fam med: PANCE review

if you found what type of organism on a child would you be most concerned for abuse?

gram negative organisms (ie chlamydia, gonorrhea)

current guidelines for universal blood pressure goal is less than?

130/80

elevated BP range

120-129

stage 1 HTN

130-139 or 80-89

stage 2 HTN

>/140 or >/90

first line medications for high HTN?

1. ACEI (ie lisinopril)

2. ARBs (ie losartan)

3. CCBs (ie amlodipine)

4. thiazides (ie HCTZ) - first-line for many

SE for ACEI

hyperkalemia

cough

angioedema

usage of ARBs

great alternative for HTN if ACEI gives cough

SE of CCBs

peripheral leg edema

SE of thiazides

hypokalemia

hyperuricemia (gout flare)

pt has CKD or DM. what is your first-line choice for HTN and why?

ACEI or ARB

protects kidneys

black pt w/o CKD or DM, what is initial therapy?

CCB or thiazides

if a pt is in stage 2 HTN and is greater than 20/10 mmHg above goal, what should you do?

start them on 2 meds simultaneously right away

diagnostic thresholds for DM - A1C…

>5.7%: normal

5-7-6.4%: pre-DM

>/6.5%: DM

diagnostic threshold DM fasting plasma glucose

<100: normal

100-125: pre-DM

>/126: DM

random glucose diagnostic finding DM

>/200 mg/dL + classic sx (polyuria, polydipsia, weight loss)

first-line management for DM

metformin

SE for metformin

GI upset/diarrhea

lactic acidosis

hold for IV contrast

when do you add GLP-1s (semaglutide) with DM?

atherosclerotic cardiovascular disease (ASCVD)

if weight loss a major goal

when do you add SGLT-2 inhibitors (empagliflozin) with DM?

HF

CKD with albuminuria

SE of SGLT-2 inhibitors

INC risk of UTIs/yeast infx

d/t glucosuria

who gets a statin?

1. clinical ASCVD (hx of MI, stroke, angina, PAD) → high intensity statin

2. severe LDL (>/190) → high intensity statin

3. DM pts (40-75 yo) if LDL is 70-189 → mod-intensity statin

4. 10 year ASCVD/PREVENT risk >/7.5% (40-75 yo) if LDL is 70-189 → mod to high intensity statin

high intensity statins

drops LDL by >/50%

atorvastatin 40-80 mg

rosuvastatin 20-40 mg

moderate intensity statins

drops LDL by 30-50%

atorvastatin 10-20 mg

rosuvastatin 5-10 mg

simvastatin 20-40 mg

breast cancer screenings

Biennial (every 2 years) mammograms for women aged 40 to 74

cervical cancer screening

Women aged 21–29: Pap smear (cytology) every 3 years

Women aged 30–65: Pap smear every 3 years, Primary HPV screening every 5 years, or co-testing every 5 years.

colorectal cancer screening

Adults aged 45 to 75.

Colonoscopy every 10 years,

FIT test every year,

or Cologuard (Stool DNA) every 3 years

lung cancer screening

Annual low-dose CT scan for adults aged 50 to 80 who have a 20 pack-year smoking history AND currently smoke or quit within the last 15 years

AAA screening

One-time screening with ultrasound for men aged 65 to 75 who have ever smoked!

diabetes screening

Screen asymptomatic, overweight, or obese adults aged 35 to 70

adult immunizations

flu: everyone >/ 6 mos

tetanus (tdap/td): tdap once, then Td or Tdap booster every 10 years. give Tdap during EVERY pregnancy (wk 27-36)

shingles: 2 dose everyone >/50 yo

pneumococcal (PNA): everyone >/65 yo (or younger if chronic illness ie COPD, DM). give PCV 20 once or PCV 15 → PPSV23 a year after

pt has monoarticular arthritis. what drug tx?

NSAIDs (ibuprofen, indomethacine, naproxen) + colchicine

what is gout

joint inflammation d/t uric acid crystals from extracellular fluid

needle-shaped monosodium urate crystals, negatively birefringent

hyperuricemia

colchicine MOA

inhibits microtubule formation → less inflam response to uric acid crystals

narrow therapeutic window

colchicine SE to educate pt

nausea, vomiting, diarrhea

what to do if pt cannot tolerate NSAIDs and they have gout?

first line: prednisone (caution if DM)

triamcinolone injections

what urate-lowing therapy can you use for gout? (chronic tx)

allopurinol, febuxosat: purine analog, inhibits xanthine oxidase and uric acid prod

probenecid: inc uric acid excretion in urine

pegloticase: converst uric acid into soluble allantoin

what drugs are CI with gout?

aspirin (INC uric acid)

loops and thiazides (INC urate resorption)

When is the most accurate time to measure the serum urate level in a patient with gout?

2 or more weeks after gout flare has resolved

serum urate is usually normal during gout flare

risk factors of gout

male sex

age >30 yo

obesity

metabolic syndrome

CKD

dietary factors

sx of gout

podagra*

(acute onset of pain in first MTP)

red hot tender joint

diabetic retinopathy findings

edema and hemorrhage → CENTRAL vision impairment

floaters or red spots, earliest = microaneurysm, later = cotton-wool spots, infarcts, macular edema

possible blindness

tx and prevention for diabetic retinopathy

tx: laser surgery or vitrectomy

prevention: control of glucose, cholesterol, BP

vitreous hemorrhage cause

trauma or retinal tears

NOT DM

when does optic disc edema occur

optic neuritis (papillitis)

papilledema

what is AV nicking found in and definition

HTN retinopathy

retinal arteries indenting/displacing retinal veins (vessel wall thickening)

pt comes do you saying they have a hx of DM. they didn’t have any sx but now see spots, floaters, and lost their visions. you see cotton-wool spots, hemorrhages, and neovascularization in their eye. you suspect?

diabetic retinopathy

meniere’s disease description

caused by idiopathic excess of inner ear fluid

intermittent vertigo, intermittent sensorineural hearing loss, aural fullness, tinnitus

vomiting, nausea

management for menieres

stress reduction

trigger avoidance

low salt diet (diuretics)

vestibular rehabilitation (if fails, then consider endolymphatic decompression or excisional labyrinthectomy)

drugs: antihistamines, cholinergic antagonists (scopolamine), benzos, betahistadine, prednisone, glucocorticoids (only if severe)

tx for myasthenia gravis

pyridostigmine

(reversible cholinesterase inhibitor)

what condition is meniere’s disease in children most often assoc with?

congenital malformations of inner ear

22 yo pt pelvic pain, vaginal discharge 3 days. no vaginal bleeding, N/V. unprotected intercourse with new partner, normoactive bowel sounds with tenderness to palpation across lower abdomen. pelvic exam = purulent discharge and cervical motion tenderness. this is what? tx?

PID

500 mg IM ceftriaxone once + 100 mg PO BID x 14 days doxy + 500 mg PO BID x 14 days metronidazole

RF for PID

<25 yo

multiple sexual partners

unprotected intercourse

past hx of STI

PID major + supporting criteria

lower abdominal pain

cervical motion, uterine, adnexal tenderness

fever, abnormal vag discharge, + culture for G/C, INC c-reactive protein or ESR

→ infertility

tx of PID inpatient vs. outpatient

inpatient: cefotetan 2g IV q12 hrs of cefoxitin 2g iV q6 hrs PLUS doxy 100 mg PO/IV q12 hrs

outpatient: ceftriaxone 500 mg IM + doxy 100 mg PO BID x 14 days + Metronidazole 500 mg PO BID x 14 days

(Ceftriaxone + doxycycline + metronidazole

Cefotetan or cefoxitin + doxycycline

Clindamycin + gentamicin)

what is most common cause of PID?

chlamydia trachomatis

tx for vitiligo

<10% of body: topical tacrolimus 0.1%

20-25%: narrowband UVB or oral psoralen plus PUVA therapy

psychosocial support, stabilization (corticoids, minocycline, MTX, vitamin supp), repigmentation = top corticosteroids, calcineurin inhibitors, vit D analogs, phototherapy

vitiligo description

hypopigmentation, cause = destruction of melanocytes

patches of pale skin, white non scaling well demarcated areas

assoc with: pernicious anemia, autoimmune thyroid dz, addisons, DMI, hx of intralesional corticosteroids or liquid nitrogen

dx: wood lamp, blue-white fluorescence

Which fungal infection may present with areas of pink or white macules, commonly on the upper torso, that may be confused with vitiligo in patients of dark complexions?

Tinea versicolor may present as pale macules that do not tan, commonly on the upper trunk

when do you suspect necrotizing otitis externa?

persistent otitis externa despite 2-3 wks of appropriate tx

sx: severe otalgia esp at night, has hx of DM

PE: affected ear is erythematous, edematous, more prominent

when treating (malig) otitis externa, what 2 organisms to cover?

pseudomonas aeruginosa

staph aureus

management of malig otitis externa

perform CT scan of head with IV contrast

if meningitis suspected → lumbar puncture + cerebrospinal fluid analysis

ciprofloxacin (FLQ) monotherapy

severe: ciprofloxacin + antipseudomonal beta-lactam

which cranial nerve is most commonly involved in malignant otitis externa?

CN VII

meds that INC risk of epistaxis

intranasal corticosteroids

anticoag

ASA

NSAIDs

anterior epistaxis description

kiesselbach plexus

tx: stop compression, if single ant bleeding site found → gauze with oxymetazoline → add 2% lidocaine → chemical cautery with silver nitrate → ribbon gauze

anterior vs. posterior epistaxis

anterior: common, children/young, d/t mucosal dryness, less severe

posterior: sphenopalatine artery, less common, older, HTN or atherosclerotic dz, severe → balloon devices, ICU monitoring, foley catheter

which arteries supply the nose?

ethmoid branch of internal carotid artery and facial + internal maxillary branches of external carotid artery

causes of fixed drug eruption

NSAIDS*

bactrim, tetra, PCN*

sulfa, tetras, acetaminophen, ASA< barbiturates, antimalarials

hallmark of fixed drug eruption

erythematous and edematous plaque, w/ or w/o blistering

same location each time offending drug is introduced**

hyperpigmented macule

tx of fixed drug eruption

stop offending drug

topical corticosteroids

oral antihistamines

erythematous plaques that are chronic, excoriated, lichenified with intense pruritis. no correlation to drugs. = ?

atopic dermatitis

erythema multiforme

acute hypersensitivity skin dz (young adults 20-40 yo)

target lesions in palms and souls

what are 2 immune cells that play key roles in fixed drug eruption?

CD8 T cells and mast cells

best test for carpal tunnel syndrome

phalens test

carpal tunnel syndrome description

RF: repetitive hand use, female, obesity

pain and numbness in 1-3 digis, esp at night

median nerve compression

phalen sign, tinel sign, carpal compression test, hand elevation test

carpal tunnel management

non-op: splinting wrist, anti-inflam meds

glucocorticoid injection, decompression

Which nerve root is affected in a patient with loss of the ankle jerk reflex (achilles reflex)?

S1

weakness of plantarflexion, numbness along lateral edge of foot

deep tendon reflexes

C5: biceps reflex, deltoid strength

L4: patellar reflex, foot inversion strength, sensation of anterior thigh, causes pain in posterior butt

L5: intact reflexes, great toe dorsiflexion weakness, numbness in web between great and second toe, pain along posterior butt radiating to lateral thigh

what triad is assoc with cauda equina syndrome?

saddle anesthesia

bowel and bladder dysfx

LE weakness

Clinical Reflexes and Their Nerve Roots

Biceps: C5–6

Triceps: C7

Patella: L4

Achilles: S1

depressions screening tools

1. edinburgh postnatal depression scale

2. 9-item pt health questionnaire

3. center of epidemiologic studies depression scale

4. geriatric depression scale

NOTE: USPSTF recommends depression screenings but NOT anxiety

IBS description

chronic abd pain

altered bowel habits

sx improve with defecation

rome IV criteria: : recurrent abdominal pain at least once/week for 3 months associated with two or more criteria

Related to defecation

Associated with change in stool frequency

Associated with change in stool form

Which extraintestinal symptoms may be seen in patients with irritable bowel syndrome?

Dyspareunia,

dysmenorrhea,

increased urinary frequency

fibromyalgia symptoms

tx for IBS

lifestyle and dietary modification (e.g., low FODMAP diet)

Constipation predominant: psyllium, osmotic laxatives, lubiprostone

Diarrhea predominant: loperamide, cholestyramine

Abdominal pain: can consider antispasmodics and antidepressants

topiramate SE

CNS SE (paresthesia)

anticonvulsant used for migraine prevention and seizures

(cannot be used w recent alc use)

BB SE

bronchospasm

TCA SE

dry mouth*

constipation

urinary retention

blurred vision

calcitonin antagonist SE

URI

What is a rebound headache?

It is also known as a medication overuse headache and occurs as a consequence of regular overuse of headache medication

migraine sx

gradual onset

adults = unilateral, children bilateral

can have aura or no aura

avoid triggers, sleep, abortive rx (triptans, valproic acids, NSAID), prophylaxis (TCA, BB, anticonvulsants, CCB)

who should avoid getting triptans?

uncontrolled HTN

CV disease

What is the reversal agent for apixaban?

Andexanet alfa or prothrombin complex concentrate

helmet education

replace q5 years for product deterioration

firm polystyrene liner that fits properly and centered on child’s head

A patient is found to have a low-pitched rumbling diastolic apical murmur. Which of the following is the most frequent presenting concern associated with this murmur?

dyspnea with exertion

mitral stenosis description

low pitch rumbling diastolic apical murmur

cause: rheum heart disease

concern: dyspnea w exertion

opening snap, loud S1

use bell, apex of heart, left lateral decubitus position

pt has mitral stenosis → atrial fibrillation. at this point, what is a common finding?

palpitations

how does mitral stenosis cause hoarseness?

left atrial enlargement → compression of recurrent laryngeal nerve

diastolic heart failure (HFpEF) description

left ventricular ejection fraction (LVEF) >/50%

dx: echo and diastolic dysfx

tx: exercise training*, diuretics (only if edema or pulm issue)

_ is used to treat HFrEF but NOT HFpEF

BB

What classic chest radiograph finding is indicative of pulmonary edema due to congestive heart failure?

Kerley B-lines

thin horizontal lines seen in the lung periphery that denote thickened edematous interlobular septa due to pulmonary edema