0 Family Medicine: 13, 14, 15

Front 1

Upper airway cough syndrome AKA

Back 1

postnasal drip

Front 2

What is the most common cause of persistent cough and wheezing?

Back 2

Asthma

Front 3

What are co-morbidities?

Give examples for co-morbidities of asthma.

Back 3

Co-morbidities are conditions that may require treatment to improve the control of a particular condition

The following are co-morbidities of asthma:
GERD
Obesity or overweight
Obstructive sleep apnea
Rhinitis or sinusitis
Stress, depression

Front 4

What is a normal FEV1/FVC?

Back 4

8-19 yr old: 85%
20-39: 80%
40-59: 75%
60+: 70%

Front 5

Describe the classification of asthma severity based on prevalence of symptoms.

Back 5

Intermittent: <2 days/week, <2 night time awakenings per month, no interference with normal activity

Mild: >2 days/week but not daily; 3-4 PM awakaenings per month; minor limitation with normal activity

Moderate: Daily symptoms, 1x week PM symptoms, some limitation of normal activity, daily use of inhaler

Severe: Symptoms throughout day, 7x PM symptoms/week, extremely limited normal function

Front 6

How does acute sinusitis differ from chronic sinusitis in presentation?

Back 6

Acute: Fever, colored nasal drainage, HA, facial pain
Toothache, doesn't respond to decongestants, failure to improve after viral URI
Nasal congestion/obstruction
Initial improvement after viral URI and then re-occurrence of worsening symptoms

Chronic sinusitis:
Must have at least 2 of following >12 weeks:
Nasal obstruction/congestion
Mucopurulent drainage
Facial pain, pressure, fullness
Dec'd sense of smell

Front 7

What are the signs of viral rhinosinusitis?

Back 7

Nasal congestion and drainage

Mild generalized HA

Syx <10 days, NOT worsening

Front 8

Diagnose:
Patient responds to inhaled corticosteroids
Normal spirometry, normal CXR
Sputum eosinophilia

Back 8

Non-asthmatic eosinophilic bronchitis

Front 9

Interpret:
Decreased FEV1
Increased FVC

Back 9

Obstructive lung disease

Front 10

By what percent must FEV1 improve to indicate reversible obstructive lung disease?

Back 10

>12%; ASTHMA ASTHMA

Front 11

Interpret:
Decreased FEV1
Decreased FVC

Back 11

Restrictive lung disease

Front 12

Interpret:
Decreased FEV1/FVC ratio

Back 12

Obstructive lung disease

Front 13

Interpret:
Increased or normal FEV1/FVC ratio

Back 13

Restrictive lung disease

Front 14

When is chest x-ray indicated in a patient with persistent cough?

Back 14

to r/o suspected infection such as pneumonia

May find hyperinflated lungs on pt with asthma, but not a specific finding since COPD can also cause this

Front 15

Pharmaceutical management of asthma.

Back 15

1) Quick acting rescue medication: short-acting beta-2 agonist
2) Maintenance: add low dose inhaled corticosteroid, followed by low dose corticosteroid plus long-acting beta-2 agonist, followed by inc'd dose of these
If severe asthma: high dose steroid
3) Exacerbation:

Front 16

Why is theophylline difficult to use in asthma?

Back 16

May be used in conjunction with low-dose inhaled steroids, but not used that often due to difficulty in titrating theophylline dose to correct level

Front 17

How would you instruct a patient to use a metered dose inhaler?

Back 17

Shake inhaler
Breathe out fully
As you start breathing in slowly through mouth, press inhaler once. Breathe in slowly, as deeply as you can.
Hold your breath and count to 10
Wait 15-30 seconds between puffs for beta-2 agonists, no need to wait for other meds

Front 18

How would you instruct a patient to use a peak flow meter?

Back 18

Stand up
Take a deep breath, filling lungs completely
Place mouthpiece in mouth, close lips around it
Blow out hard and fast in a single blow

Repeat twice and note best score

Green zone = doing well; peak flow should be >80% personal best
Yellow zone = getting worse; peak flow 50-79% personal best
Red zone = medical alert! peak flow <0% personal best

Front 19

What vaccines are recommended for patients with asthma?

Back 19

Flu, pneumococcus

Front 20

Most deliveries occur within ___ weeks of the due date.

Back 20

2 weeks (before or after)

Front 21

What genetic syndromes should be discussed during an obstetric history?

Back 21

Thalassemia in Italian/Greek/Mediterranean/Asian descent
Sickle cell in AAs
Hemophilia
NT defect--meningomyelocele, spina bifida, anencephaly
Congenital heart defects
Down's synrome
Tay-Sachs
CF
MR
Metabolic disorders

Note: ALWAYS ASK ABOUT DOMESTIC VIOLENCE

Front 22

Most home urine pregnancy tests are positive at hCG concentrations of ____.

Back 22

25+
But FDA requirement is 50

Front 23

When to hCG levels peak? Decline?

Back 23

Peak at 10-12 weeks
Decline until 22 weeks, then rise til delivery

Front 24

Which ultrasound is most sensitive in detecting early pregnancy?

Back 24

Transvaginal; can often visualize gestational sac by 4-5 weeks, fetal pole by 5-6 weeks

Front 25

What infectious organisms should be tested for in prenatal visits?

Back 25

HIV
Rubella
Syphilis
HBS antigen
Gonorrhea, Chlamydia esp in HIGH RISK GROUPS (under 25, unmarried, black, hx STDs or multiple sex partners)
HCV if high risk (prison inmate contact, IVDU, HIV pos, tattoos, elevated LFTs)

Front 26

When should pregnant women that are non-immune to chicken pox be vaccinated?

Back 26

Postpartum

Front 27

What are the screening guidelines for bacterial vaginosis?

Back 27

Screen only if symptomatic or in women with risk factors for pre-term delivery

Front 28

When should ultrasound screening be performed? What is the purpose?

Back 28

Between 18-20 weeks' gestation;checks for structural anomalies
Note: Ultrasound can be useful for accurately determining gestational age early in pregnancy

Front 29

What should a daily prental vitamin contain?

Back 29

30 mg Iron
0.4 to 0.8 mg Folic Acid

Front 30

Why should soft cheese be avoided in pregnancy?

Back 30

Listeriosis

Front 31

What are the activity recommendations during pregnancy?

Back 31

Stay active, continue to work
Avoid prolonged standing
30 mins of moderate exercise on most days of week
Sex is fine throughout pregnancy

Front 32

What is the expected weight gain during pregnancy?

Back 32

If normal weight, 20-25 lbs
If overweight, 15-25 lbs

Front 33

What is the prenatal visit schedule?

Back 33

Every 4 weeks until 28 weeks
Every 2 weeks from 28-36 weeks
Every week from 36 weeks until delivery

Front 34

When does nausea resolve during pregnancy?
Recommendations?

Back 34

Usually starts at 4th-7th week, resolves by 20th week

Recommend eating small, frequent meals; try high carb, low fat foods. Salty foods better tolerated in morning, sourt/tart liquids like lemon-lime soda better tolerated than water

1 in 200 women will develop persistent vomiting--called hyperemesis gravidarum

Front 35

When should nuchal translucency be screened?

Back 35

10-14 weeks

Front 36

What vaccine is safe to give during pregnancy?

Back 36

Flu vaccine (I.M.)--it's a killed vaccine
Pregnant women are at inc'd risk for complications from influenza, so it's recommended to all pregnant women.

Front 37

What are the components of a triple or quad screen?
When are they performed?

Back 37

Triple:
AFP
hCG
Unconjugated estriol

Quad:
All of the above + inhibin A

Performed about 15-21 weeks gestation

Front 38

When should patients be screened for gestational diabetes?
How is it measured?

Back 38

Complete at 24-28 weeks

Measure serum glucose 1 hour after 50g glucose load
Normal fasting <126
One-hour glucose <140

If abnl, perform at three hours, and then re-do with 100 gm load

Abnl values:
Need 2 or more of:
Fasting glucose >95
1-hr >180
2-hour >155
3-hour >140

Front 39

What is the most common cause of life-threatening infection in newborns?

How is it prevented?
When should screening be performed?

Back 39

GBS

Premature infants have higher risk of GBS infection, but most cases occur in full term infants.

Half of cases occur during first week of life, most preventable by giving IV Abx to women in labor (PENICILLIN is first-line, ampicillin is acceptable alternative)

Screen at 35-37 weeks' gestation

Front 40

What is placent previa?

Classic symptoms?
Risk factors?

Back 40

Placenta attached low in uterus, poentially covering cervical os, leading to excessive bleeding at or prior to delivery, jeopardizing health of fetus

Should be suspected in any woman beyond 24 weeks' gestation who presents with painless vaginal bleeding

Risks:
Prior pregnancy, smoker, >35 years old, previous twins or higher multiple pregnancy, uterine surgery including prior C-section

More likely to resolve if occurs earlier in pregnancy, If does not resolve, deliver by C-section

Front 41

Bacterial vaginosis:
How is it caused?
How is it diagnosed?
Pathology finding?
Treatment

Back 41

Caused by shift in normal bacterial flora of vagina; a/w recent intercourse or use of douches or other artificial substances in vagina

Diagnosis: prepare vaginal wet mount; clue cells typically present (CLUE CELLS)

Tx: metronidazole 500 mg bid x 1 week

Front 42

How is vaginal candidiasis diagnosed?
Treatment?

Back 42

KOH Prep
Tx: Clotrimazole

Front 43

Why are quinolones contraindicated in pregnancy?

Back 43

Interferes with fetal bone growth plates

Front 44

When is premature rupture of membranes considered preterm?

Back 44

Prior to 37 weeks gestastion

Front 45

When is labor considered preterm?

Back 45

Prior to 36 weeks--leading cause of infant mortality in US

Front 46

When is Rhogam immunization administered? (Timeline)

Back 46

At 28 weeks
Within 72 hours after delivery
With any episodes of vaginal or intrauterine bleeding

Front 47

What is considered chronic hypertension postpartum?

Back 47

BP elevation persisting beyond 12 weeks postpartum

Front 48

What are the criteria for:
Gestational hypertension
Preeclampsia
Severe gestational hypertension

Back 48

Gestational HTN: Persistent BP over 140/90 without proteinuria at or after 20 weeks in previously non-HTN pt

Preeclampsia: Over 140/90 with proteinuria of 0.3g or greater in 24 hour urine specimen

Severe gestational HTN: BP over 160/110 for at least 6 hours, inc'd risk preterm delivery, small gestational age infants, placental abruption

Front 49

WHen is the risk of preeclampsia highest?

Back 49

When BP is elevated before 30 weeks gestation

Front 50

What is eclampsia?

Back 50

Occurrence of one or more convulsions in presence of preeclampsia without presence of another underlying neurologic disorder

Front 51

What are the red flags associated with elevated blood pressure during pregnancy?

Back 51

Sever HA
Change in vision
Unusual right or upper belly pain
Nausea
Vaginal bleeding
Contractions
Decreased Urination

Front 52

What are the most common skin eruptions in pregnancy?
How are they treated?

Back 52

Pruritic urticarial papules and plaques of pregnancy (PUPPP): papulovesicular lesions on trunk and extremities

Prurigo of pregnancy--excoriated areas on trunk or limbs

Pruritic folliculitis: centered around hair follicles; have pustular appearance

Tx is relief of syx: topical emollients, glucocorticoids; antihistamines

Must be distinguished from:
Cholestasis of pregnancy (generalized itching)
Pustular psoriasis
Pemphigoid gestationis

Front 53

What's the follow-up schedule for women postpartum (c-section vs vaginal)?

Back 53

C-section: 2 weeks to assess return to ADL and healing of surgical wound

Vaginal deliv: Six weeks

Women at risk for psotpartum depression should receive closer follow-up

Front 54

Postpartum blues vs Postpartum depression:
Criteria
Risk Factors

Back 54

Postpartum blues:
Mild, though often rapid, flucturations in mood within first two weeks postpartum; peak at about day 5
Resolve over time with support, reassurance, rest

Postpartum depression:
ONset of clinical depression (SIGECAPS) within first four weeks postpartum
Risk factors:
Stressful life events over preceding year
Unplanned pregnancy
Lack of spousal or partner support
Personal hx of mental disorders
Having infant w/congenital malformation

Front 55

How long should a woman wait before getting pregnant after delivery?

Back 55

6 months; any sooner and she'll risk pre-term delivery; if wanted to be super safe, wait 18-23 months to reduce risks for low birth weight, prematurity

Front 56

What form of contraception can be started immediately after delivery?

Back 56

Protestin-only pills, injectable progestin (Depo-Provera, progestin implants (Implanon)

Minimal effect on BP, coagulation, lipid levels
No inc'd risk stroke, MI, DVT
May have irregular bleeds first few months

Can also use IUD immediately, but has a slightly higher expulsion rate than insertion at 4-6 weeks post-partum

Front 57

When can women begin combined oral contraceptives postpartum? Why should they wait?

Back 57

Women may benefit from reduced coagulation-related risks (from estrogen) by waiting 4 or more weeks post-partum

Estrogen can also suppress milk production in early post-partum period

Front 58

How do the criteria for alcohol abuse differ from alcohol dependence?

Back 58

Abuse:
Maladaptive pattern of use with one or more of following:
Failure to fulfill work, school, social obligations
Recurrent substance use in physically hazardous situations
Recurrent legal problems
COntinued use despire problems

Dependence requires three or more of following:
TOlerance
WIthdrawal
Substance taken in larger quantity than intended
Persistent desire to cut down or control use
Significant time spent obtaining, using, or recovering from alcohol use
Social, occupational, or recreational tasks sacrificed

Front 59

What is the purpose of a CAGE questionnaire? What constitutes a positive test?

Back 59

CAGE screens for alcohol abuse and/or dependence

If answers yes to two or more questions, need more intensive evaluation.

Front 60

What is cholecystitis? How is it different from biliary colic?

Back 60

Stone that cannot dislodge from cystic duct

Symptoms similar to appendicitis

Pain lasts longer than 4-6 hours, may be a/w fever, elevated WBCs

In Biliary colic, syx last 4-6 hours or less, radiates to BACK UNDER RIGHT SHOULDER BLADE
Often a/w nausea or vomiting after a heavy, fatty meal
Result of stimulated gallbladder contracting, but gallstone obstructs outlet of cystic duct.

Front 61

Symptoms of duodenal ulcer.

Back 61

Epigastric pain (possibly R or LUQ) relieved by food and/or antacids

Front 62

Labs needed to evaluate patient with RUQ pain, heartburn, and vomiting in alcoholic.

Back 62

CBC
Electrolytes (assess possibile alterations due to vomiting)
LFTs (AST, ALT, alk phos, total bilirubin--these latter two are for biliary tract involvement)
Amylase/Lipase
UA (r/o renal involvement)
Abdominal u/s: evaluates liver, gallbladder, gallstones, dilation of biliary tree

Front 63

Biliary COlic:
Management
When is a HIDA scan indicated? ERCP?

Back 63

Surgical COnsult is symptomatic gall stones
Ursodiol if atypical syx with visible stones
HIDA scan if no stones visible on u/s
ERCP if jaundiced