SAMP 1999-2005 (book3)

`1) Parkinson’s dz

  • a) Classic Triad:
    • Tremor, Rigidity, Akinesia
  • b) Yes, Parkinson’s dz can be hereditary
  • c) Neurotransmitter: Dopamine – decreased
  • d) Tx & 2 s/e:
    • Levodopa – Orthostatic HoTN, N/V, dyskinesia, psychiatric disturbances
    • Bromocriptine – pedal edema, pleuropulomonary reaction, retroperitoneal fibrosis
  • e) Prevention meds: none available

2) Shaken-baby Syndrome

  • 4 symptoms / Hx clues:
    • Decreased LOC / N/V/coma / poor feeding, delayed presentation, inconsistent stories / not forthcoming with information / vague, mechanism of injury not compatible with developmental capacity, Sz, change of tone
  • Retinal Hemorrhage – No, can’t be used to dx as there are other causes, but highly suggestive
  • PEx:
    • unequal pupils / full fontanelle, bruises / burns / soft tissue injuries / cutaneous marks, stiff neck / meningismus, unresponsive pt / lethargy / irritability
  • Ix: bone survey, brain U/S or CT / skull x-ray
  • Mechanism: Sudden rotational deceleration resulting in concussion and subdural hematoma
  • Mimics: Osteogensis imperfecta, coagulopathy, accidental trauma

3) IBS (2012 journal of family practice)

  • Most likely dx: Irritable Bowel Syndrome
    • Rome III Criteria 
    • >=12 wk (don’t have to be consecutive) in 12mo of abdo discomfort + 2 of the following
      • relieved with defecation
      • Associated with a change in frequency of stool
      • Associated with a change in consistency of stool
    • Supportive features but not dx
      • Abnormal frequency (>3/d or <3/wk),
      • abnormal form (lumpy/hard/loose/water) >1/4 of stools
      • Abnormal passage – strain, urgency, feeling incomplete evacuation >1/4 stools
      • passage of mucous >1/4 stools
      • bloating or feeling abdo distention
  • Red flags on Hx / PEx
    • constitutional symptoms: wt loss, night sweat, fever, chills
    • Bowel changes: Melena / BRBPR, pus in stool, change to the stool caliber, nocturnal defecation (IBD)
    • family Hx of IBD / colon ca, celiac
    • palpable abdominal mass
    • New symptoms in a pt >45
  • Tx: (constipation-predominant, pain-predominant, diarrhea-predominant)
    • Reassurance & a strong physician-pt relationship
    • diet: increase fibre 25g/d, increase water intake, avoid caffeine, legumes, limit lactose / fructose / citrus
    • exercise helps bloating + constipation
    • Constipation-predominant:
      • Fibre (12-30g/day – metamucil)
      • dietary modification + exercise
      • osmotic laxative (lactulose, milk of magnesia / PEG) – avoid stimulants
    • Pain-predominant:
      • Antispasmodic: buscopan 10-20mg tid, bentylol / dicetel
      • Stress management – CBT,
        • TCA (amitriptyline 10-25mg qhs po prn) better for diarrhea
        • SSRI: better for constipation
    • Diarrhea-predominant:
      • antidiarrhea (loperamide (imodium) 2-4mg qid prn) use <5wk, decrease urgency, frequency
      • Cholestyramine 4g 1-4x/d
      • Diphenoxylate (Lomotil) – second line
    • Bloating + Flatulence
      • Simethicone 40-360mg qid after meals + qhs

4) Osteoporosis

  • Non-modifiable risk factors for osteoporotic fracture
    • advanced age (>65),
    • female, caucasian / Asian,
    • Osteoporosis # in 1st degree relative,
    • dementia / poor health
  • Modifiable risk factors for osteoporotic fracture
    • Low Vit D and Ca intake (lifelong),
    • low body Wt (<127lb),
    • exercise / impaired balance/vision,
    • current cigarette smoking, alcoholism,
    • glucocorticoids (> 3/12 of >= 7.5mg daily)
    • Estrogen dificiency / early menopause (<45yo)

Indications for BMD

    1. Age >= 65
    2. Clinic risk factors for fracture (menopausal women, men 50-64yo)
      1. Fragility # after age 40yr
      2. High risk medications
        1. aromatase inhibitors,
        2. androgen deprivation Tx,
        3. Prolonged use of glucocorticoids (> 3/12 of >= 7.5mg daily)
      3. Parental hip #
      4. Vertebral # or osteopenia on x-ray
      5. high alcohol intake
      6. Current smoking
      7. low body weight (<60kg) or major wt loss (>10% at 25yo)
      8. RA
      9. Disorders associated with osteoporosis:
    3. Younger adults (<50yo)
      1. Fragility #
      2. High risk medications. eg. Prolonged use of glucocorticoids
      3. Hypogonadism or premature menopause (<45yo)
      4. Malabsorption syndrome or chronic inflammatory conditions
      5. Primary hyperparathyroidism
      6. Other disorders associated with rapid bone loss/#
  • Compression fracture:
    • >=25 % reduction of vertebral body height
  • Recommended dosage
    • 1200 mg Ca and 1000IU Vit D
  • BMD score for Tx (FRAX score in the new guideline)
    • With osteoporosis risk factors: Tx if high risk despite BMD or moderate risk + additional risk factors
    • Without osteoporosis risk factors: < -2.5 (moderate risk)
  • pharmacologic options for the prevention / tx of osteoporosis
    • Bisphosphonate: alendronate
    • Selective estrogen receptor modulator: raloxifene
    • HRT
    • RANKL-inhibitor: Denosumab

5) HIV

  • Zidovudine mechanism: nucleoside analogue – interferes with reverse transcriptase and inhibit viral replication
  • Name of another drug in the same class of zidovudine: Stavudine
  • 2 common s/e of this class of drug: H/A, N/V, fagiue/malaise, myalgias, neutropenia / anemia
  • name another new class: Protease inhibitor
    • Mechanism: inhibits enzyme that cleave inactive viral polyprotein precursors into active functional protein
    • s/e: N/V/D, anorexia, abd pain, altered taste
  • CD4>500 and undetectable viral count on daily trimethoprim-sulfamethoxazole to prevent pneumocystic pneumonia
    • Yes, safe to stop TMP-SMX when CD4 >200 for 3-6mo
  • Triple Tx:
    • NNRTI(Non-Nucleoside reverse transcriptase inhibitor) – Efavirenz,
    • NRTI – Zidovudine,
    • PI (Protease inhibitor) – Ritonavir

6) MI

  • Risk factors
    • Current Smoking, DM, Hyperlipidemia, HTN, obesity
  • Indications for long-term anticoagulant Tx after MI
    • intolerance to ASA, A fib, LV thrombus
  • 70 yo, should we Rx B-blocker – Yes
  • Exercised to 6 METS w/o angina or ischemic changes
    • Should nitro Rx: No
  • ACEi is indicated after MI in pt with:
    • s/sx of CHF, Anterior MI, LVEF <40%
  • CCB Rx routinely? No – only when B-blocker not tolerated
  • Non-sustained ventricular tachycardia in ICU – best Rx: B-blocker

7) Anorexia: 16yo fainting, loss 15kg in 6mo

  • BMI wt / ht 2 = 46kg / (1.7×1.7) = 15.9
  • classes of drugs to lose weight:
    • Synthroid / caffeine or other stimulants, and laxative, enemas, diuretics
  • Somatic and behavioural changes that may indicate an eating disorder
    • Somatic: 
      • Arrested growth / inability to gain wt, Marked change or frequent fluctuation in wt
      • CV: palpitations, cp, sob, arrhythmia, edema
      • fatigue, constipation / diarrhea, dizzy, hot flashes, cold
      • Derm: lanugo hair, hair loss, callus/scar on hands, poor healing
      • Endocrine: delayed menarche, amenorrhea, decreased libido / BMD, infertility
      • GI: epigastric pain, early satiety, GERD, hematemesis, hemorrhoids, constipatio
      • hypokalemia, hyperphosphatemia,
    • Behavioural:
      • change in eating habit, difficulty eating in social setting, limited po intake & xs exercise,
      • depression, social withdrawal, absence from school or work,
      • reluctance to be weigheddeceptive/secretive behaviour, substance abuse
  • Indications that would require inpatient care:
    • Medically unstable: cardiac arrhythmia,severe electrolyte imbalance, dehydration, HoTN, metabolic / glucose abnormalities
    • psychosis, high suicidal ideation, intractable purging
    • Refusing food, poorly motivated pt
    • Extremely low wt (<85% expected body wt) or rapid decline of wt
  • Meds Rx to stablize recover: SSRI – fluoxetine (for Bulimia)
    • CBT, Family Therapy for both AN and Bulimia
    • Tx cormobid conditions (depression etc)

8) CO poisoning

  • Potential causes other than automobile exhaust:
    • Open fire in a closed space – inhaled smoke & poorly functioning heating system
  • Acute symptoms after exposure to CO
    • Headache, N/V, lightheaded/ dizziness, visual changes
    • dec LOC, confusion,weakness
    • SOB, muscle cramps, abd pain, chest pain, ,
  • O2 Sat = 100% not accurate: CO can make blood become bright red – can’t distinguish carboxyhemoglobin from oxyhemoglobin
  • Hyperbaric O2 Tx indications in CO poisoning pt:
    • Not responsive to 100% O2 non-rebreather after 4-6hr
    • Coma, any period of LOC, carboxyhemoglobin level >40%,
    • pregnancy and carboxyhemoglobin >15%, CAD and carboxyhemoglobin >20%,
    • signs of cardiac ischemia / arrhythmia, recurrent symptoms up to 3 weeks

9) Domestic Violence

  • Screening Questions: (screen all pt)
    • HITS (how often does your partner….) 1-never & 5 often
      • Physically Hurt you
      • Insult you
      • Threaten you with harm
      • Scream or curse at you
    • Do you ever feel unsafe at home?
    • Has anyone at home hit you or tried to injure you in any way?
    • Has anyone ever threatened you or tried to control you?
    • Have  you ever felt afraid of your partner?
  • Clinical indicators for abuse:
    • PEx: Dental trauma, any injury esp H/N
    • General findings: chronic abd / pelvic / chest pain, somatic disorder, IBS, chronic gyne symptoms, Noncompliance with medical regimen
    • Psychological symptoms: Depression, SI, anxiety, PTSD, substance abuse
    • Incidental findings:
      • Delay in seeking treatment / inconsistent explanation of injuries
      • multiple vague, ill-defined complaints & repeated visits to ED / clinic
      • Jumpiness, fearfulness / crying,
      • overly attentive / verbally abusive partner,
      • identifiable social isolation
    • Common characteristic of injuries:
      • Bruises in various stages of healing,
      • defensive injuries of the forearms,
      • injuries to multiple areas that don’t seem to be explained adequately
    • Behavioural signs eg. partner book appointment
  • Essential steps in dealing with domestic violence
    1. Screen for abuse,
    2. Identify Hx/PEx findings,
    3. clear documentation,
    4. Ref to appropriate services
      • involve social worker
      • marital counsellor not appropriate until woman is safe and violence is under control
    5. Assess immediate danger and safety planning
      • Access to an exit in the home
      • safe place to go
      • having money, clothes, keys, medications, important documents
      • shelter or helping number
    6. f/u appointment regardless if better or worse
  • SOS DoC
    • Safety + support
    • Options + resources
    • Strengths – validate (courage to talk to me)
    • Document
    • Continuity
  • Risk factors
    • Pregnancy
    • disability
    • 18-24yo
    • EtOH/substance abuse
    • Financial stress, work stress, loss
    • Social isolation

10) Acute MI – Cardiogenic shock

  • Define cardiogenic shock: “Decreased cardiac output & tissue hypoxia in the presence of adequate intravascular volume”
  • Cardiac factors:
    • Infarction: Extensive Acute MI, extension of the infarction, previous infarction, large RV infarction
    • Valvular: Acute MR, valvular heart dz
    • Myocardium: rupture of interventricular septum or the free wall
      • myocarditis, end-stage cardiomyopathy, myocardial contusion
  • Characteristics make the development of cardiogenic shock more likely:
    • Massive MI – large infarct or anterior infarct,
    • previous infarct
    • advanced age – elderly pt
  • Pressor agents:
    • Norepinephrine & dobutamine
  • Other interventions: intra-aortic balloon pumping (IABP)
    • CABG, PCTA (percutaneous transluminal coronary angioplasty)

11) NSAID

  • NSAID-induced gastric ulcers risk factors:
    • Hx of ulcer, GIB,
    • high dose, multiple NSAID use,
    • advanced age,
    • concomitant use of anticoagulants or steroids
  • “NSAIDs PR has lower GI s/e than PO”: No scientific basis – the systemic effects of NSAIDs appear to have the predominant role.
  • Limit NSAIDs use to the short-term DOESN’T prevent GI injury: damage to the mucosal surface occurs within minutes to hours after NSAIDs use (prostaglandin inhibition)
  • Tx of Dyspepsia
    • H2 receptor antagonists
    • Proton pump inhibitor
  • Prevent NSAIDs induced ulcers: Proton pump inhibitor
  • New NSAIDs mechanism to reduce ulcer:
    • Selective COX2 inhibition (increase the rate of thromotic events)

12) Migraine headache IHS criteria of Migraine w/o aura (POUND)

  • Duration 4-72 hOur
  • 2 or more:
    • Unilateral,
    • Pulsating,
    • Disabling – moderate-severe intensity(inhibit daily activity),
    • aggravated by routine physical activity
  • At least one of:
    • N/V,
    • photophobia, phonophobia
  • 5 or more attacks and exclusion of secondary causes

Migraine aura presentations (>=1 fully reversible, <60min, attacks follow within 60min)

  • Visual distortion – positive or negative scotoma, fortification spectra, photopsia, diplopia
  • focal neurological deficits – unilateral paresthesias / numbness and weakness
  • Increase sensory perception: VH or AH Hypersomnia
  • Ataxia, vertigo, syncope
  • Aphasia / unclassifiable speech difficulty
  • Food craving

Features of the headache should prompt a search for more serious non-migraine etiologies:

  • Systemic- Fever or chills & night sweat + wt loss,
  • Neuro – Confusion, dec LOC, papilledema, visual field defect, CN asymmetry – Neurologic deficits, extremity drift / weakness, reflex asymmetry, seizure
  • Onset – sudden /abrupt / split seconds (SAH), subacute onset (tumor)
  • Older pt –
  • Previous Hx – changing: First-time headache, change in quality of usual headache, worse headache ever, thunder clap headache
  • Secondary Risk factors -HIV, Ca
  • ICP elevation: positional, worse lying down and better sitting up, n/v
  • Meningismus: stiff neck, petechiae, fever

PEx

  • Vitals (BP + HR)
  • palpation of scalp / temporal artery, carotid arteries, sinuses, TMJ (Temporomandibular), TM, oral cavity
  • Ocular exam: Pupils – equal and reactive & no papiledema
  • Meningismus testing: No neck stiffness, jolt negative, kernig & butzinski
  • Motor and sensory exam – No focal neurological deficits & Cranial Nerve exams & cerebellar exam
Tx:

headache diary, identify triggers & regular eating/sleep, exercise & stress reduction

  • 1st line:
    • Metoclopramide 10mg IV / IM (EPS – dystonia / akathisia, sedation, orthostasis)
    • Ketorolac 60mg IV or IM
    • Sumatryptan 6mg sq or 25mg po (no ergot in 24hr)
      • C/I: HTN, CAD, vascular insufficiency – same for ergot
  • 2nd line: (ergot)
    • DHE (Dihydroergotamine) 1mg IV/IM
  • 3rd line: (narcotic)
    • Meperidine (demerol) 50-100 mg IV x 1
  • C/I with pregnancy
    • NSAIDs c/i if pregnant
    • Ergots c/i due to oxytocic effects
    • Triptans – no proven safety profile
  • Steroid is reserved for status migrainosus (severe migrain >72hr)

13) Nursing home acquired Pneumonia

  • Risk of Death increased by: CURB65
    • Confusion, reduced mental test
    • Elevated BUN
    • RR>30, tachypnea
    • BP – <90/60 (HoTN)
    • >65yo
    • aspiration
    • Dependent functional status
  • Gram – (klebsiella and pseudomonas) colonization in nursing homes- 22%
  • Dx of Pneumonia
    • >=2 of the following
      • Fever, chills, sweats, wt loss
      • Tachypnea >25/min, SOB
      • new cough, Productive cough of sputums, hemoptysis
      • Pleuritic chest pain ( worsening mental or functional status)
    • + Crackles and decreased a/e on exam
    • + CXR showed new opacity
  • Ix:
    • CXR, WBC and differential, BUN/Creatinine, blood Cx, lactate
  • 1st line abx: fluoroquinolones – moxifloxacin for 7-14 days
    • Amoxi clav – 1st line for suspected aspiration pneumonia
    • macrolides – no gram – coverage (clarithromycin)
  • Influenza vaccine efficacy is >50% in preventing penumonia

14) Irregular periods

  • Ix:
    • b-HCG, CBC,
    • Cervical C&S, Pap smear,
    • TSH, prolactin
  • Dysfunctional uterine bleeding
  • Menstrual cycle characteristics – dx Anovulatory bleeding 
    • Metrorrhagia – unpredictable cycle length and bleeding pattern
    • Menorrhagia – infrequent heavy bleeding
    • Frequent spotting
    • no change in basal temperature at mid cycle – monophasic temperature curve
  • Possible causes of anovulatory dysfunctional bleeding
    • PCOS, hypothalamic-pituitary axis pathology
    • stress, anorexia – wt loss, xs exercisechronic illness,
  • Deficiency of what hormone: Progesterone
  • Tx:
    • Combined oral contraceptive pills
    • Mirena IUD, Depo Provera
    • Clomiphene ovulation induction if pregnancy desired
  • Characteristics of Ovulatory dysfunctional bleeding (menorrhagia)
    • Menorrhagia – heavy and prolonged
    • Dysmenorrhea
    • regular cycle length
    • Presence of pre-menstrual symptoms: breast tenderness, change in cervical mucus
    • Mittelschmerz (mid cycle ovulation pain)
    • change in basal temperature at mid cycle – biphasic temperature curve

15) BPPV

  • dx: BPPV (particle in endolymph of the posterior semicircular canal)
  • Maneuver to confirm the dx: Dix-hallpike
    • Dx criteria: rotational /vertical nystagmus and vertigo provoked by Dix-hallpike with a latency (1-2sec) between the completion of the maneuver and the onset
    • Paroxysmal nature of the provoked vertigo and nystagmus
    • Fatiguability – reduction in vertigo and nystagmus with repeated dix-Hallpike
  • Nonpharm. Tx: Epley’s manuever
    • Brandt-Daroff exercises (repetitive side-to-side head movements)
  • Other common causes of vertigo:
    • Meneire’s dz, labrinthitis, vestibular neuritis, vertebrobasilar insufficiency, panic disorder, migraine-associated

16) SAH

  • Typical symptoms of SAH:
    • Sudden onset, wake up by the headache
    • Maximal, severe, worst pain at onset
    • Onset with exertion
    • Transient LOC
    • N/V
  • PEx – classic findings:
    • Nuchal rigidity
    • Retinal hemorrhages
    • Coma, decreased LOC
    • Focal neurological findings
    • Restlessness
  • % of atypical features: 50%
  • Common misdiagnoses with atypical features
    • Primary headaches: Migraine headache, Tension headache, sinus-related headache
    • Viral Meningitis, influenza
    • Gastroenteritis
    • Cervical sprain, sciatica
    • Psychiatric diagnosis
  • Misdiagnosis of SAH stems from recurring correctable patterns of diagnostic error:
    • Failure to appreciate spectrum of clinical presentation
    • Failure to understand the limitation of CT and to perform LP
    • Failure to correctly interpret LP result
  • Negative CT – + LP findings
    • increased RBC (erythrocytes) on a non-traumatic tap
    • Xanthochromia – spectrophotometry (RBC -> heme -> bilirubin) – may be absent very earily 2 wk
    • Should undergo vascular imaging & consult

17) Thoracic aortic dissection

  • Risk factors other than advanced age (>50 & <70), HTN, Male (3x)
    • connective tissue disorders: Marfan’s and Ehlers-Danlos
    • Turner’s syndrome, Aortic coarctation, congenital bicuspid or unicuspid aortic valve, Ebstein’s anomaly, AS
    • T3 pregnancy
    • Family Hx,
    • Illicit drug use- cocaine and methamphetamine
    • Iatrogenic: cardiac catheterization / Sx
    • Trauma: blunt trauma (usually aortic rupture)
  • PEx:
    • HoTN, tachycardia or refractory HTN
    • Pulse deficits or duplication of pulses
    • Low / absent BP in upper extremities while central arterial BP is normal or elevated
    • Intermittent lower extremity paralysis
    • Acute aortic regurgitation
    • Wheezing, sudden hoarseness
    • Back pain + hematuria / oliguria
  • CXR findings: wide mediastinum with obscured aortic knob
  • ECG showed inferior MI doesn’t r/o Aortic dissection
  • Only effective Tx for symptomatic tamponade in ER – pericardiocentesis
  • C/I of acute aortic dissection
    • Discending aortic dissection – renal failure, mesenteric ischemia, acute limb ischemia
    • Assecending aortic dissection – Pleural effusion, intrapericaridal rupture & tamponade, acute AR, LVF
    • Hematemasis – rupture of the aorta into esophagus
    • Dysphagia – compression of esophagus
    • Hemoptysis – rupture of the aorta into tracheobronchial tree

18) Travel medicine

  • Prevent illness associated with long-distance air travel:
    • Motion sickness: sit at the center of the vehicle, fix eyes on a distant object, take antinauseants prophylactically
    • Dehydration: drink plenty of fluids, avoid EtOH
    • Jet lag: engage in activity in sunlight after arrival at the destination
    • DVT: avoid dehydration, move about while in transit, compression stocking
  • Most common illness of travelers: Travelers’ diarrhea
  • Ways travelers can avoid contracting Traveler’s diarrhea
    • Avoid uncooked food (other than peeled fruits/vege), nonbottled and nonpasteurized products
    • Eat only well-cooked, hot food
    • Avoid food from street venders
    • Use bottled / treated water for all drinking, teeth brushing, and ice cub making
    • Wash hands with soap + water before each meal
  • Boosters for someone received routine vaccinations:
    • Polio, tetanus, Hep B
  • Additional Vaccinations (sub-Saharan Africa, India, Nepal, Bangladesh):
    • Required: Hep A, yellow fever, Rabies, Meningococcal, Typhoid
    • Consider: varicella, Haemophilus influenza type B, influenza, Pneumococcal
    • Cholera is rare and its vaccine is poorly tolerated.
  • Drug-resistant malaria – high chloroquine resistance in sub-Saharan African, Southeast Asia, Ocania, Equatorial South
  • Prophylaxis:
    • mefloquine begin 1-2 wk before travel and continue for 4 weeks after
    • Doxycycline begin 1-2 days before travel and continue for 4 weeks after travel is complete
      • if can’t tolerate mefloquine or travelling to areas with mefloquine resistance (Cambodia, Thailand)
    • Malarone
  • Non-pharmacological methods:
    • DEET insect repellent & mosquito netting
    • Min outdoor evening and night activity,
    • long covered clothing & apply permethrin to clothing
  • Basic medical kit:
    • Thermometer, tape, tensor bandage, arm sling, gloves, Bandages
    • antibiotic ointment, sunscreen, water purification tablets or water purifier
    • Antimotility agent, sterile disposable needles / syringes
    • Rx meds, List of medical conditions, allergies, medications, dosages
    • Emergency contact number for family

19) Alopecia areata

  • round/oval, totally bald, smooth patch involving the scalp or any hair-bearing area on the body
  • Majority hair will grow entirely within 1yr w/o Tx
  • Alopecia areata: partial loss of scalp hair
  • Alopecia totalis: 100% loss of scalp hair
  • Alopecia Universalis: 1oo% loss of hair on the scalp and body
  • Ddx:
    • Trichotillomania – patch with twisted and broken hairs
    • telogen effluvium – hair loss is generalized over the entire scalp
    • androgenic alopecia – typical predicable pattern of balding and shedding is not prominent – Negative pull test
  • Dx: punch Bx
  • Medical conditions associated with alopecia areata:
    • Vitiligo, autoimmune thyroid dz, pernicious anemia, diabetes
    • Lupus erythematosus, myasthenia gravis, RA, PMR, UC
    • lichen planus
  • 1st line Tx:
    • Intralesional corticosteroids – Triamcinolone acetonide 5mg/ml with a total of 3ml to scalp in one visit, repeat Q4-6 wk
      • stop if no response after 6mo
  • 3 other Tx options:
    • Photochemotherapy, topical immunotherapy, systemic immunotherapy
    • topical corticosteroids, systemic corticosteroids
    • minoxidil (stimulates follicular DNA synthesis), anthralin (good for peds) anthralin (good for peds)
  • Indicators of a poor prognosis:
    • Atopy, nail dystrophy, extensive hair loss
    • Presence of other immune dz
    • Young age at onset, family hx of AA
    • ophiasis – AA of long duration involving the temproal and ocipital margins of the scalp in a continuous band

20) Endocarditis Prophylaxis indicated

  • Prosthetic cardiac valves
  • Previous infective endocarditis
  • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
  • Completely repaired congenital heart defect with prosthetic material or device, during the first six months after the procedure
  • Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
  • Cardiac transplant recipients with cardiac valvulopathy
  • Rheumatic heart disease if prosthetic valves or prosthetic material used in valve repair

The procedures for which prophylaxis is reasonable are as follows:

  • All dental procedures that involve the manipulation of gingival tissue, the periapical region of teeth or the perforation of the oral mucosa.
  • Dental implant or replantation of avulsed teeth
  • Endodontic Sx beyong the apex
  • Tonsilectomy / adenoidectomy, Sx involve respiratory mucosa / bronchoscopy with a rigid bronchoscope
  • Sclerotherapy for esophageal varices
  • Cystoscopy

The following procedures and events do not require prophylaxis:

  • Routine anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.

Antibiotics for prophylaxis should be administered in a single dose ~1hr before the procedure. If the antibiotic is inadvertently not given before the procedure, it may be administered up to 2 h after the procedure.

  • 1st line: Amoxicillin 2g or 50mg/kg po x 1
  • 2nd line agents: Keflex 2g or 50mg/kg po x 1
  • Keflex 2g or 50mg/kg po x 1
  • Clindamycin 600mg po or 20mg/kg x1
  • Azithromycin / clarithromycin 500mg / 15mg/kg po x 1
  • Use clindamycin or azithro/clarithromycin if already on amoxicillin or allergies

21) Chronic sinusitis

  • Ix:
    • Evaluation of allergies / asthma,
    • Sinus X-ray – CT sinuses not routinely recommended (2008 Top Alberta Doctor)
    • CT sinus if
      • complications of acute sinusitis
      • chronic sinusitis (>12 wk) not responding to Tx
      • Severe presentation, dx suspected but not clear
    • rhinoscopic exam,
    • baseline absolute eosinophil count
  • Complications:
    • periorbital cellulitis – orbital cellulitis – meningitis – intracranial abscess – intracranial venous thrombosis
    • sepsis
  • Immune deficiency (recurrent infection with incapsulative pathogens, Hx of recurrent OM, bronchitis, pneumonia) Ix
    • Ix for humoral immunodeficiency: IgA, IgG, IgM, HIV/Hep C
  • Tx
    • nasal saline irrigation,
    • intra nasal steroid spray,
    • oral decongestants short course <5d
    • abx for 1mo (10-14 days if acute sinusitis) – Amoxicllion 500mg tid (80mg/kg/d – high dose regimen)
    • Antihistamine? – may have a role where a clear allergic component is demonstrated.
      • no antihistamine in acute sinusitis
  • Return with min improvement – Tx:
    • Abx Tx for 1mo 2nd line: Amoxicillin/Vlavulanate 500 tid or 875 bid
    • prednisone for 8-10 days
    • continue nasal saline irrigation and intra-nasal steroid spray
    • ENT ref if req polpectomy
      • anatomical anomalies, complications, >4 episodes /yr
      • chronic sinusitis not responding to Tx
  • Improved symptoms: maintenance regime –
    • Nasal irrigation
    • intranasal steroid spray

22) COPDE

  • Characteristic of COPD
    • Progressive development of airflow limitation that is not fully reversible.
    • Chronic obstructive bronchitis – obstruction of small airways; defined by the presence of a productive cough >3mo for 2 consecutive years
    • emphysema – enlargment of air spaces and destruction of lung parenchyma, loss of lung elasticity, and closure of small airways
  • 2 Common Risk factors of COPD
    • Cigarette Smoking & environmental pollutants
  • 2 Common causes of an acute COPD exacerbation
    • URTI and CHF, environemental irritants, PE, MI, anemia
  • What is the mainstay of current drug therapy for COPD
    • Bronchodilators: beta2 agonist and anticholinergics
  • O2 = 63mmHg: home O2 is justified only in pt with severe COPD and chronic hypoxemia (O2 <55mmHg)
  • NO evidence on the use of prophylactic abx
  • Long-term inhaled corticosteroids alone increase infection and mortality
  • Pulmonary rehab will improve exercise capacity and quality of life; reduction in the amount of health care needed
  • Only measure to slow the progression of COPD: smoking cessation

23) Diabetic foot ulcer 

  • Vascular insufficiency: better sitting up and worse lying down
    • 2 other features of the Hx:
      • pain occurring in the arch or forefoot at rest or during the night
      • claudication
    • 2 Clinical features on PEx:
      • absent popliteal or posterior tibial pulses,
      • thinned or shiny skin, absence of hair on the lower leg and foot,
      • thickened nails,
      • depedent erythema
    • Neuropathy:
      • loss of sensation to 10g monofilament,
      • insensitive to vibration (128hz tuning fork)
  • the absence of systemic symptoms DOESN’t reliably r/o an infection in soft tissue / bone
  • Swab is likely to be polymicrobial and not useful in determining the causative organism.

24) Newborn

  • Greatest risk for developmental dysplasia of the hip: Girl with a breech presentation
    • (girl > body, ↑ in oligo and breech)
  • Equivocally positive PEx (soft click, mild asymmetry but neither a positive Ortolani or Barlow) for developmental dysplasia of the hip; what to do next?:
    • Re-examine in 2 weeks
  • Most appropriate Rx for a newborn with a positive Ortolani– orthopedic referral (Tx based on PEx in this case and u/s is unnecessary)
  • Failed to f/u at 2wk and presented at 3 mo: most reliable signs for detecting developmental dysplasia: limitation of abduction
    • other signs: Galeazzi sign (relative shortness of femur with the hips and knees flexed)
    • Discrepancy of leg lengths

25) Asthma in pregnancy

  • The course of asthma during pregnancy varies & worse in the immediate postpartum period, but soon returns to baseline after the delivery.
  • Poor asthma control is associated with the following maternal and fetal problems:
    • IUGR, small birth weight
    • Gestational hypertension, pre-eclampsia
    • Preterm birth
    • uterine hemorrhage, ↑ c/s rate
    • Congenital malformation
  • Ventolin and Budesonide are safe in pregnancy
  • Maternal health problem associated with corticosteroid use:
    • gestational diabetes, gestational hypertension
    • antepartum and postpartum hemorrhage
  • Theophyline is safe in pregnancy. Theophyline clearance is reduced by 20-35% in the T3 of pregnancy

26)  Stroke

  • Non-modifiable risk factors
    • Advanced age (double each decade after 55),
    • gender (male more common, female more evere),
    • family hx,
    • race: chinese, japanese, african-american
  • Modificalbe risk factors:
    • HTN, DM, Hyperlipidemia,
    • Smoking (back to baseline 2-5 years after cessation)
    • obesity, sedentary lifestyle
    • A Fib, asymptomatic carotid stenosis, sickle cell dz,
    • illicit drug use (cocaine, amphetamine, heroin)
  • Woke up with a stroke, candidate for thrombolytic Tx?
    • No, require certain onset of symptoms (
  • Transfer to regional referral center, agree with that?
    • Yes, better outcome, better functional recovery, shorter length of stay, decrease mortality and morbility
  • If survive the stroke, % at regaining independence?
    • Very good chance (2/3)

27)BPH

  • 2 mechanisms of BPH causes bladder obstruction:
    1. Dynamic obstruction by smooth muscle compression
    2. Mechanical compression by the adenoma (prostatic stromal cells proliferation)
      • compressed prostatic urethra, restricitng urine flow
  • 3 symptoms alert a dx of BPH (Lower urinary tract symptoms)
    • Storage: urinary frequency, nocturia, incontinence
    • Voiding / obstructive: hesitancy, intermittence, straining, weak stream
    • Post micturition: incomplete bladder emptying sensation, retention, dribbling
    • sexual dysfunction
  • 3 complications of BPH
    • urinary retention – hydronephrosis – kidney damage, sexual dysfunction,
    • infection – UTI
    • renal (bladder) calculi – hematuria
  • 2 urinary signs or symptoms that increase one’s risk of BPH progressing to acute urinary retention
    • Voiding/obstructive symptoms: weak stream, urinary frequency / urgency with small volume of void,
    • large prostate on DRE,
    • sensation of incomplete bladder emptying
  • 2 class of drugs to reduce the progression to acute urinary retention
    1. a-blokcer: tamsulosin (flomax)
    2. 5a-reductase inhibitor: finesteride
  • PSA = 4 & thus developing acute urinary retention over the next 4 yr ~20%. Name a class of drugs that reduce the risk of recatheterization after removal:
    • a-blocker: tamsulosin (flomax)
  • Dietary supplement that decreased risk of developing prostate cancer: selenium

28) Epileptic on clobazem, vomiting

  • Seizing, initial management:
    • A – maintain airway patency & remove potential airway obstructions (denture), lateral decubitus
    • B – Provide 100% Ox and mouth suction if available
    • Protect the pt from injury
  • Continue to seize beyond 2-3 min. Practical clinical definition of Generalized convulsive status epilepticus (GCSE):
    • seizing > 5min or repetitive seizures w/o fully recovered consciousness
  • Ambulance called, while waiting, adm med via a non-IV route; List 3 different meds and routes you could use in the office:
    • Clonazepam IM
    • Midazolam IM / intranasal
    • Diazepam 2-10mg PR – 15-30min
    • Lorazepam 0.5-2mg SL – 12-24hr (ativan)
  • Accompany pt in the ambulance, at ED, Sz continues, so IV combo Tx of choice for GCSE. List these two drugs:
    • Lorazepam 4-8mg 
    • phenytoin 50mg  (Thiamine 100mg IV, Glucose 25g IV)
  • List 4 s/e that must be watched for with the combo:
    • HoTN(either drug)
    • Respiratory depression (either drug)
    • Cardiac rhythm disturbances (phenytoin)
    • Venous irritation (phenytoin)
    • Purple glove syndrome (phenytoin) – progressive edema, discoloration, pain in the limb within 2-12hr
  • The Sz continues. List 2 other medicaitons that can be used and further management priorities:
    • Propofol 
    • phenobarbital
    • Prepare for Intubation & ventilation support, consult ICU/Anesthesia & transfer + EEG

29) Scaphoid #

  • Mechanism of injury most commonly associated with scaphoid #:
    • extreme dorsiflexion of the wrist with compression force to the radial side of the palm
  • PEx features:
    • snuffbox tenderness,
    • axial load tenderness (+ scaphoid compression test),
    • scaphoid tubercle tenderness,
    • wrist joint effusion
  • X-ray features that confirm an adequate scaphoid view?
    • at least one clear view of the scaphoid showing the trabecular pattern
  • Most scaphoid # are visible on initial radiographs
  • What soft tissue sign of scaphoid # should be sought on radiographs?
    • Displacement of the scaphoid fat stripe
    • swelling on the dorsum of the wrist
  • Negative radiographs but suspect a scaphoid # clinically
    • Best appropriate Tx: textbook – thumb spica cast (short arm + proximal phalanx of thumb) however, a short arm cast (colles’ cast) is sufficient
  • What is the ideal immobilization position for common scaphoid #?
    • The best position for function = position of the hand, wrist, or thumb are not thought critical.
  • What time interval is appropriate for clinical and radiographic reassessment?
    • 2 weeks
  • At this reassessment, you see a fracture on radiograph. List 3 high-risk features of scaphoid # that require referral to an orthopedic surgeon
    • proximal pole fracture
    • oblique fracture
    • fracture displaced during Tx
    • displaced fracture >1mm

30) Erectile Dysfunction

  • 3 broad pathophysiological categories that may cause ED:
    • Psychogenic: performance anxiety, relationship problems, stress, depression
    • Organic: Arterial / cavernosal, neurogenic, Endocrinology (hormonal)
    • mixed psychogenic and organic – most common
  • Negative hx / PEx – 3 Ix that would be appropriate (ED can be the presenting s/sx of DM, CAD, HTN, spinal cord compression, pituitary tumor, or hyperlipidemia)
    • U/A
    • Cholesterol, Triglycerides
    • CBC, glucose, creatinine
    • testosterone (if low, order serum free testosterone, prolactin, LH)
  • Sildenafil – mechanism of action
    • Selective inhibitor of phosphodiesterase type 5
    • inactivates cyclic GMP; when sexual stimulation releases nitric oxide into penile smooth muscle, inhibition of phosphodiesterase type 5 causes a marked elevation of cyclic GMP, resulting in increased smooth-muscle relaxation and better erection
  • Adverse effect:
    • HoTN
    • Headache
    • Flushing, nasal congestion
    • abnormal vision
    • MI, angina, death – treadmill may be indicated before Rx
    • dyspepsia
  • What particular drug class would be an absolute contraindication for sildenafil use: Nitro – causes severe HoTN and death
  • 3 other treatment options:
    • psychosexual therapy
    • Transurethral alprostadil
    • vacuum constriction device
    • surgical prosthesis
    • intracavernous alprostadil / drug mixture

31) Syncope – sudden transient, self-limited LOC from global cerebral hypoperfusion with spontaneous recover

  • 5 possible causes:
    • Cardiogenic:
      1. arrhythmia (VT, VF, AVblock, sick sinus syndrome)
      2. Decrease cardiac output (AS, HOCM, myxoma, PE)
      3. low flow state (CHF, cardiomyopathy)
    • Non-cardiogenic
      1. vasovagal: ppt by fear, emotion, stress, pain
      2. Orthostatic – postural hypotension: hypovolemic, autonomic dysfunction, medications
      3. Situational -:carotid sinus hypersensitivity– ppt by swallowing, coughing, urinating, defecatio
  • Resting HR 44, normal sinus on ECG, what is the next appropriate Ix: 24 hour holter
  • Complete Heart block, ref to cardiologist, what is your legal responsibilities: NO driving – report to motor vehicle authority
  • Pt would be a candidate for a permanent pacemaker.
  • List one other bradycardic disturbance that is a definite indication for permanent pacemaker implantation
    • Morbiz type 2

32) Acute decompensated heart failure

  • 5 potential causes:
    1. Infection (high output), shunt, anemia, thyroid dz
    2. substance abuse
    3. MI / arrhythmia,
    4. valvular dysfunction,
    5. acute cardiomyopathy
    6. Fluid overload, decreased compliances with diuretics
    7. hypertensive emergency,
    8. Renal failure, hepatic dysfunction
  • The most specific symptom: PND
  • The most sensitive symptom: Dyspnea
  • 4 PEx findings:
    1. Pulm: crackles and wheeze on auscultation, Hypoxia, tachypnea
    2. Peripheral edema / ascites
    3. cool extremities and poor u/o
    4. C/V exam: Diffuse PMI, S3/S4, Tachycardia, arrhythmiaJ, VP distention / elevated
  • CXR findings:
    • pulmonary venous congestion and interstitial edema,
    • widened cardiac silhouette, cardiomegaly
    • Kerley-B lines, pleural effusion
  • The feature that is central to the pathophysiology of most episodes of the decompensated heart failure: volume overload
  • Tx:
    • O2, PPV, IV lasix, nitroglycerine,
    • vasodilating inotropes: dobutamine
    • vasopressor inotropes: norepinephrine

33) COPD exacerbation

  • Characteristics of COPD
    • Progressive airflow limitation that is not fully reversibility:
    • Chronic obstructive bronchitis  (>3mo of productive for >2yr) with obstruction of small airways and emphysema with enlargement of air spaces and destruction of lung parenchyma, loss of lung elasticity, and closure of small airways due to mucus plugging
  • Risk factors
    • Cigarette Smoker, environmental pollutants, a-1 antitrypsin deficiency
  • A Common cause of an acute COPD exacerbation:
    • URTI, air pollution, temperature
  • Mainstay of current drug therapy for COPD:
    • Bronchodilators: b2 agonists < anti-cholinergics
      • small increase in forced expiratory volumes & reduce hyperinflation& improve exercise tolerance
  • Partial P of arterial O2 = 63mmhgl Is he a candidate for home oxygen therapy:
    • No, require PO2
    • survival is not increased in pt with less severe hypoxemia
  • Is there any evidence to support use of prophylactic antibiotics to prevent acute exacerbations: No,
    • No evidence that abx use prevent exacerbations.
  • Should he be prescribed inhaled corticosteroids on a long-term basis to reduce progression of COPD:
    • No, unlike chronic asthma, no evidence that long-term high doses of inhaled corticosteroids reduces progression of COPD
  • Exercise classes – what benefit derive from pulmonary rehabilitation (structured program of education, exercise, and physiotherapy):
    • Improve exercise capacity, quality of life and reduces the amount of health care needed.
  • The only measure known to slow the progression of COPD:
    • Smoking cessation

34) 70yo man with uncomplicated anteroseptal infarct – first MI

  • List 3 risk factors for MI
    • Obesity, Smoking, diabetes, HTN, dyslipidemia
  • List 2 indications for long-term anticoagulant therapy after MI:
    • Stents placement, Persistent A fib, LV thrombus, intolerance to ASA
  • Given his age, b-Blocker Rx?
    • yes, reduce mortality – metoprolol, propranolol, cateprolol
  • Prior to d/c, he exercised to 6 METS w/o angina / ischemia changes
  • Should long-acting nitrates be included on his discharge medication list?
    • NO, long-acting nitrates are effective antianginal and anti-ischemia drugs that should be prescribed after MI, along with B-Blockers, to those who have angina pectoris
  • ACEi should be administered after MI to older persons who have any of the following:
    • CHF, anterior MI, LVEF =<40%
  • Should CCB be used routinely?
    • No, increase mortality.
    • Use if persistent angina despite Tx with B-blockers + nitrates
    • Nondihydropyridine CCB: verapamil / diltiazem if normal LVEF (amlodipine or felodipine if abn LVEF)
  • Non-sustained VT in ICU and during recovery from his stress test.
  • What is the best drug for this condition:
    • B-blockers decrease mortality in persons with nonsustained VT or complex ventricular arrhythmias after MI
      • Consider implantable ACD.

35) 40yo smoker with hyperlipidemia: systolic ejection click on routine check up. Echo – bicuspid AV

  • % pt have BAV:
    • 1-2% – the most common congenital cardiac malformation
  • What is the most frequent complication of BAV:
    • AS
  • List one other consequence of BAV:
    • Aortic regurgitation, infective endocarditis, aortic complications: dilatation and dissection
  • ~% pt will develop a serious complication:
    • >33%
  • Measures to reduce the risk of significant stenosis:
    • smoking cessation. lower cholesterol
  • What are the indicators for aortic valve surgery:
    • Severe valvular dysfunction, symptomatic pt, abn LV dimensions or dysfunction
  • 3 siblings and 4 children, should they be checked for BAV?
    • yes, >30% 1st degree relative has BAV thus, echo screening of first-degree relatives is warranted
  • BAV is functioning normally, but has a 5cm aortic root dilation
  • Is dilatation a common finding in pt with normally functioning valves?
    • Yes, >50% of young pt with normally functioning BAV has echo evidence of aortic dilatation
  • Should Mr Leaken be considered for aortic root replacement?
    • Yes, to prevent rupture of aortic aneurysm

36) 20mo with barking cough but no audible stridor, tracheal tug, chest-wall indrawing. normal RR

  • Likely dx:
    • Croup (6-36mo, peak 12-24mo, M>F, subglottic inflammation + swelling, parainfluenza >RSV)
      • abrupt onset of barking cough, usually at night with inspiratory stridor, hoarseness, respiratory distress, and fever
      • can be proceeded by URTI (cough, rhinorrhea, fever)
      • Most resolve within 48hr, some in 5-6days
  • Mild, moderate, or severe? (determine the degree of airway obstruction in assessing children with croup)
    • Mild (happy, drinking, eating, playing, no stridor at rest)
      • Moderate: stridor at rest, accessory muscles use, ↑ HR, no distress
      • Severe: exhausted, ↑↑HR, agitation,, hypotonia, , pallor, significant distress
      • Impending failure:  ↓LOC, cyanosis, ↓stridor/retraction
  • Tx (mild Croup):
    • Dexamethasone 0.6mg/kg po x 1;
      • reduce admission & intubation, return to medical care, and duration of symptoms
      • give even if only a barky cough
      • improve within 2-3 hr
    • If mod-severe: Epinephrine 5mLs 1:1000 solution via neb over 15min
  • What are the risk factors that increase the likelihood of hospital admission after initial Tx? List 3
    • <6mo, stridor at rest
    • Return to ED within 24hr,
    • Hx of severe obstruction before presentation
    • Hx of previous severe croup,
    • structural airway anomaly
    • poor response to initial Tx, parental anxiety, uncertain dx
  • 3mo later, pt came back with inspiratory stridor at rest and using accessory muscles
  • What is the most likely diagnosis
    • Severe Croup
  • List 3 Tx options:
    1. O2,
    2. Epi neb,
    3. dexamethasone, 
    4. intubation prn

37) AOM – 2yo with ear pain + fever

  • The most useful symptom for dx of AOM:
    • Ear pain (LR 3-7.3)
  • Least useful sign in making the dx of AMO:
    • slightly red TM
  • Cloudy, bulging TM, distinctly immobile, hemorrhagic / strongly red all have good positive LR
  • Tx options:
    • A single IM ceftriaxone (2nd line) has similar efficacy as a 5d (>2yo) and 10d (<2yo) course of amoxicillin (1st line)

38) 4mo recurrent abd/p, relieved by defecation, + alt diarrhea and constipation, bloating, and gas. Worse with stress

  • What is the most likely dx:
    • IBS
      • Rome3: Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months associated with ≥ 2 of the following:
        1. Improvement with defecation
        2. Onset associated with a change in frequency of stool (>3/d or <3/wk)
        3. Onset associated with a change in form (appearance) of stool: lumpy, hard or watery, loose
      •  * Criterion fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis)
      • ** “Discomfort” means an uncomfortable sensation not described as pain
  • List 3 red flags
    • Constitutional symptoms: wt loss, fever, chills, night sweats
    • Stool change: Melena, BRBPR, Change in the caliber, anemia
    • Palpable abdominal or rectal mass
    • Family Hx of IBD / colon ca
    • New onset >50yo or nocturnal symptoms
    • Recent abx use
  • Tx:
    • A strong physician-pt relationship
    • Fiber supplementation (12-30g/d), osmotic laxative
      • lactose only be eliminated with proven lactase deficiency
    • CBT, hypnosis
    • TCA )amitriptyline 10-25mg qhs), smooth muscle relaxants, antispasmodic (buscopan, dicyclomine 10-20mg 2-4x/d), simethicone for gas/bloating, antidiarrheal (loperamide, cholestyramine)

39) 45yo M w/ severe hypertriglyceridemia (TG >10 mmol/L)

  • What is the most serious risk of his severe hypertriglyceridemia?
    • Acute hemorrhagic Pancreatitis
  • Is he at increased risk of CAD?
    • Yes, sig & linearly correlated with MI
  • List 3 medications associated with hypertriglyceridemia
    • Estrogen replacement therapy, corticosteroids, HCZ, loop diuretics, B-blockers, tamoxifen
  • List 3 other secondary causes
    • obesity, diet (xs carbohydrate intke), alcohol intake
    • Poorly controlled DM, hypothyroidism, nephrotic syndrome, CRF
  • What additional laboratory investigations would be appropriate?
    • FBG, serum creatinine,
    • TSH, apo B
  • List 3 non-pharmacologic steps to improve his triglyceride levels
    • dietary modification: Mediterranean diet / low fat diet
    • Increase Exercise: daily 30-60min moderate aerobic exercise
    • No alcohol intake
    • Wt loss: decrease waist circumference, BMI 20-27
  • Which medications would be appropriate for Tx of severe hypertriglyceridemia?
    • Fibrates (f/u LFT & CK at 6wk then q3mo to monitor hepatic s/e & rhabdomyolysis)
      • Fenofibrate 48-200mg
    • niacin (B3), salmon oil (omega3)

40) 52yo M woked up with drooping R face, R accumulation of saliva, Taste different on R, unable to close R eye which lacks tears, unable to show teeth or puff R cheek

  • What is this pt’s likely dx?
    • Bell’s palsy (onset ~40yo)
      • weakness / paralysis of all muscles of facial expression = peripheral facial palsy
      • Facial weakness is best demonstrated by requesting pt to “close your eyes” and “how me your teeth”
      • The Nerve intermedius carries parasympathetic fibbers that stimulates salivation and lacrimation
    • Central weakness of the unilateral lower face is due to a lesion above the facial nucleus in the pons of the contralateral hemisphere, with contralateral hemiplegia, BUT DOESN’T affect the salivary & lacrimal secretions or the sense of taste
  • Any Ix indicated?
    • Imaging & investigations are not routinely indicated
    • If the weakness is central, then evaluate for ischemia, infection, and inflammatory dz:
      • lab, MRI, lumbar puncture, ESR,  syphilis, HIV work up
  • What is suspected in the pathogenesis of the dz?
    • HSV affecting the facial nerve
  • Outline Tx:
    • eye drops to lubricate the cornea, patch the eye to prevent drying & infection
    • Prednisone 1mg/kg daily x 7d
    • Valacyclovir 1g bid x 7d
  • Is the pt expected to make a full recovery?
    • Yes, most pt recover completely

41) 35yo M w/ Low back pain x months, c/o prolonged AM stiffness & nocturnal pain. SLR negative

  • What dx should you consider?
    • Ankylosing spondylitis: +HLAB27, sacroilitis, enthesitis
  • NSAIDs x 1mo, improved significantly, but not completely. Pain w/ lumbar extension & some loss of forward flexion.
  • Further investigations. Indicate which initial imaging and serologic tests should be ordered:
    • Lumbar & sacroiliac x-ray r/o bamboo spine
    • HLA B27, CBC, CRP/ESR (low sensitivity in AS) r/o inflammatory causes
  • Imaging negative, serology positive. What Ix would be most helpful in confirming dx?
    • Fat-suppressed MRI
  • The dz is as disabling as RA, remain active into the late decades of life.
  • Pt returns years later, dz progressed, applying for a disability pension; lessened spinal flexion, hip ROM, persistent knee effusion
  • What other therapy should you consider?
    • TNF-a

42) Cellulitis

  • Are cultures of needle aspirates indicated in routine care? Why or why not?
    • No, likely gram + cocci
  • Are blood Cx indicated in routine care of most pt with cellulitis? why or why not?
    • No, bacteremia is uncommon; only for systemically ill pt
  • When are plain film radiographs indicated in cullulitis?
    • Deep infection,
    • r/o osteomylitis or questionable bony lesions
  • List one of the common organisms that cause cellulitis?
    • Stap aureus & streptococci
  • List one of the abx for a usual case of cellulitis?
    • Keflex
  • What 2 ancillary measures can be used to care for cellulitis?
    • elevation and immobilization of the involved limb
    • Cool sterile saline dressings
    • good skin hygiene
  • Bacterial species & std abx at specific sites or with particular exposure
    • Human bites: oral anaerobes – clavulin 500 q8h
    • Dog & cat bites: pasterella species, S. aureus, anaerobes – clavulin 500mg q8h
    • Exposure to salt water: Vibrio – doxycycline
    • Exposure to fresh water: aeromonas – ciprofloxacin 400mg q12h
    • Butcher, fish or clam handler, veterinarian: Erysipelothrix – amoxicillin 500mg po q8h
    • Limb-threatening DM foot ulcer – aerobic gram-negative bacilli / anaerobes – Piptazo

43) 52yo F w/ urinary incontienence

  • Name 2 common types of urinary incontinence & briefly define each
    • Stress incontinence: leakage from effort, exertion, sneezing, coughing
      • poor intrinsic sphincter function
    • Overflow incontinence: over distension of the bladder with overflow due to obstruction or neurological dz
      • obstruction from pelvic organ prolapse or a neurological condition (spinal cord injury)
    • Urge incontinence: leakage accompanied by or preceded by urgency
      • detrusor overactivity
    • Mixed incontinence – a combination of stress & urge incontinence
  • List 5 factors that increase the risk of developing urinary incontinence
  • Any of the risk factors modifiable? if so, which ones?
    • Modifiable:
      • Smoking, high caffeine intake
      • Urological / GI: recurrent UTI, dysuria, fecal incontinence, constipation, bowel problems
      • Gyne: cystocele, uterine prolapse, poor pelvic floor muscle contraction
      • Obesity – high BMI
      • Comorbid dz: DM, HTN, cognitive impairment, parkinsonism, arthritis, back problems, hearing & visual impairment
      • Meds: diuretics, estrogen, BZD, antidepressants, hypnotics, laxatives, abx
    • Nonmodifiable
      • Hysterectomy, prolapse surgery, vaginal delivery, forceps delivery, C/S, increased parity, fetal birth wt
      • Age, white race, higher education, childhood enuresis, >2 comorbid dz
  • What non pharmacological management strategies can be effective?
    • Pelvic floor muscle training (kegel exercises),
    • bladder training (scheduled voiding),
    • weighted vaginal cones, electrical stimulation
    • no xs fluid intake, caffeine reduction, moderate alcohol, smoking cessation,
    • wt loss, prevent constipation, exercise
  • The leakage is often preceded by a marked sense of urgency. You conclude that this woman has urge incontinence.
  • What pharmacological agents might be indicated?
    • anticholinergics: oxybutynin
    • Smooth muscle relaxant – flavoxate
    • MgOH, doxepine (TCA)
  • If this woman’s symptoms were consistency with stress incontinence, name a surgical intervention that has a high success rate.
    • suburethral sling procedure
    • open retropubic cloposuspension

44) bacterial Pharyngitis -19yoF sore throat x 3/7 with fever, fatigue, swollen glands. no cough/rhinorrhea/conjuncitivits.

  • What other condition should be considered as part of the ddx:
    • mononucleosis (posterior cerv LN) or other viral pharyngitis
  • What c/i may occur when a pt has GAS pharyngitis?
    • rheumatic fever – suspected if jt pain & swelling, subcutaneous nodules, erythema marginatum / heart murmur, & confirmed strep infection
      • Jone’s Dx Criteria- 2 majors or 1 major + 2 minors
        • Major Criteria: carditis, polyarthritis, subcutaneous nodules, erythema marginatum, chorea
        • Minor Criteria: fever, elevated WBC/ESR/CRP, arthralgia, prolonged PR, previous rheumatic fever or rheumatic heart disease
    • scarlet fever
      • punctate, erythematous, blanch able, sandpaper-like exanthem @ neck, groin, axillae, body folds/creases (Pastia’s lines) &
      • strawberry tongue (bright red tongue with white coating)
    • post-strep glomerulonephritis – abx doesn’t prevent this
      • hematuria, frequency, edema
    • peritonsillar abscess
      • hot potato voice, fluctuant peritonsillar mass, deviated uvula
      • intraoral u/s is an accurate dx test
  • What Ix would you order to confirm dx?
    • throat Cx (tonsils + posterior pharynx – 97% sensitive & 99% specific) or rapid strep antigen test (specific but not sensitive – 70%)
    • monospot test for EBV – misses 1/3 in the first week & 80% sensitive in the second week

45) 50yo F, heel pain, worse on wt-bearing, esp in AM. Tender over calcaneal tubercle

  • Most likely dx:
    • plantar fasciitis
      • heel pain w/ wt bearing after inactivity / AM,
      • tender at anterior-medial heel,
      • limited dorsiflexion due to Achilles tightness
  • What other dx are possible:
    • Stress #, bone bruise, rupture of plantar fascia
    • infection, Bursitis, Enthesopathies
    • cancer, paget’s dz,
    • Fat pad atrophy, 
    • Nerve contrapment or compression syndromes:
      • Posterior tibial nerve (Tarsal tunnel syndrome),
      • medial calcaneal branch of posterior tibial nerve,
      • nerve to abductor digit quinti, SI radiculopathy, neuropathic pain
  • Name 3 risk factors:
    • Obesity, prolonged standing, pea plans (foot pronation),
    • reduced ankle dorsiflexion, running
    • inferior calcaneal exostoses (bone spurs)
  • read advertisement about orthotics. Pt wondering what her other options might be: List 3 other tx options:
    • PT, night splints, extracorporeal shock-wave therapy,
    • NSAIDS, steroid injection, surgery & stretching
    • self-limiting & resolves in 1yr

46) TIA – 65yo F w/ R facial droop, R hand/leg weakness lasted 30min

  • Risk of stroke in the next two days = 5% after first TIA
  • TIA is neurologic dysfunction last less than 24hr
  • Hx suggest the dx of TIA:
    • acute onset, transient deficits usually <30min, no marching of symptoms, no scotomata,
    • negative symptoms – loss of function: aphasia, weakness, numbness
  • Nonfocal symptoms that are usually not attributable to TIA:
    • LOC/syncope, dizziness,
    • confusion,
    • general weakness,
    •  loss of vision with reduced LOC,
    • incontinence of feces or urine
  • List 5 neurologic symptoms that, in isolation are unlikely to be caused by a TIA
    • Vertigo, loss of balance, tinnitus
    • diplopia, scintillating scotomas
    • dysphagia,
    • sensory symptoms confined to part of one limb / face
    • amnesia, drop attacks, isolated dysarthria
  • List 3 tests to consider for dx
    • CT head r/o hemorrhage
    • carotid u/s doppler
    • ECG, echocardiagram
    • thorough neurological exam
  • The ideal test to truly distinguish stroke from TIA is:
    • MRI w/ diffusion-weighted imaging
  • Her ECG shows A fib, which is new. List 2 additional high risk factors for stroke
    • ASA failure TIA,
    • Possible cardioembolic stroke: A fib, Valvular dz,
    • Crescendo TIA (>3 TIA in 72hr period with increase in frequency, duration, severity),
    • high ABCD2 score –
      • Age>60,
      • BP >140/90,
      • Clinical features,
      • DM, Duration (60min =2)
  • Tx:
    • admission, anticoagulation, rate / rhythm control for a fib

47) Well Score system for PE: Low<2, Mod 2-6, high >6

  • DVT s/sx = 3, No alt dx = 3
  • HR>100 = 1.5, immobilization or Sx in last 4 wk = 1.5, hx of DVT/PE = 1.5
  • hemoptysis =1, cancer Tx within 6mo = 1

48) 50yoM smoker with chronic bronchitis; 3/7 increased productive cough – green sputum. Bilateral exp wheezing.

  • 3 major clinical criteria that define Acute Exacerbation of Chronic Bronchitis
    • Increase sputum volume
    • Increase sputum purulence
    • Increase SOBOE over baseline
  • Would a CXR be helpful in making the dx?
    • No, clinical dx for AECB, but consider CXR to r/o PNA / CHF
  • What probable pathogens should you aim to cover? Name 2 likely pathogens
    • Haemophilus influenzae, moraxella catarrhalis, strep penumoniae
  • Would sputum C&S be helpful? If so why?
    • Very limited role because the airways of pt with chronic bronchitis are chronically colonized with bacteria. Sputum analysis should be reserved for pt with freq exacerbations or chronic purulent sputum.
  • List 3 possible 1st line abc for this pt:
    • doxycycline, clarithromycin, ceftriaxone
  • If pt was on O2 at home (with risk factors), what abx would you consider?
    • Fluoroquinolone: ciprofloxacin, piptazo or clavulin to cover klebsiella / gram – species & pseudomonas
  • Besides the use of home oxygen, what other risk factors would prompt you to use the abx?
    • FEV1 <50%, >4 exacerbations,
    • cardiac dz, chronic steroid po use,
    • failed initial Tx, recent abx use in the past 3/12
  • Pt has neglected atrovent & ventolin puffers perviously Rx. Should you initiate Tx with methylxanthines?
    • No, restart with ventolin, iptropium, and consider long-acting B2 agonist & inhaled corticosteroid combo
  • Could you give pt steroids? Why or why not?
    • Yes, for 5-14days

49) 32yo F with UTI, sexually active. U/A + lurk & nitrites

  • Urine Cx in the management of UTI?
    • No, not needed in uncomplicated UTI (classic dysuria, urgency, frequency and no vaginal symptoms)
    • Cx only if factors associated with upper tract infection or complicated infection
      • DM, chronic renal dz, immunosuppressed
      • Recent urinary tract instrumentation / catheter
      • Pregnant
      • Anatomical or functional abnormality
      • Male
  • If u/A negative, would this alter dx?
    • No, a negative dipstick can’t r/o infection when the pretest % is high
  • Opt to Tx. What is an acceptable Tx regimen? Please include the drug name, frequency, duration
    • Macrobid 100mg po bid x 7 days
  • Pt asks whether recent sexual activity is a risk factor for UTI?
    • Yes, increase UTI risk by a factor as great as 60 during the 48hr after sexual intercourse
  • Does use of spermicidal agents elevate the risk of UTI?
    • yes, E coli and staph by a factor of 2-3.
  • Pt routinely voids post-intercourse
  • What evidence, if any support this practice?
    • No evidence, studies indicates it doesn’t prevent cystitis
  • What evidence support cranberry juice at the onset of symptoms?
    • randomized studies showed risk reduction of symptomatic, recurrent infection by 12-20%, but poor evidence
  • Is routine f/u necessary after Tx?
    • No, not necessary after tx of cystitis
    • f/u if symptomatic

50) 22yo F with menses q3-6mo. Menarche at 12yo, regular x years. Lately, BMI ↑ 29, unwanted facial & abd hair.

  • What is the most probable dx:
    • PCOS: dx – 2/3 –
      • oligomenorrhea / irregular menses x 6mo,
      • clinical / lab evidence of hyperandrogenism (acne, alopecia)
      • polycystic ovaries on u/s
      • (hyperandrogenism, hyperinsulinemia – Acanthosis nigrican, abn lipid, obesity)
  • What b/w would you do? List 3:
    • TSH, prolactin to r/o thyroid dysfunction & hyperprolactinemia
    • androstenedione (dx)
    • 17a-hydroxyprogesterone to exclude adrenal hyperplasia
    • Total & free testosterone, DHEAS – r/o androgen secreting tumor
    • B-HCG r/o pregnancy
    • fasting insulin / glucose – exclude hyperinsulinemia / DM2,
    • lipids – monitor lifestyle changes
  • What are the medical Tx options? List 3:
    • Metformin, OCP, spironolactone
    • Finasteride (5-a reductase inhibitor) or Flutamide (androgen reuptake inhibitor)
  • What are the non-pharmacologic Tx options? List two
    • Wt loss – 10-15% reduction resulted in spontaneous conception in >75% of obese pt with PCOS
    • hair depilatory electrolysis or laser ablation
    • lifestyle modifications (smoking cessation)
  • Later, if she wishes to have a child, on what issues would you counsel her? List two
    • infertility
    • increased first trimester loss, GDM
  • What pharmacotherapy might be needed in this situation? List two
    • Clomiphene citrate, metformin, gonadotropin (FSH/LH)
    • Bromocriptine (hyperprolactinemia)
    • Ovarian drilling

51) 19yo F w/ seasonal allergic rhinitis received allergen immunotherapy & noticed itching in the palms, followed by SOB & throat swelling.

  • List 4 features that would constitute the dx of anaphylaxis
    • Sudden onset & last < 24hr
    • involves 2 or more body systems
      • Derm – flushing, pruritis, urticaria, maculopapular rash, angioedema
      • CV – HoTN, lightheadedness, tachycardia, MI, arrythmia
      • GI – N/V/D, adbo pain
      • Resp – Wheeze, SOB, airway obstruction due to edema, nasal congestion, sneezing, hoarseness, stridor, cough, tachypnea, accessory muscle use
      • Neurologic – dizziness, weakness, syncope, Sz
      • Ocular – pruritis, conjunctival injection, lacrimation / tearing
  • List 3 of the most common cause of anaphylaxis
    • Food: Peanut, tree nuts, shellfish, milk, egg, wheat allergies
    • inset stings
    • medications
    • Latex
  • What dose of epi (1:1000 dilution) should be administered?  0.3-0.5ml (adult) & 0.01ml/kg (up to 0.4ml) for kids
  • Which is the best route of administration?  IM
  • If the pt were taking a beta blocker, what additional medication could be considered if she didn’t respond to epinephrine?
    • Glucogan
  • List 3 other steps that should be taken in the initial management of this pt
    • Remove the causative agent if possible
    • Monitor & maintain adequate Airway, intubate prn, O2 through non-rebreather,
    • Transfer to ED – start big bore IV, ECG monitoring
    • Rinitidine 50mg IV & benadryl 50mg IV
    • Prednisone 50mg po or Prednisolone 50mg iv
  • Worrying about a biphasic, what % of anaphylactic rxn follow a biphasic course? 20%
  • What class of medications is beneficial in preventing or min the second phase?
    • Corticosteroids
  • How should she be followed up?
    • Monitor in emergency department for > 6 hours and f/u with her allergist
    • Rx of EpiPen
    • Medical Alert Bracelet or necklace
    • 4 day course of prednisone + diphenhydramine

52) Emergency Contaception

  • Rx:
    • Plan B (Levonorgestrel 750ug po Q12h x 2)
  • How effective is this medication:
    • 89% reduced risk of pregnancy
  • In what situation would this medication be ineffective?
    • Pregnancy
    • >5 days since unprotected intercourse
  • List 3 potential common side effects for this medication
    • N/V
    • dizziness, fatigue
  • What Tx option is available to a pt who presents 5d after unprotected intercourse?
    • Copper IUD

53) 7yo F, head lice. (common 5-11yo in girls, only infests human head, distinct from body/pubic lice; feeds by sucking blood)

  • Could the head lice have come from the family dog?
    • No; pets are not vectors for head lice
  • Could the head lice have jumped to Julia from “the dirty little boy next door?
    • No, Lice can’t jump or fly
  • How are head lice typically spread?
    • direct head-to-head contact and is common within household
  • other than visual inspection, what is an alternate method of dx?
    • Combing hair with a fine-toothed “nit”
  • What is your recommended tx?
    • Topical insecticides: Permethrin 5% crm, 1 week apart x 2.
  • If the pt were 18mo old, would the same Tx be indicated?
    • No, topical insecticides are not recommended <2yo

54) 54yo F c/o severe hot flashes x 1mo + irregular periods x 12mo

  • Transdermal progesterone crm reduces hot flushes
  • Androgen replacement Tx DOESN’T reduces hot flashes
  • Vit E – poor evidence, not recommended
  • Soya – doesn’t seem to be substantially more effective than placebo
  • Sertraline was no more effective than placebo for hot flushes
  • Good evidence with venlafaxine, mirtazapine, gabapentine, clonidine

55) 41yo M with C/P

  • ECG: regular sinus rhythm @ 100bpm, with diffuse ST elevation & PR depression
    • Presumptive dx: Acute pericarditis
  • Characteristics:
    • Onset: often sudden (gradual and progressive in MI)
    • Main location: L precordial or substernal (same as MI)
    • Radiation: variable, similar to MI possible
    • Quality: sharp, stabbing (heavy, pressure, burning in MI)
    • Duration: Persistent, wane and wax
    • ↑ w/ inspiration, movement, lying down & improve w/ sitting (no change in MI)
    • no change with nitrates (relief in MI)
  • List 2 12-lead ECG features that support your dx:
    • PR depression &
    • concave ST elevations (convex in MI) in non-anatomical distribution
    • No rhythm / conduction abnormality or Q waves (frequent in MI)
  • Describe the expected precordial finding on auscultation:
    • pericardial rub – diagnostic of pericarditis (100% specific)
  • B/W: slightly elevated CK & Trop
  • What influence do these lab results have on your presumptive dx?
    • Doesn’t change the dx: reflecting superficial myocarditis.
  • How would you Tx?
    • Ibuprofen 800mg tid x 2 weeks, then taper
  • any form of pericardial inflammation can induce pericardial effusion and bleeding; an echo is recommended

56) 24yo M, multiple visits: diarrhea, wt loss, sexual dysfunction, insomnia, depressed, absent from work; Hand shaking at times and aftershave smell. PE: regular HR at 120bpm, 160/90; No HTN hx

  • List 3 other physical findings that support suspected dx (EtOH):
    • alcohol odor on breath, marijuana door on clothes
    • diaphoresis, sweating in palms, labile BP/HR
    • Agitations, mild tremors, ?hepatomegaly
    • Nasal irritation (cocaine insufflation), conjunctival irritation (marijuana)
  • EtOH withdrawal
    • 12-24hr: tachycardia, tremors, anorexia, insomnia
    • 24-72 hr: Sz (“rum fits”)
    • 3-5d: delirium tremens: disorientation, fever, hallucinations
  • What screening test would you consider using to confirm the dx?
    • CAGE – cut down, annoyance, guilty, eye opener
    • American society of addition Medicine: >14 drinks/wk or >4 drinks /occasion in men (fewer in women)
  • What Ix are most useful in the evaluation of this pt?
    • Serum EtOH level, GGT, AST>ALT (2), MCV (increased)
    • urine drug screen

Red flag complaints for substance-abuse problems

  • Absenteeism – Frequent absences from school or work
  • Accidents: hx of frequent trauma or accidental injuries
  • Depression or anxiety, sleep disorders
  • Labile HTN, GI symptoms: epigastric distress, diarrhea, wt changes
  • Sexual dysfunction
  • nasal irritation, tremor, EtOH on breath
  • hepatomegaly, hepatitis

57) 34yo M Q about altitude illness

  • What is considered high altitude? >2500m altitude
  • Name 2/3 syndromes for developing altitude illness
    • Acute mountain sickness
    • high altitude cerebral edema
    • high altitude pulmonary edema
      • SOBOE, cough, usually 2-3 days after arrival at altitude
  • List 2 risk factors for developing altitude illness
    • The rate of ascent: fast ascent
    • The actual altitude reached
    • The elevation at which the traveler sleeps
    • individual susceptibility
  • Name 2/4 Tx that have been shown to be effective in prevention of altitude illness
    • acetazolamide 250mg q8-12hr (carbonic anhydrase inhibitor)
      • initiate 1d before ascent & continue until adequate acclimatization
      • s/e: mild diuresis or paresthesia
    • dexamethasone 8mg then 4mg q6hr,
    • aspirin, gingko biloba
  • Name 3 symptoms of acute mountain syndrome
    • N/V/anorexia
    • H/A, difficulty sleeping, dizziness / lightheadedness
    • Fatigue or weakness
    • typically 6-12 hr after arrival at a new altitude
  • List 3 effective tx for mild acute mountain syndrome
    • Rest days, relaxation, consider descent
    • acetazolamide, ASA, ibuprofen, paracetemol
    • antiemetics may be useful
  • Pt experiences acute mountain syndrome, decided to camp at 2500m for amazing scenery and up at 0500, complaining he can’t sleep and wants to begin the ascent to the summit in the dark. Climbing, singing, urinates in his pants, while gait is increasingly ataxic. What is the most likely cause of his behaviour?
    • High altitude cerebral edema
  • Name 3 signs of this condition
    • papilledema, retinal hemorrhage
    • Ataxic gait, decreasing GCS
    • (h/a, n/v, hallucination, disorientation/confusion)
  • List 2 Tx that should be initiated
    • descent, evacuation, O2 with pressure bag to facilitate descent
    • dexamethasone 8mg then 4mg q6hr

Acclimation and rates of ascent

  • Above 3000m: increase 300-600m / d and take a rest day for every 1000m of elevation
  • Don’t fly or drive to high altitude
  • climb high and sleep low
  • If symptoms not improving, delay further ascent & descents if deteriorating

58) SARS

  • Where did the illness likely originate? Southern China
  • List 3 countries, other than Canada, that experienced an outbreak of SARS
    • China, Hong Kong, Taiwan
  • What is the suspected etiologic agent for this illness?
    • A novel CoronaVirus – transmitted through droplets and hand contamination
  • List 2 of the criteria in the case definition for SARS
    • Respiratory illness of unknown aetiology since Feb 1, 2013 &
      • Fever >38oC & clinical findings of respiratory illness (cough, SOB, dyspnea, hypoxia, CXR – PNA or ARDS)
      • travel within 10 days of onset of symptoms to an SARS endemic area or close contact within 10 days of onset of symptoms with suspected SARS
  • What is the typical incubation periods? 2-11 days
  • Describe the typical CXR due to SARS?
    • Normal on initial presentation, diffuse airspace dz with focal opacities involving multiple lobes ± acute respiratory distress syndrome.
  • Has SARS been identified in the paediatric population? Yes
  • What is the suggested Tx?
    • Isolation and supportive Tx with adequate oxygenation & ventilation
  • What is the case-fatality rate? 4%
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CCFP ExamApril 30th, 2015
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