Family Medicine Questions Review
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Apr 3, 2024
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Uploaded by JusticeTarsier4007
Review of Practice Questions for Family Medicine Shelf
Useful resources
Family Medicine Modular Subject Exam - Content Outline | NBME
o
Unique focuses of the FM shelf include:
100% focus on ambulatory medicine
Equal distribution of concepts in cardio, pulmonary, GI, endocrine (compared to heavier focus on cardiology in IM shelf
Special focus on pregnancy and childcare on FM shelf (not just Ob/Gyn)
20% of questions for pediatrics
Divine Intervention Episode 206 – Family Medicine Shelf Review Series 1. (divineinterventionpodcasts.com)
o
Family Medicine Shelf (divineinterventionpodcasts.com)
High Yield Family Medicine Review for Step 2 CK & Shelf Exam - YouTube
Adult male health maintenance exam (Case Files)
A 52-year-old male presents to the office for an annual physical exam. He has no family hx of cancer of any kind. What screening tests for cancer should be recommended in this patient? o
Colorectal cancer should be assessed in anyone over 50 years of age either through fecal occult blood testing (at-home sample or digital rectal exam), flexible sigmoidoscopy,
colonoscopy, or double contrast barium enema. o
PSA testing may be indicated if the patient has any symptoms associated with BPH or prostate cancer or indicated a family hx of prostate cancer. It is not recommended as a routine screening exam for prostate cancer.
o
Chest X-ray should only be performed in patients above the age of 50 with a 30-pack-
year smoking history. It should not be assessed regularly for lung cancer otherwise.
What vaccines should be recommended for this patient at this time? o
Depending on the season, an annual flu vaccine is obviously a good recommendation. If the patient were ~10 years older, perhaps a shingles vaccine would be recommended. Otherwise, a Tdap is typically given every 10 years
.
All adults over 65 years of age should receive the pneumococcal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13) vaccines. Note that the pneumococcal conjugate (PCV-13) is not commonly used. These vaccines should also be given to anyone with chronic medical conditions. Dyspnea (COPD) (Case Files)
A 52-year-old male with a history of 60-pack-year smoking and chronic COPD presents with worsening cough for the last 2 days and green sputum
. No fever, chills, night sweats, cyanosis, chest pain, peripheral edema. o
Patient presents with a classic exacerbation of chronic COPD. Description of green sputum may point towards an infection (e.g. pneumonia), but the lack of fever or leukocytosis would decrease that likelihood.
What acute treatments should be used for acute exacerbation of COPD? o
Antibiotics just in case an infection is present. Even if there is no current infection, the risk
of acquiring one during an exacerbation of COPD may be elevated. Azithromycin is a common antibiotic used for this purpose.
o
Bronchodilators and systemic corticosteroids should be used to expand the lungs and reduce inflammation. For example, albuterol + IV budesonide is a common treatment plan at the hospital for this condition.
What interventions should be utilized to reduce risk of future exacerbations? o
Smoking cessation! This is arguably the biggest contributor to exacerbations. Smoking cessation may not reverse the effects of COPD, unfortunately, but the rate of decline in lung function will dramatically decrease
. Specifically, the rate of decline in lung function in
someone who quits smoking will be almost equal to the rate of decline associated with normal aging. o
Long-acting bronchodilators (β2 agonists such as salmeterol and formoterol) with inhaled corticosteroids are the medications prescribed for long-term management of COPD in patients with recurrent acute exacerbations.
Influenza and pneumococcal polysaccharide vaccines should be administered in these patients as well.
Supplemental oxygen therapy is recommended in stage 4 COPD
. It is the only intervention that has shown to decrease mortality and must be worn for at least 15 hours a day.
Adjustment disorder and differential diagnoses (UWorld)
Adjustment disorder is defined by an acute (within 3 months) onset of mood and behavioral symptoms with an identifiable stressor. Marked distress and/or functional impairment are seen in patients with adjustment disorder. Typically, this diagnosis is given to those who do not meet criteria for another DSM-5 disorder. o
Case presented in the question was a college girl who did not get into her school of choice. She becomes depressed with suicidal ideation and clearly has an excessive reaction to the event. However, the inciting event was only 1 week ago so she would not meet any criteria for MDD or other mood disorders.
Ottawa ankle rules (UWorld)
Determines which patients with ankle pain require X-ray rather than simple casting or pain relief. Basically, Ottawa rules indicate severity of the underlying problem causing ankle pain. o
Plain radiographs of the ankle are required in patients with pain to the malleoli with point tenderness over the posterior margin of the malleolus OR inability to bear weight on the foot after injury
. o
Plain radiographs of the ankle are also required in patients with pain in the midfoot and tenderness at the navicular bone or 5
th
metatarsal OR inability to bear weight on the foot after injury
. Treatment for UTI during pregnancy (TrueLearn) Acute lumbosacral radiculopathy (UWorld)
Herniated intervertebral discs are the most common cause of acute lumbosacral radiculopathy. Other causes include degenerative spondylosis, malignancy, and epidural abscesses. o
Acute lumbosacral radiculopathy presents as low back pain radiating down the posterior legs with a positive straight-leg or crossed straight-leg raising test
. Patients may experience dermatomal sensory loss and myotomal weakness. Patient history typically reveals a traumatic incident such as hurting their back while lifting heavy boxes.
Clinical features are typically enough to diagnose this condition, but it may be useful to do an MRI
if the patient has bilateral neurologic deficits, saddle anesthesia, bowel/bladder incontinence, or suspected malignancy or abscess. MRI is very sensitive in detection of spondylosis. o
X-rays are not generally used in detecting the source of back pain because they have poor visualization of the intervertebral discs and spinal nerve roots.
Initial management of acute lumbosacral radiculopathy involves activity modification and NSAIDs
.
Simple symptom management in this way is useful because the condition is often self-limiting. If
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the pain continues after 2 weeks, consider physical therapy and oral glucocorticoids. If the pain continues after a month, obtain MRI and assess for surgical indication. Endometrial hyperplasia and cancer (UWorld)
Obesity is a major risk factor for the development of endometrial hyperplasia (and eventually cancer). Primary mechanism behind endometrial hyperplasia is unregulated endometrium proliferation due to high estrogen levels. In patients with obesity, peripheral adipose tissue increases conversion of androgens to estrone, thereby increasing estrogen levels and causing unopposed estrogen exposure. o
Signs of endometrial hyperplasia involve abnormal uterine bleeding in women older than 45 years of age. Endometrial biopsy is typically indicated due to the risk of endometrial cancer, especially if the patient is obese.
Acute angle-closure glaucoma (ACG) (UWorld)
ACG is characterized by an acute rise in intraocular pressure (IOP) due to impaired drainage of the aqueous humor through the anterior chamber and into the trabecular meshwork at the iridocorneal angle. Impaired drainage of the aqueous humor causes the substance to overflow into the corneal space. Increased IOP can damage the optic nerve and lead to permanent vision loss. o
ACG can be triggered by pupillary dilation or certain medications in patients with predisposing anatomy. Medications that can cause ACG include decongestants and anticholinergic drugs
.
Symptoms include acute eye pain, headaches, nausea, diminished vision, halos around lights, conjunctival redness, corneal edema/cloudiness, and a fixed, mid-dilated pupil.
Gold-standard for diagnosis is a gonioscopy
, which is a specialized prismatic lens with slip lamp to visualize the iridocorneal angle. An ocular tonometer is used to measure IOP. Management of ACG includes IV acetazolamide and pressure-lowering eye drops. Laser iridotomy provides definitive care.
Barotrauma of the ear (UWorld)
A 30-year-old female states she experienced severe acute ear pain during a flight from London to
NY. She notes having an upper respiratory infection a few days before the flight, for which she was taking antibiotics. She presents today with hearing loss. What is going on? o
Barotrauma of the ear most commonly occurs during flights due to pressure differences during plane ascent and descent. Under normal conditions, the eustachian tube opens intermittently, typically during swallowing or yawning. Failure of the eustachian tube to open adequately leads to a pressure difference between the middle ear and outside environment. This may happen due to functional obstruction of the eustachian tube due to upper respiratory infections (as in this patient). The pressure difference during plane ascent/descent is therefore worsened and may cause stretching and rupture of the tympanic membrane. This leads to ear pain and hearing loss.
o
Management of barotrauma involves reassurance and follow-up in 1-2 weeks because the tympanic membrane will heal over this time. Hearing will also improve as the tympanic membrane rebuilds. Persistent hearing loss may require further evaluation.
Tympanoplasty is a surgical solution to repair persistent tympanic membrane perforations.
Oxymetazoline is a topical decongestant that may be used prior to air travel to reduce URI-
induced obstruction of the eustachian tube. This reduces the risk of barotrauma. However, oxymetazoline is unlikely to improve a tympanic membrane rupture after it has already occurred. Exercise management in type 1 diabetics (UWorld)
Case: A 17-year-old patient with type 1 diabetes would like to run a marathon. He is currently taking 1 insulin glargine at bedtime and insulin lispro before meals. What treatment modifications should be applied to this patient so he may successfully run the marathon? o
Main issue here is a risk of hypoglycemia in the diabetic patient taking insulin. To understand this, we need to separate the impact of exercise on non-diabetic patients vs diabetic patients:
Non-diabetic patients have mechanisms in place that prevent hypoglycemia in the setting of intense exercise. Initially, muscle usage increases glucose uptake and demand. At the same time, there is a decrease in endogenous insulin levels because the body prevents a hypoglycemic state from manifesting during the exercise.
A diabetic patient on exogenous
insulin therapy cannot regulate the insulin levels
as effectively. When glucose uptake in the muscles increases, the exogenous
insulin levels do not change
. This increases the risk for hypoglycemia. o
Treatment modification for diabetics on insulin who want to run a marathon involves decreasing the dosage of insulin. Doing so will prevent the hypoglycemic episodes. Patients should also increase carbohydrate intake, especially if training sessions are more than 60 minutes in duration. Spermicide and recurrent UTIs
Diaphragm with spermicide is a contraception method used by females to prevent pregnancy. This form of contraception carries an increased risk of UTIs due to synergistic effects:
o
Spermicide (nonxynol-9) is directly toxic to vaginal lactobacilli
, altering the vaginal microbiome and resulting in increased uropathogen adherence to vaginal epithelial cells. This increases the risk of urethral contamination due to the close proximity of the urethra and vagina.
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o
A diaphragm places pressure on the anterior vaginal wall, leading to depression of the urethra and bladder trigone. This decreases the voiding sensation and causes incomplete
bladder emptying
, thereby increasing the likelihood of bacterial replication and infection. The diaphragm also causes venous stasis to the bladder wall, weakening of the epithelium and allowing for bacterial invasion into the bladder wall.
Patients who have this form of contraception and experience recurrent UTIs are recommended to
switch their contraceptive methods. Antibiotic prophylaxis is considered if the switch is not appropriate for that specific patient.
Asthma classification (TrueLearn)
Asthma Guidelines: Guidelines Summary, Classification Guidelines, Management Guidelines (medscape.com)
Intermittent asthma o
Symptoms occur less than twice a week and nighttime symptoms occur less than twice a month o
Flare-ups are the main issue – there are few symptoms between flare-ups o
LFTs (FEV1 and FEV/FVC) > 80% of normal values
Mild persistent asthma
o
Weekly symptoms (3-6 times a week) with occasional (3-4 times a month) nighttime symptoms o
LFTs (FEV1 and FEV/FVC) > 80% of normal values
Moderate persistent asthma o
Daily symptoms controlled by inhaler/nebulizer and nighttime symptoms once a week
o
LFTs between 60-80% of normal values
Severe persistent asthma o
Constant symptoms not effectively controlled by the treatments and frequent nighttime symptoms o
LFTs below 60% of normal values
Types of prevention (TrueLearn)
Question I missed involved a patient who comes in wanting help with smoking cessation. He has a family history of lung cancer (father) and a 9-pack-year smoking history. Which type of prevention is this? o
Primary prevention would be the answer because the smoking cessation is an action that
will prevent potential disease (lung cancer). o
Secondary prevention is not the answer because that involves early detection of a disease and then testing to see how much that disease has progressed. Example of secondary prevention would be a mammogram done for a patient complaining of a breast
mass. Suicide and antidepressants (UWorld)
A slightly increased risk of suicidal ideation does exist for children and adolescents (< 25 years old) taking antidepressants. Ultimately, the decision to prescribe antidepressants for an adolescent must involve a risk assessment; does the benefit of prescribing the antidepressant outweigh the risk of the adolescent potentially having suicidal thoughts? Most experts believe the answer is yes and prescriptions should occur. Tinea pedis (UWorld)
This fungal infection of the foot most commonly occurs between the toes (“
interdigital pattern”) but may involve skin near the soles or sides of the foot (“
moccasin pattern”). There is also the “
vesiculobullous pattern” of tinea pedis that involves formation of painful bullae and erythema of the lateral foot. Tinea pedis often presents with significant hyperkeratosis and flaking. o
KOH prep of skin scrapings is the diagnostic tool of choice. Treatment involves topical antifungals such as miconazole, terbinafine, and tolnaftate. If the topical agents do not work, oral antifungals may be given (e.g. fluconazole). Postpartum contraception options (UWorld)
Patients who are <1 month postpartum should not receive an estrogen-containing contraceptive devices because estrogen increases the risk for thromboembolism and can negatively affect breastfeeding.
Nonhormonal options are preferred in patients who are <1 month postpartum because they do not interfere with coagulation or breastfeeding. These options include copper-containing IUDs and progestin-only contraception methods. o
Note that a patient who also has heavy menstrual bleeding and iron-deficiency anemia will actually worsen if they are given a copper-based IUD. In contrast, the progestin-only contraception methods help decrease menstrual bleeding while also providing the contraceptive benefits to a postpartum female.
Progestin-releasing IUDs and subdermal progestin-releasing implants are great options for postpartum contraction in females who need a reliable and highly effective form of contraception. Both these methods carry a 99% efficacy for pregnancy prevention and do not increase risk of thromboembolism or problems with breastfeeding. o
Both the IUDs and the implants last for several years, which is another huge benefit.
Guidelines for initiating statin therapy (UWorld)
Pooled cohort equations cardiovascular risk calculator is the formal name of the system used to calculate the need for initiating statin therapy in a patient with atherosclerosis.
o
Variables considered in this calculator are ethnicity, age, sex, total cholesterol, HDL cholesterol, smoking status, hypertension status, and diabetes status
. Surprisingly, family
history is not a variable used in this calculator. o
A 10-year risk of atherosclerotic cardiovascular disease (ASCVD) >7.5% is the target for initiating statin therapy in these patients.
Make sure to encourage lifestyle changes in all patients regardless of whether they are going to receive the statin. Oftentimes patients believe that the pill is curative, and it minimizes the work they themselves need to do to prevent future incidents.
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Niacin for dyslipidemia (TrueLearn)
Niacin (vitamin B3) is no longer used in the treatment of dyslipidemia. It does have useful effects such as lowering LDL and increasing HDL levels, but the side effects and lack of any mortality benefit are considered to outweigh the benefits of using B3. Side effects of niacin include pruritis, flushing, and GI upset. o
Statins meanwhile do carry a benefit to significant lowering of LDL, decreased cardiovascular events, and decreased mortality. This is why statins are first-line.
Treatment of benign prostatic hyperplasia (TrueLearn) CREST syndrome and limited vs diffuse systemic sclerosis (TrueLearn)
CREST syndrome is a type of scleroderma that slightly differs from limited systemic sclerosis. CREST stands for calcinosis cutis, Reynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.
Systemic sclerosis can be divided into two forms: Limited and diffuse. o
Limited systemic sclerosis is characterized by Reynaud’s phenomenon and a distinct skin
thickening involving the fingers, forearms, and face. It is “limited” in the sense that only these 2 sets of symptoms are present. o
Diffuse systemic sclerosis differs from limited type in that it affects visceral organ systems
as well as the skin. The esophagus is often affected, causing dysphagia in the patient. Myocardial fibrosis and cardiomegaly may also be seen if the heart is affected. Other organ systems that undergo sclerosis include the muscles, kidneys, and lungs.
Most concerning manifestation of diffuse systemic sclerosis is malignant hypertension resulting in kidney failure.
As you can see, the distinctions between CREST, limited, and diffuse sclerosis lie in the organs affected by the disease. CREST syndrome is a distinct set of symptoms; limited systemic sclerosis is a thickening of the skin and also Reynaud’s phenomenon; diffuse systemic sclerosis affects visceral organ systems and is the deadliest form of scleroderma. Raloxifene (TrueLearn)
Raloxifene is a selective estrogen receptor modulator (SERM) that acts as both an agonist and antagonist of estrogen receptors in different tissues. For example, raloxifene is used to treat osteoporosis because it improves bone density because it acts as an estrogen receptor agonist. Bisphosphonates are first line for treatment of osteoporosis in most patients, as raloxifene carries risk of worsening postmenopausal symptoms. However, certain patients may actually benefit from
raloxifene > bisphosphonates because of the secondary benefit of raloxifene on decreasing risk of breast cancer
. Therefore, a postmenopausal female with a family history of breast cancer may benefit from raloxifene despite the side-effects of worsening postmenopausal symptoms (e.g. vaginal dryness and hot flashes). Tuberculosis screening (TrueLearn)
Initial tuberculosis screening is done using a purified protein derivative (PPD) test. A negative initial PPD is followed up with a second PPD test 1-2 weeks later. A positive PPD test requires further testing with a chest X-ray. o
Positive chest X-ray suggests active TB infection and the patient should be treated with a
combination therapy of rifampin, isoniazid, ethambutol, and pyrazinamide for 2 months. This is followed by continued treatment with rifampin and isoniazid for 4 months. o
Negative chest X-ray for a positive PPD suggests latent TB infection and the patient should be treated with rifampin for 4 months. Isoniazid used to be the treatment of choice
for 4 months, but recent studies show rifampin has the same efficacy with fewer side effects, so that is the preferred method now. Performing PPD on a patient who is immunosuppressed (TrueLearn)
Question stem described a PPD test being done on a patient with rheumatoid arthritis for which she is taking azathioprine. Azathioprine is an immunosuppressant, so it may decrease the sensitivity of the PPD due to poor cell-mediated immune response. However, the benefit of performing the PPD still greatly outweighs the risks in this situation. A positive PPD result would be very useful information and further testing (e.g. CXR) would be ordered. A negative PPD result
would be followed up with another PPD test, and all this would be considered benign. If there is strong suspicion still for TB in the patient, blood tests can be used. All in all, the benefit of doing a
PPD is far greater than associated risks and the immunosuppression meds do not change this.
Hypothyroidism and obstructive sleep apnea (OSA) (TrueLearn)
Hypothyroidism can indeed lead to OSA. Specifically, hypothyroidism often presents with macroglossia and increased soft tissue mass in the pharynx. These two factors cause an obstruction of the airway at night that presents as sleep apnea. Hypothyroidism is also associated
with myopathy that contributes to upper airway dysfunction.
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Should you screen every patient with signs of OSA for hypothyroidism as well? o
No, because the incidence of hypothyroidism in patients with OSA is no different from the
incidence of hypothyroidism in the general population. Therefore, patients with OSA should not be screened regularly for hypothyroidism. Desmoid tumors (desmoid fibromatosis) (TrueLearn)
Desmoid tumors are rare benign masses with an incidence of 3 in every million people. They occur in patients between 15-60 years of age and are typically seen in the extremities, abdominal wall, and abdominal mesentery. Although desmoid tumors are benign, they do carry a high likelihood of local recurrence
.
Desmoid tumors are seen in 16% of patients with familial adenomatosis polyposis (FAP)
, which is
also known as adenomatosis polyposis coli (APC). Most patients with FAP will have their colon removed at an early age and avoid these additional problems. This association is the only example of a familial inheritance for desmoid tumors.
Preeclampsia vs gestational hypertension (TrueLearn)
Preeclampsia is hypertension that first presents at 20 weeks gestation with proteinuria and edema. Patients will typically come to the office with complaints of headaches that are not relieved by OTC medications. Patients may also experience blurry vision and dizziness. If they experience seizures, a diagnosis of eclampsia should be made, and the patient should be administered magnesium sulfate to prevent further seizures.
Gestational hypertension is an elevation in blood pressure that occurs at any time during a pregnancy and does not present with proteinuria or edema. Diagnosing a Baker’s cyst (TrueLearn)
Baker’s cyst is a benign swelling of the joint cavity within the popliteal space. It is commonly associated with chronic arthritis and is filled with synovial fluid. The cyst may burst and cause pain, swelling, and redness. o
Ultrasound and MRI are the best imaging modalities for diagnosing a Baker’s cyst. Ultrasound is used first because MRI is expensive and takes a long time to complete. If the patient has a fever or significant pain and erythema surrounding the cyst, a septic joint may be suspected. Septic joints must be aspirated as soon as possible to diagnose and treat the infection.
Joint aspiration is not the test to diagnose a Baker’s cyst and is considered unnecessarily invasive if the patient has no symptoms pointing to a septic joint. Factitious hyperthyroidism vs Graves disease (TrueLearn)
Factitious hyperthyroidism is seen in patients who take excess exogenous thyroid hormone. They
experience symptoms of hyperthyroidism such as palpitations, tremor, weight loss, heat intolerance, etc., but will also have a normal thyroid scan
. The thyroid scan is normal because there is no intrinsic issue with the thyroid gland.
Graves disease is seen in patients who have excess thyroid hormone production secondary to thyroid-stimulating antibodies made by the immune system. Patients will have the same symptoms as those with factitious hyperthyroidism but will also likely experience exophthalmos and pretibial myxedema
. A thyroid scan will show excess uptake of iodine diffusely through the thyroid gland.
How do you tell the difference if the patient presents with typical signs of hyperthyroidism? o
FH will present with a normal thyroid scan, whereas GD will present with an excess uptake of iodine by the thyroid gland. o
FH will not present with signs of GD such as exophthalmos and pretibial myxedema. o
Patient’s history may involve access to levothyroxine, perhaps for weight loss. For example, a patient with anorexia nervosa who has a family member that takes levothyroxine may be taking the exogenous hormone. This patient would be at risk for factitious hyperthyroidism.
Tetanus vaccine series (TrueLearn)
Note in the table below that the only time tetanus immune globulin is administered is if the patient presents with a wound and has incomplete or uncertain vaccination history.
Warfarin-induced skin necrosis (TrueLearn)
Warfarin carries an uncommon but serious side effect of skin necrosis
. This is seen in patients who receive warfarin too quickly in too large of a dose
. When administering warfarin, it is important to start patients off slowly and gradually increase the dose, especially in those who require larger doses for sufficient anticoagulation. It is also important to observe the patient for 1 week after starting warfarin, because the skin necrosis typically occurs within that first week
. o
Patients will typically feel a sensation of pain or coldness in the area, followed by development of a well-demarcated erythematous lesion. This lesion progresses to formation of bullae and subsequent localized skin necrosis.
Ménière disease vs presbycusis vs sensorineural hearing loss (TrueLearn)
Ménière disease has an unclear pathogenesis but causes vertigo, tinnitus, hearing loss, and a sense of fullness in the affected ear. It characteristically presents with trouble hearing low-pitched
sounds rather than high-pitched sounds, which is the more common presentation in other causes of hearing loss.
Presbycusis refers to the age-related hearing loss that occurs naturally. Hearing loss in presbycusis is often bilateral and patients have difficulty hearing higher-pitched sounds
. These patients often do not hear the high-pitched buzz that comes out of their hearing aids when they are placed close together (very annoying when in the room!).
Sensorineural hearing loss is a pathologic condition in which the nerves themselves are affected. Patients will have trouble hearing all frequencies
, regardless of high or low-pitched.
o
Conductive hearing loss presents similarly to sensorineural hearing loss, but typically affects one ear only. Right vs left bundle branch blocks (TrueLearn)
Important observations in the ECG for a right bundle branch block (RBBB) include: o
Wide QRS (>120 msec)
o
rSR complex in lead V2
o
Wide R wave in lead V1
o
QRS pattern with wide S wave in lead V6
Important observations in the ECG for a left bundle branch block (LBBB) include:
o
QRS greater than 80 msec o
QS or rS complex in lead V1 o
Monophasic R wave in leads I and V6
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Treatment of osteoarthritis of the knee (TrueLearn)
Initial management of osteoarthritis of the knee involves nonpharmacologic treatments such as weight loss and exercise. If symptoms persist, topical or oral NSAIDs may be used. Duloxetine and topical capsaicin have also proven beneficial. If these options fail and the patient is a surgical
candidate (above a certain age), total knee arthroplasty can be done. If the patient is not a surgical candidate, chronic pain management with systemic glucocorticoids. However, this option is not great as the side effects are unattractive.
Other nonsurgical options for pain relief in osteoarthritis include: o
Hinged unloader knee brace for a patient with unilateral osteoarthritis. This refers to OA affecting either the medial or lateral aspects of the knee, but not both. o
Therapeutic arthrocentesis is used for inflammatory or rapid-onset effusions such as septic arthritis or hemarthrosis. Diaper dermatitis (TrueLearn)
Most common cause of diaper dermatitis is a contact dermatitis in which stool/urine deposition into the diaper causes skin irritation and breakdown, resulting in the dermatitis. This type of diaper dermatitis classically spares skin folds
.
Candida
dermatitis
, on the other hand, is the second most common type of diaper dermatitis and does involve the skin folds
. The erythema from this type is also dark red.
Antihypertensive drugs safe for pregnancy
First line agents for treating hypertension during pregnancy can be remembered with the mnemonic “New Moms Love Hydralazine” – nifedipine, methyldopa, labetalol, hydralazine
. o
Second line agents include clonidine and thiazide diuretics.
Drugs that are contraindicated for the treatment of hypertension during pregnancy include ACE inhibitors, ARBs, direct renin inhibitors, nitroprusside, and mineralocorticoid receptor antagonists such as spironolactone.
Psoriatic arthritis (TrueLearn)
Psoriasis is an immune mediated skin disease characterized by erythematous plaques with overlying silvery scales and sharply demarcated borders. Psoriasis is typically asymptomatic and involves the knees, elbows, gluteal cleft, and scalp. A specific type of psoriasis, referred to as psoriatic arthritis
, occurs above joints in response to joint trauma and/or inflammation. This is known as the Koebner phenomenon
, or the development of lesions in areas of trauma.
Initial treatment of psoriasis involves topical corticosteroids, topical vitamin D analogs, and topical
retinoids
. Sometimes, psoriasis can progress to involve more than 30% of body surface area. In this scenario, topical ointments are insufficient, and a full UV light exposure is required for treatment. o
Using systemic corticosteroids (e.g. switching from topical to PO for more psoriasis) is not recommended because psoriasis is known to worsen after the initial effect of corticosteroids wears off.
Amaurosis fugax (TrueLearn)
Sudden painless loss of vision that may be described as a “curtain falling over the eyes”. Amaurosis fugax is a transient monocular loss of vision due to retinal ischemia secondary to atherosclerosis. Some patients may describe fogging of their vision prior to the vision loss. Important difference between this and retinal detachment is that vision returns in amaurosis fugax.
o
Amaurosis fugax is typically associated with atherosclerosis of the retinal artery, but may also be associated with thromboembolism, hypoperfusion of the retina secondary to cardiac disease, increased plasma viscosity (seen in leukemias and lymphomas). o
Amaurosis fugax episode places the patient at an increased risk for future stroke
.
Interesting correlation between this concept and the lecture at OMED by a cardiologist: Prevention of stroke involves aspirin + statins because strokes are most commonly ischemic secondary to atherosclerosis of the cerebral arteries. In
the same breadth, realize that amaurosis fugax is prevented by these treatment options as well. Metabolic syndrome (TrueLearn)
Notice in the table below that metabolic syndrome is not defined by a triad of diabetes, hypertension, and hyperlipidemia. It is, however, a triad of abnormal values. This can come in many forms, as explained below. Also notice that LDL levels are not used for diagnosing metabolic syndrome.
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Erythema nodosum (UWorld)
Considered a delayed-type hypersensitivity reaction to various antigens. Those antigens include infections (e.g. Streptococci
), IBD (e.g. Crohn), sarcoidosis, malignancy, and medications (specifically penicillins, sulfonamides, and oral contraceptives).
Venlafaxine and hypertension (UWorld)
Venlafaxine is an SNRI and works to inhibit both serotonin and norepinephrine reuptake. More specifically, venlafaxine inhibits serotonin reuptake when given at lower doses, and also inhibits
norepinephrine reuptake when given at higher doses
. At those higher doses, the lack of norepinephrine causes a modest elevation of blood pressure due to peripheral vasoconstriction. Therefore, if the drug is prescribed at its higher concentrations, patients may develop hypertension. Those who are already hypertensive should have controlled blood pressure prior to
receiving venlafaxine.
Adverse effects of antihypertensive medications (TrueLearn)
Fast facts from NBME self-assessments
Ottawa ankle rules o
These rules help reduce the number of ankle X-rays ordered after an ankle sprain. The rules state that an X-ray is only needed to rule out a fracture in cases where the patient
cannot bear weight/ambulate and feels tenderness to palpation on the posterior aspect of
the lateral or medial malleoli. In patients who do not meet even one of these two criteria, an ankle X-ray is unnecessary, and the sprain should be treated conservatively with ice, OTC pain relievers, elevation, and stretching/exercise. Notably, a severe ankle sprain should be treated with splinting/immobilization.
Iron deficiency in a newborn o
Premature infants are at an increased risk for iron deficiency because iron storage does not begin until the 3
rd
trimester of pregnancy. Furthermore, infants who have spent some time in the NICU after birth will also likely experience iron deficiency secondary to frequent blood draws. o
Infants who are exclusively breastfed are also at an increased risk for iron deficiency because breast milk lacks iron. It also lacks vitamin D. Both of these nutrients must be supplemented for these babies.
Acute pyelonephritis in males o
UTIs in general are not commonly seen in males due to males having a longer urethra than females. However, BPH is a risk factor for UTIs due to the incomplete voiding seen in patients with enlarged prostates. UTI can complicate by ascending the ureters and invading the kidneys, resulting in pyelonephritis.
Pyelonephritis is a clinical diagnosis that does not require imaging for proper diagnosis. The common symptoms are flank pain, fever, chills, nausea, vomiting, and back pain with costovertebral angle tenderness bilaterally. o
Treatment for acute pyelonephritis includes oral fluoroquinolones. However, this is only sufficient for mild to moderate cases. Some patients may present with signs of sepsis such as hypotension and dry mucous membranes. These patients must be admitted because they are at risk for septic shock. Treatment for septic pyelonephritis includes IV antibiotics and fluid resuscitation if the patient is hypotensive. Again, imaging is not necessary because even severe cases of pyelonephritis care clinical diagnoses.
Management of lumbar disc herniation o
Although it seems like a lumbar disc herniation would be a serious issue that requires imaging and bed rest for recovery, this problem is actually very common and responds best to conservative management. Most cases of lumbar disc herniation occur after a minor traumatic event like bending and lifting a heavy object. Symptoms may be back pain with or without radiculopathy in a dermatomal/myotomal pattern with respect to the pinched nerve. Patients with severe neuro symptoms may require further testing with an MRI or CT scan, but this is not necessary in most patients with mild or moderate disc herniation.
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Treatment for most cases of lumbar disc herniation involves a return to normal daily activities. Obviously, patients should be advised to practice caution for a few weeks, so the herniation does not worsen. However, there is no need for bracing or bed rest. In fact, these therapies can actually prolong recovery time because the surrounding muscles will atrophy. Physical therapy with a focus on improving abdominal strength is a first-line treatment for those who are able to achieve this.
NSAIDs and ACE inhibitors o
Interaction between NSAIDs and ACEIs is an indirect relationship. NSAIDs inhibit cyclooxygenase (COX) enzymes, thereby decreasing prostaglandin synthesis. Prostaglandins are necessary for many physiological processes, including modulation of pain sensation and thermoregulation, maintenance of the gastric mucosal barrier, and regulation of renal blood flow.
Renal blood flow (RBF) is especially notable in this discussion because a decrease in prostaglandin synthesis results in a decrease in RBF. In response, the kidneys secrete renin and try to increase blood pressure. Therefore, NSAIDs can cause asymptomatic hypertension. o
Patients taking ACE inhibitors such as lisinopril are at risk for worsening hypertension if they take systemic NSAIDs. Although this seems paradoxical considering ACEIs bring down blood pressure, the mechanism here is an inherent increase in renin secretion by the kidneys that already exists in response to the ACE inhibitors. NSAIDs essentially ramp up the existing renin secretion because they worsen the renal blood flow seen in patients who already take ACEIs.
Pseudodementia o
Pseudodementia is a cognitive impairment associated with major depression in elderly patients. The patient described in the question stem had recently emigrated from his home country of Micronesia to live with his daughter after the death of his wife. This patient has experienced a significant trauma and is a classic example of someone at risk for developing major depression leading to pseudodementia.
Pseudodementia responds well to SSRIs because these drugs are treating the underlying cause of the dementia.
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