Lmcc Ii

Front 1

What are some things to ask a pt about who presents w/ a laceration? What would you assess for on physical exam?

Back 1

HISTORY
- mechanism
- timing
- bleeding
- tetanus status
- hiv / diabetes RFs
- allergies to tape, latex, abx, local anesthetics

PHYSICAL EXAM
- careful exploration of tendons, vessels, muscle, and bone
- neurovascular and motor exam (sensation, motor, cap refill)

Front 2

A patient presents w/ a laceration. List some indications for a specialist referral (eg. plastic surgeon).

Back 2

- deep wounds to hands, feet
- full thickness lacerations: eyelid, lip, ear
- lacerations involving nerves, arteries, bones, and joints
- penetrating wounds of unknown depths
- severe crush injuries
- severely contaminated wounds
- concern for cosmetic outcome

Front 3

Discuss the different types of wound closure.

Back 3

primary (1°) closure (first intention)
- wound closure by direct skin approximation of edges within hours of wound creation (i.e. w/ sutures, staples, skin graft, etc.)
- indication: recent (<6hrs, longer w/ facial wounds), clean wounds
- contraindication: animal/human bites (except on face), crush injuries, injection, long time lapse since injury (>6h), retained foreign body

secondary (2°) closure / spontaneous healing (second intention)
- wound left open to heal spontaneously
- this is done when first intention is not possible or indicated

tertiary (3°) closure / delayed primary closure (third intention)
- intentionally interrupt healing process (eg. w/ packing), then wound is usually closed at 4-10d post-injury after granulation tissue has formed and there is a lower bacterial count
- indicated with wound contaminated w/ high bacterial count, long time lapse since initial injury, severe crush component w/ significant tissue devitalization.
- prolonging inflammatory phase decreases bacterial count and lessens chance of infection after closure

Front 4

What are some adverse outcomes of obstetrical lacerations?

Back 4

- chronic perineal pain
- dysparunia
- urinary incontinence
- fecal incontinence

Front 5

Discuss the 4 degrees of obstetrical lacerations after child birth.

Front 6

Discuss postpartum care of perineal lacerations.

Back 6

- sitz baths
- tylenol/advil
- stool softener (eg. colace)

Front 7

What are some relative contraindications to primary wound closure?

Back 7

- infected or inflamed wound
- human or animal bite
- serious crush wounds
- primary repair time constraints above not met

note: primary wound closure in these situations can lead to high infection risk

Front 8

note:

Back 8

Actively bleeding wounds require hemostasis before repair. Hemostasis is best achieved with direct pressure and elevation. Clamping bleeding vessels is generally avoided due to the risk of adjacent nerve damage. Topical anesthetic containing epinephrine may also contribute to hemostasis.

note: vascular injury is suggested by signs of:
- pallor
- dec. pulses,
- delayed cap refill

Front 9

List a few complications of lacerations requiring more than simple suturing.

Back 9

- bites to the hands or face
- neurovascular injury
- flexor tendon lacerations
- open fractures
- foreign bodies

Front 10

note:

Back 10

Given a deep or contaminated laceration, throughly clean with copious irrigation and debride when appropriate, before closing wound.

Irrigation is the most important means of decreasing the incidence of wound infection because soil or small foreign bodies that remain in the wound reduce the bacterial load required to cause infection. Irrigation may not be necessary for all low risk wounds, particularly those in well vascularized rise locations.

Debridement is important in the management of the contaminated wound. It removes permanently devitalized tissue which, is not removed, impairs the wound's ability to resist infection.

Front 11

List 3 types of wounds that should not be closed due to a high risk of infection.

Back 11

i. animal bites
ii. puncture wounds
iii. contaminated wounds

Front 12

List a few things to do for good cosmetic results when repairing a laceration.

Back 12

- minimize tissue trauma: following curve of needle, handle wound edges gently using forceps
- evert skin edges when closing
- avoid skin tension
- ensure equal width and depth on each side
- remove sutures within 7-10 days (5 if face)

Front 13

What are some RFs for multiple medical problems in patients?

Back 13

- older age
- female
- low socioeconomic status

Front 14

note

Back 14

In a patient with multiple medical complaints, one should consider underlying:
- depression
- anxiety
- abuse (examples physical, medication, or drug abuse)...

...as the cause of the symptoms, while continuing to search for other organic pathology.

Front 15

note

Back 15

2° depression is 2-3x more common in patients with chronic health condition.

Front 16

note

Back 16

In patients with multiple medical problems and recurrent visits for unchanging symptoms, lunch etc. limits for consultations when appropriate.

Front 17

Why is it a good idea to periodically readdress and reevaluate the management of patients with multiple medical problems?

Back 17

- simplify overall management
- limit polypharmacy
- minimize possible drug interactions
- update therapeutic choices (e.g., because of changing guidelines of the patient's situation)

Front 18

Which benzodiazepines are safest in the elderly (even though they should still be avoided).

Back 18

LOT

lorazepam
oxazepam
temazepam

Front 19

What is polypharmacy?

Back 19

It is the prescription and administration or use of many medications at the same time.

Front 20

Discuss the principles for prescribing medications in the elderly population.

Back 20

CARE

Caution/compliance
Age (adjust dosage for age)
Review regimen regularly
Educate

Front 21

What are some risk factors for noncompliance of medications in the elderly population?

Back 21

- number of medications (compliance w/ 1 med'n is 80% but drops to 25% w/ ≥6 medications
- dosing, frequency
- labelling, instructions, container design
- financial constraints (medication cost, coverage)
- cognitive impairment
- sensory deprivation
- previous side effects/adverse events with meds
- transportation

Front 22

How might adverse drug reactions in the elderly present as?

Back 22

- delirium
- falls
- fractures
- urinary incontinence/retention
- fecal incontinence/impaction

Front 23

How can one prevent polypharmacy?

Back 23

Consider:
- drugs: safter s/e profile, easier dosing schedules, convenient route
- patient: other meds, clinical indications, co-morbidities
- review drug list regularly
- avoid treating an adverse drug reaction w/ another medication's's's's's

Front 24

In medico-legal terms what is competence?

Back 24

In a person is competent, society grants them their legally guaranteed rights and freedom; usually, this is permanent.

Front 25

What is capacity?

Back 25

Capacity is a presumption of competence and mental ability to:
1. understand that information relative to a (treatment) decision.
2. appreciate the reasonable foreseeable consequences of a decision or lack of position = ability to make a decision

note:
- capacity is decision specific (eg. surgery versus chest x-ray)
- it's a change over time, Therefore there's a need to reassess capacity on an ongoing basis (eg. loc, delirium)
- a person is presumed capable unless there is good evidence to the contrary, i.e. a formal capacity assessment is not necessary.
- capacity is one component of valid consent.
- capable patients can refuse treatment even if it leads to serious harm or death; however, decisions that put patients at risk of serious harm or death require careful scrutiny.

Front 26

Discuss the aid to capacity evaluation.

Front 27

note

Back 27

If the MD feels the SDM is not acting in the patient's best interest, the MD can apply it to the 'consent and capacity board' for another SDM.

Front 28

What would you do in a situation where you needed to treat an incapable patient and nonemergent situation?

Back 28

obtain informed consent from SDM

Front 29

Discuss the legislated hierarchies for SDMs in Ontario.

Front 30

note

Back 30

And capacity decision may warrant further assessment:
- psychiatry
- courts
- legal review boards (eg. in ontario, the consent and capacity review board)

Front 31

What are some exceptions to consent?

Front 32

What are some basic requirements for valid consent?

Front 33

note

Back 33

- no age of consent in Canada; consent depends on patient’s decision-making ability (capacity)

- N.B. PEl, NB, QC, SK, BC have specific age of consent, but common law and case law deem underage legal

- minors are capable to make their own choices, adolescents usually treated as adults (mature minor)

- infants and children are assumed to lack mature decision-making capacity for consent but they should still be involved

- Consent does NOT have to be written (and written consent does not imply “informed”) and may be implied by patient’s action

Front 34

What is an advanced directive?

Back 34

- a living will
- these are written instructions that allow patients to exert control over their care once they are not capable

Front 35

What is a power of attorney (POA)?

Back 35

A legal document in which one person gives another authority to make personal care decisions (healthcare, nutrition, shelter, clothing, hygiene) on their behalf if they become mentally incapable.

Front 36

What is the diagnostic criteria of a personality disorder?

Front 37

Discuss the different cluster A personality disorders.

Front 38

Discuss the different cluster B personality disorders.

Front 39

Discuss the different cluster C personality disorders.

Front 40

note

Back 40

It is important to meeting limits in dealing with patients with identified personality disorders. This includes specifying appointment length, drug prescribing, and accessibility.

Front 41

How do you distinguish between obsessive-compulsive disorder and obsessive compulsive personality disorder?

Back 41

A key distinction between obsessive-compulsive disorder (OCD) and obsessive compulsive personality disorder (OCPD) is that in OCD the symptoms are ego-dystonic (the patient realizes that the obsessions are not reasonable) whereas in OCPD the symptoms are ego syntonic (consistent with the patient's way have thinking).

Front 42

What are some investigations to consider in a diagnosis of pneumonia?

Front 43

Discuss the use of immunizations to reduce the risk of developing pneumonia.

Back 43

i. vaccine for influenza a and b annually for everyone
ii. pneumococcal vaccine for all:
≥65 yrs of age
current smokers
concurrent disease (that predispose to invasive pneumococcal disease)
- asplenia
- sickle cell disease
- hepatic cirrhosis
- CRF
- hiv
- immunosuppression related to disease / therapy

Front 44

T/F. If a cxr is negative one can rule out pneumonia.

Back 44

False. cxr does not rule out pneumonia

Front 45

If you take sputum cultures for a pneumonia and it turns out to be TB or legionella, are you obligated to notify public health?

Back 45

Absolutely, notify public health for TB or legionella, which will probably start doing contact tracing.

Front 46

When should a f/u cxr be done for a pneumonia?

Back 46

@6wks; no point doing it earlier b/c even if treated w/ abx, cxr findings won't disappear till 6 wks later.

Front 47

Discuss the CURB 65 scoring system to stratify pneumonia pts as outpatients, hospitalized, or ICU.

Front 48

What is the treatment for community acquired pneumonia?

Front 49

A patient needs to be put on antibiotics for pneumonia. You decide to prescribe biaxin; however, after further inquiry the pt tell you that they've been on biaxin 2 months ago. Would it be okay to prescribe biaxin?

Back 49

No, if an antibiotic is used within 3 months, one should choose a different antibiotic

Front 50

What are some markers/cues for possible violent/aggressive behaviour by a patient?

Back 50

- direct threats
- pressured speech
- agitation, restlessness, and frequent movement: pacing, clenched fists, hitting
- threatening posture/gestures
- eye to eye confrontation
- invasion of personal space
- banging of tables or throwing chairs
- facial muscle tension
- towering gestures
- sudden changes in behaviour
- uneasy feeling (you)

Front 51

What is the ddx of an aggressive/violent patient?

Back 51

- psychosis: schizophrenia spectrum, delusion disorder, manic patients
- personality disorder: anti-social, borderline, paranoid
- organic: drug/alcohol intoxication/withdrawal, brain disease: trauma, infection, toxins, dementia, delirium

Front 52

T/F. In a violent or aggressive patient, one should ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient.

Back 52

True

Front 53

What are some safety measures one can take prior to assessing an aggressive/ violent patient?

Back 53

- speak in a calm manner
- show willingness to help, and empathize
- ask for security personnel to be present during the interview
- position self between door and patient; may leave door open
- lower your voice if the patient is loud
- avoid prolonged eye contact
- keep hands in front in a non-threatening manner and also ready to defend any blows
- avoid arguing with demanding or manipulative patients
- prepare physical/chemical restraints if necessary
- have a safety plan in place before assessing patient
- offer patient medication to help them calm down
- determine if the patient needs to be placed on a form 1

Front 54

What are the indications for restraints in an aggressive/violent patient?

Back 54

- imminent harm to others
- imminent harm to the patient
- significant disruption of treatment or environment
- continuation of ongoing treatment

Front 55

Discuss physical restraints in an aggressive/agitated/violent patient?

Front 56

Discuss the use of chemical restraints in an aggressive/violent patient.

Back 56

Chemical restraints can be used in combination with either the physical restraints for alone. Ideally, the medication should work rapidly, Have an effective route of administration, And have minimal side effects. There are 3 major classes of medications used for chemical restraints in the agitated patient:

1. benzodiazepines
- lorazepam
- midazolam

2. typical antipsychotics: haldol (haloperidol)

3. atypical antipsychotics: risperidone, olanzapine

Front 57

What is the workup for the agitated/aggressive/violent patient?

Back 57

- vitals, complete physical, mse
- blood glucose and pulse oximetry
- delirium workup (cbc, lytes, Cr, tsh, lfts, Ca, Mg, albumin, b12, ferritin, urine and blood drug screen +/- ct head)

Front 58

What is the difference between naltrexone and naloxone?

Back 58

NALTREXONE
- long half life
- used for opioid and EtOH dependence

NALOXONE
- short half life (v. fast acting)
- used for life-threatening CNS/respiratory depression in opioid overdose
- high affinity for opioid receptor
- induces opioid withdrawal symptoms

Front 59

How is cocaine taken up? How does it produce its effects? what are the effects?

Back 59

Taken up: inhalation or IV

Cocaine blocks the presynaptic uptake of dopamine (causing euphoria), norepinephrine and epinephrine (causing vasospasm and HTN)

COCAINE INTOXICATION:
- elation, euphoria, pressured speech, restlessness, sympathetic stimulation (tachycardia, sweating, dilated pupils)
- prolonged use may lead to paranoia and psychosis

COCAINE OVERDOSE:
- medical emergency: HTN, tachycardia, tonic-clonic seizures, dyspnea, ventricular arrythymias
TREATMENT is IV diazepam (benzo) to control seizures; propanolol or labetalol to manage HTN and arrythmias

COMPLICATIONS: include CV: arrythmias, MI, CVA, ruptured AAA; neurologic - seizures; psychiatric: psychosis, paranoia, delirium, suicidal ideation

Front 60

Describe the relative safety in overdose for SSRIs, SNRIs, TCAs, MAOIs and NDRIs?

Back 60

SSRI - relative safe in OD

SNRI - tachycardia and N/V in OD

TCA - TOXIC IN OD, 3X THERAPEUTIC DOSE IS LETHAL

MAOI - Toxic in OD, but wider margin of safety than TCA

NDRI (wellbutrin) - tremors and seizures seen in acute overdose (wellbutrin lowers seizure threshold)

Front 61

What are somatoform disorders?

Back 61

- physical signs and symptoms LACK a MEDICAL/ORGANIC basis in the presence of psychological factors that are judged to be important in the initiation, exacerbation, or maintenance of the disturbance.
- cause significant distress or impairment in functioning
- symptoms are produced unconsciously
- symptoms are NOT the result of malingering or fictitious disorder which are under conscious control

These include:
- Conversion disorder
- Somatization disorder
- Pain disorder
- Hypochondriasis
- Body dysmorphic disorder

Front 62

What is Somatization disorder?

Back 62

- recurring, multiple, clinically significant physical complaints which result in the patient seeking treatment or having impairing functioning

8 or more physical Sx that have no organic pathology including each of:
- 4 pain symptoms related to at least 4 different sites or functions
- 2 GI Sx, not including pain
- 1 sexual Sx, not including pain
- 1 pseudo-neurologic Sx, not including pain (eg. numbness, paresthesia)

- Onset before the age of 30; extends over a period of years
- complications: anxiety, depression, unnecessary medications/surgery

Front 63

What is conversion disorder?

Back 63

One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition.

Psychological factors are judged, in the clinician's belief, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience.

Front 64

What is Pain disorder?

Back 64

- pain is the primary Sx and is of sufficient severity to warrant medical attention
- usually no organic pathology but when it exists, reaction is excessive

- psychiatric disorders (mood, anxiety, substance) may precede, co-occur or result from pain disorder

Front 65

What is hypochondriasis?

Back 65

- preoccupation with fear of having, or the idea that one has, a serious disease based on a misinterpretation of one or more bodily signs or symptoms
- evidence does not support diagnosis of a physical disorder
- fear of having disease despite medical reassurance
- belief is not of delusional intensity (as in delusion disorder) as person acknowledges unrealistic interpretation
- duration for more than 6 months

Front 66

What is body dysmorphic disorder?

Back 66

Preoccupation with imagined defect in appearance or excess concern around slight anomaly usually related to face.

Front 67

note

Back 67

As part of the well child visit, it is important to discuss preventing and treating poisoning with parents (for children). This includes for example: childproofing, poison control center number.

Front 68

In intentional poisonings (overdose), it is important to think about multi-toxin ingestion. What are the universal antidotes one should use in an overdose situation?

Front 69

Which populations are at higher risk of thiamine deficiency?

Back 69

- alcoholics
- anorexics
- hyperemesis of pregnancy
- malnutrition states

Front 70

Discuss the approach to the overdose patient?

Front 71

Discuss the major toxidromes and examples of medications that may cause these.

Front 72

When assessing a patient with a potential poisoning, what do you do on physical exam?

Back 72

- ABCs
- loc/gcs
- vitals
- pupils
-----------------------------------------
also:
- skin (colour, needle/track marks)
- mucous membranes (for powder residue, bleeding)
- nasal septum (erosion)
- assess tongue (seizures --> tongue biting)
- cn exam
- signs of trauma
- odours

Front 73

note:

Back 73

When assessing a patient exposed (contact or injection) to a substance, clarify the consequences of the exposure (e.g. don't assume it is non-toxic, call poison control for specific antidotes and treatments). Follow the four principles to consider with all toxic ingestions:

i. resuscitation (ABCs)
ii. screening (toxidrome)
iii. decrease absorption of drug (ocular/dermal/GI decontamination) I
iv. increase elimination of drug (urine alkalinzation, multidose activated charcoal, hemodialysis)

Front 74

Discuss general management of an overdosed patient.

Back 74

Note:
When managing a patient with a poisoning, it is essential to assess the ABCs and manage them, while regularly reassessing their ABCs (do not focus on antidotes and decontamination while ignoring the effects of the poison on the patient)

Front 75

Discuss relevant investigations in a patient who is suspected for poisoning overdose.

Front 76

Management of specific toxin overdoses. See note

Front 77

note

Back 77

Somatization in a patient should only be diagnosed after an adequate workup is done to rule out any medical or psychiatric condition (eg. depression)

Front 78

note

Back 78

One should not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. One should periodically reassess the need to extend/repeat the workup in these patients.

Front 79

Discuss the general management of somatoform disorders.

Back 79

i. brief frequent visits
ii. limit no. of physicians involved in care
iii. focus on psychosocial NOT physical symptoms
iv. minimize medical investigations; co-ordinate necessary investigations
v. bio-feedback
vi. psychotherapy
vii. minimize psychotropic drugs

Front 80

note

Back 80

In patients who somatize, inquiry about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (e.g. with biofeedback, acupuncture, or naturopathy)

Front 81

What is biofeedback?

Back 81

Biofeedback is the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will. Some of the processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception.

Biofeedback may be used to improve health, performance, and the physiological changes which often occur in conjunction with changes to thoughts, emotions, and behaviour. Eventually, these changes may be maintained without the use of extra equipment, even though no equipment is necessarily required to practice biofeedback.

Biofeedback has been found to be effective for the treatment of headaches and migraines.

Front 82

What are the 6 stages of change (eg. for quitting smoking)>

Back 82

i. pre-contemplation
ii. contemplation
iii. preparation
iv. action
v. maintenance
vi. relapse

Front 83

What are some long term consequences of smoking?

Back 83

- cad
- copd
- cancers: h+n, lung, liver, stomach, colorectal, bladder,
- pud
- dm
- osteoporosis
- infertility
- pregnancy: lower birth weight, inc. risk of preterm labour
- cost ++

Front 84

What are some adverse effects of nicotine withdrawal?

Back 84

- irritability, restlessness
- anger
- difficulty concentrating
- insomnia
- anxiety, depressed mood,
- wt gain
- relapse

Front 85

What are the 5As to ask a pt who is willing to quit smoking?

Back 85

Ask if pt smokes
Advise pt to quit
Assess willingness to quit
Assist in quit attempt
Arrange f/u

note: it is important to regularly assess in quitting or reducing smoking

Front 86

note

Back 86

When a pt presents with a crisis situation, one should discuss the use of:
- crisis line
- counselor
- encourage pt to use personal supports (family, friends)
- coping strategies (inquire about drugs, alcohol, gambling, violence)
- review of psych hx and medical hx relevant to past crisis
- d/ followup plan

note: it is essential to assess suicidality in pts facing a crisis situation

Front 87

What are some RFs for homicide?

Back 87

- hx of aggressive behaviour to self / others
- hx of criminal behaviour
- hx of experiencing childhood abuse, witnessing domestic violence
- neurological impairment, low iq
- hostility
- substance abuse or dependance
- perceptions of threat
- low SES

note: a lot of these are RFs for suicide as well

Front 88

Discuss the 5 principles of crisis management.

Front 89

What are some critical incidents that may precipitate a crisis?

Front 90

note:

Back 90

Benzodiazepines are not recommended as monotherapy for pts with ptsd because discontinuation has been associated with profound exacerbation of symptoms.

Front 91

What are some medications that can be used in a crisis situation?

Back 91

- short term benzos (caution in pts w/ alcohol/substance abuse)
- sleep medication (if affected) such as trazodone or melatonin
- short term atypical antipsychotic such as seroquel, risperidone (if psychotic features)

Front 92

T/F. Benzodiazepines should be used judiciously in practice.

Back 92

True

Benzos have a high addictive potential. One must use with extreme caution in pts who have a hx of alcohol/substance abuse

Front 93

What are the 3 side effects to watch out for with trazodone?

Back 93

- sedation
- orthostatic hypotension
- prispism (1 in 6000)

Front 94

note

Back 94

It is legally required to report sexual assault if victim if <16 years of age to the Children's Aid Society (CAS)

Front 95

What is domestic violence? How might it present itself in the clinic setting?

Front 96

What are some potential barriers a patient might face in disclosing abuse from their partner?

Back 96

- limited time allotted during visits
- lack of privacy in certain settings (i.e. triage, ER)
- partner may accompany pt to appointments and answer questions or stay during physical exam
- shame

Front 97

A 29 year old lady comes in to your office. She mentions to you that she is the victim of a domestic violence. After talking to her, you decide to discuss a safety plan with the patient. What do you discuss?

Back 97

MANAGEMENT

Safety plan:
- having an exit strategy in place
- having essential ready to go: money, clothes, keys, medication, important documents, and emergency items
- having a safe place to go/stay
- having a shelter or helpline number with legal advocacy and counselling services
- involving social workers or domestic violence advocates

- reassure pt that he/she is not to blame and that the assault is a crime.
- discuss appointment for followup to re-assess situation.

note: Reporting suspected or known child abuse is mandatory. On the other hand, spousal abuse is a criminal act, but not reportable without the woman's/man's permission

note: marital counselling is inappropriate until safety is established and violences is under control

note: it is important to document all evidence of abuse related visits for medico-legal pruposes

Front 98

What are the effects of domestic violence on children?

Back 98

- Learned behaviour (abuser and victim)

- females = distrust of males, negative attitudes toward marriage, accept abuse as natural

- males = some intervene to prevent abuse; others might identify with batterer, adopt same beliefs about women, sex roles and use of control tactics

- may develop symptoms of PTSD (bedwetting, nightmares, somatic symptoms)

- depression, low self-esteem, mistrust

- may be abused themselves, suffer neglect, or be overly disciplined as protective mechanism

- some will become next generation of abusers

Front 99

Discuss the cycle of domestic violence.

Front 100

What is the Canadian Immigration Medical Examination (IME) and what does it comprise of?

Back 100

The IME is an exam that must be done in all children and adults seeking permanent residence in Canada. This exam must be done within 12 months preceding arrival in Canada for new immigrants and those seeking refugee status from abroad. Refugee claimants must undergo an IME within 60 days of claiming refugee status of the border.

The IME is designed to assess a limited number of public-health risks, not to provide preventative screening. Is is comprised of:

- a complete physical exam with vision and hearing screen
- cxr (age≥11)
- syphilis serology (age≥15)
- urinalysis: protein, glucose, blood; if positive, then microscopy
- hiv testing (age≥15 as well as children who have receive blood or blood products, or have a known hiv mother)

---------------------------------------------------------------
note: The IME does not include a review of immunization status, routine TB testing, or hep b/c serology.

note: after the IME, pts should be screened for infectious diseases, chronic and non-communicable diseases, women's health, and mental health

Front 101

Discuss some of the screening recommendations for immigrants and refugees.

Front 102

A refugee couple comes to your office. You're asking the lady some questions, but she's not answering. What might be the reasons for this?

Back 102

- cultural reasons (only men talk in their culture to another man)
- language barrier

Front 103

note

Back 103

As part of the periodic health assessment of newly arrived immigrants, one should assess the vaccination status as it may not be up-to-date and provide the necessary vaccinations to update their status.

Front 104

What might be some of the barriers when having an interaction with a refugee/immigrant pt with the help of an interpreter?

Back 104

- different agendas
- lack of medical knowledge
- something to hide

Front 105

When dealing with a 'difficult patient', how might this impact the physician-patient relationship?

Back 105

- may elicit strong feeling in the physician
- lead to problematic physician-patient relationship
- complicate diagnosing and managing medical and psychiatric disorders
- patient may feel rushed or ignored if not given enough time

Front 106

Discuss management of dealing with a 'difficult patient'

Front 107

note

Back 107

The following characteristics are more likely to be associated with 'difficult' patients:
- depression
- generalized anxiety
- panic disorder
- alcohol/substance abuse or dependance
- somatoform disorder

Front 108

What should you do if you are concerned that you may be at risk for boundary crossing?

Front 109

Discuss two situations that may result in a decision to end a physician patient relationship.

Discuss when it is inappropriate for a physician to end a physician-patient relationship.

Front 110

Discuss the steps for ending a physician-patient relationship

Front 111

A child presents with a parent for "behavioural problem". What is your DDx?

Back 111

medical conditions
- hearing impairment

psychiatric conditions:
- adhd
- learning disorder
- autism spectrum disorder
- global developmental delay
- conduct disorder
- depression
- anxiety
- bipolar
- schizophrenia
- dementia (elderly)

psychosocial factors:
- family chaos
- abuse
- substance use
- bullying/lack of friends
- parental expectations unrealistic

Front 112

When obtaining a hx pertaining to behaviour problems in general, what are some things to ask about?

What is the management of general behavioural problems?

Back 112

- in infants/children: eating and sleeping patterns, potty training
- older children and adolescents: activity level, aggression, disobedience
- gradual onset vs more rapid
- chronology of child's activities during typical day
- parent's expectations of child's behaviour (may be unrealistic for child's age
- ask child about their perception of the situation.

note:
Important to get co-lateral information from:
- daycare
- school
-----------------------------------------------------------------
• Early intervention is important as problem behaviours are more difficult to treat the longer they persist
• Reassure that child is physically well
• Parental education, spending time with child doing pleasurable activities
- Consistent rules and limits
- Positive reinforcement for appropriate behaviour
- Minimize anger and increase positive interactions with the child
- Time out procedures starting at age 2

Follow-up/Referral
- Reassess behavioural problem if it does not resolve in 3-4 months
- Consider referral for psychiatric evaluation

Front 113

What are breath-holding spells?


[behavioural problems]

Front 114

Discuss the management of eating problems in a child.


[behavioural problems]

Front 115

Discuss toileting problems in children.


[behavioural problems]

Front 116

Discuss the management of temper tantrums in a child.


[behavioural problems]

Front 117

What is ADHD (attention deficit hyperactivity disorder)?


[behavioural problems]

Front 118

What is the treatment of a child with adhd?


[behavioural problems]

Back 118

NON-PHARMACOLOGICAL
- individual/family therapy
- parent management
- social skills training
- positive reinforcement
- anger control strategies
- specialized education

PHARMACOLOGICAL
- Stimulants
* Methylphenidate - Ritalin (shorter acting), Concerta (long acting)
* mixed amphetamine salts - Adderall
* also SNRI - Strattera (?non stimulant med)
- For comorbid conditions can give antidepressants, antipsychotics


NOTE: stimulants can suppress appetite; if you don't eat enough it can affect growth
Also, stimulants can cause TICs, decrease sleep

Front 119

ADHD is often associated with other co-morbid conditions. List these.


[behavioural problems]

Back 119

- learning disability
- language disorder
- tic disorder
- ODD / ASPD
- enuresis
- encopresis
- substance abuse
- anxiety / depression

Front 120

What are some RFs for adhd?


[behavioural problems]

Back 120

- bw<1000g
- head trauma
- lead exposure
- prenatal exposure to alcohol, tabacco, cocaine

Front 121

For adhd, the use of psychostimulant meds is superior to behavioral interventions or community care in treating adhd symptoms. List some non-pharmacological strategties that may be helpful.



[behavioural problems]

Back 121

- structure and routines
- anger control strategies
- positive reinforcement
- social skills training
- individual/family counseling
- tutors/classroom special ed.
- extracurricular activities

Front 122

What is a useful tool for assessing ADHD (children)?



[behavioural problems]

Back 122

SNAP-IV

For example: if a mother comes in with her child, saying that her son's teacher was requesting ADHD testing, you would give one copy of the SNAP IV to her and one copy to give to the teacher. Have them fill it out, and f/u with the patient. Based on the results, you can refer the patient to a pediatrician.

Front 123

T/F. ADHD is more prevalent in males?



[behavioural problems]

Back 123

True. M:F is 4:1, although girls may be under-diagnosed

Girls tend to have inattentive/distractible symptoms; boys have impulsive/hyperactive Sx

Front 124

T/F. Use of psychostimulant meds is superior to behavioural interventions or community care in treating ADHD Symptoms. Combined Meds + behaviour treatment is not more efficacious than medications alone.


[behavioural problems]

Back 124

True

Front 125

What are learning disorders?



[behavioural problems]

Front 126

What is the difference between Rett's disorder vs. childhood disintegrative disorder (CDD)?



[behavioural problems]

Front 127

What is the management of autism spectrum disorder?



[behavioural problems]

Back 127

multidisciplinary approach:
- behaviour analysis
- speech and language therapy (signing, pictures, and speech)
- pt and ot to help with deficits
- possibly try ssri to improve ritualistic behaviours, antipsychotics and mood stabilizers for self-injurious behaviour

Front 128

What is conduct disorder?



[behavioural problems]

Back 128

≥3 in past 12 months and ≥1 in past 6 months

[pneumonic 'TRAP']
i. theft (breaking and entering, deceiving, non-confrontational stealing)
ii. rule breaking (running away, skipping school, out late)
iii. aggression (ppl, animals, weapons, forced sex)
iv. property destruction
- disturbance causes clinically significant impairment in social, academic or occupational functioning

Front 129

T/F. conduct disorder is worse than oppositional defiant disorder.



[behavioural problems]

Back 129

True

50% of conduct disorder (CD) children become adult anti-social personality disorder (ASPD)

Front 130

What are some management strategies for conduct disorder?



[behavioural problems]

Back 130

- medications not v. helpful (used for comorbid disorders)

- individual / family counseling
- cbt
- social skills training
- anger replacement training
- parent management training

Front 131

What is oppositional defiant disorder (ODD)?



[behavioural problems]

Back 131

Pattern of negativistic/hostile and defiant behaviour for ≥ 6 months with ≥ 4 of:
i. annoying
ii. resentful
iii. easily annoyed
iv. blames others
v. rule breaker
vi. argues w/ adults
vii. temper
viii. spiteful or vindictive

[pneumonic: ODD kids 'ARE BRATS']

- behaviour causes significant impairment in social, academic or occupational functioning
- behaviour does not occur exclusively during the course of a psychotic or mood disorder
- criteria not met for conduct disorder (CD); if 18 or older, criteria not met for ADPD

- may progress to CD

Front 132

T/F. when assessing a child with behavioral problems, it is important to screen not only the child and the parent(s), but with consent and when appropriate, other parties aware of the child's functioning (e.g. daycare, school, coach)

Back 132

True

Front 133

What are considered 'disruptive behavioral disorders'

Back 133

- ODD
- CD
- ADHD

often co-exist together

Front 134

note

Front 135

For patients with chronic disease, they're often on numerous medications. This can lead to non-compliance. What are some strategies one can use to improve compliance?

Back 135

- better communication between doc to patient (write instructions on paper)
- reminders for medication refill
- using dosettes, blister pack
- med review (remove unnecessary meds, switch to alternatives for meds with a high s/e profile)
- direct observation of treatment (DOTS) by health worker or family members

Front 136

note:

Back 136

In pts w/ chronic disease, it is important to actively inquire about:
- functional impairment
- how affecting pt mentally
- depression, anxiety, suicide risk
- substance abuse

Front 137

What is the definition of a learning disability?

Back 137

A learning disability is “characterized by academic functioning that is substantially below that expected given the person’s chronological age, measured intelligence, and age-appropriate education. Specific learning disorders listed in DSM-IV TR are Reading Disorder, Mathematics Disorder, Disorder of Written Expression, Learning Disorder Not Otherwise Specified.These subtypes have been consolidated under the term Specific Learning Disorder in the new DSM V, with specifiers depending on the area of weakness. They are a distinct entity from intellectual developmental delay or mental retardation. It is estimated that 5-10% of children are affected by a learning disability of some sort.

Front 138

For a child who presents with a learning disorder, what would you check for on physical exam?

Back 138

- vitals
- neurological, cn exam
- general appearance (dysmorphisms)
- ht, wt, hc
- hearing inquiry
- visual testing
- thyroid
- mse

Front 139

Discuss the different specialties involved in a multidisciplinary team for assisting a child with learning disorder(s).

Back 139

- family physician
- parents
- school psychologist
- school teacher
- special educator
- school nurse
- school administrator
- school counsellor
- school social worker
- speech and language pathologist

Front 140

Discuss the stages of change.

Back 140

note: change suggestion should fit within the pt's life. If they cannot afford the change, they will not do it, and you will have made them less comfortable to speak to you

note: before making recommendations about lifestyle modification, explore a pt's readiness to change, as it may alter advice

Front 141

Discuss the steps of motivational interviewing to facilitate counseling in the primary care setting

Front 142

Discuss the 5As interviewing technique.

Front 143

For counseling:

List 3 approaches changing high risk pt behavior, optimizing medical conditions; NOT psychotherapy

List 1 approach to supportive counseling

List 1 approach to psychotherapy - cbt

Back 143

high risk behaviours and optimizing medical conditions
i. 5As (for health risk behaviors eg. smoking, ++ alcohol)
ii. stages of change (for health risk behaviors eg. smoking, ++ alcohol)
iii. motivational interviewing (for health risk behaviors eg. smoking, ++ alcohol and optimizing medical conditions - htn, lipids, dm)

supportive counseling
i. BATHE technique

psychotherapy
i. cbt

Front 144

Discuss the BATHE technique of supportive counseling.

Front 145

For patients who've had previous prostate cancer, what is one test you want to do on a regular basis in the office (bw test)

Back 145

psa total (NOT psa free)

Front 146

What are paraphilias?

Back 146

Sexual arousal, fantasies, sexual urges, or behaviors involving
- non-human objects
- suffering or humiliation of oneself or one's partner
- children
- non-consenting person

Front 147

What is childhood disintegrative disorder (CDD)?

Back 147

- one of the 5 pervasive developmental disorders
- similar to autism, but there must be a period of at least 2 years (and upto 10 years) of normal development
- rule out degenerative brain disease, schizophrenia

Front 148

What is Rett's disorder?

Back 148

- one of the 5 pervasive developmental disorders
- X-linked dominant disorder, therefore predominantly in girls
- restriction of brain growth beginning in 1st yr of life
- normal development between 6 months and 4 years, then regression (loss of purposeful hand movements, mental retardation, seizures, neurological, respiratory and motor deficits)

Front 149

What is PDD NOS?

Back 149

Pervasive developmental disorder not otherwise specified

- marked deficits in the other PDD areas, but does not meet full criteria for another PDD

Front 150

Which psych conditions are antipsychotics used for ?

Back 150

- schizophrenia
- other psych disorders
- mood disorders with or without psychosis
- violent behaviour
- autism
- Tourette's
- somatoform disorders
- dementia
- OCD

Front 151

Describe some of the main extrapyramidal symptoms. (typically occur with typical antipsychotics such as haliperidol (haldol).

What is the management of the different presentations of EPS?

Front 152

What are the advantages and disadvantages of Typical vs Atypical Antipsychotics?

Back 152

TYPICAL ANTIPSYCHOTICS

Advantages
- inexpensive
- plenty of injectable forms available (both short/long acting)
- relatively minor metabolic S/E

Disadvantages
- EPS symptoms
- not mood stabilizing
- poorly tolerated in the short term
- prolongs QT interval
-------------------------------------------------------

ATYPICAL ANTIPSYCHOTICS

Advantages
- mood stabilizing
- better tolerated in the short/long term
- lower risk of EPS

Disadvantages
- expensive
- few injectable forms available
- metabolic S/E - including diabetes, lipid dysregulation, and severe wt gain
- exacerbation of (or new-onset) obsessive behavior (at high doses)
--------------------------------------------------------

NOTE: efficacy, speed of response, and stability of remission between atypicals and typicals is similar

Front 153

List some anti-Parkinsonian agents (anticholinergic agents in the context of extrapyramidal symptoms (eps))

Back 153

i. Benztropine (Cogentin)
ii. Amantadine (Symmetrel)
iii. Diphenhydramine (Benadryl)

These meds should only be given if there's a high risk of developing EPS of it EPS develops acutely. They SHOULD NOT be given for tardive syndromes because they worsen the condition (eg. tardive dyskinesia)

Front 154

In all patients presenting w/ mood or psychotic disturbances, it is important to rule out two things. What are these?

Back 154

- if Sx are due to a medical condition
- if Sx are due to any substances

Front 155

How would you manage an acutely agitated and psychotic patient +/- manic?

Back 155

- ensure safety of self and others, as well as pt
- have an exit strategy in place
- decrease stimulation
- assume a non-threatening stance
- IM medications (benzo + antipsychotic) often needed as pt may refuse oral meds
- physical restraints may be necessary
- DO NOT use antidepressants or stimulants

Front 156

What is the DDx of psychosis?

Back 156

GASPP

- general medical condition (GMC)
- affective d/o
- substance induced
- psychotic d/o
- personality d/o

Front 157

What is the diagnostic criteria for schizophrenia?

Front 158

Describe ECT? What are the indications? Are there any contraindications?

Back 158

Induction of a grand mal seizure using an electrical pulse through the brain while the patient is under general anesthesia and a muscle relaxant

INDICATIONS
- depression refractory to adequate pharmacological trial
- high suicidal risk
- previous good response to ECT
- elderly
- psychotic depression
- catatonic features
- marked vegetative features
- acute schizophrenia
- mania unresponsive to meds

CONTRAINDICATION: increased ICP

Front 159

Are there any side effects from ECT? What are they if any?

Back 159

Yes there are.

- risk of anesthesia related complications
- memory loss (may be retrograde and/or anterograde, tends to resolve by 6-9 months,
- H/As
- myalgias

Front 160

What are the indications for a form 1?

Back 160

FORM 1: Application by physician to hospitalize a patient for psychiatric assessment against his/her will to a schedule 1 facility. (Form 42 given to patient).

- Filled by Any MD
- Filled within 7d of examination
- Expires in 72 hrs after hospitalization. It is void if not implemented within 7d
- Patient does NOT have a right to review board hearing
- From form 1, patient can be put on a form 3 or voluntary admission (form 5) or send home +/- follow up

Front 161

What is the management of schizophrenia?

Back 161

MANAGEMENT

Medications:
- antipsychotics +/- anxiolytics (benzos) +/- anticonvulsants
- management of s/e

Psychosocial
- psychotherapy (individual, family, group): supportive, cbt
- assertive community treatment (ACT)
- social skills training, employment programs, disability benefits
- housing (group home, boarding home, transitional home)

Front 162

What are good prognostic factors for individuals with schizophrenia?

Back 162

- acute onset
- precipitating factors
- good cognitive functioning
- good premorbid functioning
- no family history
- presents of affective symptoms
- absence of structural brain abnormalities
- good response to drugs
- good support system

Front 163

What is the difference between schizophreniform disorder, brief psychotic disorder, and schizoaffective disorder?

Front 164

What is delusional disorder? What is a shared psychotic disorder (Folie a deux)?

Front 165

Discuss prognosis for schizophrenia?

Back 165

In schizophrenia,
1/3 improve
1/3 stay the same
1/3 worsen

- early in illness: negative symptoms are more prominent
- later in illness: positive symptoms appear and typically diminish with treatment; negative symptoms may become more prominent/disabling.

Front 166

Discuss the different subtypes of schizophrenia?

Back 166

note: subtypes are no longer included in the dsm V

Front 167

What is the best antipsychotic for treatment resistant schizophrenia?

Back 167

clozapine

cons:
- regular bw check for agranulocytosis (wkly x 1 mo; then biweekly)
- must do cardiac workup (? prolongs QT interval)

Front 168

What is the suicide risk for pts w/ schizophrenia?

Back 168

10%

Front 169

note

Back 169

Antipsychotics have a small risk of metabolic syndrome, therefore before starting patients on these medications it is important to check the following:
- cbc, lytes, Cr, bun
- lipids
- glucose

Front 170

note

Back 170

Patients w/ schizophrenia co-morbid substance abuse problems, Therefore it is essential to ask these patients if they're using any substances.

Front 171

note

Back 171

In schizophrenia, mean onset of age is
- males: 21
- females: 27

M=F (no. of schizophrenia)
prevalence 1% of population

Front 172

Which thyroid autoantibodies are increased in Hashimoto's disease? in Grave's disease?

Back 172

Hashimoto's disease
- Anti-thyroid peroxidase (90-95%)
- anti-thyroglobulin antibodies (20-50%)
- TSH receptor inhibiting antibodies

Front 173

What are some of the methods for thyroid assessment?

Back 173

- serum thyroid hormones (TSH, T3, T4)
- antibodies
- thyroglobulin
- thyroid imaging/scans (u/s, RAIU)
- biopsy (FNA)

Front 174

Just read. Distinguish between the different thyroid diagnostic tests and how they apply to hyper/hypothyroidism.

Front 175

What are the signs and symptoms of hyperthyroidism?

Back 175

THYROIDISM

Tremor
Heart rate up
Yawning
Restlessness
Oligomenorrhea/amenorrhea
Intolerance to heat
Diarrhea
Irritability
Sweating
Muscle wasting/weight loss

Front 176

What are the treatment options for thyrotoxicosis?

Back 176

i. Anti-thyroid drugs: Thionamides --> Propothiouracil (PTU) or methimazole (MMI) for Grave's disease
ii. B-blockers
iii. radioactive iodine thyroid ablation for Grave's
iv. surgery

NOTE:
- MMI is preferred over PTU due to longer duration of action, rapid efficacy, and lower s/e incidence
- MMI is contraindicated in pregnancy

Front 177

What is subacute thyroiditis?

Back 177

Acute inflammatory disorder of the thyroid gland characterized by an initial thyrotoxic state followed by hypothyroidism, eventually followed by euthyroidism in most cases. There are 2 subtypes: painful and painless.

note: subacute thryoiditis is presume to be the result of a viral infection

Front 178

What are the different classes of thyroid medications?

Front 179

For thyroid nodules:

What is the definition, etiology, and investigations

Front 180

T/F. When prescribing synthroid for hypothyroidism, one should be cautious about higher doses if the patient has multiple cardiac co-morbidities.

Back 180

True. For example a patient with a hx of MI or multiple bipass surgery, should be started on Synthroid 50mcg od as opposed to a normally healthy patient who can be started on Synthroid 75-100mcg.

You want to avoid excess of thyroid hormone in patients with heart disease as you run the risk of hyperthyroidism.

Front 181

A patient comes in for synthroid refill. You as usual give him/her a bw requisition for tsh. When should this patient do the bw?

Back 181

in 6wks

Front 182

A hypothyroid pt is symptomatic at TSH level of 8.2. She is not on any medication. What would you prescribe? Would you do any bw in the near future to check her levels?

Back 182

Prescription:
Synthroid
Take 75mcg po od M: 3 months

bw_tsh in 6 weeks
NOTE: it take 6 wks for tsh levels to adjust to thyroid med - synthroid

Front 183

What instructions would you give to a patient re: taking thyroid medication (eg. synthroid)?

Back 183

- take on an empty stomach
- do not take any Ca or multivitamin supplements at the same time

The above two can affect absorption of the medication




[eg. one pt who was taking this medication with food developed carpal tunnels syndrome; possibly due to edema from hypothyroid states caused by poor absorption of the medication]

Front 184

For thyroid bw, when would you order a T4?

Back 184

- a T4 should be ordered if the pt is not having typical Sx of hypothyroidism and the tsh is high than normal. The T4 may be within the normal range which means the pt is not hypothyroid (this may be referred to as subclinical hypothyroidism (normal t4, elevated tsh)

- a T4 should be ordered if the tsh is lower than normal indicating hyperthyroidism

- a T4 should be ordered whenever whenever the tsh does not correlate with the pt's clinical status.

Front 185

Usually when the tsh is low, the t4 is high. Also, when the tsh is high, the t4 typically is low. When would both be high and when would both be low?

Back 185

high tsh, high t4
secondary hyperthyroidism
- tsh-producing pituitary adenoma

low tsh, low t4
secondary hypothyroidism
- pituitary lesion causing tsh deficiency
- hypothalamic lesion causing trh deficiency

Front 186

List the different etiologies of thyrotoxicosis and hypothyroidism.

Back 186

THYROTOXICOSIS:
- Grave's disease
- toxic nodular goitre
- toxic nodule
- thyroiditis

Front 187

Apart from the symptoms of hyperthyroidism, which 3 other symptoms tend to occur specifically in Grave's disease?

Back 187

i. grave's ophthalmopathy
ii. goitre
iii. pretibial myxedema

------------------------------------------------------------------------
note: pretibial myxedema is a waxy, discolorati induration of the skin on the anterior aspect of the lower legs, spreading to the dorsum of the feet, or as a non-localised, non-pitting edema of the skin in the same areas. In advanced cases, this may extend to the upper trunk (torso), upper extremities, face, neck, back, chest and ears.

Front 188

What are the signs and symptoms of hypothyroidism?

Back 188

Main Symptoms:
- cold intolerance
- constipation
- weight gain
- fatigue
- dry skin, coarse hair
- paresthesias
--------------------------------------------------------
HIS FIRM CAP

Hypoventilation
Intolerance to cold
Slow HR

Fatigue
Impotence
Renal impairment
menorrhagia/amenorrhea

constipation
anemia
paresthesias

Front 189

Which thyroid conditions are associated with increased RAIU and which conditions are associated with decreased RAIU?


[iodine]

Back 189

INCREASED RAIU
- Grave's
- toxic adenoma
- multinodular goitre

DECREASED RAIU
- subacute thyroiditis
- recent iodine load
- exogenous thyroid hormone

Front 190

What factors are associated w/ an increased prevalence of thyroid nodules?

Back 190

- radiation to head and neck
- family hx of thyroid nodules
- iodine deficiency

Front 191

List some benign thyroid nodules?
List some malignant thyroid nodules?

Back 191

BENIGN:
i. follicular adenoma (adenoma is a benign tumor of glandular origin)
ii. thyroid cyst
iii. hashimoto's thyroiditis
iv. multinodular goiter

MALIGNANT
i. follicular nodule
ii. papillary nodule
iii. lymphoma
iv. metastatic nodule

Front 192

What is the only thyroid function blood test required in the initial evaluation of a thyroid nodule?

Back 192

TSH

Front 193

Illustrate the thyroid hormone pathway.

Front 194

What are some RFs for thyroid disease?

Back 194

- hx of neck irradiation
- women age>50 or post-menopausal
- goitre
- personal or family hx of thyroid disease
- hx of autoimmune disease (type I diabetes)
- atrial fibrillation
- lipid disorders
- drug therapy: lithium, amiodarone
- period of 6 months post-partum

Front 195

Discuss thyroid disease in pregnancy.

Back 195

PRE-PREGNANCY (hypothyroidism prior to pregnancy)
- thyroxine dose should be adjusted to maintain tsh <2.5mU/L prior to conception
- a tsh test is indicated as soon as pregnancy is confirmed
- thyroxine dose may need to be increased by as much as 30-50% by 4-6 wks gestation
---------------------------------------------------------------------
PREGNANCY (hypothyroidism diagnosed during pregnancy)
- tsh should be normalized as rapidly as possible
- tsh range should be 0.4-2.5mU/L
- during pregnancy tsh should be checked q6wks

- tsh may be suppressed as a normal finding in pregnancy; hyperthyroidism may be ruled out with a normal fT4
- thyroid scans (RAIU) are contra-indicated during pregnancy and the postpartum period (radioactive isotopes can cross into the breast milk

Adverse Outcomes of hypothyroidism in pregnancy:
- pre-eclampsia
- low bw
- preterm delivery
- postpartum hemorrhage
- placental abruption
- miscarriage
- dec. IQ in newborn
---------------------------------------------------------------------
POST-DELIVERY
- most hypothyroid women will need to dec. the thyroxine dose that they received during pregnancy

Front 196

What is the treatment of subacute thyroiditis?

Back 196

- subacute thyroiditis is a self-limiting condition
- best treated w/ nsaids
- most pts do not need thyroid supplementation
- typically triphasic course: hyperthyroidism --> hypothyroidism --> normal thyroid function
- hypothyroidism may perist in 5-15% of pts

Front 197

What is considered subclinical hypothyroidism?

Back 197

This is when lab findings show an elevated tsh (above upper limit) and free t3 and free t4 within normal limits.

Front 198

What is considered subclinical hyperthyroidism?

Back 198

- normal t3 and t4, but low tsh

This can occur w/ over replacement therapy for hypothyroidism. The main risk of subclinical hyperthyroidism is atrial fibrillation (usually in the elderly)

Front 199

T/F. Routine screening of thyroid function is not recommended in asymptomatic patients.

Back 199

true

Front 200

note

Back 200

Once an appropriate levothyroxine (synthroid) dose has been established, annual tsh testing is recommended. If the tsh level remains in the target range, no adjustment is needed.

note:
you don't have to test tsh q6months if tsh is within normal range and stable

Front 201

What does the thyroid u/s used to determine?

Back 201

- thyroid gland size
- solid vs. cystic nodule
- facilitate fine needle aspiration biopsy (fnab)

Front 202

When is a radioisotope thyroid scan ordered (RAIU)? What does it do?

Back 202

When there is a thyroid nodule and the patient is hyperthyroid with a low tsh

A RAIU scan differentiates between a hot (functioning --> excess thyroid hormone production) and cold (non-functioning) nodules
- hot nodule --> 0% chance of malignancy; treat hyperthyroidism
- cold nodule --> 5% chance of malignancy; further workup required (i.e. u/s and fnab)

Front 203

What does a thyroid biopsy used for?

Back 203

Used to distinguish between benign and malignant disease

Front 204

Should subclinical hypo/hyperthyroidism be treated?

Front 205

Illustrate the flowchart that shows the relationship between the thyroid hormones and the various forms of thyroid disease.

Front 206

What is considered statutory rape?

Back 206

Sexual intercourse (by adult) in someone younger than age of consent (16).

Front 207

Discuss physical exam in a rape/sexual assault victim.

Back 207

- informed consent before evidence collection for forensic use
- photograph areas of trauma w/ pt consent
------------------------------------------------------
- general (extragenital incl. oropharynx, breasts) trauma to any area
- genital trauma: perineum, hymen, vulva, vagina, cervix, or anus [in men: penis, scrotum, rectal exam]
- uv light to detect foreign debris or seminal/blood

Front 208

What are some things that are collected as part of forensic evidence in a rape/sexual assault victim?

What investigations would you consider doing?

Back 208

In addition to the forensic evidence mentioned:
- baseline sti testing (chlamydia, gonorrhea, hiv serology, syphillis serology)
- hep b serology
- swabs for candidiasis, bv, trichomoniasis
- pregnancy test (urine, serum)

*also incl. imaging/labwork relevant to pt injuries


note: urgent medical needs take priority over forensic evidence collection

Front 209

Discuss the management of the rape/sexual assault victim.

Front 210

note

Back 210

In a case of sexual assault, one should offer counselling to all patient affected by this whether they are victims, family members, friends, or partners. One should not discount the impact of sexual assault on all of these people.

Front 211

What is the most common sti?

Back 211

chlamydia followed by gonorrhea

Front 212

note

Back 212

hepatitis b is the most common form of sexually transmitted hepatitis and anal>vaginal>oral transmission

Front 213

For which STIs is there a vaccination?

Back 213

i. hep b
ii. hpv (covers against 70% of cervical cancer types)

Front 214

What are the RFs for STIs?

What are the more common STIs (Canada)?

Front 215

T/F. When a sti is detected in a prepubertal child, evaluation for sexual abuse is mandatory.

Back 215

true

Front 216

note

Back 216

Most often chlamydia is asymptomatic

Front 217

What are some long term complications of untreated gonorrhea and chlamydia?

Back 217

- arthritis
- inc. risk of acquiring and transmitting hiv

males
- urethral strictures
- epididymitis
- infertility

females
- pid
- infertility
- ectopic pregnancy
- perinatal infection
- chronic pelvic pain

Front 218

What are important things to ask about on history for a suspicious case of STIs?

Front 219

note

Back 219

If urethritis/cervicitis is suspected, always treat for both gonococcal and non-gonococcal types (i.e. cefixime and azithromycin)

Front 220

For the following STIs:
- Gonorrhea
- Chlamydia
- HPV (warts)
- Genital herpes (HSV1 and HSV2)
- Syphilis

What are the signs and symptoms, relevant investigations, management, and complications?

Front 221

note

Back 221

Consent is required before testing for hiv.

Front 222

note

Back 222

Normally, you treat an isolated gonorrhea infection with cefixime 400mg (single dose); however, if the pt has PID, then you must treat for both gonorrhea and chlamydia (800mg x 1 plus doxycycline)

Front 223

note

Back 223

If you are treating for chlamydia, prior to the test results, you must treat for gonorrhea as well as co-infection is common).

Front 224

note

Back 224

In a pt w/ symptoms that are atypical or non-specific for STIs (eg. dysuria, recurrent vaginal infections), one should consider STIs in the ddx and investigate appropriately.

Front 225

For measles, what is the:
- clinical presentation?
- treatment?
- complications?

Front 226

note

Back 226

Pneumocystis pneumonia (PCP) or pneumocystosis is a form of pneumonia, caused by the yeast-like fungus (which had previously been erroneously classified as a protozoan) Pneumocystis jirovecii. [1]
Pneumocystis is commonly found in the lungs of healthy people, but, being a source of opportunistic infection, it can cause a lung infection in people with a weak immune system. Pneumocystis pneumonia is especially seen in people with cancer[citation needed], HIV/AIDS and the use of medications that affect the immune system.

Symptoms of PCP include fever, non-productive cough (because sputum is too viscous to become productive), shortness of breath (especially on exertion), weight loss, and night sweats. There is usually not a large amount of sputum with PCP unless the patient has an additional bacterial infection. The fungus can invade other visceral organs (such as the liver, spleen, and kidney), but only in a minority of cases.
Pneumothorax is a well-known complication of PCP. An acute history of chest pain with breathlessness and diminished breath sounds is typical of pneumothorax.

Front 227

T/F. Any adnexal mass in postmenopausal women should be considered malignant until proven otherwise.

Back 227

true

Front 228

T/F: hpv cannot be prevented using condoms

Back 228

true

Front 229

A pregnant pt at 19wks gestational age comes in c/o of white vaginal d/c. You diagnose vulvovaginal candidiasis. What would you prescribe?

Back 229

- avoid oral meds such as fluconazole (safety in preg. unknown)
- avoid canestan cream applicator (traumatizing to vagina in pregnancy)

- recommend them to get monistat cream (otc) for vulvovaginal candidasis

Front 230

When ear syringing, what temperature water should you use?

Back 230

lukewarm

cold water - impairs balance
hot water - very uncomfortable

Front 231

What does an actinic keratosis look like?

Front 232

note

Back 232

As part of the assessment of a pt who has lost consciousness, obtain focused hx from the pt or witnesses that would include:
- duration
- trauma
- pre-existing medical conditions
- seizure activity
- drugs, toxins, meds

Front 233

Distinguish between ecchymosis and hematoma? (with picture)

Back 233

A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise.

[picture: hematoma]

Front 234

note

Back 234

A patient should never be on an Ace-I and an ARB at the same time.

Front 235

T/F. The MMR vaccine does not cause autism or IBD

Back 235

true

Front 236

Show diagrammatically how to check for CVA tenderness?

Front 237

What is MS Contin?

Back 237

Morphine (continuous release)

An opioid

Front 238

What is OxyNeo?

Back 238

Oxycodone

An opioid for moderate to severe pain

Front 239

Which is the most commonly seen arrhythmia?

Back 239

atrial fibrillation

Front 240

When assessing a patient who is having hearing loss and plugged ears, if on physical exam you notice 1 ear that has dry cerumen vs the other which is wet, what would you do?

Back 240

Syringe the wet wax ear.

Tell the patient to add 1-2 drops mineral oil in the ear with the dry cerumen and come back after 1 weeks time for syringing.

Front 241

What is a numbing cream to apply before getting bloodwork done on a child?

Back 241

emla

in your orders, just write "emla to blood letting area"

Front 242

What is the 1st line hypoglycemic agent to use in diabetics?

Back 242

metformin

Front 243

What are some RFs for suicide?

Back 243

- previous attempts (biggest RF)
- depression
- family hx of suicide
- substance abuse
- severe anxiety
- schizophrenia
- eating disorder
- stressful life event
- serious illness
- limited social supports
- LGBT

Front 244

note

Back 244

In any pt w/ mental illness (i.e., not only in depressed pts), actively inquire about suicidal ideation (eg. ideas, thoughts, a specific plan)

Front 245

T/F. One main sexual side effect of SSRIs is erectile dysfunction.

Back 245

true

Front 246

What is the first line therapy for COPD?

Back 246

- smoking cessation

note: the biggest RF for copd is 'smoking'

Front 247

What medication would you give to someone with uncomplicated urinary tract infection (uti)?

Back 247

Macrobid 100mg
1 tablet bid M: 5d

Front 248

What are the 3 main types of tremors?

Back 248

1. Resting tremor - tremor at rest (extinguishes with movement such as in Parkinson’s)

2. Kinetic tremor (tremor w/ movement)

3. postural tremor (when you maintain a posture)

Front 249

What the diagnosis you think of with a resting tremor?

Back 249

Parkinsonism (NOT parkinson's disease)

Remember: Parkinson's disease is a dx of idiopathic parkinsonism

Other conditions that can cause Parkinsonism include:
- meds: maxeran, typical antipsychotics
- drug induced: LSD
- vascular: ischemic event (in the substancia nigra)

Front 250

Do you need a dating u/s in a pregnancy?

Back 250

No. If their periods are regular, stable and their sure of their LMP, no need for dating u/s.

You only need 1 u/s in a stable pregnancy and thats at 20 weeks

Note as the pregnancy progresses, the accuracy of the dating ultrasound goes down

In the 1st trimester, you estimate the EDC by ultrasound if the discrepancy between the u/s and lmp dating method is >1 wk; after the 1st trimester, you use the u/s dates if the discrepancy is >2wks

Front 251

Discuss the common causes and treatment of pneumonia at different ages in children.

Front 252

What are empiric antibiotics given to children w/ sepsis/fever <1 month?

Back 252

ampicillin and gentamycin

Front 253

What are some side effects of meds such as ritalin, concerta used for ADHD?8

Back 253

insomnia
dec. appetite
h/a
tics

Front 254

Discuss medications safe in breastfeeding. Harmful in breastfeeding






[breastfeeding and drugs]

Front 255

What are some RFs for depression?

Back 255

- sex: female > male
- age: onset 25--50
- family hx: depression, alcohol abuse
- childhood experiences: abuse, loss of family member
- personality: insecure, dependent, obsessional
- recent stressors: illness, financial, legal
- postpartum >6mo
- lack of intimate, confiding relationships or social isolation
- chronic pain
- low ses
- co-morbid psychiatric illnesses

Front 256

Explain how erythropoiesis works?

Front 257

note

Back 257

Pulling on the pinna may be extremely painful in otitis externa, but is usually tolerated in pts with otitis media. This may be helpful in differentiating otitis externa from otitis media, unless both conditions exist.

Front 258

What is the difference between bipolar I disorder and bipolar II disorder?

Front 259

What is the difference between a manic episode, mixed episode, and hypomanic episode?

Front 260

A patient comes in w/ generalized pruritis. You've ordered bw for all the potential possible causes. How would you manage this patient?

Back 260

Advise trial of
benedryl +/- claritin (both otc 1st and 2nd generation)

Front 261

Discuss the different toxidromes. Give some examples of drugs that would fit these toxidromes.

Front 262

What is postpartum thyroiditis?

Back 262

Postpartum thyroiditis is a phenomenon observed following pregnancy[1] and may involve hyperthyroidism, hypothyroidism or the two sequentially. It affects about 5% of all women within a year after giving birth. The first phase is typically hyperthyroidism. Then, the thyroid either returns to normal or a woman develops hypothyroidism. Of those women who experience hypothyroidism associated with postpartum thyroiditis, one in five will develop permanent hypothyroidism requiring lifelong treatment.

For most women, the hyperthyroid phase presents with very mild symptoms or is asypmtomatic; intervention is usually not required. If symptomatic cases require treatment, a short course of beta-blockers would be effective.

Front 263

How would you treat bipolar disorder in pregnancy?

Back 263

CANNOT GIVE LITHIUM OR CARBAMAZEPINE OR EPIVAL IN PREGNANCY ——> that is very BAD

In Bipolar, better to give atypical antipsychotics such as risperidone.

Front 264

If you were to choose 1 antidepressant in a pregnant patient, what would it be?

Back 264

Sertraline (zoloft)

Front 265

T/F. Post-stroke depression is common.

Back 265

True

Front 266

note

Back 266

With any dementia YOU HAVE TO think about DRIVING safety

Front 267

What is GTPAL? Give an example

Front 268

What is the management of GDM?

Back 268

lifestyle
- diet modification
- dietician
- freq. sugar monitoring

medications
- insulin - 1st line
- glyburide and metformin - 2nd linechlay

Front 269

Is HSV reportable?

Back 269

NO

Front 270

note:

Back 270

combined ocps should not be used in breast feeding; a better alternative would be a progesterone only pill (micronor)

Front 271

read only (travel medicine)





[general travel precautions]

Front 272

A couple is trying to get pregnant. No luck after 6 months of trying. What do you tell them?

Back 272

Keep trying

- discuss full sexual hx; make sure timing frequency appropriate

MUST TELL THEM TO TAKE FOLIC ACID

Front 273

Which antidepressant is preferable in pregnancy?

Back 273

sertraline (zoloft) - shown to be safe in pregnancy

Front 274

What are the ABCs of preterm labour?

Back 274

Antibiotics
Betamethasone (used to prevent RDS)
CCBs

Front 275

There's a neonate w/ sepsis. Which antibiotics would you give this newborn?

Back 275

ampicillin and gentamicin

If child has fever; you have to do a FSWU (includes LP); given the amp and gent before LP is done but do the blood drawing for cultures prior to starting abx. note: drawing blood is quick; LP more cumbersome.

Front 276

What are the 2 most common causes of failure to thrive (FTT) in children?

Back 276

- dietary problems (swallowing etc)
- abuse (neglect)

Front 277

What is the one of the biggest RFs for colon cancer?

Back 277

familial adenomatous polyposis (FAP)

Front 278

One medication for treatment of hypercalcemia (common in pts w/ cancer --> bones --> releases calcium)

Back 278

Pomidronate

Front 279

note

Back 279

bph can cause both irritative (urgency) and obstructing sx

Investigations: Cr, (psa), urinalysis, u/s

Front 280

Diffuse ST elevations and t wave inversions. What might this be?

Back 280

pericarditis

Front 281

What's the biggest RF for aortic dissection?

Back 281

htn

Front 282

note

Back 282

macular degeneration --> central vision loss
glaucoma --> peripheral vision loss

Front 283

What are the 4 different grades of acne?

Back 283

grade 1. papular
grade 2. pustular
grade 3. nodules
grade 4. nodulo-cystic

Front 284

List 2 ways to differentiate contact irritant diaper dermatitis from candida dermatitis.

Back 284

- candida --> satellite lesions
- contact irritant dermatitis --> spares the folds

(contact just intact w/ the skin, candida likes those moist spaces)

Front 285

Give 2 classes of medications that can be used for atopic dermatitis (eczema).

Back 285

i. topical steroids
ii. calcineurin inhibitors - protopic ointment

Front 286

What are the different types of psoriasis?

Back 286

i. plaque psoriasis
ii. guttate psoriasis
iii. erythrodermic psoriasis
iv. pustular psoriasis
v. psoriatic arthritis

Front 287

Discuss the management of plaque psoriasis.

Back 287

non-pharmacologic:
- prevent dry skin (avoid harsh soaps/cleansers and use moisturizers)
- trigger identification and avoidance (eg. alcohol, stress, certain drugs - lithium, b-blockers)

pharmacological:

First line
i. mod-potent steroids (reduces scaling and thickness)
ii. vitamin d analogues - dovobet (inhibits kerotinocyte proliferation)
iii. retinoids - tazorac cream (retinoid derivative)
iv. coal tar solution (anti-proliferative)
v. salicylic acid (removes scales)
vi. phototherapy
vii. biologics - infliximab, remicade (anti-TNF agents)

Second line
- methotrexate, acetritin (immunosuppresants)


note: if the affected area of skin is >10% one should try using topical medications as adjuncts to phototherapy and systemic drugs (methotrexate, infliximab)

note: methotrexate, infliximab useful in psoriatic arthritis

Front 288

What is psoriasis? What is the clinical presentation?

Front 289

What is guttate psoriasis (drop-like)?

Front 290

What is erythrodermic psoriasis? What is pustular psoriasis. What is their management?

Front 291

List some anti-allergic drugs (otc) that patients can use.

Back 291

First generation
- benedryl (sedating)

Second generation
- reactine (non-sedating)
- claritin (non-sedating)






note: these drugs can also be used in pts w/ generalized pruritis (as a trial)

Front 292

What is the management of allergic rhinitis? (allergic rhinitis is IgE mediated.

Back 292

management

non-pharmacologic / lifestyle
- trigger ID and avoidance
- saline rinses
- allergy referral - allergy testing
- allergy shots

medications
- benedryl (1st generation), claritin or reactine (2nd generation) (different mechanisms of action)
- topical nasal steroids (nasonex); rhinocort (can be used in pregnancy)
- anticholinergics: atrovent
- singular (leukotriene receptor inhibitor)
- decongestants (pseudoephidrine) - can raise bp





note: allergic rhinitis often part of the atopy triad. must ask about self and fmhx of atopy

note: must ask about exposure to smoking, occupational exposure, family hx important

Front 293

Discuss non-pharmacological management of asthma.

Back 293

- education: how to take medications
- trigger identification and avoidance
- asthma action plan

Front 294

Which bug is most commonly associated w/ bronchiolitis?

Back 294

RSV


note: bronchiolitis is first episode wheeze (think of it as asthma in kids <2 yrs of age)

Front 295

What are the 4 principles of family medicine?

Back 295

i. the family physician is a skilled clinician.
ii. family medicine is a community-based discipline.
iii. the family physician is a resource to a defined practice population.
iv. the patient-physician relationship is central to the role of the family physician.

Front 296

What does DASH stand for?

Back 296

Dietary Approaches to Stop Hypertension

Front 297

What is stievamycin a combination of ?

Back 297

retinoid + erythromycin

Front 298

Are doxycycline, erythromycin, tetracycline contraindicated in pregnancy?

Back 298

yes

Front 299

note

Back 299

For asthmatic pts, you have to ask about smoking status.

Go through all the asthma triggers (biggest trigger - viral urtis)

Front 300

note

Back 300

For all chronic conditions, management should include consideration of "multidisciplinary team"

Front 301

note

Back 301

Try and avoid laba in kids 6-11; thats should be by the respirologist. So after inc. their ICS --> add LTRA

Front 302

note

Back 302

on lmcc, anytime you prescribe puffer, write also 'age congruent spacer device' (2 neurons)

Front 303

note

Back 303

No imaging can tell you if there's a breast cancer or even lung cancer or any type of cancer. They can suggest cancer but cancer is a dx made by biopsy.

Front 304

note

Back 304

In woman <30 if you feel a breast lump or the pt brings it to your attention, you do a U/S; b/c women in that age group have denser breasts and mammogram have very poor sensitivity and specificity in that age group.

U/S —> specific finding or not
if no specific finding and you feel a mass, what do you do? you can watch it for a couple cycles, but if mass still there then patient needs to be sent for a biopsy.

If U/S shows something it would either be a mass that is solid or cystic. If cystic mass see if you can aspirate; if aspirated and mass diminishes and fluid is not bloody —> then a simple cyst; pt can be followed; if the mass is solid or it can’t be aspirated then pt is going to need a biopsy —> need to find out whats going on

Women > 30: breast mass felt or brought to your attention: mammogram or u/s. You gotta do BOTH; less denser breasts

mammogram: specific finding or not; if no specific finding and lump felt —> core biopsy; if shows a cyst and u/s shows this as well, you try to aspirate it; if non-bloody —> watch; if anything else —> biopsy.

Front 305

Discuss the spirometry interpretation of copd.




[note: need fev1/fvc <0.7 first; then fev1>80% is N; <80% if not

Front 306

Discuss the 5 classes of dyspnea on the dyspnea scale.

Front 307

note

Back 307

Its important to bring up need for vaccinations in patients w/ copd; this is a live longer intervention.

Front 308

What are the indications for oxygen therapy in patients w/ copd?

Back 308

survival benefit w/ long term continue oxygen (>15h/d to achieve O2 sat ≥90% in pt w/:

severe hypoxemia
i. PaO2 ≤55mmHg
ii. PaO2 ≤60mmHg in presence of bilat. ankle edema, cor pulmonale or hematocrit >56%

Front 309

note

Back 309

An acute copd exacerbation is defined as:

worsening:
- dyspnea
- cough
- sputum production

Front 310

Compare the management of acute asthma vs. copd exacerbation.

Front 311

When do you give antibiotics in COPD?

Back 311

If there's purulent exacerbations; if exacerbations not purulent, you DO NOT give abx.

Front 312

Which antibiotics do you choose to use in copd exacerbation?

Back 312

It depends

simple patients
- amoxicillin, septra

complicated patients
- levofloxacin, macrolides - azithromycin, clarithromycin

Front 313

note

Back 313

When copd gets really really bad and its progressive, its important to have a discussion w/ the patient re: end of life care.

Front 314

At what age do we start screening for dyslipidemia?

Back 314

men > 40
women > 50

Who else do you screen?

patients w/ other cardiovascular RFs (even if age<40)
- fmhx of cvd
- htn
- dm
- chronic kidney disease
- smoker
- obesity
- peripheral vascular disease
- hiv patients
- xanthomas / xanthalasma
- signs of pcos

Front 315

note

Back 315

Diabetics are already considered high risk on framingham risk calculator. Usually their risk >20%

Other conditions that are automatically high risk?
- stroke
- mi
- peripheral vascular disease

Front 316

When would you draw a CRP with respect to hyperlipidemia screening?

Back 316

CRP to be drawn only in the intermediate (10-20% risk Framingham group for coronary artery disease) in:
men>50
women>60

This value is used to further risk stratify into high vs. low risk.

This is the only time you draw crp w/ respect to hyperlipidemia screening

Front 317

note

Back 317

Once you decide to treat someone with a statin for hyperlipidemia, you're treating to a target of <2.0; no matter which risk category they originally belonged to

Front 318

note

Back 318

Primary lipid targets:
i. ldl below cut-off or 50% reduction in ldl (going from 10 —> 5, thats fine)
ii. apoB

Front 319

note

Back 319

parkinsonism is NOT parkinson's disease; very important distinction

parkinsonism is TRAP sx:
TRAP: tremor (resting), rigidity, akinesia, postural instability


parkinson's disease is idiopathic parkinsonism

Front 320

What are some causes of parkinsonism?

Back 320

- stroke - substantia nigra
- maxeran (drug induced parkinsonism
- lewy body dementia
- idiopathic parkinsonism --> parkinson's disease

Front 321

note

Back 321

It's very important to be cautious in treating pts w/ parkinson's disease. If pt's function is impaired, only then start medication. The parkinson's meds keep losing their effect w/ time. So if these drugs are used earlier on, the clocks ticking and patient will have refractory sx (no benefit from medications anymore)

Front 322

What is one of the biggest s/e of levodopa-carbidopa?

Back 322

postural hypotension

Front 323

List 5 classes of drugs, the drugs themselves, and mechanism of action for Parkinson's disease

Back 323

i. dopamine precursor: levodopa-carbidopa (basically dopamine)
ii. dopamine agonist: pramipexole
iii. COMT inhibitors (catecholamine-O-methyl transferase inhibitors) —> the enzyme COMT breaks down dopamine: entacapone: helps make levodopa-carbidopa last longer
iv. MAO-B inhibitor (inhibit the enzyme that breaks down dopamine): rasagaline
v. NMDA receptor antagonist: amantadine

Front 324

As per obesity guidelines, when do you start patients on pharmacotherapy? When do you consider bariatric surgery?

Back 324

pharmacotherapy
- bmi ≥27 kg/m^2 + RFs or bmi ≥30 kg/m^2
- meds as adjunct to lifestyle modifications (consider meds if pt has not lost 1-2 lbs per wk by 3-6 months after lifestyle change

bariatric surgery
- bmi ≥35 + RFs or BMI ≥40 (consider if other wt loss attempts have failed. Requires lifelong medical monitoring

Front 325

What is tetralogy of fallot?

Back 325

i. ventricular septal defect (VSD)
ii. right ventricular outflow tract obstruction (RVOTO)
iii. overriding aortic root
iv. right ventricular hypertrophy (RVH)

Front 326

Discuss acyanotic vs. cyanotic congenital heart disease.

Front 327

A baby is born with cyanotic congenital heart disease. You realize this after you see a 9hr baby turning cyanotic and don't notice much benefit even after giving oxygen (think brain lungs heart); why is the baby decompensating in the 9th hours?

Back 327

Because the pda (patent ductus arteriosus) is closing; blood moving mainly by r-->l shunt; blood not passing lungs --> no longer getting oxygenated.

Objective should be to keep the PDA open b/c to wanna keep the blood from mixing.

What kind of medications close the pda? nsaids
What kind of medications keep the pda open? prostaglandins










[pda = patent ductus arteriosis

Front 328

Which medications keep the patient ductus arteriosis open (pda)?

Back 328

prostaglandins

Front 329

List 3 organisms that can cause otitis externa.

Back 329

bacterial (90% of OE): pseudomonas aeruginosa, s. aureus

fungus: candida albicans, aspergillus niger

Front 330

What are the common bugs in ear, nose, and throat infections





[bacterial]

Back 330

common bugs

s. pneumoniae
h. influenza
m. catarrhalis

Front 331

note

Back 331

chronic sinusitis is sinusitis > 3 months

Front 332

Chronic sinusitis can be classified into 3 categories. What are these?

Back 332

i. chronic sinusitis w/ polyposis
ii. chronic sinusitis w/o polyposis
iii. chronic sinusitis w/ fungal component

management: longer course abx; may need short course of oral steroids (prednisone)


imaging: CT face (in kids mri)

Front 333

What is 1st line medication for strep throat?

Back 333

Pen V

NOT amoxicillin

Front 334

What is the CURB-65 score?

Back 334

CURB-65, also known as the CURB criteria, is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia[1] and infection of any site. The CURB-65 is based on the earlier CURB score[3] and is recommended by the British Thoracic Society for the assessment of severity of pneumonia.
The score is an acronym for each of the risk factors measured. Each risk factor scores one point, for a maximum score of 5:

- Confusion of new onset (defined as an AMT of 8 or less)
- Urea greater than 7 mmol/l (19 mg/dL)
- Respiratory rate of 30 breaths per minute or greater
- Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less
- age 65 or older


The risk of death at 30 days increases as the score increases:[1]
0—0.7%
1—3.2%
2—13.0%
3—17.0%
4—41.5%
5—57.0%

Front 335

Discuss the cutoffs for the TB skin test

Front 336

What is the management of a prolapse form least support to most?

Back 336

i. ring pessary
ii. ring pessary w/ support
iii. ring pessary w/ support and gellhorn
iv. surgery

Front 337

What 2 groups do you treat for asymptomatic uti?

Back 337

i. pregnancy
ii. instrumentation (prior to) --> eg. in pts going for a cystoscopy


note: asymptomatic uti not treated in pts w/ a catheter b/c people w/ catheters have uti organism all the time and you'd be treating them all the time.

Front 338

note

Back 338

if you have trace nitrites --> dx of uti
if you have negative nitrites and some leukocytes you can't w/ confidence call that a uti.

Front 339

When is HTN screening typically done?

Back 339

every visit

Front 340

What are some s/e of b-blockers?

Back 340

- postural hypotension
- erectile dysfunction
- may make asthma/copd worse

Front 341

What are some s/e of Ace-i (ace-inhibitors)

Back 341

- cough (10% of patients)
- may make renal function worse (esp. if dehydrated)

Front 342

What is Conn syndrome?

Back 342

Conn syndrome is an aldosterone-producing adenoma.

Measuring aldosterone alone is not considered adequate to diagnose primary hyperaldosteronism. The screening test of choice for diagnosis is the plasma aldosterone:plasma renin activity ratio. Renin activity, not simply plasma renin level, is assayed. Both aldosterone and renin are measured, and a ratio greater than 30 is indicative of primary hyperaldosteronism.


Surgery required to remove tumour. Can use spironolactone in the mean time to control htn.

Front 343

Who would you suspect to have secondary HTN?

Back 343

- extremes of age (<30)
- more than 3 agents (resistant, refractory htn)
- marked hypokalemia
- worsening kidney function

Front 344

What is the 1st line treatment of otitis externa?

Back 344

- vinegar:water solution (agent that adjusts the flora)
- ear plugs

If this does not work, then cipradex drops

Front 345

For which patient groups do we do endocarditis prophylaxis?

Back 345

i. congenital heart disease (cyanotic)
ii. previous endocarditis
iii. prosthetic heart valves

Front 346

What antibiotics can be used for endocarditis prophylaxis. What do you prophylaxis in these patients

Back 346

- penicillin / amoxicillin
or
- clindamycin



Prophylaxis w/:
- dental procedures (pts recommended good dental hygiene)
- bronchoscopy w/ biopsy

Front 347

note

Back 347

kids <6 should not be placed on a LABA; should be used w/ caution in kids 6-11


respirologists can give LABAs to all children however




[asthma]

Front 348

Patient comes in with limited finances asking you what she should do for money. What can you advise her?

Back 348

Contact social services

Front 349

For henoch schönlein purpura (hsp) discuss clinical presentation, management, prognosis.

Front 350

For kawasaki disease, discuss the diagnostic criteria, management, and complications.

Front 351

What is immune thrombocytopenic purpura (itp)? presentation? management?

Front 352

cervical (upper limp) dermatomes and myotomes

Front 353

List 2 anti-hypertensive drugs that can cause erectile dysfunction (ED).

Back 353

i. hydrochlorothiazide
ii. propanolol

*thiazides most common cause followed by beta-blockers

Front 354

Which anti-hypertensive are not associated with any sexual side effects?

Back 354

Ace-inhibitors such as ramipril



note: CCBs are not associated with erectile dysfunction but can be associated with impaired ejaculation

Front 355

Name two classes of drugs used in benign prostatic hyperplasia (BPH).

Back 355

i. alpha reductase inhibitor (eg. flomax aka tamsulosin)
ii. 5 alpha reductase inhibitor (eg. proscar aka finasteride)

Front 356

Name one class of the anti-hypertensives that can be used for both benign prostatic hyperplasia (bph) and hypertension (htn).

Back 356

alpha receptor blockers (eg. flomax, hytrin)

Front 357

List 2 types of incontinence associated with benign prostatic hyperplasia (bph).

Back 357

i. urge incontinence
ii. overflow incontinence

Front 358

samp

Front 359

samp

Front 360

What is erythema infectiosum? Clinical presentation? Treatment? Complications?

Front 361

samp

Front 362

samp

Front 363

T/F. Domestic violence usually escalates during pregnancy.

Back 363

true

Front 364

What are some RFs for fetal alcohol syndrome (FAS)?

Back 364

- excessive alcohol use
- prolonged use
- low socioeconomic class
- poor prenatal care

Front 365

What are 3 mainstays of treatment of acute pancreatitis?

Back 365

- npo
- fluids
- pain control



others include:
- oxygen
- treating local and systemic complications

Front 366

What are the signs and symptoms of acute pancreatitis?

Back 366

- pain: epigastric, constant non-noncolicky radiating to back, may improve on leaning forward
- tender rigid abdomen; guarding
- N and V
- abdo distention from paralytic ileus
- fever
- jaundice - compression or obstruction of bile duct

Front 367

For a patient that comes in with gallstone pancreatitis, what should be done in general.

Back 367

Pancreatitis should be managed, and then do cholecystectomy

Front 368

What is the Ranson criteria and what does it include:

Back 368

Ranson criteria is a measure of the severity of acute pancreatitis and prognostic indicator for complications or death. High mortality if > or = 3 present.

Front 369

What are some complications of acute pancreatitis?

Back 369

Local: hemorrhage, necrosis, fluid collection, infection

Systemic: pulmonary, cardiac, renal dysfunction

Front 370

Investigations in acute pancreatitis include:

Back 370

- Panc enzyme: amylase and lipase (both inc, lipase more sensitive)
- ALT > 100 (strongly suggests bilary pancreatitis)
- inc. WBC

Imaging:
- X ray - sentinel loop (dilated proximal jejunum)
- U/S: best for evaluating biliary tree
- CT scan with IV contrast
- ERCP or MRCP

Front 371

What are signs and sx of chronic pancreatitis?

Back 371

Signs
- H/A
- Confusion
- Coma
- Arrhythmias

Symptoms - abdo pain, diabetes, steatorrhea

Front 372

What is the management of chronic pancreatitis?

Back 372

PAPA

1) pancreatic enzyme replacement
2) alcohol abstinence
3) pancreatic resection if ductular blockage
4) analgesics

Front 373

List 2 most common causes of acute pancreatitis and then other causes.

Back 373

1. Gallstones (45%)
2. Ethanol (35%)

Others: Infection, tumors, trauma, emboli/ischemia, scorpion stings, autoimmune

Front 374

What is the most cost effective diagnostic investigation in a man who presents with epigastric pain, nausea, vomiting, radiating to the back?

Back 374

abdominal ultrasound

Front 375

samp

Front 376

A young boy presents with acute otitis media. What would be the finding on pneumatic otoscopy?

Back 376

decreased tympanic membrane movement

Front 377

Discuss the different phases of clinical drug trials.

Front 378

samp

Front 379

A 13 year old girl comes in to the office asking for OCP. You need to get informed consent from her to start the medication. Name 3 parts of informed consent you must discuss with her.

Back 379

i. understanding of the nature of the rx and its expected effects
ii. if the patient understands the benefits of the rx
iii. if the patient understands the risks of the rx
iv. if the patient understands the alternatives to the proposed rx
v. understanding of the consequences of not using the rx

Front 380

In osteoarthritis, which joints of the hands are typically involved?

Back 380

- dip
- pip
- 1st cmc

dip joints --> heberden's nodes
pip joints --> bouchard's nodes (bouchards --> close to the body)
thumb squaring

Front 381

What role does digoxin have in congestive heart failure (chf)?

Back 381

digoxin slows and strengthens heart contractility but only effective in sedentary patients w/ lower pulse rate.

Front 382

List some signs of respiratory distress.

Back 382

- nasal flaring
- tracheal tug
- stridor
- altered loc
- cyanosis
- intercostal indrawing

Front 383

Discuss what a patient needs to do in the different scenarios where she forgets to change her transdermal patch.

Front 384

samp

Front 385

samp

Front 386

What are the 5 stages of change?

Back 386

- precontemplation
- contemplation
- preparation
- action
- maintenance

Front 387

samp

Front 388

samp

Front 389

What is pheochromocytoma? What are the symptoms? investigations? management?

Front 390

What is the estimated risk of transmission by needlestick injury for the following:
- hep b
- hep c
- hiv

Back 390

hep b: 30%
hep c: 0.5%
hiv: 0.3%



note: intercourse transmission rate of hiv is 0.1% (1 in 1000)

Front 391

samp

Front 392

A patient is started on an ssri for depression. List 4 substances you could use to augment her treatment.

Now if the question said 4 types of substances, you may want to put down medication class (note: lithium is its own class)

Back 392

i. lithium
ii. thyroid hormone
iii. olanzapine
iv. gabapentin

Front 393

samp

Front 394

samp

Front 395

samp

Front 396

samp

Front 397

What does pitiriasis rosea (rash) look like?

Front 398

samp

Back 398

Front 399

samp

Back 399

Front 400

What is one major complication of influenza?

Back 400

pneumonia

Front 401

What is guillain-barré syndrome? RFs/etiology? signs and sx? investigations? treatment?

Back 401

Front 402

What is celiac disease? Etiology? Clinical features? Investigations?

Back 402

Front 403

What is the management of celiac disease?

Back 403