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Family Medicine CAN
Family Medicine Notes 2021 for CCFP Exam
| Question | Answer |
|---|---|
| Breast Cancer Risk Factors (6) | BRCA. Gender F>M, Age >50, 1st degree relative, Unopposed estrogen, Radiation Exposure |
| Breast Cancer Modifiable to Decrease Risk (7) | Decrease Wt. Incresae Activity, Decrease EToH, Decrease Hormone exposure, Early pregnancy <35, breastfeed |
| Breast Cancer Screening (low risk) | 50-69 screen every 2 years 70-74 screen q2-3 years |
| Breast Cancer SCcreening- no longer recommends doing what? | Breast Exams or Self Breast Exam |
| Breast Cancer Screening (high risk)- age | 30-69 for annual mammography Known BRCA 1/2 carrier, 1st degree relative BRCA 1/2 carrier |
| Breast Cancer Investigation: Female <30 | Ultrasound |
| Breast Cancer Investigation: Female >30 | U/S + Mammogram |
| If Diagnosed with Breast CA: what investigations do you do? | Bone Scan, Abdominal U/S, CXR, Head CT |
| Breast Cancer can spread to what parts of the body | Bone>Lung>Liver>Brain |
| Breast Cancer Treatment- Menopausal Symptoms offer? | SSRI, SNRI or Gabapentin + lifestyle modifications |
| HPV: Lifetime prevalence % | 80% |
| Cause of HPV | Human Papillomavirus which can be transmitted through intimate sexual contact. |
| HPV Risk Factors (6) | Sex at young age <20, Multiple partners, smoking (weakens immune system), Long term OCP, Birth to multiple children |
| HPV Protective Factors (2) | Routine Pap. HPV Immunization (grade 8 to age 45) |
| HPV Screening | q3 years. Start age 25, if ever sexually active (intercourse, digital, oral with partner of either gender) |
| Cervical Cancer Screening when to stop testing | If >3 normal paps in past 10 years, can stop at 70 |
| What is after pap there is lacking T-Zone | May continue at regular interval (unless suspicious abnormality) |
| Pap Special Populations - screening - HIV and SLE? | HIV- Annual Screen. SLE- Annual Screening |
| Pap for pregnancy? | Same screening as not pregnant. ASCUS and LSIL found in pregnancy- don't repeat until after 6m postpartum |
| Cervical Cancer - signs and symptoms | Abormal Vaginal Bleeding. Bleedign or spotting between regular menstrual periods. Bleeding pain after sex. Menopause bleed. Pain in pelvis/back, more discharge |
| Cervical cancer- Managing Abnormalities | Excisional Procedure, Cone biopsy, LEEP, laser excision |
| Cervical Cancer- CIN 1- what do you do? | Observation with repeat in 12m. Consider excisional Biopsy |
| Cervical Cancer- CIN 2 and <25- what do you do? | Colposcopy q6m up to 24m before considering treatment |
| Cervical Cancer- CIN 3 and <25y/o- what do you do? | Excisional procedure, if positive margins, repeat colposcopy |
| Cervical Cancer- CIN 2 and >25- what do you do? | Excisional Procedure, if positive margins, repeat colposcopy |
| Colorectal Cancer- Most arises from what type of polyp? | Adenomatous polyp (30% of 50 y/o have adenomatous polyps) |
| Colorectal Cancer- Risk Factors (9) | Age (90% >50), Family hx, IBD, Polyps, High fat diet, ETOH intake, Obestity, Sedentary life, Smoking, Vitamin E increase risk of polyps |
| Colorectal Cancer- Signs | Recal Mass (DRE), Signs of Anemia, Weight loss Abdominal Mass |
| Colorectal Cancer- Symptoms | Rectal Bleed. Blood in stool (melena), change in bowel habit, Bloating, feeling full, anorexia, vomiting, weight loss, Polyps, cramps, weakness |
| Colorectal Cancer- Lab work shows | Anemia- Microcystic - order ferritin |
| Colorectal Cancer- Mets go to where? | Liver, LUng, Peritoneum |
| Colorectal Cancer- Screening | 50-74y/o DO NOT USE COLONOSCOPY For sceening avg risk pt |
| Colorectal Cancer- Screening- Increased Risk - 1st line | 1st line screen: 1st degree Relative (parent, sibling, child) 40-50y/o or 10 years young than the age relative was dx |
| Colorectal Cancer- Screening- Increased Risk- 2nd line | Screen with FIT age 40-50 y/o or 10 years younger than the age the relative was dx. Screen 1-2 years |
| Colorectal Cancer- Screening- Inflammatory Bowel Disease | Colonoscopy 8-10 years after pancolitis or 12-15years after left sided colitis done q1-2 years. |
| Lung Cancer- Screening | Between 55-74 y/o and high risk- smoker and >30 year pack Screen with CT every year for 3 years |
| Lung Cancer- Mets sites | Liver>bone> lymphatics>brain |
| Lung Cancer- Blood work with suspected CA diagnoses | CBC, ALP, AST, ALT, Calcium, Albumin , Lytes, Urea, Cr. |
| Lung Ca: Risk Factors | Smoking, Vapings, Cigars, Second hand smoke, occupational exposure- dust, silica, disesel engine emissions, brick layers, family hx of ca- lung, head and neck, COPD, high caffeine |
| Prostate Ca- Mean age of diagnoses | 72 |
| Prostate Ca- Risk Factors | Blacks, Family hx- 1st degree relative 2X risk, Increase Diatary fat- 2X risk, Smoking |
| Prostate Ca- Signs and Symptoms | Usually asymptomatic. LUTS and incontinence, Lower back pain (mets). DRE- hard irregular nodule |
| Prostate Ca- Screening | <55- No PSA 55-69 No PSA Screening. > 70 No PSA screening USA Task Force- No screening after 70 |
| Prostate Screening- Urology Association 2018 recommends | Start age 50- q4 every 4 years Discontinue if age 60 PSA <1 or when 70 y/o |
| Prosate Screening- If order a PSA then should do what? | PSA then do DRE as well |
| Don't do a PSA if what? | Acute UTI, PRostatitis, Urinary Retention, Recent Catheterizaiton |
| Gleason Score meanings | 1-4- Well Differentiated 5-6 Moderate Differentiated. 8-10 poorly differentiated |
| Prostate CA Managment | Low risk- Active Surveillance (PSA q3-6m, DRE annually) Intermittent Risk- Prostatectomy, Radiation, PSA q6-12m |
| Prosate Ca- Mets go where? | Adrenal, Bone, Liver, Lung |
| Esophageal Cancer- Signs and Symptoms (9) | Difficulty swallowing, Pain on swallowing, Food obstruction, early satiety, vomiting, weight loss, hematemesis/melena, Fe Deficiency |
| Esophageal Cancer- Barretts- what type of survellance | Endoscopy and long term PPI (regular endoscopy)\ |
| A. Fib- Definition | Supraventricular Tachycarida with uncoordinated atrial activation |
| A. Fib- Definitions (4 types) | 1. New onset. 2. Paroxysmal- in and out within 7 days. 3. Persistent- lasting >7 days. Permanent Lasting 1 year |
| A. Fib Symptoms (8 types) | Asymptomatic. Palpitations. Reduced Exercise capacity, syncope/dizziness, heart failure, chest pain, dyspnea, stroke |
| A. Fib Etiology- Causes | Cardiac- HTN, Valve Disease, CAD, CHF, Cardiomyopathy, Non Cardiac- Thyrotoxicosis, infection (pneumonia), COPD, OSA, PE, Obesity, DM, GERD, Stress, Alcohol cocaine (NOT CAFFEINE) |
| A. Fib - Complications | Stroke, HF, Cognitive Decline, new dementia |
| A. Fib- Investigations | EKG, ECHO (valve disease), CBC- anemia/infection A1C and lipids (risk strat), INR Baseline |
| A. Fib Investigations- Consider doing these | Holter, Stress test, CXR- Excludes CHF, Sleep Study (OSA) |
| A. Fib - ER Management - stable- low risk | Antithrombotic and Consider rate/thythm treatment |
| A. Fib- ER Management- New | EKG, CBC, INR, Cr, LFT, TSH (glucose + lipids), ECho as outpatient |
| A. Fib - ER Management - Unstable- present as? | Rapid AF with Hypotension, ACS, Pulmonary Edema |
| A. Fib - ER Management - Unstable patient- Treat how? | IV Diltiazem, Metoprolol, Verapamil, Digoxin, Immediate Oral Anticoagulation (NOAC/ HEPARIN) then cardioversion |
| A. Fib- Post Cardioversion Managment | Anticoagulation for 4W. Consider long term anticoagulation based on CHADS-65 |
| A. Fib- What is CHADs2 | CHF, HTN, Age >75, DM, 2 points for stroke/TIA |
| Factors that Increase Bleeding Risk- HASBLED | HTN, Abnormal LFT, Stroke, Bleeding/anemia, Labile INR, Elderly >65, Drugs or alcohol |
| Management of INR - Supratherapeutic | 3-5- Lower weekly dose +/- Omit dose 5-9- Omit 1-2 doses + lower weekly dose or omit 1 dose and vit K 1-2.5mg PO- monitor >9- Hold warfarin and Vit K 5-10mg PO monitor |
| Lower Risk Dental- do you need to stop NOAC / Warfarin | Dental Extraction 1-2 teeth, scaling.- Interruption of warfarin / DOAC X 1 dose or use transexamic acid mouthwash 5ml TID before and after procedure |
| Dyslipidemia- Cardiovascular Risk Factors (9) | Age, Male, Smoking, DM, increase cholesterol, low HDL, HTN, Family hx of CVD <60, Overweight |
| Dyslipidemia- CCS Risk Factors to consider earlier screening (14) | Fm Hx of Premature CVD, Current smoker, obesity BMI >30, DM, HTN, ED, COPD, Chronic Renal Failure (egfr <60), AAA, First nations, Xanthomas |
| 2nd Causes of Increase LDL | Drugs- Diuretics, Steroids, Amiodarone, Retinoids Hypothyroidism, Anorexia, Pregnancy, Biliary obstruction |
| 2nd Causes of Increase TG | Oral estrogens, Steroids, B-Blockers, Thiazides, Tamoxifen, Antipsychotics, Retinoids, Obesity, pregnancy |
| Dyslipidemia- Lifestlye Management | Sat Fat <9%, Mediterranean Diet, DASH Diet, Exercise 30-60min, Smoking Cessation |
| AC/ AHA Guideline for Screening for Lipids - 2018 | Screen age 40-75, screen every 4-7 years Order lids at age 9-11 and again at 17-21 |
| Statin Induced Myalgia - Guideline | CK Normal- D/C Statin, Resume when asymptomatic, repeat 6-12 weeks after restarting CK <10X upper limit normal- Stop statin, follow CK until normal |
| CFP Guideline 2015- Lipid Screening | Male 40-75 Female 50-75 Consider >75 if longer life expectancy If on statin- no monitoring/screening |
| Do you stop a Statin | If pt on statin and tolerating, age is not a reason to stop |
| Heart Failure- Definition | Abnomral heart function results in or increase risk of clinic symptoms and low caridac output and pulmonary or systemic congestion |
| Heart Failure Stages | Class 1- Asymptomatic- no limits Class 2- Symptoms with ordinary activity, slight limits Class 3- Sympatoms with < ordinary activity, moderate limits Class IV- symptoms at rest, severe limits |
| Heart Failure Etiology Causes | Cardiac- Tachy, Valve dx, CAD, LVH Toxic Agent- Alcohol, Amphetamines, cocaine, steroids Pregnancy- cardiomyopathy, pre-eclampsia, Destation DM Inflammatory- Myocarditis Metabolic- DM, Thyroid, Adrenal insufficiency, Pheochromocytoma |
| Heart Failure- Precipitating Factors: FAILURES | Forgetting Med- BB, CCB, NSAID, Thiazide, Chemo Toxin Arrhythmia / Anemia- A. Fib + Anemia Ischemia / Infection- Worsening / New CAD, Pneumonia, Influenza Lifestyle- Increase salt, alcohol, increase fluid intake |
| Heart Failure- Precipitating Factors: FAILURES Cont URES | Upregulation- Pregnancy, Hyperthyroid Renal Failure- Increase Preload, Progression CKD Embolims- Right sided Stenosis- Worseing AS, RAS |
| Heart Failure Prevention | Exercise PRevent/Treat Cardiovascular Risk factors- Lipids, HTN, DM, Smoking |
| Heart Failure Signs | Fatigue, Wieght gain, Weakness, Confusion, Viral Symptoms Orthopnea, Chest Pain, Cough, Exertional Dyspnea, Nocturia, edema, Abdominal distension |
| Heart Failure- Physical | Confusion, Hypotension, Tachycardia, Tachypnea, Hypoxia, Increase Weight, Skin Pallor, cold, Increase JVP, Murmur S3, Dyspnea, Rales, Crackles, Abdomen Ascites, Extremities Edema, PVD |
| Heart Failure- PRIDE SCORE | HF <5 Low- 6-8 Intermiediate, 9-14 High Age >75, Orthopnea (2), Lack of Cough, Current Loop use, Rales on lung, Lack of fever (2), elevated BNP (4), Interstital Edema CXR (2) |
| Heart Failure - Investigations | Labs- Hbg, Ferritin, Cr, Urea, Sodium, Potassium, FBG, Lipids, TSH, U/A Troponin CXR- Kerley B Lines, Cardiomegaly, Vascular markings, Interstital Edema EKG- Tachy, A. Fib, LVH, Inverted T Waves, Q Waves, LBBB |
| Heart Failure- Investigations- Routine | Check Cr/Lytes 5-7 days after adjusting diuretic 7-10 days after adjusting ACEI/ARB, Spironolactone, NSAID Otherwise q1-3 months if stable Repeat Echo- 3 months after titrating meds and q1-3 years if stable |
| Heart Failure- Self Care- Patient Education | Monitor- Worseing cough, Dyspnea (at rest, with less excertion), edema, Weight gain >2kg in 2 d or 3kg in 7 days), dizziness, confusion, decreased appetite, impaired sleep |
| Heart Failure- Self Care- Non Pharmacotherapy | Monitor weight daily Regular Exercise Resistance Training 3-5d/wk Restrcit Salt 2-3d/d (1teaspoon) + Fluid restriction 1.5-2L/Day |
| Heart Failure- Pharmacotherapy | ACEI- Ramipril 1.25- 2.5mg BID , Lisinopril 2.5mg-5mg OD BB- Carvedilol 3.125mg BID, Bisopriolol 1.25mg od, Metoprolol CR 12.5mg OD ARB: Candesartan 4-8mg or Valsartan 40mg BID MRA- Spironolactone 12.5mg SGLT2- Dapagliflozin 10mg |
| Heart Failure- SGLT2- Dapagliflozin- when to add | Mild-Mod HF with LVEF <40% |
| Management of Acute HF | Referral after Inital HF diagnosis or after HF Hospitalization |
| Management HF- Criteria for Discharge | Symptoms Resolved, Vitals Signs stable / resolved X 24hrs, Returned to dry weight + stable 24hrs |
| Hypertension- Diagnosis with 1st visit if | Office BP >180/110 or HTN Emergency |
| Hypertension- Diagnosis Home with Visit 2 within 1 month of visit 1 | Daytime BP >135/85 or 24hr ambulatory BP >130/80 or home BP > 135/85 |
| Hypertension- Diagnosis Office with Visit 2 within 1 month of visit 1 | BP 140/90 and macrovascular organ damage / CKD |
| HTN: Monitoring | Lifestyle Change- q3-6m Pharmacotherapy- q1-2m until 2 consecutive reading in target then 3-6m Home Monitor- 1w per 3m |
| Hypertension- Behaviour Change | If BP < 160/100 or <140/90 + Macrovascular Damage / Cardiovascular risk. Exercise 30-60m 4-7d/wk Wt Loss Decrease ETOH DASH DIET Reduce Salt Stress Reduce |
| HTN- Pharmacology Approach- how to lower to target | Decrease BP 20/10 Aim BP control within 3 months When Combining, small doses of multiple better than big dose of few |
| Ischemic Heart Disease- STEMI Classification | >1mm in 2 consecutive leads of >2mm in V2+V3, can also have q waves |
| Unstable Angina Classification | Myocardial Damage. No ECG / Blood work changes |
| Ischemia Heart Disease- Risk factors - Modifiable and Non Modifiable | MODIFIABLE- smoking, DM, Obesity, HTN, Dyslipidemia, CKD, Inactivity, Depression NON Modificable- Age, Gender, family hx |
| Angina Criteria- Signs and Symptoms . 3 Major | 1. Substernal Chest Discomfort- Dull/ache/heaviness that might or might not radiate to the jaw, neck shoudlers or arms 2. Provoked by exertion or stress 3. Relieved within 5 minutes of rest or nitro use |
| Angina Criteria More signs and symptoms | Chest pain- discomfort / tightness / constriction / squeezing / burning- retrosternal 2-5min, stabbing Radiates to L Shoulder neck, jaw or BOTH ARMS Exacerbated by exertion / emotions / meals / lying down Relieved by rest / nitro / sitting up Hiccups |
| Differental For Chest Pain | Pericarditis / Dissection / Vale Dz / CHF Pneumonia / malignancy / PE GERD ? Hiatial Hernia / Biliary Colic Costochondritis / Herpes zoster Anxiety / Panic / Somatoform |
| Investigations for Stable Chest Pain | EKG- 50% normal, Increase ST, Decrease ST, NEW LBBB, New Q Wave Blood- CBC, INR< Lipids, FBG/A1C, LFT, Renal CXR Stress Test |
| Ischemic Heart Disease- Meds to consider to help with pain | AVOID NSAIDS- Naproxen safest Consider Tylenol, Tramadol |
| Ischemic Heart Disease MEDS- Long term use | Nitro- Spray used PRN BB: Heart Rate < 70 is target Long acting CBB if BB contraindicated Statin- Rosuvastatin 20-40mg ASA 81mg |
| Acute Management of ACS Chest Pain | ABCs- IVF, 02 If 02 <90% ASA 325mg chewd Plavix 300mg Nitro Subling 0.4mg 2 sprays q5min X 3 (if SBP >90) Morphine 3-5mg for pain |
| Acute Management of ACS Chest Pain- Order what? | EKG- if normal repeat in 30min ST elevated or ST depression, New LBBB or new Q Wave Blood work- Trop 3-6hr, CBC, INR |
| Other causes of increased Trop | CHF, Malignancy, Pericarditis, PE, Renal failure, Stroke, Sepsis |
| Acne- Contributing Factors | Hormones (cushings, PCOS, Adrenal Hyperplasia) Mechanical Environmental Emotions Drugs- Steroids, Lithium Dilantin |
| Acne- Differentials | Rosacea- Centra face, pustules, flush, telangiectasia Perioral Dermatitis- Only pustules, around mouth mostly Folliculitis- Pustules around beard area Acneiform- Drug reaction |
| Acne- Classifications- Mild/Mod/Severe | Mild- <20 comedones, <15 papules, No nodules Mod- 15-50, Pustules, rare nodules Severe- Mostly nodules, cysts, >125lesions |
| Acne Pharmacy- start with | Benzoyl Peroxide- 2.5-5% Start topical Retinoids- Adapalene |
| Acne Pharmacy- If Benzoyl and Topical retinoids don't work | Clindoxyl (Benzol Peroxide + abx) or Tactupump (Benzoyl Peroxide + retinoid) |
| Acne Pharmcy- If Clindoxyl don't work or Tactupump | OCT- Diane 35 Alesse Spironolactone 50mg-200mg od |
| Papulopustular (what systemic ABX) | Minocycline 100mg Doxycycline 100mg Oral ABX should always be combines with Topical benzoyl peroxide and /or topical retinoid |
| Isotretinoin- What do you monitor? | CBC, LFT and Lioids and 0, 1 and q3months |
| Isotretinoin- Dosing | 0.5mg/kg/d od-BID X 4 weeks then 1mg/kg/d X 3-7months |
| Skin Cancer- Melanoma- Clinical Features | A- Asymmetry B- Border (irregular) C- Colour (varied) D- Diameter (increasing or >6mm) E- Enlargement, elevation |
| Diabetes Type 1: Symptoms | Polyuria, Polydipsia, Unexplained Weight Loss |
| Diabetes Type 1: Complicatons | Macrovascular Disease- CVD, CVA, PAD) Microvascular Disease- Retinopathy, Nephropathy, Neuropathy), Infection, ED |
| Diabetes Type 1: Hypoglycemia (<4) | Palpitations, Sweating, Trembling, Anxiety, Hunder, Tingling, Confusion, Aeakness, Drowsiness, Vision Change, Headache, Dizziness, Seizure, COMA |
| Diabetes Type 1: Hypoglycemia Severe + Unconscious. Give what med? | 1mg glucagon subcut / IM |
| Diabetes Type 1: Hyperglycemia Symptoms | Polyphagia, Polydipsia, Polyuria, Blurred vision, Fatigue, Dry Mouth, Parasthesia, Arrhythmia, Coma |
| DKA- Describe it | Deep Rapid Breathing (Kussmaul) Confusion / Decreased LOC Dehydration Fruit smelling breath Imparied cognitive function Ab Pain (nausea/vomiting) |
| Diabetes Type 1- testing | Islet Autoantibodies usually present C-Peptite undetectable/low Insulin production abscent |
| Diabetes Type 1- Targets for Sugar | Preprandial (4-7) Postprandial (5-10) |
| Diabetes Type 1- Investgations and Targets | EKG- >40 years or DM >15years + >30 years and > CVD risk factor (smoker, HTN, family hx of premature CVD, CKD, Obesity, ED) |
| Diabetes Type 1: Goal for 3-6 months out of diagnosis | BP: < 130/80 A1C- target met over 6-12 months Each 1 % of A1C = 21% mortality Children and Adolescents <18 should have A1C <7.5 |
| Diabetes Type 1: Annual Labs | Fasting Lipid q1-3 years (q1yr in peds) If on statin +/- ezetimibe: repeat lipids in 3-6m Target is LDL <2 or >50% reduction |
| Diabetes Type 1: Optometry starts when? | Start 5 years after DX r/o retinopathy q1-2 years |
| Diabetes Type 1: When Albumin /Cr ratio and Cr | Start 5 years after diagnosis R/O nephropathy q1 year |
| Diabetes Type 1: Foot exam starts when | 5 years after hx- ROM, Skin, Neruopathy, PAD / pulses |
| Diabetes Type 1: when to get flu, pneumo shots | Influenza- q 1 yearly Pneumo X1 19-64 and then X1 >65 |
| Diabetes Type 1: Driving rules | Consider GB immediattley before driving Recheck BG every 2-4hrs while driving Keep Fast acting car and glucose monitor in car DON"T Drive if BG <4 Report to licensing body if on insulin and - SEVERE hypo while driving in past 12mon OR Hypo while awake |
| Type 2 Diabetes Definition | Metabolic disorder characterized by Hyperglycemia due to impaired insulin secretion and/ or defective insulin action |
| Risk Factors for T2DM | 1st degree relative with it Hx of prediabetes / Gestational DM Vascular risk factor (low HDL, increase TG, HTN, Obesity, smoking) |
| Type 2 DM: Symptoms and Complications | Symptoms: Polyuria, Polydipsia, Unexplained weight loss Complications: Macrovascular dx (CVA, CVA, PAD) Microvascular (Retinopathy, Nephropathy, Neuropathy) |
| Type 2 DM: Hypoglycemia (<4) symptoms | Palpitaitons, swearing, Trembling, anxiety, hunger, tingling, confusion, weakness, drowsiness, vision change, headache, dizziness, seizure |
| Type 2 DM: Hyperglycemia symtpoms | Polyphagia, Polydipsia, Polyuria, blurred vision, fatigue, dry mouth, parasethesia, arrhythmia, coma |
| Type 2 Diabetes: Screening of Adolescents | q 2years with A1C and FPG / random BG IF > 3 if non pubertal, >2 if pubertal if: obesity, ethnic group, Relative with T2DM, |
| Type 2 Diabetes: Adults screen if | > 40 (use both FBG + A1C if 70-80) q3years Regardless of age and more frequent (q6-12m) if risk factors or canrisk score very high |
| Type 2 Diabetes- Lifestlye Modifications | Nutrition- 45-60% carb, 15-20% Protein, 20-35% fat Regular meals Low glycemic carbs and reduced refined carbs Fiber 30-50g Mediterranean diet ETOH 2hr after dinner can can decrease glucose in AM |
| Type 2 Diabetes- Physical Activity | Aerobic- consider alternating short periods of high + low. 150min over >3d/wk Resistance >2X/wk Weight loss- 5-10% (90%Q are overweight) |
| Type 2 Diabetes- Pharmacology If A1C <1.5 from target or >1.5% from target- use what? | A1C <1.5 away- Consider meds, start if not in target in 3months A1C >1.5 away- Start meds + consider 2 agents- target achieved in 3-6months |
| Type 2 Diabetes: What is the gold standard for starting med? | Biguanide- Metformin |
| Type 2 Diabetes: What is Biguanide medications | Metformin |
| Type 2 Diabetes: What are some DDP-4 Inhibitors | Linagliptin (trajenta) 5mg Saxagliptin (onglyza) 2-5mg Sitagliptin (januvia) 100mg |
| Type 2 Diabetes: What are some Insulin Secretagogues (sulfonylurea) | Gliclazide (diamicron) 30-120mg Glyburide (diabeta) 1.25-10mg BID Repaglinide (gluconorm) 0.5mg-4mg TID |
| Type 2 Diabetes- SGLT2 Inhibitors | Canagliflozin (invokana)- 100mg-300mg Empagliflozin (Jardiance)- 10-25mg Dapagliflozin (Forxiga) 5-10mg |
| DKA- How does it happen | Absence of insulin- decrease glucose utilzation- increase triglyceride, breakdown into free fatty acides then ketone production |
| Risk factors for DKA | Infection (UTI/Pneumonia/sepsis) Alcohol misure Stress Pregnacny Stroke/MI Trauma Meds: Steroids, thiazide GI- pancreatitis or obstruction No causes- 40% |
| DKA Signs and Symptoms | Polyuria, polydypsia (hyperglycermia + dehydration) Fatigue, Lethargy, Weakness, Vision change, Mental status change, headache, Nausea, Vomiting, AB Pain Tachycardia, rapid breathing |
| DKA Management- Adult | Rehydrate- NS 1-2L/hr Check Na- If corrected Na normal swtich to 1/2ns When Glucose <14- go D5W to maintain glucose 12-14 When K <5.5 and pt urinating - add KCL Insulin- Correct Hyperglycemia after K>3.3 Infusion- Short acting Insulin 0.1u/kg/hr |
| Subclinical Hypothyroidism | No treatment if TSH <10, normal T4, asymptomatic, not pregnant 62% normalize within 5 years |
| Hypothyroidism- Treat if | TSH 5-10 and Elevated TPO antibodies Goitre Strong family hx of autoimmune disease Prengnacy |
| Cholecystitis- definition | Inflammed gallbladder 2 to impacted gallstone |
| Choledocholithiasis - definition | Gallstone in the common bile duct |
| Cholangitis- definition | obstruction of common bile duct causing biliary sepsis |
| Diverticulitis- Definition | Infection or perforation of the diverticulum (abnormal sac or pouch protruding from the wall of a hallow organ |
| Diverticulitis- Signs and Symtoms | Fever LLQ pain / Tender often for days Possible LLQ mass (abscess) Alternating Constipation / Diarrhea, Urinary Symptoms Nausea/vomiting |
| Diverticulitis- Investigations | AXR- free air, localized diverticulum CT- 97% sensitive |
| Diverticulitis- Management | Outpatient: Bowel rest + clear fluids X 2-3 days Abx: Cipro 500mg BID + Flagyl 500mg BID X 7-10days |
| Pancreatitis: Etiology | I GET SMASHED Idiopathic, Gallstones, Ethanol, Tumors, Scorption stings, Microbiology, Autoimmune, Sugery/Trauma, Hyperlipidemia TG>11, Hypercalcemia, EMBOLI, Drugs- Lasix, h2 blcokers, Estrogen |
| Pancreatitis: Signs and Symptoms | Pain- Persistent, epigastric, non colicky, radiates to back, decrease pain leaning forward, N+V, fever, jaundice, tachycardia, hypotension, Cullens (umbilicus) / Gret Turners (flank) |
| Pancreatitis: Complications | Abscess Lungs- Pleural Effusion, Pneumonia, ARDS ARF- due to hypovolemic shock CVS- pericardial effusion, pericarditis |
| Pancreatitis: Investigations | Increase WBC Increase Amylase Increase Lipase Increase ALT >100 AXR- sentinel Loop, U/S, CT, ERCP |
| Pancreatitis: Management | IVF- NS or Ringers lactate- goal to normal vitals and urine output NPO, NG Suction early Analgesia Follow clinical with CT Drain Abscess |
| Celiac: Definition | Immune medical condition in which ingested gluten (wheat/rye/barley) casues damage to the absorptive surface of the small intestine (villous atrophy) |
| Celiac: Screening / Testing Consider If? | Ab pain/bloating, Chronic diarrhea/constipation/IBS, weight loss, Chronic fatigue, Enamel defects, Dermatitis herpetiformis, Aphthous stomatitis, Iron Deficiency, Infertility |
| Celiac: Complications? | Nutritional deficiencies, Autoimmune disorders + Malignancies |
| Celiac: Pediatric Signs and Symptoms | Anorexia, Chronic Constipation, Delayed puberty, Irritability, Recurrent vomit |
| Celiac: GI Symptoms | Ab distention / pain Chronic Diarrhea (50%) Steatorrhea Anorexia Weight loss, |
| Celiac: Non classic Signs / Non GI Symptoms | Irritability Dermatitis Herpetiform- pruritic papulovesicular rash affecting extensor surfaces, such as the shoulders, elbows, knees, back and buttock. Peripheral neuopathy, ataxia, epilepsu, migraine, depression. Elevated Liver enzymes |
| Celiac: Investigations | Response to gluten free diet shouldn't be used to diagnose celiac. Can be sensitive that is not celiac and does NOT have same associated nutrional deficiency risk |
| Celiac: Management | Gluten free for life (Proteins from Wheat, barley and rye) Introduce OATS with caution Test and treat deficiencies (b12, vit D, Calcium, folate, iron) Referal to dietitian Screen 1st degree relatives T-Cell lymphoma risk |
| Crohn's Disease- definition: | Inflammatory disease primarily affecting the gut (potentially entire gut) but usually ileum + colon |
| Crohn's Disease: Risk Factors | Smoking, Ashkenazi Jews |
| Crohn's Disease: Exacerbating Factors | Infection Smoking, NSAIDS |
| Crohns DIsease: Signs and Symptoms | Abdo Cramping Chronic / Nocturnal Diarrhea + weight loss Postprandial Pain, RLQ pain Rectal Bleeding Anemia Fistulae Fatgiue Fever |
| Crohn's Disease: Exraintestinal Features | Dermatology- Erythema Nodosum Pyoderma Grangrenosum Rheumatic- inflammatory arthropathy Occur- Uveitis Hepatobilliary- Primary sclerosing cholangitis Urologic- Calculi, Ureteral Obstruction |
| Crohns: Differential | Diverticulitis Infection Malabsorption (celiac/lactose) Malignancy (colon CA) Pancreatitis Ulcerative Colitis IBS |
| Crohn's Disease: What does Fecal Calprotectin Help distinguish between? | IBS and IBD |
| Crohn's Disease: Initial Investigation | CBC, CRP, ESR, LFT B12, Albumin Serology for celiac Stool culture + C. Diff Consider CXR (? TB) Hep Screen in prep for biologics |
| Crohn's Disease: Complications of IBD | Urinary Calculi Liver Problmes Cholelithiasis Retardation fo growth Arthralgias Vitamin Deficiencies Eyes Colon Ca Obstruction Leakage Iron Deficiency Stricture |
| GERD: Definition | Symptoms or mucosal damage produced by abnormal reflux of gastric contents into the esophagus, oral cavity or lung |
| GERD: Etiology | Transient LES relaxation Decrease LES tone Impaired esophageal Clearance Delayed gastric emptying Decrease Salivation |
| GERD: Risk Factors | Obestiy Spicy/fatty/citrus foods Caffeine / Alcohol / Smoking |
| GERD: Symptoms | Heartburn (retrosternal Burning sensation that may rise to the back of the throat) Acid Regurgitation Chest pain Cough Globus sensation Dyspepsia, nausea, bloating, Belching |
| GERD; RED FLAG SYMPTOMS | Vomiting Evidence of GI blood loss Anemia Involuntary Weight loss Dysphagia Chest Pain |
| GERD: Complications | Esophageal Erosions Ulcers Hemorrhages Strictures Barrett's Esophagus Asth/aBronchitis Pulmonary Fibrosis Aspiration Pneumo Laryngitis Dental Erosions |
| GERD: Medications and Herbals Associated with GERD | Anticholinergics Caffeine CCB Estrogen Ethanol Opioids Nicotine Progesterone Alendronate ASA Clindamycin Iron NSAIDS Tetracyclines |
| GERD: investigations | CBC- r/o anemia DO NOT routinely do endoscope DO NOT test of H. Pylori before starting treatment for typical GERD |
| GERD: Lifestyle Changes | Wieght loss Elevate head of bead Avoid meals 2-3 hr before bedtime |
| GERD: Management: Mild GERD <3 epidoes / week, short duration | OTC antacids Low dose histamine H2 receptors Assess after 1 month |
| GERD: Management: Moderate / Severe | PPI- use in morning For 4- 8 weeks Rabeprazole 20mg is cheapest and equal efficacy |
| GERD: Management: Inadequate response to PPI | Try double dose or PPI BID after adequate trial 8-16 weeks |
| GERD: Management: Long term- Do you screen adults for esophageal adenocarcinoma or barretts? | NO |
| GERD: Long term use PPI risks? | Hip fracture C. Diff Pneumonia Decrease Vit B12, Magnesium, Iron, hypopathathyroid |
| IBS: Definition | Functional bowel disease, characterized by recurrent ab pain and altered bowel habits with bloating |
| IBS: Signs and Symptoms | Altered Bowels (Constipation- diarrhea) Sensation of incomplete evacuation or urgency Pain- diffuse or left lower No radiation Precipitated by meals / stress, improved by defecation Ab distention, bloating, gas Clear white mucus Dyspepsia |
| IBS: ROME IV Criteria | Recurrent ab pain, 1 day per week in last 3 months with 2 of the following Related to defication Associated with change in frequency of stool Change in form of stool Abnormal frequency (>3/d or <3/week) Form (lumpy/hard/loose/watery) |
| IBS: Differential | Infectious IBD (crohns, UC) Malabsorption / Food intolerance Metabolic (thyroid) Neoplasm Anxiety disorder |
| IBS: Aggravating Factors | ETOH Caffeine Fat Fibre Sorbitol Stress Menstruation |
| IBS: Managmet | FODMAP Diet- short term 4 weeks with dietitan diet Probiotic- lactobacillus Exercise (helps blaoting and constipation) Bloating- Peppermint oil Bentyl 20-40mg TID-QID Buscopan 10-20mg TID |
| IBS: Diarrhea Predominant | Soluble fibre, FODMAPS, Probioitcs TCA med- Amitriptyline 10-100mg Don't use Cholestyramine |
| IBS: Constipation Predominant | Soluble FIber, Exercise, fluid intake SSRI(fluoxetine, paroxetine, citalopram) |
| Peptic Ulcer Disease / H. Pylori Symptoms | Upper ab discomfort Nausea Bloating Fullness Early Satiety Dyspepsia Bloating Distention Belching Heart burn Melena |
| Peptic Ulcer Disease / H. Pylori RED FLAGS | VBAD: Vomit Bleeding / Anemia Ab Mass / Weight Loss Dysphagia Family Hx of GI Cancer Peptic Ulcer previously |
| Peptic Ulcer Disease / H. Pylori Precipitating Factors | Dietary- Indiscretion (caffeine, high fat) excessive alcohol, smoking NSAIDs >12 weeks Prescrtiption Meds- CCB, Bisphosphonates |
| Peptic Ulcer Disease / H. Pylori Investigations | Anemia + FIT test Urea Breath test Blood Test (if no previous hx of H. Pylori) If <50- no alarm symptoms, no nsaids, no gerd Endoscopy- if >50, Alarm features, fail repeated trial of therapy |
| Peptic Ulcer Disease / H. Pylori Lifestyle modifications | Eat small frequent Meals Stop smoking Reduce alcohol, caffeine, avoid irritating food Maintain ideal wegiht |
| Peptic Ulcer Disease / H. Pylori Empiric Treatment | Don't preteat with PPI until H. Pylori results are knwon as it can decrease efficacy of H. Pylori Treatment |
| Peptic Ulcer Disease / H. Pylori Treatment Meds- CLAMET | CLAMET: Amoxicillin 1000mg BID and Clarithromycin 500mg BID and Flagyl 500mg BID and PPI BID X 14 days |
| Peptic Ulcer Disease / H. Pylori Treatment Meds- Quad Therapy | Bismuth 2 tabs QID, Flagyl 500mg QID, Tetracycline 500mg QID and PPI BID X 14 days |
| Ulcerative Colitis: Definition | Immune mediated inflammatory disease affecting colonic mucosa anywhere from the rectum to cecum, but RECTUM is ALWAYS involved |
| Ulcerative Colitis: Signs and Symptoms | Relapsing and Remitting Rectal Bleeding (hematochezia) Mucous Diarrhea Increase Inflammation= Increase Stool volume and blood Tenesmus (sense of pressure), urgency and incontinence Ab Crmaping / Pain Fever, anorexia, weight loss, fatigue |
| Ulcerative Colitis: History should include ? | Severity Triggers (smoking, NSAIDs, Infection) Frequency of BM Number of nocturnal BM Proportion of BM with blood mixture |
| Ulcerative Colitis: Extraintestinal Features | Dermatology- Erythema nodosum, Pyoderma, Perinala skin tages, Oral Mucosa lesions, Psoriasis Rhematologic- Joint pain Ocular- Uveitis Herpatobiliary- Cholelithiasis, fatty liver Urologic- Calculi, Fistulas |
| Ulcerative Colitis: Differential | Salmonella, Shingella, Yersinia, Campylobacter, Parasitic C. Diff Malabsorption - celiac / lactose |
| Ulcerative Colitis: Investigations: Initial | Colonoscopy to distal ileum + Biopsy CT Abdo- acute setting only Fecal Calprotectin Hbg, CRP, ESR, Albumin Celiac Stool culutre and C. Diff |
| Ulcerative Colitis: Poor Prognosis Factors / Risk of Colectomy | Age <40 diagnosis Extensive colitis Hospitalziation of colitis Elevated CRP Low serum Albumin |
| Contraception: mechanism | Suppresses Gonadotropin Section, preventing ovulation Endometrial atrophy preventing implantation Viscous Cervical mucus preventing sperm transport Falloprian sectretions + motility egg + sperm Transport |
| Contraception: Contraindications (cat 4- ABSOLUTE) Combo Hormone | <4w Postparum (breast feeding) < 21 d postpartum (not breastfeeding) Smoker (.15 cigs/day) >35 y/o Vascular Disease HTN 160/100 ACte VTE Hx of VTE not on anticoagulants CAD CVA SLE Migraine with aura Current Breast CA |
| Contraception: Contraindications (cat 3- risks usually outweigh benefits) COMBO Hormone | 4-6 wk postpartum with other risk factors for VTE VTE on anticoagulants with no risk factors MS Smoker (<15 cit/day) > 35 Risk factors for CVD Controlled HTN HTN < 160/100 Hx of breast CA with no recurrence in 5 years Gallbladder disease |
| Contraception: Combined oral contraceptive What is only exam needed? | BP is only exam needed |
| Contraception: Combined oral contraceptive Prescription on how to use | R/O pregnancy Start 1st Sunday of Period Facts: Non cause cancer, no pill breaks, doens't affect fertility, doens't cause birth defects can be used >35 years old, doens't cause acne |
| Contraception: Evra Patch When is it leff effective | If wt is >90kg |
| Contraception: Evra Patch Rx | Same start as COC 1 patch/wks X 3 weeks then 1 week off Buttock, deltoid, lower abdo, upper torso KEEP IN FRIDGE |
| Contraception: Evra Patch FACTS | Ok in shower/exersise 20% sin reaction Decrease Breakthrough bleeding < COC Increase Breast tenderness N/V Dysmenorrhea |
| Contraception :Nuvaring Rx | Same start as COC Ring X 3 weeks then 1 week ring free Keep in fridge |
| Contraception :Nuvaring S/E | Leukorrhea 25% foreign body sensation Coitus issue Expulsion Decrease Acne, Nausea, mood lability Shorter perido than COC No wt gain |
| Contraception :Progestin Oral Contraceptive Rx | 1st day of menstrual cycle Take same time of day (within 3 hrs) If started >7 days after LMP, use backup X 7 days |
| Contraception :Progestin Oral Contraceptive Trouble shoot Irregular Bleeding | If no other cause Add NSAID Change to combined OCP Supplement Estrogen |
| Progestin Mechanism | Alters cervical mucus Partial ovulation suppression |
| Progestin Injection (depo-provera) Rx | 1st 5 days of period or r/o pregnancy, give immediately Backup X 7 days and recheck for pregnancy in 3-4 weeks If w14- no unpretected sex- test for preg and give dose Counsel- vit D, Ca, no smoking, wegiht bear exercises |
| Progestin- Depo-Provera Trouble shooting Irregualr bleeding after 6m | If no cuase found Advil 800mg BID X 5 days Add OCP for 1-3 months Tranexamic acid 500mg BID X 5 days Conjugated equine estrogen 0.625-1.25mg daiyl X 28 days |
| Intrauterine Device IUD Absolute Contraindication | Pregnancy Recent PID Recent STI within 3 months Puerperal Sepsis Post septic ABortion Unexplained vaginal BLeeding Cervical/endometrial CA Progesterone receptor positive Breast CA |
| Intrauterine Device IUD- Beneftis | Decrease Menstral Flow Decrease Dysmenorrhea All IUDs decrease endometrical CA |
| Intrauterine Device IUD Facts | Can use in nulliparous Does not cause infertility Can keep IUD while treating PID CPS recommends IUD as 1st line for adolescents |
| Intrauterine Device IUD Rx | Insert at any time (while menstruating, decrease risk of pregnancy, increase risk of infection Increase risk of expulsion. If inserted >7 days from LMP- use backup X 7 days F/U in 4-12 weeks after insertion- routine U/S NOT REQUIRED |
| Dysmenorrhea Primary- Definition | Pain occuring during menses in the abscence of pelvic pathology |
| Dysmenorrhea secondary- Definition | Manstrual pain associated iwth underlying pelic pathology (ex.. endometriosis) |
| Dysmenorrhea-Pathophysiology | Believed to be associated with painful uterine contractions (causing uterine ischemia) tirggered by progesterone withdrawal |
| Dysmenorrhea- Risk Factors | Impves with - Age Worsens with SMoking Frequent life changes Fewer social supports Stressful close relationships Mood disorder |
| Dysmenorrhea: Symptoms | Cramping / colickly Suprapubic pain Lower abdo but can go to bother lower quadrants, lumbar area , thighs Occurs few hours before and few hours after onset of menstrual bleeding Persist for 2-3 days Diarrehea N/V Fatigue Headaches |
| Dysmenorrhea: History questions | Menarche Length/regular cycles Amount of bleeding Pain location Radiation Associated symptoms Severirity Duration Pregression GI symptoms not related to menses Dyspareurnia Contraceptions STI PID Violence Pelvic surgery Moods Previous Tx |
| Dysmenorrhea: Physical Exam | Abdo Exam: R/O palpable Pathology Pelvic Exam is NOT needed in pt who has NEVER been sexually active |
| Dysmenorrhea: Differential | Endometriosis Adenomyosis Uterine Myomas Cervical Stenosis Lesions PID Pelvic Adhesions IBS IBD I.C Mood Disorder Myofacial Pain |
| Dysmenorrhea: Pharmacotherapy | Tylenol NSAID Start at onset of bleeding or 1-2 days prior Mefenamic Acid 500mg loading then 250 q8hrs (1000mg/d) Naproxen 500mg loading- then 250mg q4-8hrs prn (daily 1250) Ibuprofen 600mg loading- then 400mg q4-6hrs (2400mg/d) |
| Endometriosis: Definition | Presence of endometrial glands + stroma tissue outside of the urterus |
| Endometriosis: Risk Factor | Family Hx (3-10X risk) Anatomy- causes backflow Nulliparity Short menstrual cycle Diet in red meat and trans fats Decrease Risk Multiparity Prolonged/Irregular menses |
| Endometriosis: Symptoms and Signs | Dysmenorrhea Deep Dyspareurnia Dyschezia Dsuria Lower back / Ab discomfort Chronic Pelic Pain Infertility |
| Endometriosis: Physical exam | Pelvic- Retroverted / Fixed uterus (suggests adhesions |
| Endometriosis: Investigations | U/S- r/o ovarian cysts / fibroids GOLD STANDARD- Laparoscopy |
| Endometriosis: Treatement | Trail 1st line- 3-6m Combined pill therapy Progestin only therapy IUD GnRH agonist with HT add back |
| Menopause: Definition | No cycle for 12 months Premature- if <40 years old If not on hormonal contraceptive- assume sterility if >50 and amenorrheic for 1 year <50 and amenorrheic for >2 years |
| Menopause: Epidemiology | Median age 51.3 but irregular menses marks the menopause transition begins 4 years prior |
| Menopause: Risk of early menopause | Smoking (median age 50.2) Surgery, chemo, radiation |
| Menopause: Signs and Symptoms | Vasomotor symptoms increase as stages of menopause progress Should start to decrease within 4 years of final peroid 10% have sypmtoms 7-10 years after final peroid Hot flashes/flush- palpitations/sweating Vaginal Dryness |
| Menopause: Signs and Symptoms continued | UTI increase (urogential AtrophY) Sleep Disturbance- 2nd to night sweats Skin changes (thinning) Mood disorder- depression, anxiety Forgetfulness Back pain, stiffness Vertigo/headache Sexual Dysfucntion |
| Menopause: Lifestyle modifications - Vasomotor | Smoking Cessation Decrease ETOH Exercise Dress in layers |
| Menopause: Lifestyle modifications - Urogenital Symtoms | Vaginal Moisturizer (replens) Regular Sexual activity (increase blood flow) Kegel Exercises |
| Menopause: Differential: Hot flashes and night sweats (vasomotor) | Stress Panic attacks Alcohol Thyroid Infections Carcinoid Syndrome Pheochromocytoma Leukemia Neoplasm |
| Menopause: Menstrual Irregularity | TSH Pregnancy Pathology Pathology (vaginal Cervical ) OCP Hyperprolactinemia |
| Menopause: Pharma- For Vasomotor Symptoms | Attempt to withdraw every 6-12m If uterus intact- Estrogen and Progesterone (min 12d/month If patient had hysterectomy for endometriosis- Just estrogen |
| Menopause: Pharma- For Vasomotor Symptoms MEDS | Estrogen Only- Premarin or Estrace Progesterone Only- Prometrium Estrogen and Progesterone- Activelle |
| Pulmonary Embolism: Clinical Features | Sudden onset of Dyspnea Pleuritic chest pain Syncope Hemoptysis Tachypnea Tachycardia Hypoxemia Hypotension |
| Pulmonary Embolism: EKG looks like? | RV Strain S1Q3T3 RBBB T inversion in lead V1-V4, Tachy |
| Bronchiolitis: Definition | Lower Tract Respiratory Infection (LRTI) Caused by RSV (respiratory Synytial Virus) Other cauaes- flu, Rhino, Adeno, Parainfluenza |
| Bronchiolitis: Epidemiology- Most common in ? Starts in what months | LRTI in childen <2y/o Begins Nov-Jan and lasts 4-5months |
| Bronchiolitis: Signs and Symptoms | Usually proceeded by 2-3d URTI Cough, fever and +/- Rhinorrhea Progresses to Wheezy cough Inspiratory crackles or expiratory wheeze Crackles Tachypnea >70 Nostril Flaring Intercostal indrawing Desaturation Lasts 3-14 days |
| Bronchiolitis: Investigations? | CXR: Non specific- Patchy, hyperinflation NPS: does NOT alter management |
| Bronchiolitis: Treatment | 02: if sat <90% Hydration Epinephrine Nebs Possibly OKAY Nasal Suction 3% Hypertonic Saline Nebulization Combines Epinephrine and Dexamethasone |
| Common Cold: Signs and Symptoms | Generally "unwell" Chills Rhinorrhea + Congestion + Sneezing Sore throat Pain in facial Bones Earache Cough- can last up to 18 days |
| Common Cold: Signs and Symptoms | High Fever Rash Neck Stiffness Lethary Rash Decrease Muscle Tone Signs of AOM, Sinusitis, Chest Pathology- Crackles, rales |
| Common Cold: VIt C decrease symptoms how many day? | Decrease by 1-2 d by using 1G/day |
| Croup: Definition | Childhood Respiratory Illness caused by variety of viruses- usually parainfluenza |
| Croup: Epidemiology | Usually 6m-3years boys>girls Usually autumn, winter (Sept-Dec) |
| Croup: Etiology and Pathophysiology | Viral Infection Causes upper airway mucosa edema and airway inflammation Subglottic region narrows causing upper airway obstruction |
| Croup: Signs and Symptoms | Abrupt / rapid onset Barking cough Usually at night Inspiratory stridor Hoarseness Respiratory distress Fever |
| Croup: Signs and Symptoms | Fluctuate iwth calmness Can be proceeded by URTI (cough, rhinorrhea, fever) Usually lasting 3-7 days Can be Tachycardiac, Tachypnea (moderate <50ppm) |
| Croup: Investigations | CXR- Steeping (cone shaped narrowing instead of normal square subglottic area, suggests croup |
| Croup: Management | Dexamethasone 0.6mg/kg PO X 1 dose Max 10mg Can consider IM if vomiting or significant respirology disease Improves within 2-3 hrs and persists for 24-48hrs In ER: Epinephrine 5ml 1:1000L-epiniphrine via neb over 15min Lasts up to 2 hrs |
| Croup: When to admit | Sternal Wall indrawing Stridor at rest |
| Mononucleosis: Investigations | EBC Serology- Monospot test CBC- Elevated WBC, no anemia ESR- Elevated in EBV, not in strep Mild increase in LFTs (not GGT or ALP) If severely elevated suspect viral hepatitis) |
| Mononucleosis: Management | Monitor CBC weekyl to observe trend of WBC to normal No medications Can return to sports after 3 weeks 4 weeks if in contact sports |
| Otitis Media: Definition of AOM | Inflammation and pus in the middle ear accompanied by signs and symptoms of ear infection |
| Otitis Media: Definition of Myringitis | Inflammation fo the tympanic membrane alone or associate with otitis extrena |
| Otitis Media: Definition of OME (otitis media with effusion) | AKA serous otitis media Fluid in the middle ear without symptoms of acute inflammation |
| Otitis Media: Definition of Chronic Suppurative Otitis Media | Persistent inflammatory process associated iwth perforated tympanic membrane and draining exudates for >6 weeks |
| Antibiotics for AOM: | Amoxicillin 80mg/kg/d divided by BID OR 60mg/kg/d divided by TID or Cefprozil 30mg/kg/d divided by BID |
| AOM referral when? | >3 episodes in 6months >4 episodes in 12 months Retracted TM Hearing Loss- ENT |
| Pneumonia: Symptoms | Need at least 2: Fever, rigors New cough +/- sputum Chronic cough with change in colour of sputum Hemoptysis Pleutritic Chest pain Dyspnea Sweats Weight loss AND Auscultatory findis (crackles, bronchial breath sounds) and New opacity on CXR |
| Pneumonia Symptoms PEDS | Fever Cough Increase work of breathing Decrease feeding Vomiting Chest/Ab pain |
| Pneumonia: Exam | Temp: >37.8 Tachypnea >25/min Diminished chest expansion Increase Tactile Vocal Fremitus Dullness to percussion Diminished air entry Brachonical sounds Crackles Pleural Rub Egophony |
| Pneumonia Severity score is called what? | CURB65 |
| Prostatitis: Epidemiology | Most common urologic diagnosis in men >50 |
| Prostatitis: Risk factor for Acute Bacterial Prostatitis | Indweling or intermittent catheter DM Immunosuppression |
| Prostatitis: Signs and Symptoms | UTI Irritative and obstructive voiding symptoms Abrupt voiding sypmtoms Fever/chills Pain in lower back/rectum/perineum/scrotum/penis or inner part of leg Prostate warm, firm, swollen, tender Irritative or obstructive genitoruinary syptoms |
| Prostatitis: Treatment | Fluoroquinolon 2-4weeks Septra- 2-4weeks |
| Concussion: Physical (11) | Headache Nausea Dizziness Visual Disturbances Photophobia Phonophobia LOC Amnesia Loss of Balance/Poor Cordination Vertigo Tinnitus |
| Concussion: Signs and Symptoms | Loss or decrease Consciousness less than 30min Lack of memory for events immediate or before or after injury <24hrs Alteration in mental state at the time of the injury (slow thinking) Physical Symptoms: Headache, Weakness, Vision) |
| Concussion: Emotional / Behaviour | Irritability Emotional Lability Sadness / Depression Anxiety Fatgiue ? Lethargy / Drowsiness Inappropriate emotions |
| Concussion: Cognitive | Slowed Reaction Times Difficulty concentrating Difficulty remembering Confusion Feeling in a fog Feeling dazed |
| Concussion: Sleep | Drowsiness Trouble Falling Asleep Sleeping more than usual Sleeping less than usual |
| Concussion: Complicatons | Poor attention Concentration down Decrese speed proceessing Impaired memory and learning |
| Concussion: Differential | Chronic Pain Syndrome Cervical Strain Whiplash Fibromyalgia |
| Concussion: Discharge from ER | Normal Mental status with clinical improving post concussive symtpoms after observation until at least 4hrs post injury |
| Concussion: Discharge from ER | No clinical risk factors indicating CT |
| Concussion: Indictors for prolonged observation are? | Clinicla deterioration Persistant abnromal CHS or focal neurological deficit Abnormal mental status Vomiting / Severe headache Known coagulopathy Drug / Alcohol intoxication Multi system Injury Presence of concurrent medical problems > 65 year old |
| Concussion: CT scan? | Note increase lifetime risk of cancer with radiation exposure PEDS: PECAN |
| Canadian CT Head Rule: High Risk | High Risk: GCS <15 after 2 hrs from injury Suspected open or depressed skull fracture ANy sign of basal skull fracture (hemotympanum, Racoon eyes, CSF otorrhea / rhinorrhea, battle's sign > 2 episodes of emesis > 65 |
| Canadian CT Head Rules: Medium Risk | Amnesia before impact of >30min Dangerous mechanisms- Occupant ejection Fall from elevation > own height or 5 stairs |
| Concussion: General Approach | DOnt' drive 24 hrs Supervision for 24-48hrs Acute 0-4W-Educate- reassure (most recover in 3 months) Post Acute 4-12w- Refer to interdisciplinary team if symptomatic |
| Concussion: Post Traumatic Headache | 30-90% with COncussion Investigations: Brain CT / MRI if neurological S&S of intercranial pathology Use headache diary |
| MIgraines: RED FLAGS | SNOOPS: Systemic- Fever, HTN, Myalgia, Scalp Tenderness Neuro: Confusion , LOC, Visual Field Defect, CN Asymmetry Weakness, Reflex Asymmetry Onset: Sudden / Abrupt / Split Second Older Patients: > 50 y/o |
| Migraine: Investigations: Do you need CT? 4/5 symptoms | IF 4/5 symptoms: Pulsatile Duration 4-72 HOURS untreated Unilateral Nausea Disabling |
| Abortion: Inevitable | Cervix Dilated No products expelled |
| Abortion: Incomplete | Some but not all prodcuts expelled Retained products |
| Abortion: Complete | All products of conception expelled |
| Abortion: Missed | Fetal Demise but no uterine activity |
| Abortion: Recurrent / Habitual | > 3 consecutive pregnancy losses |
| Abortion: Risk Factors | Advanced Maternal Age Thrombophillia Autoimmune Infection (BV, HSV) Previous spontaneous abortion Conception within 3-6m of previous delivery IUD Uterine abnormalities (adhesions) Smoking / cocaine / alcohol / heavy caffeine use |
| Post Partum Routine Management | 6 B's Brain- Blues vs Depression Breasts: Feedign / formula or combo Blood Pressure- Gestational HTN Bladder / Bowel- Incontinence / UTI Bleeding: colour / smell / clots (increase or decrease) Baby: Bonding / Feeding / Health Concerns |
| Post Partum: Physical Exam | Vitals Signs of anemia Abdomen (BS, distention , palpate uterus) |
| Post Partum: Contraception | Non Lactating- Can begin combo OCP 3 weeks postpartum Lactacting: Micronor 6weeks postpartum change to OCP when patient introduces supplemental feeding or begin OCP at 3 months if breastfeedign exclusively Can give IUD 6 weeks postpartum |
| Post Partum 6 weeks followup | Bladder/Bowel Bleeding / pelvic Brain: Do depression screen on all Brest: feeding and formula Baby; Bonding Confirm last pap- can do if due for one- but usually wait 3 months |
| Post Partum: risk identification GDM | 75g ogtt 6w-6m postpartum and A1C q1-3 years |
| Pregnacny Induced Hypertension Definition | Office / Hospital BP: >140/90 (avg two reading, 15 min apart) |
| Elbow / Shoulder: Causes of elbow Pain- Anterior | Bicep Tendinopathy OA R/A Gout Pronator Syndrome |
| Elbow / Shoulder: Causes of elbow Pain- Posterior | Olecranon Bursitis Triceps TEndinopathy Posterior Impingement |
| Elbow / Shoulder: Causes of elbow Pain- Lateral | Lateral Epicondylitis Pica Radial Tunnel Syndrome |
| Elbow / Shoulder: Causes of elbow Pain-Medial | Medial Epicondylitis Cubital Tunnel Syndrome Ulnar Collateral Ligament |
| Elbow / Shoulder: Bursitis what is it? | Jelly like sac that contains synovia fluid that lies between tendon + bone/skin |
| Elbow: Medial Epicondylitis (golfers Elbow) what tendons involved | Tendinopathy of common flexor tendon (usually flexor carpi radialis and the pronator teres) |
| Elbow: Lateral Epicondylitis (Tennis Elbow)- what extensor? | Tendinopathy of the suprinator (extensor carpi radialis brevis) |
| Clavicular Fracture: Classifications and when to refer? | Group 1- middle 1/3. Group 2- distal 1/3- refer to ortho- increase risk of non union Group 3- medial 1/3- almost always non operative ER Suspect posterior sternoclavicular dislocation (difficult breathing, asymmetric pulses, asymmetric clavicle) |
| Ottawa Ankle Rules- sensitivity in Adults? What about kids <18? | Adults sensitivity is 100% Children - not recommended to use |
| Ottawa Ankle Rules: x-ray if? | Pain in Malleolar Zone and any of the following - Bone tenderness on posterior 6cm of lateral malleolus - BOne tenderness on posterior 6cm of medial malleolus - inability to weight bear (4 steps) boht immediately and in ER |
| Canadian C-Spine Rules: what are they?- X-ray if | X-ray if: Age >65 Dangerous Mechanism(fall >3ft / 5 stairs Paresethesia in extremities No simple rear end collision No sitting position in ER No ambulatroy at any time No delayed onset of pain Middle C- Spine Tenderness Can't rotate neck 45 degree |
| Ottawa Knee Rules: X-ray if | Age >55 Isolated patellar tenderness Tenderness of head of gibula Inability to flex 90 Can't weight bear (4 steps) |
| Acute Lower Back Pain- Definition | Pain < 3months Up to 6 weeks acute 6-12 weeks subacute |
| Lower Back Pain- Red Flags Symptoms | Bladder Retension / Incontinence Anethesia (saddle) Wt floss, fever Chronic disease- immunosuppresion Parasethesia ? radicular pain Age >50 IV Drug use Neuro deficits- wide spread |
| Lower Back Pain-when to do investigations? | >50, trauma or corticosteroids ? Infection- CBC, ESR, CRP, MRI, joint aspirtaion Inflammation- CRP +/- ESR |
| Neck- Acute Pain vs Chronic Pain- how many months | Acute- <3months Chronic- > 3months |
| Neck: Whiplash- how may recover and when | 56% recover within 3 months 80% recover in 1 -2 years 15-40% continue to have symptoms |
| Risk Factors for Chronic Neck Pain | Demographics- old age, female, not employed fulltime Physical- Pain/numbness radiating to the upper limb |
| Neck Pain Red Flags | Neck Stiffness + kernig Sign (meningitis) H/A - rule out aneurysm Avoiding rotation |
| Red Flags of the neck- Infection/Fracture/tumor/neuro/Spinal Hemorrhage/carotid aneurysm | Infection- Fever/chills Fracture-hx trauma TumorHx of malignancy Neuro- parasetehsia / weakness upper extremities Spinal Hemorrhage confusion Carotid Aneurysm- tia / CVS |
| Neck Acute- Canadian C-Spine Rules | Parasetehsia in Extremity Dangerous mechanism Fall greater than 3 feet or 5 steps Not ambulatory Delayed onset of pain midliness c-spine tenderness Can't rotate 45 degree bilaterally Age >65 |
| Canadian C-Spine Rules- Eligibility criteria- | Stable Patient CGS 15 Injury <48 hrs Age >16 No vertebral disease No penetrating injury Not pregnant |
| CKD: Definition | Presence of eGFR <60 for >3 months OR kidney damage X 3months persistnent proteinuria |
| CKD: Symptoms | Edema Fatigue Nocturia, Oliguria Anemia Anorexia, Nausea Vomiting Pruritus |
| CKD: Factors affecting GRF | Extreme weights Muscle mass Specific Diet- High/low protein Meds that affect CR excretion Illness Pregnancy Paralysis Amuptation |
| CKD: Work Up | ? BP Cr, UN, lytyes and calcium and phosphate CBC, Ferritin/TIBC Albumin (? Proteinuria) Serum Protein electrophesis + Bence Jones proteins |
| CKD: Work up- U/S? looking for | Stones Hydronephrosis Cyst Mass |
| CKD: Medicaitons | ACE/ARB- slow progression to endstage Add dirutetic if not at target BP Monitor Cr and K- 2-4 weeks after starting or chaning Reduce dose or stop if hyperK or >3% Cr |
| Incidentalomas:: Hepatic Lesions Hepatic Adenoma? | <5cm and low risk or low attenutation / benign imaging feature- then no futher w/u |
| Incidentalomas:: Hepatic Lesions Hepatoculleular adenoma | > 5cm- consider referral Due to risk of rupture, risk of malignancy |
| Incidentalomas:: Hepatic Lesions Hepatic Adenoma in female on OCP | D/C OCP and Serial Image |
| General Anxiety Disorder: SICK FM | Sleep Disturbance Irritable Concentariton poor or mind goes blank Keyes up or resless Fatigue easily Muscle tension |
| General Anxiety Disorder: Questionaires | Burns Penn State Worry Questionnaire GAD Questions |
| Panic Disorder +/- Agoraphobia | STUDENTS far the 3cs Sweating Trembling Unsteadiness Derealization Excess HR Nausea Tingling SOB Fear or death Choking Chills Chest pain |
| Bipolar: manic episode: DIG FAST | Distractibility Indiscretion Grandiosity Flight of ideas Activity Sleep Deficit Talkative |
| Bipolar: manic episode: Giddiness | Grandiosity Increased Goal Decrease judgement (risky activity) Distractibility Irritablity Need for sleep Euphoria Speedy thoughts Speedy talks |
| Asthma: Symptoms | Dyspnea / Difficulty Breathing / Breathlessness Chest tightness Cough( worse at night or morning) Wheeze Sputum production |
| Asthma: Physical Exam | Wheeze Prolonged expiration Signs of atopy Severe: Tachypnea Decreased Breath Sounds |
| COPD: Pharmacology what all should have | All patients should have SABA: Salbutamol |
| COPD: Pharmacology: Mod/Severe: low risk AECOPD | LAMA or LABA LAMA: Spiriva LABA: OXeze (formoterol) or Salmetrerol (Serevent) or LAMA/LABA/ICS As above and Symbicort or advair or breo |
Created by:
Mcinb