CFPC – SAMP 2011

1. Endometriosis

Ms. Pella Vicpane, age 23, comes to your office with a three-year history of cyclic pelvic pain and dyspareunia. A pelvic exam reveals focal left adnexal tenderness. You suspect she has endometriosis.

  • List two risk factors for endometriosis.
    • Family Hx
    • Obstruction of menstrual outflow
    • Short menstural cycles
    • Low Birth Weight
    • Diet high in red meat and trans fat
    • Exposure to diethylstilbesterstrol in utero or endocrine-disrupting chemicals
    • Prolonged endogenous estrogen exposure (early menarche, late menopause, obesity)
  • Protective factors: prolonged lactation and multiple pregnancies
  • You refer her to a gynecologist who performs a diagnostic laparoscopy that confirms stage 2 endometriosis. She is having considerable pain and wants to consider non- surgical options. List three possible non-surgical treatments.
    • OCP
    • Mirena IUD
    • NSAIDs
    • Medroxyprogesterone acetate
    • GnRH agonists (deplete pituitary gonadotropins, inhibit further synthesis, interrupting the menstrual cycle and resulting in a hypoestrogenic state, endometrial atrophy, and amenorrhea. )
  • Pella has recently married and wonders about future fertility. Which, if any, non- surgical treatments can increase her spontaneous pregnancy rate? none
  • Pella returns six months later and brings her husband Bill. They would like to start a family soon. Bill has been searching the internet about endometriosis and has read that surgery (ablation) for endometrial lesions can increase the chance of pregnancy. Is this statement true or false?  1. True 
  • You send Pella and Bill back to the gynecologist for consideration of further treatments. They return one year later unable to conceive. The gynecologist has referred them to a fertility clinic for consideration of in vitro fertilization (IVF). What treatment before IVF improves live birth rate?
    • GnRH agonist for 3-6 months
2, Occipital Neuralgia
  • paroxysmal shooting or stabbing pain in the dermatomes of the nervus occipitalis major or nervus occipitalis minor

Mrs. O’Connor, age 64, comes to your office today because she has a paroxysmal stabbing pain in the neck which radiates over the vertex. She is in relatively good health, having only osteoarthritis and hypertension. The resident you work with thinks of occipital neuralgia since the history is not compatible with migraine, cluster headache, nor tension headache, and since the patient presents no red flags.

  • Occipital headache can be caused by damage (trauma) or irritation of the nervus occipitalis major or minor. List three causes. – r/o tumor, infection, and congenital anomalies (Arnold-Chiari)
    • Vascular: Giant cell arteritis, aberrant arteria vertebralis, Dural AV fistula at the cervical level
    • neurogenic: C2 myelitis, MS, Schwannoma of the nervus occipitalis
    • muscular / tendinous
    • osteogenic: C1/2 arthrosis, cervical osteochondroma
  • List four symptoms that can be associated with occipital neuralgia.
    • Vision impairment / ocular pain
    • Tinnitus, dizziness, nausea
    • congested nose
      • occur due to the connections with CN 8,9,10 and the cervical sympathicus
  • What are the three signs that would support this diagnosis?
    • Hypo or dysesthesia in the area of the nervus occipitalis major or minor
    • Tenderness to pressure over the course of the nervus occipitalis major or minor
    • + Tinel’s sign
  • In Mrs. O’Connor’s record, you see a recent open-mouth X-ray of the cervical spine and remember that she has cervical osteoarthritis. You know she already has regular massages to help for cervical and dorsal pain, and that a physiotherapist already worked with her to improve her posture. Mrs. O’Connor would like to manage this headache without a daily pharmacological treatment. What other treatment can you offer her?
    • Infiltrate culprit nervi occipitales with local anesthetic and corticosteroids
3.HIV Post-exposure Prophylaxis

Greta Johanson, a 35-year-old nurse, comes to your walk-in clinic. She is anxious about unprotected sexual intercourse that happened yesterday. Greta tells you she was at a party and had sexual intercourse with an unknown partner. She does not use IV drugs and she did not have anal intercourse. She is at the clinic to receive information about post- exposure prophylaxis (PEP) against HIV.

  • If the unknown partner is HIV-positive, what is the baseline risk for Greta being infected with HIV?
    • ❍ 2. 1-3 in 1,000
  •  PEP should be initiated as soon as possible. Greta wants to know more about adverse effects and toxicities of antiretroviral medication before considering starting PEP. List five potential adverse reactions.
    • Nausea, Vomiting, Diarrhea, Abdominal Pain
    • Headache, weakness, abnormal dreams
    • Pancreatitis, hepatitis, renal toxicity
    • Anemia, neutropenia, ↑ cholesterol and TG, diminished BMD
    • Rash (SJS), hyperpigmentation on palm and sole
  • When should HIV tests be done in Greta’s case? (Check all that apply).
    • ❍ 1. Immediately
    • ❍ 2. In four to six weeks
    • ❍ 3. In three months
    • ❍ 4. In six months
  • After discussing the pros and cons of PEP, Greta decides to begin the treatment. If Greta’s exposure source is tested and found to be HIV-negative, should the full course of PEP be continued?
    •  ❍ 2. No
  •  There have been no reports of HIV transmission after injuries from discarded needles or syringes found in the community.

Screenshot 2015-04-25 22.38.13

3.Prostatitis: Diagnosis and Treatment

Peter Smith, aged 55, comes to your office this afternoon for urinary urgency lasting for 36 hours. His medical history shows high blood pressure and diabetes, for which he takes ramipril 10 mg and amlodipine 5 mg a day and metformin 800 mg three times a day. He has no allergy to medication. Based on further history and appropriate clinical examination, you suspect an acute bacterial prostatitis.

  • List four symptoms consistent with this diagnosis.
    • urinary frequency, urgency, and dysuria
    • hesitancy, poor/interrupted stream, straining to void, incomplete emptying
    • F/C/N/V/malaise
    • Pain in the suprapubic / perineal region or in the external genitalia
  • At the physical exam, the prostate is slightly tender and enlarged. You order a urine sample. What finding on microscopic analysis will help you to confirm the diagnosis?
    • >10 WBC per high-power field
  • Three years later, he comes back and tells you that he has had recurrent urinary tract infections in the last two years. He has some irritative voiding symptoms and occasionally some testicular pain. He looks well and your medical exam is strictly normal. You suspect chronic bacterial prostatitis. What are the two most common organisms seen in this condition?
    • E coli
    • Enterococcus
  • You recommend treatment with antibiotics. List four possible agents.
    • Fluoroquinolones are the first line therapy: ciprofloxacin
    • 2nd line:
      • Doxycycline
      • Clarithromycin
      • Septra
  • What duration of therapy (acute bacterial prostatitis) is usually recommended?
    • 4-6 weeks and often 6-12 weeks are required
Prostatitis – four clinical entities, including
  • acute bacterial prostatitis
  • chronic bacterial prostatitis
  • chronic pelvic pain syndrome
  • asymptomatic prostatitis – noted during the evaluation and treatment of other urologic conditions
4. Headache

Meg Grain, aged 30, is visiting you today at your office because she has been suffering from a throbbing headache over her right temple for the last three days. She was initially not able to do anything except lie down in a dark room for the first two days. She has some nausea and vomiting at times. She has experienced at least five of these episodes over the past year.

  • What is the most likely diagnosis?
    • Migraine headache without aura
  • What would the diagnosis be if Meg had associated symptoms such as speech disturbance, sensory symptoms such as pin and needles or numbness, and/or visual symptoms such as flickering lights or loss of vision?
    • Migraine headache with aura
  • List two first line treatments for this condition.
    • NSAIDs
    • Triptans – avoid in pregnancy
  • List two other effective therapies for this condition.
    • Metoclopramide – Category B
    • Ergotamines (DHE) – absolutely contraindicated in pregnancy
    • Dexamethasone
    • Intranasal Lidocaine 4% solution
  • If Meg were pregnant, what medications could you use to treat her condition? List one.
    • Metoclopramide
    • Acetaminphen
  • What are the indications for starting prophylactic therapy? List two.
    • Headache >2d/wk
    • Headache severely limit quality of life despite abortive Tx
    • Uncommon migraine conditions: hemiplegic migraine, basilar migraine, migraine with prolonged aura, migrainous infarction
    • Contraindications or intolerance to abortive Tx
  • POUND – Pulsatile, One day duration (4-72hr), Unilateral, N/V, Disabling
    • 92% migraine if 4/5
IHS Dx: Migraine with aura
  • Recurrent disorder manifesting in headaches of reversible focal neurologic symptoms that usually develop gradually over five to 20 minutes and last for less than 60 minutes
  • Headache with the features of migraine without aura usually follows the aura symptoms
  • Less commonly, headache lacks migrainous features or is completely absent
Diagnostic criteria:
Aura consisting of at least one of the following, but no motor weakness:
  • Fully reversible dysphasic speech disturbance
  • Sensory symptoms that are fully reversible, including positive features (pins and needles) and/or negative features (numbness)
  • Visual symptoms that are fully reversible, including positive features (flickering lights, spots, lines) and/or negative features (loss of vision)
  • At least two of the following:
    • Homonymous visual symptoms and/or unilateral sensory symptoms
    • At least one aura symptom develops gradually over five minutes or different aura symptoms occur in succession over five minutes
    • Each symptom lasts at least five minutes, but no longer than 60 minutes
  • Headache fulfilling criteria for migraine without aura begins during the aura or follows aura within 60 minutes
  • Not attributed to another disorder
  • History of at least two attacks fulfilling above criteria
5. Stress Fractures

Bonnie Payne, a varsity basketball player, has been suffering from knee and shin pain for the past month. Her coach has given her more playing time recently. She likes to run recreationally to keep in game shape. She also mentions that she has not been getting her period for the past few months. On examination, she has a positive hop test. You suspect that she has a stress fracture.

  • What are the risk factors for stress fracture? List three.
    • Tracking – Running sports or Running >25miles/wk
    • xs physical activity with limited rest periods or Sudden increase in physical activity
    • Smoking or EtOH >10drinks/wk
    • Female sex or female athlete triad: eating disorder, amenorrhea, osteoporosis
    • Low 25-hydroxyVitamin D
  • O/E:
    • The hop test (i.e., single leg hopping that produces severe localized pain) is often used and cited in texts as a diagnostic test for lower extremity fractures; no recent literature was found to validate its accuracy.
  • What imaging investigations could help to confirm your diagnosis? List two.
    • X-ray (plain radiography)
    • MRI (if n/a: Bone scintigraphy)
    • U/S
  • What is the typical range of healing times for Bonnie once her activity is restricted?
    • 4-12 weeks
  • What preventive measures and treatment options would you consider for Bonnie? List three.
    • Prevention
      • address modifiable risk factors
      • Modify activity or training pattern and ensure adequate rest
      • Consider daily Calcium (200mg) and Vit D (800IU)
      • Address abnormal biomechanics prn and consider shock-absorbing shoe inserts
    • Tx
      • reduce activity to the level of pain-free functioning
      • Tylenol > NSAIDs
      • Stretch and strengthen supporting structures in rehab program
      • Gradual increase of activity after several weeks of rest and improved symptoms
      • use pneumatic compression device or other biomechanical measure for lower extremity stress fractures
      • Encourage cross-training to maintain CV fitness
      • Consider Surgery for pt with recalcitrant or high risk stress #
6. Well-baby and Well-child Care

Today, many infants and children are on your schedule. This will be a well-baby care day! Besides asking the usual questions on nutrition and development and performing a complete physical exam, you are particularly interested in giving appropriate advice for parents.

  • The first baby is Sarah, a six-month-old, breastfed baby. She started eating cereals last week, and everything in her development is going well. You plot her growth. Which growth chart does the College of Family Physicians of Canada (CFPC) recommend?
    • WHO growth standards
  • You continue your physical exam, including examination of the hips. How long should you keep examining her hips as part of her periodic health exam?
    • Until age 1 or until baby is walking
  • Thomas is Sarah’s two-year-old, healthy brother. As recommended at his one-year- old visit, he drinks regular milk (3.25%). His father wonders when he should switch to 1% or 2% milk.
    • 1% or 2% milk should be started at 2yo
    • Soy-based formula is not recommended for routine use due to the potential adverse effects of phytoestrogens and the substantial risk of cross-allergy
      • restricted to infants with galactosemia or those can’t consume dairy-based products for cultural or religious reasons
  • There are many children with flu-like symptoms at Thomas’s day care. His parents are used to giving him acetaminophen when he has a fever. But they have heard that other parents are alternating acetaminophen with ibuprofen. Is this treatment strategy recommended?
    • no, the alternating regimen encourage fever phobia and the potential risks of medication error outweigh measurable clinical benefit.
  • The next baby on your schedule is Laurie, aged two months. After you have completed your history and physical exam, her parents ask you if it is true that pacifier use is associated with a reduced risk of sudden infant death syndrome (SIDS). Is this true?
    • True, thus pacifier use should not be discourage in the first year of life after breastfeeding is well established. 
    • Use should be restricted in children with chronic or recurrent OM
  • Toward the end of your morning clinic, the nurse practitioner sharing the well-baby care clinic with you has some questions about fluoridated tooth paste and dental care in children.
    • Should fluoridated toothpaste be used in children? Fluoridated toothpast should be sued bid, with a min amount of water used to rinse the mouth after brushing. 
    • Until what age should children have their teeth brushed by an adult? 3yo – use only a smear of toothpaste
    • Supervision during brushing should be done until the child is what age? 6yo – use a pea sized portion of toothpaste
    • Are fluoride supplements recommended in children under age six? no, not until 6yo unless the child is considered to be at high-risk of dental carries. 
    • Avoid sweetened liquids and constant sipping of milk or natural juices in both bottle and cups to avoid caries
  • Good evidence for visual screening during well-baby and well-child exam
    • Red reflex r/o retinoblastoma and cataracts
    • Position of the corneal light reflex and cover-uncover test (>=6mo) along with parental inquiry to detect strabismus.
7. Altitude Illness: Risk Factors, Prevention, Presentation, and Treatment

Andrew, aged 26, comes to your office to get some information about altitude illnesses which could occur during his holiday in South America next month. He plans to stay for a few days in Cuzco before joining a group hiking to Machu Picchu. He has no medical problems and is not taking any medication.

  • For persons at altitudes higher than 3,000 m, what is the general rule of thumb for limiting ascent in one day to decrease the likelihood of developing acute mountain sickness?
    • No more than 300-600 m above the previous night’s elevation
    • No more than 600-900 m above the previous night’s elevation
    • No more than 900-1000 m above the previous night’s elevation
  • Not to sleep more than 300-600m above the previous night’s elevation
  • List at least three symptoms of acute mountain sickness and early high altitude cerebral edema.
    • Headache + 
      • Insomnia – difficulty sleeping
      • anorexia, n/v
      • Dizziness or lightheadedness
      • Fatigue or weakness
  • High altitude cerebral edema can progress in a matter of hours from mild ataxia to coma and death.
    • ❍ 1. True
  • Andrew would like to prevent acute mountain sickness and high altitude cerebral edema and asks which medication would you recommend.
    • acetazolamide – carbonic anhydrase inhibitor (contraindicated in sulfa allergy)
  • If he had an allergy to sulfa, what would be an appropriate alternative?
    • Dexamethasone 
  • His father flew directly from Montreal to Cuzco last year and started his ascent to Machu Picchu the next day. He developed high altitude pulmonary edema. List four risk factors for developing high altitude pulmonary edema.
    • Rapid ascent- Fly directly to an high altitude – most important modifiable risk factor
    • Hx of altitude illness
    • individual susceptibility
    • Strenuous physical exertion
    • Living at low altitude, young age
  • Of the following medications, which one is not recommended as a prophylactic agent for high altitude pulmonary edema (fatigue, weakness, dyspnea, decreased exercise tolerance, delayed recovery from exertion + o/E: frothy sputum, tachypnea, tachycardia & dx confirmed with decreased O2 sat)
    • Dexamethasone
    • Nifedipine
    • Salmeterol
    • Acetazolamide 
    • Phosphodiesterase-5 inhibitors (tadalafil, sildenafil)
8. Primary Hyperparathyroidism (PHPT)

Colleen Paterson, aged 58, came for her periodic health exam two months ago. Since she presented with fatigue, you ordered some blood work, including calcium that was found to be elevated. This was confirmed by a subsequent ionized calcium level. You therefore ordered a parathyroid hormone (PTH) level, which was found to be elevated. She returns to your office today to discuss the results. You believe that she has primary hyperparathyroidism.

  • What is the differential diagnosis for this condition? List three.
    • parathyroid carcinoma
    • PTH secreting adenomas
    • Multiglandular hyperplasia
    • familial hypocalciuric hypercalcemia
    • Drugs: thiazide (reduce urinary Ca excretion thus unmask PHPT), lithium (decrease parathyroid gland’s sensitivity to calcium)
  • Which of the following tests are the most relevant to include in your subsequent workup? Check all that apply:
    • ❍ 1. Complete blood count
    • ❍ 2. Creatinine
    • ❍ 3. PTH (repeat measurement)
    • ❍ 4. Urinary calcium-to-creatinine clearance ratio
    • ❍ 5. International Normalized Ratio (INR)
    • ❍ 6. 25(OH)D level
    • ❍ 7. Lipid profile
    • ❍ 8. Serum phosphorus levels
    • ❍ 9. Fasting glucose
  • If not treated, primary hyperparathyroidism can lead to a spectrum of bone disease (such as fragility fractures), renal manifestations (such as nephrolithiasis and renal insufficiency), gastrointestinal symptoms (nausea, vomiting, peptic ulcer disease, constipation and pancreatitis), rheumatologic diseases (gout and pseudogout) and neuropsychiatric disturbances (lethargy, decreased cognitive and social function, depressed mood, psychosis and coma). To avoid such problems, parathyroidectomy is the definitive therapy for primary hyperparathyroidism. Which one of the following is not an indication for surgery in patients with asymptomatic primary hyperparathyroidism?
    • Serum calcium above 0.25 mmol/L
    • Urinary calcium-to-creatinine clearance ratio below 0.01
    • Creatinine clearance below 60 mL/min
    • T score less than -2.5 at any site on bone mineral density or previous fragility fracture
    • Age under 50
  • If Colleen has contraindications to or does not wish to have this surgery, medical management can be of value. To reduce the risk of developing serious hypercalcemia and to decrease bone resorption, what medical measures might you consider? List three.
    • Decrease bone resorption: physical activity, Vit D and Ca intake, bisphosphonate
    • Reduce risk of developing serious hypercalcemia or nephrolithiasis: adequate hydration, avoid lithium or thiazide, avoid immobilization and intravascular volume depletion
  • List three tests that you should prescribe for medical surveillance of Colleen if she does not have surgery.
    • ionized calcium
    • Creatinine/eGFR
    • BMD q2-3yr
9. Muscle Toxicity of Statins

Samantha Smith, aged 73, comes to your office complaining of muscle aches. She tells you that she had a myocardial infarction two months ago, and subsequently underwent angioplasty. Her medical history includes high blood pressure, dyslipidemia and type 2 diabetes. Her medications include hydrochlorothiazide 12.5 mg qd, verapamil CD 180 qd, irbesartan 150 mg qd, clopidogrel 75 mg qd and aspirin 81 mg qd, simvastatin 40 mg qd. She has no medication allergies and drinks two glasses of wine every day.

  • Because she started taking simvastatin two months ago, you suspect she has statin- induced myopathy. What are the types of statin-induced myopathy? List three.
    • Myalgia (muscle ache / weakness w/o CK elevation)
    • Myositis (elevated CK)
    • Rhabdomyolysis (CK elevation >10x upper limit of normal)
  • List three risk factors for statin-induced myopathy.
    • >70yo of age and female
    • High dose therapy (>half the max recommended dosage)
    • Impaired liver/renal (eGFR<30) function
    • untreated hypothyroidism
    • Drug-drug interactions
    • Low body mass
    • EtOH or substance (cocaine, heroin, amphetamines) abuse
  • What initial investigation would you order to rule out rhabdomyolysis? creatinine kinase
  • Which one of Mrs. Smith’s medications would be most likely to interact with statins? Verapamil
    • Diltiazem, azole antifungals, grapefruit, macrolides, amiodarone
  • You recommend that Mrs. Smith discontinue her statin medication. When should she expect resolution of her myopathic symptoms? ❍ 3. Less than two months
10. Carpal Tunnel Syndrome

Carl Paul, a 30-year-old factory worker, is at your office today because he is suffering from pain and tingling over the thumb, index, and middle finger of his right hand over the past month. The pain radiates into his forearm. He has no swelling of his hand, but he reports a loss of strength when performing certain tasks. He also experiences some night-time pain. You highly suspect that he has carpal tunnel syndrome. (often night-time pain, shaking or flick the hand to alleviate the discomfort – Flick sign)

  • What sign is highly predictive of carpal tunnel syndrome?
    • The flick sign 
  • What other physical examination findings help confirm the diagnosis? List three.
    • Tinel’s sign
    • Phalen maneuver
    • Thenar atrophy
    • numbness over the 1st to the radial half of the 4th digit
    • Hypalgesia (↓ ability to sense pain) & can’t discriminate 2 point
    • weak abductor pollicis brevis
  • What diagnostic test could you order to confirm the diagnosis?
    • EMG – electromyography and nerve conduction studies – can stratify dz
  • The diagnostic test confirms that Carl’s case is mild to moderate in severity. What are considered first line therapies? List three.
    • neutral and cock-up wrist splints (24hr better than night time only) x 6-8 wk
    • Oral corticosteroids
    • Lifestyle modifications:
      • Avoid repetitive motion
      • using ergonomic equipment 
      • Taking breaks
  • What are the other options if Carl’s condition worsens in severity?
    • Corticosteroid (Kenalog) injection
    • Carpal tunnel release (surgery)
11. Switching Contraceptives

Amber Green, a 25-year-old marketing executive, is visiting you today at your clinic because she would like to switch from a higher dose combined contraceptive pill to a lower dose one.

  • Does Amber need to wait for a withdrawal bleed before starting a new oral combined contraceptive? No
  • If Amber requested to switch to a progestin-only contraceptive, would she need to wait for a withdrawal bleed before starting it? no
  • After using the contraceptive pill for a year, Amber would like to switch to the vaginal contraceptive ring. When should she start using the ring? Start the day after she takes the last pill. No need to complete the pack before switching. 
    • Hormone levels reach a plateau approximately 48 hours after a woman applies her first patch. When women switch from a pill to a patch, a two-day overlap avoids a decline in hormone levels and maintains full contraceptive effectiveness. Therefore, women should start the patch the day before they take the last pill.

      Hormones in the vaginal ring are more rapidly absorbed than are those in the patch. Women switching from a pill to the ring should start the ring the day after they take the last pill.

      Women switching from a patch or ring to a pill should take the first pill the day before they are scheduled to remove the patch or ring, creating a one-day overlap.

      The copper IUD becomes effective immediately after insertion.

  • After using the ring for a few months, Amber would like to consider using a levonorgestrel-containing intrauterine device or a progestin injection. How long does it take for these methods to reach full efficacy? 7 days after initiation (same for depo provera IM)
    • To switch safely from one contraceptive to another without overlap, women may go directly from the old method to the new method, abstaining from sexual intercourse or using a barrier method, such as condoms or spermicide, for the first seven days.

  • After using a levonorgestrel-containing intrauterine device (IUD) for a year, Amber decides that she would like go back on the contraceptive pill. When should she start the pill?
    • Take the pill one week before IUD removal
12. Urticaria

Natalie Hives is at your office today because she has been suffering from urticaria on most days for the past six weeks. She gets erythematous, well-circumscribed, intensely pruritic, raised wheals typically 1-2 cm in diameter on various parts of her body. It has been affecting both her home and work functioning. You suspect that she has chronic urticaria (associated with Hashimoto dz). Natalie is wondering if a specific trigger is causing her symptoms.

  • How often is a specific trigger found? 10% – 20% of cases
  • What are common triggers for urticaria? List four.
    • IgE mediated
      • Food allergens- Peanut,
      • Contact allergens – latex,
      • insect sting / venom
      • medications
      • Parasitic infections or aeroallergens
    • NonIgE mediated
      • Autoimune, cryoglobulinemia, infections, vasculitis
    • Non-immunologically mediated
      • Elevated core body temperature, Food pseudoallergens
      • light, medications, physical stimuli (cold, local heat, pressure, vibration)
  • You perform a thorough history and physical examination to determine a possible cause for Natalie’s chronic urticaria. However, no causative factor is found. You are considering some bloodwork to help figure out a causative factor. What are the strongly recommended tests for chronic urticaria?
    • CBC with differential, CRP, ESR
  • What are the first-line treatments for chronic urticaria? List two.
    • Trigger avoidance
    • Daily second generation antihistamines – Claritin (Loratadine)
  • What are other treatment options for chronic urticaria?
    • Titrate second-generation antihistamine to 2-4x the usual dose
    • Switch to another 2nd generation antihistamine
    • Brief burst of po corticosteroids (3-10days)
    • Consider H2 blocker: ranitidine
    • Consider 1st generation antihistamine at night – benadryl
    • Ref for 2nd line – hydroxychlorquine or tacrolimus
13. Nail Changes in the Elderly

Since she recently attended a conference on common nail changes and disorders in the elderly, one of the nurses you work with at the nursing home has become more aware of nail problems in older people. During one of your visits to this nursing home, she brings to your attention many patients who have abnormal nails.

  • What factors contribute to pathologic nail changes in the elderly? List three.
    • Impaired circulation at the distal extremities
    • Faulty biomechanics
    • infections, neoplasms
    • Sin or systemic dz with nail manifestations
  • Before visiting the patients, you check the charts and the nurse’s note about the nail problems. What would be the most likely diagnosis for each of these presentations?
    1. Transverse/lamellar splitting of the free edge and distal nail plate portion, triangular fragments at the free edge, longitudinal thickening – Brittle Nail Syndrome – onychorrhexis (anemia / arteriosclerosis)
    2. Discoloration, loss of nail plate translucency, subungual hyperkeratosis – Onychauxis (faulty biomechanics)
    3. Subungual hyperkeratosis, onycholysis, nail thickening, white area under the lunula that progresses distally, progressive nail plate destruction. onychomycosis
    4. Red swollen nail folds, cuticle loss, secondary nail plate changes. Paronychia
  • How should you treat brittle nail syndrome?
    • Correct underlying factors & daily intake of biotin 2.5mg and silicon (choline-stabilized orthosilicic acid)10mg
    • daily 15min soaks using emollient rich in phospholipids
    • Using enamel for mechanical nail plate protection and fracture filling
    • Application of nail hardeners containing formaldehyde to strengthen the nail plate
  • What is the most effective oral agent for treatment of onychomycosis in elderly patients?
    • Oral Terbinafine > azoles
  • Onychocryptosis – ingrown toenail – due to inappropriate nail cutting, long toes, prominent nail folds, ill-fitting or high-heeled shoes, hyperhidrosis, bony abnormalities

    Tx with warm water soak to partial nail avulsion and lateral matricectomy


Reference:

  • CFPC Self-learning 2011
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CCFP ExamApril 30th, 2015
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