoms: catching, medial or lateral knee pain, swelling
Signs: joint line tenderness, effusion if acute, McMurray’s sign
X-ray may show joint space narrowing or early osteoarthritis changes
MRI specific and sensitive
Treatment: RICE, PT, surgical repair possible

Front 37

Discuss common knee injures, their mechanism, symptoms signs and special tests
and initial therapy
-Collateral ligament injury

Back 37

Mechanism: Valgus or varus stress to knee, blow to lateral or medial leg with planted
foot
Symptoms: pain and instability
Signs: tender over collateral ligament, valgus or varus stress test
X-ray usually nondiagnostic, MRI sensitive and specific
Treatment: RICE, analgesia, bracing, PT, rarely needs surgery

Front 38

Discuss common knee injures, their mechanism, symptoms signs and special tests
and initial therapy
-PCL tear

Back 38

Sag sign and posterior drawer

Front 39

Discuss common knee injures, their mechanism, symptoms signs and special tests
and initial therapy
-Patellofemoral pain

Back 39

Anterior knee pain, worse with bending or going up stairs
Crepitus under kneecap,
Tender over facets of patella, apprehension sign suggests possible instability
X-rays may show lateral deviation or lift
Treatment options
If too loose/weak, strengthen quads, correct and support alignment
If to tight, stretch hamstrings, correct alignment
Surgery is last resort, lateral release or patellar realignment

Front 40

Differentiate findings between articular and extra-articular pathology during a shoulder
evaluation.

Back 40

- Inability for AROM (active range of motion)and PROM (passive range of motion) =
articular.
- Inability for AROM while PROM is normal or less compromised = extra-articular (i.e. the
greater the loss of PROM, the greater the joint mobility is limited).

Front 41

Demonstrate the physical findings in the shoulder evaluation and initial treatment for
each of the problems listed below:
-rotator cuff tendonitis/impingement

Back 41

Check for tenderness in the sub-acromial area (lateral or anterior) and inability to
actively abduct the arm, especially in an “uncomfortable” 60-120 degree range (painful
arc). Note: if no AROM > 15-30 degrees (scapular elevation) then possible complete
tear.
Treatment is NSAIDs, frequent comfortable AROM especially: Codman’s pendulum
shoulder circle exercises (to prevent frozen shoulder), rest from resistive and repetitive
lifting. Consider P.T. for corrective shoulder girdle mechanics. Consider possible
subacromial steroid-xylocaine injections. Surgical repair for tears.

Front 42

Demonstrate the physical findings in the shoulder evaluation and initial treatment for
each of the problems listed below:
-adhesive capsulitis (frozen shoulder)

Back 42

This is an inability to move shoulder actively or passively (abduction > flexion and
external rotation > internal rotation)
Treatment is repeated AROM, stretching. Frequently necessitates referral to P. T. for
mobilization and corrective shoulder girdle mechanics).

Front 43

Demonstrate the physical findings in the shoulder evaluation and initial treatment for
each of the problems listed below:
-bursitis

Back 43

This presents with tenderness in the sub-acromial area (lateral or anterior) and with
uncomfortable overhead mobility in all directions. It is often not the only condition
present. For example: patients can have signs of tendonitis and /or other overuse
syndromes present at the same time.
Treatment is same as rotator cuff tendonitis/impingement.

Front 44

Demonstrate the physical findings in the shoulder evaluation and initial treatment for
each of the problems listed below:
-bicepital tendonitis

Back 44

Patients have point tenderness in the bicepital groove of the humerus and
positive Yergason’s sign (pain with resisted elbow flexion and forearm supination).
Treatment similar to rotator cuff tendonitis.

Front 45

Recall the two “Ottawa” decision rules for the use of radiography in acute ankle
sprains:

Back 45

-inability to bear weight (four steps) both immediately and in the emergency
department, and
-bone tenderness at the posterior edge or tip of either malleolus (localized).

Front 46

Describe the severity of ligamentous injury in grades 1, 2, and 3 ankle sprains and
important differences in the treatment of each grade.

Back 46

Grade 1: partial tear; intact joint
Grade 2: partial tear; joint motion abnormal if manipulated/stressed.
Grade 3: complete tear with frank instability.

Front 47

Interdigital (Morton's) neuroma

Back 47

Is caused by an inflamed plantar nerve
Characterized by severe "burning" pain in the third web space
Treatment: This can be relieved by padding and taping to disperse weight away from the
neuroma. Shoes with art support (orthotic) and wide toe boxes should be used, high
heels should be avoided. Steroid-xylocaine injections can be used to reduce
inflammation. Consider surgery if conservative treatment fails.

Front 48

Plantar Faciitis

Back 48

Classic signs are heel pain with the first few steps in the a.m.
Treatment: R.I.C.E, NSAIDs, orthotics (arch supports, heel lift), weight loss. NEVER go
without shoes.

Front 49

Demarcate the distribution of pain/paresthesias/numbness/weakness and demonstrate
provocative tests in:
-carpal tunnel syndrome

Back 49

Median nerve (carpal tunnel syndrome)
 sensory: numbness volar pads of thumb, index long and radial side of ring.
 motor: weak opposition; base of thumb wasting.
Positive Tinel’s (tap median nerve at wrist) or Phalen’s (hold wrist into flexion
> 60 seconds) reproduce numbness or paresthesias.

Front 50

Demarcate the distribution of pain/paresthesias/numbness/weakness and demonstrate
provocative tests in:
ulnar nerve (entrapment)

Back 50

Ulnar nerve
 sensory: numbness volar aspects of ring and small
 motor: weakness/wasting Abd. DM

Front 51

Demarcate the distribution of pain/paresthesias/numbness/weakness and demonstrate
provocative tests in:
-multiple nerve crush/entrapment of wrist

Back 51

Double/multiple crush nerve entrapment)
 sensory: stocking glove numbness/paresthesias/pain, diagnose with
electro-diagnostic testing

Front 52

Dequervian tenosynovitis

Back 52

DeQuervain's tenosynovitis
This is caused by cumulative/repetitive stress and is a tendonitis of the abductor
pollicis longus and extensor pollicis brevis within the first dorsal compartment
(snuffbox). Patients are usually tender to palpation over first compartment and have a
positive Finklestein’s test (tuck thumb into fist and cock wrist into ulnar deviation).
Note the differential diagnosis includes arthritis/DJD of the carpal/metacarpal joint and
scaphoid fracture (caused by trauma). Distinction can be made with positive “grind”
test or tap down through tip of thumb to reproduce pain symptom.
Treatment: thumbspica splint, P.T. for function recovery.

Front 53

Ganglion cyst

Back 53

Ganglion cysts
Are caused by cumulative/repetitive stress and are comprised of small tear in the
overlying ligaments that allow synovial herniation. This is one of the most visible and
common soft tissue disorders of the hand.
Treatment: Do nothing unless

Front 54

Septic arthritis

Back 54

Septic arthritis
This is caused by infection and is an inflammation of a synovial membrane with
purulent effusion into the joint capsule, usually due to bacterial infection. Suspect if
signs or symptoms of:
-fever
-swelling
-pain
-non-weight bearing/disuse
-erythrocyte sedimentation rate higher than 40 mm/h
-WBC count higher than 12,000/mL

Front 55

Describe signs and Sx of common cold

Back 55

 Variable symptoms
 Sneezing, rhinitis, nasal congestion predominate by day 2-3
 Sore or scratchy throat early in disease
 Cough, if present, becomes problematic day 4-5
 Fever if present is low grade (higher fevers more common in influenza)
 Severe myalgias uncommon (more common in influenza)
 Duration: 5-7 days, but 25% last as long as two weeks

Front 56

Common cold epidemiology
(MC causes)

Back 56

 Rhinoviruses account for up to 50% (100 subtypes)
 Corona and RSV
 Unable to tell which virus by symptoms
 The elderly with chronic illnesses are especially at risk for respiratory
complications such as pneumonia and should be monitored carefully.

Front 57

Describe transmission of cold virus

Back 57

 Direct contact, with hand-to-hand being most important
 Virus can remain viable on hands and surfaces for hours
 Direct aerosol spread occurs - spread through airplane not a huge risk
 Saliva not a risk

Front 58

Discuss options for sx treatment of common cold (5 drug classes)

Back 58

1) Ipatropium bromide nasal spray
Two sprays 3-4 times daily
Decreases volume of nasal discharge by 26% and reduces sneezing
2) Cromolyn sodium
One spray/nostril tid-qid
Recent studies show symptoms resolve faster if treatment started within 24
hours of onset
3) Antihistamines
Studies mixed whether helps reduce nasal symptoms
Use limited by sedation
4) Decongestants
Pseudoephedrine shown to decrease symptoms in the first few days of cold
by 13% compared to placebo in meta-analysis
5) Anti-tussives/Mucolytics
Studies show variable efficacy when compared to placebo

Front 59

Differentiate between viral and bacterial sinusitis

Back 59

 Acute sinusitis usually viral etiology
 2% of viral sinusitis complicated by bacterial infection
 CT of sinuses not helpful acutely

Front 60

What are the signs/sx of secondary bacterial sinusitis

Back 60

Maxillary pain or tenderness in teeth and face and persistent nasal discharge
without improvement for 7-14 days.

Front 61

What are the Rx choices for bacterial sinusitis in children vs adults

Back 61

-Adults: Amoxicillin 1.5-3.0gm/day or doxycycline 100mg BID or
trimethaprim/sulfamethoxasole 1 DS tablet BID
-Children: Amoxicillin 45-90 mg/day divided BID or cefdinir 14mg/kg/day in one to
two doses; or defpodoxime10mg/kg/day BID; or clarithromycin 15mg/kg/day BID;
or azithromycin 10mg/kg/day times one then 5mg/kg/day for four days.
-Children who do not improve, who have been in daycare recently or have recently
received antibiotics, use amoxicillin/clavulanate 80-90mg/kg/day of amoxicillin
component and 6.4 mg/kg/day of clavulanate BID

Front 62

Describe the Dx and Rx of acute uncomplicated bronchitis

Back 62

-Evaluation of adults and children with acute cough should rule out serious illness,
particularly pneumonia.
-Purulent sputum is not a sensitive indicator of bacterial source
-Absence of the following abnormalities in vital signs reduces likelihood of
pneumonia sufficiently that other testing is not needed:
• Heart rate >100
• Resp. rate >24 breaths/min
• Oral temperature >38
• Abnormal chest findings (rales, fremitus, egophony)
- >90% of acute bronchitis have non-bacterial cause
- Routine treatment of uncomplicated acute bronchitis is not recommended,
regardless of duration of cough.
- Treatment of symptomatic
• Acute or early coughs due to viral URIs do not appear to respond to
dextromethorphan or codeine
• Chronic cough (2-3 weeks) may respond to above agents

Front 63

Differentiate influenza from the common cold

Back 63

 Very acute onset
 High fever (38-40oC, severe myalgias, headache, sore throat, non-productive
cough, rhinitis, substernal soreness, nausea common
 Cough can persist for two weeks or more
 Malaise may persist for weeks
 Mortality related to influenza as high as 36,000 per year in the USA

Front 64

Describe the classical differences between sore throat caused by Group A Strep (GAS) and other causes

Back 64

-Strep: Presence of fever, anterior cervical adenopathy ,abdominal pain, erythematous
pharynx and absence of other URI symptoms increase the likelihood that Strep is the
cause
-Most commonly seen from age 5-15
-80% negative predicative value if following are present:
cough, rhinorrhea, minimal or no

Front 65

Understand the goal of treatment of GAS pharyngitis

Back 65

-Treatment of illness aimed at preventing rheumatic fever and other suppurative
complications
o Peritonsilar abscess
o Retropharyngeal abscess
o Otitis media
-Decrease the duration of illness by 1-2 days
o Strep is a self-limited disease
-Decrease contagion

Front 66

List Abx that are effective in treating strep pharyngitis

Back 66

 See Table
 Antibiotics can be started up to 9 days after onset of illness to provide a five to ten-fold
decrease in risk of complications
 Penicillin still drug of choice due to cost, narrow bacterial spectrum and lack of
resistance
 Erythromycin can be used for penicillin allergy
 Amoxicillin as effective as penicillin, and may be used in children because of higher
acceptance rate (due to taste)
 Although other macrolides and cephalosporins are effective, their routine use has
been discouraged because of fear of creating antibiotic resistance

Front 67

What is the role of strep culture and rapid Ab testing (RAT) in the treatment of strep pharyngitis

Back 67

-Strep culture is gold standard
-RAT has specificity of >95%
o If test is positive treatment should be started
o Useful in making a diagnosis quickly
-RAT sensitivity 60-80%
o If RAT is negative and pre-test index of suspicion is high based on clinical signs
and symptoms, do Strep culture to confirm in children.
o No need to confirm negative RAT in adults because incidence of Strep is
markedly less in this population and the pneumatic complications are extremely rare

Front 68

Name 5 organ systems as possible sources for chest pain

Back 68

-cardiac
-pulm
-GI
-MSK
-Neuro (also psych)

Front 69

List at least 10 non-cardiac causes of chest pain

Back 69

-Pulmonary: pulmonary embolism; pneumonia; pleurisy; pneumothorax
-Neurologic: shingles (zoster)
-GI: peptic ulcer disease; esophagitis; cholecystitis
-Musculoskeletal: costochondritis; trauma; rib pain
-Psychologic: anxiety and hyperventilation; somatization syndrome; depression

Front 70

Name the 3 most common causes of chest pain in primary care setting

Back 70

The top 3 are non-cardiac
-MSK chest pain
-GERD
-Panic disorder

Front 71

List 7 major risk factors for cardiac dz -3 demographic (non-modifiable)
-4 preventable

Back 71

Demographic
-Age: increased risk of CAD with increased age
-Gender: male greater risk than females until age 50 (protected effect of estrogen)
-Family history: early MI in family member (males <55 yrs, females <65 yrs)
Preventable
-Hyperlipidemia: cholesterol >200 (HDL cholesterol <35 and LDL above 130 (mg/dl)
increases risk of CAD
-Hypertension: diastolic >105 increases risk of CAD 4x
-Smoking: 1 ppd 70-200% increased risk
-Diabetes: 2x increased risk due to small and large vessel changes

Front 72

List appropriate tests if MI is suspected

Back 72

-ECG resting (cannot rule out MI if negative)
-Stress ECG - not appropriate in the setting of acute myocardial infarction (baseline
ECG changes or enzyme elevations) or unstable angina
-CBC - check for anemia; WBC elevation in MI is later and neither sensitive nor
specific
-Renal panel - electrolyte, kidney abnormalities; diabetes
-Lipid profile - check for hyperlipidemia
-CPK with MB band - check for MI; SGOT may be helpful if MI occurred 1-6 days
ago (refer students to Table 4); has been replaced with troponin in acute situations
-Troponin

Front 73

List 3 drugs that can be used for the initial management of acute cardiac ischemia

Back 73

-Aspririn
-B-blockers
-morphine
-oxygen
-nitroglycerine

Front 74

Initial management of patient w/ suspected acute MI in outpatient vs inpatient setting. How would this be different in a rural area?

Back 74

-Start an IV and give oxygen
-Give nitroglycerin
-Administer morphine sulfate for pain relief
-Give a BETA blocker if clinically appropriate
-Give patient 160mg “two baby aspirin” to 325mg aspirin to chew
-Evaluate patient for thrombolytic therapy/revascularization procedures in
conjunction with receiving facility
-Any patient with suspected MI requires rapid transportation to a facility (urban or
rural) equipped for cardiac emergencies. The patient should be transferred by air or
road ambulance

Front 75

Describe sx, dx, and rx of costochonditis

Back 75

+++in diff dx for chest pain
-Rib pain of the costochondral junctions or chondrosternal joints
-Clinical diagnosis based on patient history and PE
-Treatment consists of pain relief with acetaminophen, NSAID’s, heat, minimize
activities that cause pain and reassurance, physical therapy not often necessary

Front 76

Describe signs/sx, dx, rx, of PE

Back 76

-Shortness of breath, hemoptysis, tachycardia, hypoxia, as well as the associated
history, signs and symptoms of a DVT as a possible source
-Refer to Wells Prediction Rule for Diagnosing PE.
o Gold standard is CT angiography.
o A helical CT scan has been used but PE cannot be ruled out in patients
with a neg scan.
o D-dimer test largely excludes the diagnosis of proximal DVT and PE in
younger patients whose symptoms are of short duration and whose
pretest probability of venous thromboembolism is low.
-Oxygen, IV fluids if pt with hypotension (SBP < 90 or decrease in SBP > 40mmHg
from baseline and may need norepinephrine, dopamine or epinephrine
(see algorithm for patients with suspected PE.
-The diagnosis of a PE often requires a high level of suspicion and its
consideration in cases that are less than classic presentations.

Front 77

Differentiate acute vs chronic cough

Back 77

Acute is less than three weeks; sub-acute is between 3 and 8 weeks; chronic is
eight weeks or more in duration.

Front 78

Identify the most common causes of chronic cough (6)

Back 78

• Asthma
• GERD
• Upper and lower respiratory tract infection
• Post-nasal drip
• Smoking and other irritants
• Angiotensin converting enzyme inhibitors.

Front 79

Discuss sx management of cough in patients with common diagnoses
-acute vs chronic

Back 79

-Acute: usually hydration and reassurance. Rarely need cough suppressants.
Mucolytics or expectorants are not more effective than hydration with water.
-Chronic: consider asthma, GERD, ace inhibitors, post-nasal drip and smoking.

Front 80

List at least 4 common triggers of asthma exacerbations and potential measures to decrease these triggers

Back 80

 Environmental allergens, irritants (cigarette smoke and pollution)
 Sensitivity to aspirin or to food additives
 Respiratory infection (upper or lower)
 Exercise
 Cold
 Medication-non compliance

Front 81

Explain at least 5 assessment parameters that help determine severity of an asthma exacerbation

Back 81

-Asthma severity classification, see Asthma Cards (see appendix)
-History of intubation, hospitalizations
-Vital signs, including respiratory rate, pulse, BP, pulsus paradoxus, an
exaggerated (>10mm Hg) fall of systolic BP during inspiration
-Peak expiratory flow rate (PEFR)
-Office spirometry (FEV1)
-Work of breathing (accessing muscle use; degree of dyspnea)
-Wheezing (beware the lack of wheeze -- silent chest secondary to severe
bronchospasm and poor ventilation)
-Oxygen saturation (pulse oximetry); color (cyanosis)
-Alertness; carbon dioxide retention

Front 82

Discuss the initial treatment of a patient presenting with an acute asthma exacerbation

Back 82

-Baseline peak flow and pulse ox; repeat peak flows as to assess treatment efficacy.
-Albuterol nebulizer treatments, may give 3 back to back; consider adding atrovent to
nebulizer treatment.
-Consider continuous nebulizer treatment/consider oxygen therapy.
-Consider PO or IV steroids.
-If severe consider epinephrine, theophylline, terbutaline or magnesium (controversial).
**Admit if no or minimal response to above.

Front 83

Summarize the importance of family involvement in asthma management

Back 83

Family cooperation is necessary to avoid triggers, such as cigarette smoke and
allergens, like pet dander/saliva or dust and improve medication compliance. Children
may require parental advocacy to ensure appropriate evaluation and treatment of their
disease.
Families may experience stress due to a family member with a chronic disease such as
asthma.

Front 84

Explain the development and benefit of a home asthma management plan

Back 84

A crucial part of this plan is for family physicians to prescribe peak-flow meters for their
patients and teach them how to use them. Patients also need education in how to use a
spacer.

Front 85

Differentiate potentially malignant skin neoplasm from those that are benign, discuss
screening recommendations for skin cancer and counsel patients on malignant skin
neoplasm and their prevention.

Back 85

REVIEW DERM SLIDES!!!!!
-Answers to LOs are not covered in cards
Squamous cell carcinoma.
Basal cell carcinoma.
Malignant melanoma; describe the ABC’s (asymmetric, border irregularities, color
variegation, diameter greater than 6mm, enlargement greater than 0.5cm, have
irregular border and multiple colors.
Refer to Table 1
Avoid sun exposure; use hats and sunscreen.

Front 86

Describe the initial therapy for acne

Back 86

Topical treatment with benzoyl peroxide, or topical antibiotics (e.g. cleocin T) for mild.
Systemic antibiotics (tetracycline or erythromycin) for more severe. Consider birth
control pills for women. For severe acne, topical tretinoin (Retin A) or isotretinoin
(Accutane) orally. Accutane is teratogenic-strict contraception precautions. (Now
requires new consent form and consent process).

Front 87

List the common sx of T2DM

Back 87

Diabetes type 2 is characterized by a mild and often insidious onset. Patients can be
asymptomatic for years often delaying the diagnosis. In fact, the CDC estimates that in
2002, 13 million people had diagnosed diabetes. An additional 5.2 million had the disease,
but did not know they had it. Common presentations at diagnosis are weight loss, fatigue,
excessive thirst, recurrent fungal infections, visual changes, periodontal absess, nocturia,
polyuria, and burning, tingling, or numbness in the extremities.

Front 88

State the dx criteria for T2DM

Back 88

1. A1C -6.5%. The test should be performed in a laboratory using a method that is NGSP
certified and standardized to the DCCT assay.*
OR
2. FPG -126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose -200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose -200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.

Front 89

List the PE and Labs that are followed in a T2DM patient

Back 89

1) Physical Exam
-Physical examination annually
-Dilated eye examination annually
-Foot examination annually; more often in patients with high-risk foot conditions
Review how to perform the microfilament foot assessment. (See Diabetic Foot
Screening)
-Every regular diabetes visit
-Weight
-Blood pressure
-Previous abnormalities on the physical exam

2) Laboratory evaluation
-Glycated hemoglobin also called hemoglobin A1C
-Quarterly if treatment changes or patient is not meeting goals
-Twice per year if stable
-Fasting plasma glucose (optional)
-Fasting lipid profile annually, (including HDl, LDL, total cholesterol, total triglyceride)
-Microalbumin measurement annually (if indicated)

Front 90

List patient variables that are considered in management of T2DM

Back 90

-Age
-Gender
-Race
Compare rates of diabetes for ages 40 to 74, in Caucasians (11/2%), Mexican
Americans (20.3%), African Americans (18.2%), and American Indians (ranges
from 33 to 72%!)
-Cultural issues
-Support issues
-Family history
-Insurance status, employment issues, access to care
-Patient motivation

Front 91

Practice obtaining a patient's view of their illness and treatment using the ETHNIC pneumonic (diabetes)

Back 91

-Explain. Ask the patient to explain what they believe to be the cause of their illness.
-Treatment. Ask the patient about treatments that they have tried.
-Healers. Ask about the patient’s use of folk healers or other non-allopathic providers.
-Negotiate mutually acceptable options.
-Intervention. Agree on an intervention that is acceptable to the provider and the
patient.
-Collaboration with the patient, family members, and folk healers.

Front 92

Discuss the known complications of T2DM (7)

Back 92

 Retinopathy
 Nephropathy
 Neuropathy
 Cardiac disease
 Dysmotility
 Dyslipidemia
 Amputation

Front 93

List the treatment goals to prevent complications in T2DM

Back 93

-Exercise, weight control, and medication to keep hemoglobin A1C < 7%, preprandial
blood glucose between 90 and 130 mg/dl and postprandial (2 hours after initiating a
meal) less than 180 mg/dl. Ideal is to get as close to normal range as possible without
inducing hypoglycemic episodes
-Self glucose monitoring
-Control of cholesterol/TG with aggressive treatment (diabetes poses as great a risk
for having a heart attack in 10 years as does having known heart disease.) LDL
should be less than 100 mg/dl, but a goal of less than 70 mg/dl may be even better.
-Control of blood pressure - <130/80
-Annual retinal examination
-Consider ACE inhibitors for preservation of renal function and blood pressure control.
-Daily aspirin therapy – 75-325mg
-Annual podiatry visits
-Immunization updates

Front 94

Explain the rationale for using metformin as a 1st line agent in most patients What is the recent issue with Rosiglitazone?

Back 94

Metformin is the initial treatment for most patients with type 2 diabetes. This drug enhances insulin sensitivity and also improves other factors
related to increased cardiovascular risk. Metformin does not lead to weight increase and can
induce slight weight loss through its appetite-suppressive action. This is true of monotherapy
and in combination with other agents. Metformin should be used cautiously in persons with
renal or liver impairment.

Rosiglitazone recently linked to INCREASED rates of myocardial infarction.

Front 95

Identify the 6 components of the Chronic Dz Model using T2DM as an example

Back 95

1. Self-Management: Patients have a central role in determining their care, one that fosters a
sense of responsibility for their own health.
In diabetes, it is important for providers to encourage self-monitoring of blood glucose.
Patients’ self-monitoring results should be discussed at visits with health providers.
2. Decision Support: Treatment decisions need to be based on explicit, proven guidelines
supported by at least one defining study.
The ADA publishes guidelines annually every January. These guidelines are mostly
evidence-based, but occasionally expert opinion is included if clinical study data are lacking
or equivocal.
3. Clinical Information System: An information system that can track individual patients as
well as populations of patients is a necessity when managing chronic illness or providing
preventive care.
This is becoming easier to do with electronic health records. Records can be set up to flag
when last cholesterol was checked and when next is due, for example.
4. Delivery System Design
The delivery of patient care requires not only determining what care is needed, but clarifying
roles and tasks to ensure the patient gets the care; making sure that all the clinicians who
take care of a patient have centralized, up-to-date information about the patient’s status; and
making follow-up a part of standard procedure.
The family physician coordinates care by a full team of professionals including diabetes
educators, nutritionists, pharmacists, nurses, social workers, spiritual leaders etc. Group
visits are one way to achieve much of this coordination in a single visit with the further
advantage of peer support. This model is currently the subject of research.
5. Organization of Health Care
Health care systems can create an environment in which organized efforts to improve the
care of people with chronic illness take hold and flourish.
Support for diabetes management must occur at all levels of an organization. Buy in from
CEO’s and staff is important. Training nursing staff to remove patient’s shoes has been
shown to increase the likelihood that physicians will do a foot exam.
6. Community
To improve the health of the population, health care organizations reach out to form powerful
alliances and partnerships with state programs, local agencies, schools, faith organizations,
businesses, and clubs
Many physicians offices participate in community health fairs. These can include blood
pressure monitoring and diabetes screening. Family physicians can also be important
advocates for legislative changes such as mandatory physical education in public schools.

Front 96

Identify the aspects of care that should be recognized in the elderly with T2DM

Back 96

-In 1993, 41% of the 7.8 million people diagnosed with diabetes were over 65 years of
age. Remember to consider this as a new diagnosis in the elderly
-Diabetes management is more challenging in the elderly because of co-morbidities
and the increase in prevalence of frailty with age
-Nationally published guidelines often do not apply to geriatric care
-Because of the normal physiological changes associated with aging (decrease in
perception of thirst decreases polydipsia, increased threshold for glycosuria gives
negative urine test for glucose), elderly diabetic patients rarely present with the typical
symptoms of hyperglycemia. More often, changes such as confusion, incontinence, or
complications relating to diabetes are the presenting symptoms
-Both insulin-dependent and non-insulin-dependent diabetes occur in the elderly. The
primary impairment in obese elderly diabetic patients is insulin resistance, whereas
lean elderly patients have impaired glucose-induced insulin release
-Counter-regulation involving glucagon, epinephrine, and growth hormone responses
to hypoglycemia are diminished, increasing the incidence of hypoglycemia

Front 97

List 6 causes of dysuria in women

Back 97

-cystitis
-urethritis
-vaginitis
-chemicals/irritants
-estrogen deficiency
-pregnancy

Front 98

List 3 causes of dysuria in men

Back 98

-urethritis
-prostatitis
-cystitis

Front 99

State which is the most sensitive aspect of UA for dx of UTI

Back 99

WBC count >5-10/HPF on/clean-void urine or leukocyte esterase on urine “dip stick”; a
microscopic examination is the most sensitive and the presence of nitrite is highly specific for
diagnosing a UTI.

Front 100

List 3 medications recommended for standard 3-day or 1-day therapy for uncomplicated UTI

Back 100

1) Trimethoprim-sulfamethoxazole (Bactrim DS) -1 tab twice daily
2) Fluoroquinolone Ciprofloxacin - 250mg twice daily
3) Fosfomycin (Monurol) 3gm once

Front 101

List 5 categories of patients who need longer therapy duration for UTIs

Back 101

-Male
-Unreliable pt
-Pregnant
-Diabetic
-Recent or recurrent UTI
-Pyelonephritis
-Elderly

Front 102

Discuss the utility of urine cultures for UTI

Back 102

In the setting of a female adult patient with an uncomplicated UTI, several studies have shown
that a urine culture is not necessary. However, due to changing resistance patterns, especially
E.coli to trimethoprim-sulfamethoxazole, many providers continue the practice of culturing the
urine for almost all women who present with uncomplicated UTI's.
The traditional diagnostic cutoff of 100,000 colonies/ml may miss many women who have a
UTI but have lower colony counts. In symptomatic patients, a colony count as low as 100
colonies/ml suggests UTI and may require antibiotic treatment.

Front 103

Describe 3 regimens that women can use if they have recurrent UTIs

Back 103

>3 UTI/yr - patient-initiated therapy for symptomatic episodes. If temporally related to coitus,
then post-coital prophylaxis, if no relation to coitus, then daily prophylaxis.

Front 104

Highlight the features of dx and management of UTIs in men vs children vs elderly

Back 104

1) Men - Always do urine cultures
- Treat urine infections for 7-10 days
- Treat prostatitis for 4-6 weeks (suspect if patient presents with fever; rectal, lower
back or perineum pain; frequency; and or signs of urinary obstruction.
2) Children - under two months require hospitalization and parenteral antibiotics. Urine cultures
should always be obtained regardless of negative urinalysis. Further imaging studies are
indicated for children under 2 years of age and for children older than 2 with recurrent UTI's or
an episode of pyelonepehritis.
3) Older adult - diagnosis is more difficult because older adults can be asymptomatic or present
with other manifestations of illness such as mental status changes.
- Treat elderly women with UTI for 7 days
- Treat older men for 10-14 days

Front 105

List 3 common causes of infectious vaginitis, findings of each on wet prep, rx of each

Back 105

1) Vulvovaginal Candidasis: clotrimazole or miconazole cream by vaginal applicator h.s. x 7
days (or, if recurrent, oral one-dose fluconazole 150 mg)
2) Trichomoniasis: metronidazole - 2 gm stat for patient and partner (“trich” is an STD)
3) Bacterial vaginosis: metronidazole - 2 gm stat or 500 mg BID x 5d or vaginal metronidazole
(Metrogel) 5 gm p.v. BID x 5d

Front 106

Discuss briefly the care and hazards of contact lenses

Back 106

-daily vs. extended wear (cleaning) vs. disposable (expenses).
-all could lead to corneal ulcer (painful, positive stain with fluorescein)

Front 107

Review key components in the physical exam of a patient w/ eye complaints

Back 107

-Visual acuity (can be measure of severity of eye disease, also important to
document before you perform any interventions)-check each eye.
External exam.
-Fluorescein staining (for foreign body or corneal laceration).
-Eyelid eversion.
-Exam of anterior chamber and fundus.
-If possible, intraocular pressure and slit lamp exam

Front 108

List the common causes of eye problems in the elderly

Back 108

-Presbyopia
-Cataracts
-Age-related macular degeneration
-Primary open-angle glaucoma
-Diabetic retinopathy

Front 109

Define
-emmetropia
-hyperopia
-myopia
-astigmatism
-presbyopia

Back 109

-Emmetropia- the normal state
-Hyperopia- far sighted- fix with plus (convex) lens
-Myopia- near sighted- fix with minus lens (concave)
-Astigmatism- refractive errors in horizontal and vertical axes differ
-Presbyopia- natural loss of accommodation with age

Front 110

List 3 appropriate components of the hx and initial dx work up to evaluate patients complaining of fatigue

Back 110

-History – events at onset; duration, diurnal variation, and progression of fatigue;
sleep patterns; symptoms of depression; dietary intake, medications; family
violence, life stress, alcohol or substance abuse; effect of symptoms on patient's
job performance, family, marital and social relationships.
-Lab/diagnostic tests - CBC, sed rate, thyroid function tests, U/A, chemistry
profile, calcium chest x-ray for elderly; Beck Depression Inventory or other
similar test, HIV.

Front 111

Describe the nutritional considerations in the evaluation and treatment of fatigue

Back 111

Note weight loss (or gain); inadequate diet, especially in iron and caloric content.
Chronic dieting and anemia with <25% Hct can both cause fatigue. Treat specific
cause anemia, e.g. 325 mg FeSO4 daily or TID and with foods high in iron: red
meat, dried beans and peas, and enriched cereals are recommended. Caloric
intake >1200 kcals and never less than 10 kcals/lb IBW. Identify source of iron
deficiency-nutrition vs blood loss.

Front 112

State 5 reasons primary care physicians need to be able to recognize and treat depression

Back 112

1) Depression is the seventh most common diagnosis in family medicine.
2) Depression is an under-diagnosed illness. As many as 50% of depressed
patients may not be correctly diagnosed.
3) Primary care physicians are in a unique position to screen for depression.
4) USPSTF recommends a routine screening for depression in clinical practices
that have systems in place to ensure accurate diagnosis, effective treatment,
follow up. “Many formal screening tools are available (e.g., the Zung Self-
Assessment Depression Scale, Beck Depression Inventory, General Health
Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CESD]).
Asking two simple questions about mood and anhedonia ("Over the past 2
weeks, have you felt down, depressed, or hopeless?" and "Over the past 2
weeks, have you felt little interest or pleasure in doing things?") may be as
effective as using longer instruments.3There is little evidence to recommend one
screening method over another, so clinicians can choose the method that best
fits their personal preference, the patient population served, and the practice
setting”
5) Lethality risk

Front 113

List 5 factors that can cause or contribute to depression

Back 113

-Untreated chronic pain
-Substance abuse - alcohol, illicit drugs, prescription drugs such as
benzodiazepines or narcotics.
-Prescription medicines - reserpine, steroids, beta-blockers.
-Medical disorders - hypothyroidism.
-Family history

Front 114

List 5 risk factors for suicide in patients with depression

Back 114

 Caucasian race
 Male
 Advanced age
 Living alone
 Prior suicide attempts
 Widowers

Front 115

Describe an appropriate treatment plan for patients with depression

Back 115

Psychotherapy, medication or both. Be aware that many HMOs may pay for only a
few psychotherapy visits.

Front 116

Forty-five year old black female, seen for the first time in your office complains
of being "too tired all the time". T 36.7, P 60, BP 115 /78, R 18. This information is
available on the chart before you enter the examining room.
Common causes include:

Back 116

1. Anemia (esp. if dysfunctional uterine bleeding)
2. Depression
3. Diabetes Mellitus, Type II
4. Hypothyroid
5. Substance Abuse
6. Domestic Violence

Front 117

A 19-year old college sophomore complains of being "sleepy all the time". She
recently flunked a chemistry final exam, and broke up with her boyfriend. She had a
sore throat two weeks ago, but is otherwise well now.
Common causes include:

Back 117

1. Infectious mononucleosis
2. Depression
3. Adjustment reaction
4. Pregnancy
5. Hypothyroid (e.g. Hashimoto’s
6. Hepatitis
7. Anemia
8. Substance Abuse
9. Domestic Violence

Front 118

A 70-year old man brought in by his daughter because he "doesn't have any
energy--he seems to sleep all day long and can't even do the garden work he loves
so much".
Common causes include:

Back 118

1. Depression
2. Drug abuse (esp. alcohol, sedative/hypnotics)
3. Dementia: Alzheimer's, multi-infarct
4. Malignancy (esp. chronic lymphocytic leukemia, colon carcinoma)
5. Congestive heart failure
6. Pulmonary insufficiency with CO2 retention
7. Diabetes Mellitus, Type II
8. Elder Abuse

Front 119

Define primary and secondary headache

Back 119

 Primary headaches are not due to a causal disease.
 Secondary headaches are due to a causal disease.

Front 120

Common vs severe/life threatening causes of headaches
-children vs adults

Back 120

CHILDREN
MC
-migraine HA
-tension HA
Severe
-neoplasm
-congenital malformation
ADULTS
MC
-migraine HA
-tension HA
-cluster HA
-caffeine withdrawal
Severe
-cancer
-intracranial bleed
-meningitis
-stroke
-temporal arteritis
-pseudotumor cerebri

Front 121

Discuss the differential historical features and physical findings for the 3 classic types of headaches

Back 121

1) Migraine: Location usually starts as unilateral, pounding, throbbing; aura in classic;
rapid onset; often with nausea + vomiting; duration of 4-72 hours; photophobia;
photophobia; family history. Most migraines are not classic.
2) Muscle Tension: Location occiptofrontal, dull aching; constricting; tender scalp
and/or neck muscles; becomes worse as the day goes on; lasts hours to weeks; no
aura; nausea and vomiting are very rare; no family history.
3) Cluster: Unilateral and orbital; severe, intense, stabbing (not throbbing); lacrimation;
nasal congestion; rhinorrhea; conjunctival injection; ptosis; miosis; bradycardia;
occur in clusters of 4-6 attacks per day over 2 to 12 weeks; may occur at the same
time each year; severe enough to wake patient from sleep; last 30-60 minutes.

Front 122

List the warning signs of headaches that are associated with significant underlying dz

Back 122

-Sudden onset
-no previous history of this type of headache
-change in mental status,
-concomitant facial infection
-headache with vigorous exercise
-trauma

Front 123

Describe Sx that are concerning in pediatric headaches

Back 123

-sleep related
-nocturnal awakening with headache
-no family history
-vomiting
-lack of visual symptoms
-duration of less than 6 months

Front 124

List challenges that present when managing headaches in older patients

Back 124

-Recognizing the sometimes atypical ways that benign dysfunctional headaches,
especially migraine, may present
-Treating the elderly with special regard for their reduced tolerance to medications
and the potential for increased contraindications to medications due to concomitant
disease
-Diagnosing systemic and intracranial diseases and other disorders that are more
often a cause of headaches in old age

Front 125

List acute treatment and prevention in headaches
COMPARE:
-Tension
-Migraine
-Cluster

Back 125

1) Muscle tension
-Acute: NSAIDs, ASA, Tylenol, short course of p.o. narcotics; heat, massage, stretching;
trigger point injection; calcium channel blockers; anti-depressants.
-Prophylactic: Tricyclic and other antidepressants; beta-blockers; calcium channel
blockers; NSAIDs; biofeedback.
2) Migraine
-Acute: Ergotamines; Sumatriptan and other triptans; NSAIDs including ketorolac;
stadol; narcotics; IV fluids; anti-emetics..
-Prophylactic: Beta blockers; calcium channel blockers; tricyclics; removal of
environmental triggers; NSAIDs; valproic acid, tegretol.
3) Cluster
-Acute: Inhaled oxygen; DHE/antiemetic; narcotics/antiemetic; triptans; NSAIDS;
cafergot.
-Prophylactc: Alcohol avoidance; calcium channel blocker; lithium carbonate;
ergotamine (in combination with above); methylsergide (beware of retroperitoneal
fibrosis -> ureteral obstruction); prednisone (not for long term prevention); lithium;
cyproheptadine.

Front 126

List 3 categories of further studies that may help to determine the cause of a secondary headache

Back 126

-Lumbar puncture for meningitis, encephalitis, subarachnoid bleed.
-CT or MRI for space-occupying lesions, CVA, acute hydrocephalus.
-ESR or temporal artery biopsy for temporal arteritis.

Front 127

List the complementary therapies that may help alleviate tension headaches

Back 127

Physical therapy, massage, behavioral changes, nerve blocks, guided imagery,
biofeedback.

Front 128

List some public health measures over the last century that have lead to major reduction of morbidity/mortality

Back 128

Discuss with students decrease in morbidity and mortality resulting from safe water,
sanitation, immunizations, occupational safety, food safety, consumer product safety,
building codes, motor vehicle safety (safer cars and better roads), etc.

Front 129

Manage, from a clinical/epidemiologic perspective, patient-care encounters across the
family-practice spectrum, from diagnosis to case-finding to screening.

Back 129

This is the “global” goal of the FCM Clerkship, stated here at the outset of the Prevention
Series; the spectrum is discussed in detail in Objective 4, below.
Definitions:
A) disease diagnosis: identifying disease in an ill patient who seeks medical
care.
B) case-finding: finding disease in a high-risk person who is ill, but is not
seeking medical care. At the center of the “spectrum” case finding occurs
when the alert physician either:
-a. identifies associates of an ill patient who is at high risk because of
shared genetic or environmental factors. Examples include: breast
cancer in a first order female relative, familial lipid elevations, hepatitis A,
tuberculosis, STD’s, or
-b. identifies additional high risk factors in a well patient that leads the
physician to be more aggressive than the standard screening protocols.
Examples include: applying PPD to all foreign born persons new to the
U.S., blood lead testing on those whose verbal risk screen is high, adding
routine Chlamydia testing for women over age 24 if they have new or
multiple partners.
C) screening- proactively searching for disease in asymptomatic persons.
See Objective 8 for more detail on screening.

Front 130

Relate the three terms in Objective 2 (above) to diagnostic thinking (Bayesian problemsolving)
in primary care, comparing and contrasting to diagnostic thinking in subspecialty
clinic populations.

Back 130

-The more restricted/selected the population of patients, the higher the +PV of a test
will be in specialty/referral clinics. This is because the prevalence of the disease
being tested for is higher in these referral “populations” of patients than in primary
care.-- Note that Prevalence is the most widely variable (i.e. many orders of
magnitude), and thus the most “powerful,” term in Bayes “equation”; sensitivity and
specificity can only vary between 0-1.0 (0% to 100%). (See “equation 3” on the +PV
sheet)
-Working or doing clerkships in a tertiary care setting can give the impression that
tests are more useful (than they actually are in primary care), leading to reliance on
“tests” rather than on clinical acumen and reasoning.
-Since primary care doctors, unlike sub-specialists, do not have a narrow spectrum
of patients referred to them, they must utilize a combination of clinical findings, as
well as epidemiologic/demographic information, in order to “narrow down” the
clinical picture. This will yield a smaller denominator population of pertinent patients,
thus increasing the a priori likelihood that disease “x” is present. In turn, this will lead
to a higher positive predictive value and cost-effectiveness for the tests employed
later in the diagnostic encounter (including further history details and physical exam
maneuvers – which one also “tests”).
-Combinations of risk factors and clinical findings in primary care can have a high
+PV, often making technologic “lab” testing superfluous, since in those cases, lab
may add little or no more “certainty”, i.e. +PV. (Illustrate this by Venn diagrams of
overlapping circles, e.g., cough+weight loss+foreign birth) (or illustrate it with +PV
“equation”).

Front 131

Extend this “diagnostic” process to “case-finding” and to “preventive screening” in the
population served by the clinic at the students’ site.

Back 131

Although the (Bayesian) thought process is the same across this spectrum, the +PV
becomes lower in going from diagnosing a sick patient  case-finding  screening.
Case-finding and screening then become a matter of cost-benefit “pay-off” -- as per the
factors used in selecting which diseases to screen for -- see the Session on Screening.
Each site has a different patient population, so the cost-benefit ratio of screening may
differ (for the same health problem) in different clinics.

Front 132

Describe three levels of preventive intervention in the pathogeneses of a disease,
providing specific examples.

Back 132

-Primary: disease agent not (yet) present in host (e.g., condoms, tetanus
vaccination)
-Secondary: agent present, but “disease” is pre-clinical (e.g., Pap screening or
INH preventive treatment of latent TB (those with +PPD, i.e., persons who are
infected but not ill.)
-Tertiary: clinical disease is present; aim of tertiary prevention is to prevent (or reverse) progression (e.g. LEEP, post-MI aspirin, or 4-drug therapy of active,
infectious TB)

Front 133

List three major types of source (“expert panels”) of clinical prevention guidelines.

Back 133

-Government agencies
1. US Preventive Services Task Force (update provided continuously via the Web.)
USPSTF is the most rigorously evidence based – so it is the “final authority” in this
clerkship
2. CDC
-Medical specialty groups (e.g. American Academy of Family Physicians, American
College of Physicians [ACP], and others)
-Disease-specific public voluntary agencies (American Cancer Society, American
Heart Association, American Lung Association)

Front 134

Identify the three major methods of clinical prevention; all three are evaluated by the
U.S. Preventive Services Task Force in the Guide to Clinical Prevention (GCP).

Back 134

-Counseling (behavioral change/lifestyle) Covered in Prevention Week 2
-Screening Covered in Prevention Week 3
-Immunization/chemoprophylaxis Covered in Prevention Week 4

Front 135

Review six criteria for judging the value of screening tests (three related to the
disease and three related to the test-- ie 3 disease criteria vs 3 test criteria)
How do these criteria apply to genetic testing?

Back 135

Disease Criteria:
-Disease must cause significant morbidity or mortality.
-Disease is common enough to justify screening.
-Early detection and treatment must reduce morbidity or mortality. (The disease must
have an asymptomatic period, and an effective treatment must be available.)

Be alert for lead-time bias - early diagnosis can appear to increase survival.
Also look out for length bias - cases detected by the screening test have a better
prognosis than those picked up in the interval between screening tests. This is not due
to efficacy of the test in reducing morbidity or mortality, but rather is because cases
occurring in the interval between screenings tend to be more aggressive and progress
more rapidly, e.g., breast cancer.

Test Criteria:
-Benefit of test must outweigh the risk and the cost.
-Test must be relatively safe, practical and feasible (acceptable to patients).
-Test must be specific and sensitive enough to avoid large numbers of falsepositives
or false-negatives, respectively. This, in turn, depends largely on
prevalence – see objectives 3 and 4 and the diagram on page 5.

Genetic Testing The same 6 criteria (above) apply. More than 800 genetic tests are
currently available. Most are for rare diseases, but some tests have been developed to
identify inherited risks for common diseases such as breast and colorectal cancer,
Alzheimer’s disease, and coronary heart disease.
• Pro: Potential for early identification of those at increase risk.
• Con: Lack of consensus or research on what to do with a positive result. No studies to
show whether those with positive results need more frequent preventive services such
as mammography or colonoscopy. Those with positive tests may be discriminated
against by health care insurers.

Front 136

What is the difference between lead-time and length-time bias

Back 136

-Lead time- early dx (probably from screening) leads to false increase in survival
-Length time- cases found earlier because of screening have better prognosis than those detected between intervals- the test doesn't necessarily improve morbidity/mortality b/c cases caught in the interval are more aggressive and progress more rapidly.

Front 137

Identify the top 10 causes of overall mortality in the US

Back 137

1) Heart disease: 597,689
2) Cancer: 574,743
3) Chronic lower respiratory diseases: 138,080
4) Stroke (cerebrovascular diseases): 129,476
5) Accidents (unintentional injuries): 120,859
6) Alzheimer's disease: 83,494
7) Diabetes: 69,071
8) Kidney Dz 50,476
9) Influenza and Pneumonia: 50,097
10) Intentional self-harm (suicide): 38,364

Front 138

List two reasons why physicians should perform behavioral counseling.

Back 138

1) 50% of the mortality in the US from the 10 leading causes of death has been linked to lifestyle related behavior.
5 lifestyle factors:
-tobacco use
-obesity
-physical activity
-substance abuse
-responsible sexual behavior
2) Addressing lifestyle factors is an important aspect of reducing health disparities

Front 139

Examine evidence of prevention effectiveness by physicians towards initiating, sustaining, and/or enabling patients to succeed with tobacco cessation.

Back 139

-Discuss effectiveness of brief physician interventions (tobacco cessation) in promoting behavior change among patients
-A 3-minute, physician-based, brief intervention, delivered in a primary care setting, significantly improves smoking cessation rates by 25-34%
-A dose-response relationship exists between the length of intervention (50 sec-15 min) and the effect or outcome
-The physician, as a counselor, role model, and/or facilitator can be a powerful tool for promoting smoking cessation in a primary care setting

Front 140

Provide specific lifestyle recommendations for the management of coronary artery
disease.

Back 140

Nutrition
-Decrease cholesterol, saturated and trans-fat
-Increase omega-3 fats, increase soluble fiber intake (fruits, vegetables, legumes,
whole grains)
Review role of micronutrients
-Folic acid, calcium, magnesium, potassium, sodium, antioxidants
Promote weight control/loss
Encourage regular physical activity
-Goal is 30-60 minutes daily at moderate exertion
Review and discuss the various diets prescribed: DASH, Am. Heart Assoc., Mediterranean, Dean Ornish, Omni Heart Trial

Front 141

Discuss the role of functional foods in the nutritional management of cardiovascular
disease.

Back 141

Soy
Garlic
Omega-3 fatty acids
Soluble fiber
Green tea
Plant stanols

Front 142

List 3 classes of medications used in the primary prevention of cardiovascular disease.

Back 142

-Aspirin
-Cholesterol lowering meds
-Anti-hypertensives

Front 143

Discuss the role of screening and office interventions for overweight and obesity in the
primary care office.

Back 143

- Screen all patients for obesity using BMI (USPSTF- see below))
-Intensive counseling and behavioral interventions may result in modest, sustained
weight loss for
obese patients. May require referral for most family physicians. USPSTF
-Low- or moderate-intensity counseling and behavioral interventions (that most family
physicians
could do in the office) have not been shown to be effective for obese patients. USPSTF
-Type of diet does not seem to matter; sustained weight loss is difficult; [Sacks F et al.
Comparison of weight-loss diets with different compositions of fat, protein, and
carbohydrates.

Front 144

Recognize the value of information technology for promoting adherence to clinical practice
guidelines.

Back 144

-Provides rapid collection of specific information. Access to patient education materials
(don't have to reinvent the wheel for common problems).
-Easy access to evidence-based, effective prevention programs/strategies.
-Provides no- or low-cost information for patients. Patient can be active in own
information access.
-Can initiate patient-care reminders.
-Can provide feedback to providers for specific patients, as well as their patient
population.

Front 145

Review the definition and goal of secondary prevention

Back 145

-Secondary prevention
Identifying preclinical disease in easily treatable state (asymptomatic).
-Goal
Initiate treatment if disease identifiable.

Front 146

List 6 criteria for judging the value of screening tests
(3 dz criteria vs 3 test criteria)

Back 146

Disease Criteria:
-Disease must cause significant morbidity or mortality
-Disease common enough to justify screening
-Early detection and treatment must reduce morbidity or mortality
(Lead-time bias - early diagnosis can appear to increase survival)
Test Criteria:
-Benefit of test must outweigh the risk and the cost
-Test must be practical and feasible (acceptable to patients)
-Test must be specific and sensitive enough to avoid large numbers of false-positives
or false-negatives, respectively

Front 147

Give 2 examples of secondary preventative screening used in each age group
-children vs adolescent vs adults

Back 147

CHILDREN
-Screen Hb/Hct for anemia
-Lead screen
-Growth charts
-Developmental milestones
ADOLESCENT
-PAP test
-Screen for tobacco use> recommend cessation
-Alcohol/substance abuse
ADULT
-breast cancer
-cervical cancer
-colon cancer
-CAD
-depression
-elder abuse

Front 148

Discuss the role of BRCA1 and 2 genetic testing. What are the prevention implications?

Back 148

Genetic testing is available and may be appropriate for patients with a strong history of
breast/ovarian cancer, but several questions remain unanswered. If a patient tests positive, does
she need to undergo prophylactic procedures such as bilateral mastectomy or oophorectomy?
Does she need to have more frequent mammograms? Will she be discriminated against by
insurance companies? More research is needed in this area and will be discussed in detail in
week 6 Genomics

Front 149

Define the unique role for family practice in secondary prevention.

Back 149

-Able to follow patients and their families longitudinally.
-Aware of family risk factors.
-Ability to evaluate guidelines and make rational recommendations to patients about
screening options.

Front 150

List the vaccines included in the routine adolescent immunization schedule (4)

Back 150

-Tdap
-HPV
-MCV (meningococcus)
-Influenza

Front 151

List the vaccines included in the adult immunization schedule
Name the 5 vaccines that should be considered for all adults

Back 151

Td/Tdap, influenza, pneumococcal, MMR, varicella (consider for all),
Hepatitis B and A and meningococcus if at risk, zoster vaccine should be discussed,
HPV vaccine where appropriate.

Front 152

List the true contraindications to vaccines and conditions that are commonly mistaken
to be contraindications.

Back 152

1) Contraindications:
-Serious allergic reaction (e.g., anaphylaxis) after a previous vaccine dose
-Serious allergic reaction (e.g., anaphylaxis) to a vaccine component
2) Not Contraindications:
-Mild acute illness with or without fever
-Mild to moderate local reaction (i.e., swelling, redness soreness); low-grade or
moderate fever after previous dose
-Lack of previous physical examination in well-appearing person
-Current antimicrobial therapy
-Convalescent phase of illness
-Premature birth (hepatitis B vaccine is an exception in certain circumstances)+
-Recent exposure to an infectious disease
-History of penicillin allergy, other non-vaccine allergies, relative with allergies,
receiving allergen extract immunotherapy

Front 153

Discuss with patients common misconceptions and misinformation regarding vaccine
risks and benefits.

Back 153

Does not cause autism, diabetes or other chronic diseases. Does not weaken the
immune system. Still needed due to world wide incidence.

Front 154

Where do you go for info on immunization schedules, vaccine SE, and recommended vaccines for international travel
-and current rx recommendations for STDs

Back 154

www.cdc.gov

Front 155

Discuss why the CDC now recommends routine and widespread screening for HIV and
compare the USPSTF recommendation for HIV screening to that of the CDC.

Back 155

Close to one-fourth of all those HIV infected do not know of their condition. This leads to
late detection of the disease and worse outcomes. It also causes prolonged periods of
unknowingly spreading the infection. Risk assessment is inaccurate. Routine testing
reduces the stigma of the test. The U.S. Preventive Services Task Force (USPSTF)
strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all
adolescents and adults at increased risk for HIV and makes no recommendation for
those not at increased risk for HIV infection.

Front 156

Formulate a differential diagnosis for cervicitis, vaginitis, and urethritis.

Back 156

-Cervicitis –gonorrhea, chlamydia, mycoplasma, other organisms grouped into purulent
cervicitis.
-Vaginitis – candida, bacterial, trichamonas, gonorrhea, chlamydia (these last two are
actually a cervicitis that presents with symptoms that resemble vaginitis), chemical.
-Urethritis – gonorrhea, chlamydia, ureaplasm, mycoplasm, nonspecific urethritis,
chemical irritation.

Front 157

Describe the presenting symptoms of gonorrhea, chlamydia, syphilis, herpes and
papilloma virus in both men and women.

Back 157

1) Those that cause discharge:
-Gonorrhea—men – urethritis, proctitis, pharyngitis, arthritis, asymptomatic (gram stain
is specific in urethritis); women - cervicitis, PID, arthritis, pharyngitis, proctitis,
asymptomatic.
-Chlamydia – Same as gonorrhea except lack of arthritis.
2) Those that cause lesions:
-Syphilis—primary is a painless chancre; secondary can be skin rash,
lymphadenopathy, fever, malaise.
-Herpes—initial prodrome of irritation and purities followed by vesicles.
-Human Papilloma Virus - many serotypes; most asymptomatic; oral, anal, or
urogenital warts (painless); linked to cervical cancer

Front 158

Discuss the USPSTF recommendations for screening for chlamydia

Back 158

The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial
infection for all sexually active non-pregnant young women aged 24 and younger and for
older non-pregnant women who are at increased risk.
Grade: A Recommendation.
The USPSTF recommends screening for chlamydial infection for all pregnant women aged
24 and younger and for older pregnant women who are at increased risk.
Grade: B Recommendation.
The USPSTF recommends against routinely providing screening for chlamydial infection for
women aged 25 and older, whether or not they are pregnant, if they are not at increased
risk.
Grade: C Recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of screening for chlamydial infection for men.
Grade: I Statement.

Front 159

Discuss the USPSTF recommendations for screening for gonorrhea

Back 159

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all
sexually active women, including those who are pregnant, for gonorrhea infection if they are
at increased risk for infection (that is, if they are young or have other individual or population
risk factors; go to Clinical Considerations for further discussion of risk factors).
Grade: B Recommendation.
The USPSTF found insufficient evidence to recommend for or against routine screening for
gonorrhea infection in men at increased risk for infection (go to Clinical Considerations for
discussion of risk factors).
Grade: I Statement.
The USPSTF recommends against routine screening for gonorrhea infection in men and
women who are at low risk for infection (go to Clinical Considerations for discussion of risk
factors).
Grade: D Recommendation.
The USPSTF found insufficient evidence to recommend for or against routine screening for
gonorrhea infection in pregnant women who are not at increased risk for infection (go to
Clinical Considerations for discussion of risk factors).
Grade: I Statement.
The USPSTF strongly recommends prophylactic ocular topical medication for all newborns
against gonococcal ophthalmia neonatorum.
Grade: A Recommendation.

Front 160

Discuss the USPSTF recommendations for screening for syphillis

Back 160

The U.S. Preventive Services Task Force (USPSTF) strongly recommends that
clinicians screen persons at increased risk for syphilis infection.
Grade: A Recommendation.
The USPSTF strongly recommends that clinicians screen all pregnant women for syphilis
infection.
Grade: A Recommendation.
The USPSTF recommends against routine screening of asymptomatic persons who are not
at increased risk for syphilis infection.
Grade: D Recommendation.

Front 161

Discuss the collaborative role of family physicians and local health departments in
community control of sexually transmitted infections.

Back 161

Physicians should report STI’s to the local health department and consult with them on
questions of diagnosis and treatment. The LHD does epidemiology, provides advice on
diagnosis and treatment, may provide free treatment services, and conducts contact
tracing and notification if resources permit.

Front 162

Discuss challenges in assessing prevention strategies in the elderly.

Back 162

Goal is "Compression of Morbidity"
Prevention strategies affected by:
-Predicted life expectancy
-Other co-existent diseases
-Change in the prevalence of disease with age
-Risk of interventions (treatments) e.g. PSA
-Exclusion of older adults from studies on preventive screening and intervention,
especially those with multiple medications and co-morbidities

Front 163

List five leading causes of death in the older adult and discuss strategies for prevention.

Back 163

1. Heart disease-primary prevention: lipids, BP, smoking, ASA/antiplatelet therapy, beta
blockers, ACE-I)
2. Cancer – 55yo vs 85yo with asymptomatic cancer
a. Lung – smoking
b. Colon – cost/benefit of stool hemoccult, flexible sigmoidoscopy, risk of screening
colonoscopy older patient (when to stop)
c. Breast – best evidence 50-70, >75 not in studies. Women with poor functional status,
multiple co-morbidities, 20X more likely to die of something else
e. Prostate- 85 yo man, 50% microscopic prostate CA 3% die because of it, most die with it
f. Cervical – OK to stop at 70 if at least 3 normals in last decade
3. Stroke – systolic hypertension, atrial fibrillation (benefit/risk of various treatment), role of
diabetes and age, role of carotid disease and screening (not recommended), role of current
interventions
4. COPD – smoking cessation/avoidance
5. Pneumonia and influenza – vaccines!

Front 164

Identify and define the six components of a comprehensive assessment of older adults.

Back 164

1) Availability of family or other support systems in order to promote independence
2) Financial resources available to purchase care
3) Personal functional capabilities and disabilities
4) Nutritional status
5) Person’s preference for care in various situations (advanced directives)
6) Presence of polypharmacy including duplication of drug (generic/brand name) or class
(Aleve/Ibuprofen), appropriate monitoring of drug level, allergies, drug interactions, etc

Front 165

Differentiate between basic activities of daily living (BADLs), instrumental activities of daily
living (IADLs), and advanced activities of daily living (AADLs) and the role each plays in
overall function and quality of life.

Back 165

Functional assessment means what a person can or cannot do. The BADLs assess the basic
activities (bathing, dressing, transferring, continence, and feeding). The IADLs augment this
basic information with more complex tasks important for independent living in the community
such as the ability to use the telephone, clean house, drive safely, shop, prepare food, etc.
AADLs focus on high level function such as gainful employment, hobbies, socializing and community activities. These evaluations are necessary to complete in order to assess how
much independence can be tolerated or what additional plans need to be made to optimize
community living.

Front 166

List and discuss 10 common syndromes associated with older adults.

Back 166

-Dementia (discuss pros and cons of Apo E4 testing for Alzheimer's)
-Incontinence: consequences for skin, socialization, stigma as barrier to reporting, common
causes.
-Hearing/visual impairment: role in orientation and socialization, common causes and
treatments
-Osteoporosis (prevention, risk factors, indications for screening, medical and exercise
options for treatment)
-Impaired mobility/balance: multifactorial nature of falls, the impact of fractures on quality of
life, cost to society
-Sleep disorders: differing aspects of sleep in the elderly, validity of sleep hygiene, risk of
pharmacologic treatment, assessing amount of sleep per 24 hours
-Depression (suicide is one of the leading causes of death in the elderly)
-Poly-pharmacy
-Malnutrition: factors range form money to buy food to preparing it, being able to chew to the
biochemical aspects.
-Pressure ulcers: role of moisture, friction, pressure & impact including sepsis

Front 167

Identify four strategies that promote independence and optimal aging.

Back 167

-Good nutrition
-Exercise and fall prevention
-Attitude and social relationships (i.e. sexuality, pets, spouse, etc)
-Support of the Caregiver (see Caregiver Burden Assessment form )

Front 168

List and discuss how aging can uniquely affect older adults with disabilities

Back 168

-Aging demographics for persons with developmental disabilities (DD)
-Accelerated aging for some with disabilities (e.g., early dementia with Down Syndrome).
-Aging caregivers and implications for anticipatory guidance in future care planning

Front 169

Define the following terms pertaining to genomic tests: ---analytic validity
-clinical validity
-clinical utility

Back 169

-Analytic validity
-Clinical validity
-Clinical Utility

Front 170

Discuss the potential benefits and harms from genetic and genomic tests.

Back 170

--

Front 171

Describe how genetic tests might be used to personalize drug therapies and personalize
cancer therapy.

Back 171

--

Front 172

Describe current recommendations from EGAPP and the USPSTF, and the justifications for
each, regarding genetic tests for the prevention of:
a. Cardiovascular disease
b. Diabetes
c. Breast cancer
d. Hereditary nonpolyposis colorectal cancer
e. Hemochromatosis
f. Venous thromboembolism
g. Dementia

Back 172

--

Front 173

Name 1 cause of abdominal pain that you always forget

Back 173

Pneumonia (lower lobes)