Clinical Pearls Flashcards

Terms Definitions
A patient falls. What are some things that you want to know?
Was is a mechanical fall or a "syncopal" fall (did they black out)?
In for boards:

Bug: infectious presentation
Strep: ?, Staph: ?

In actual practice:
Bug: infectious presentation
Strep: ?, Staph: ?
In for boards:

Bug: infectious presentation
Strep: Cellulitis, Staph: Abscess

In actual practice:
Bug: infectious presentation
Strep: Cellulitis, Staph: Abscess OR Cellulitis
What do you do with anything that is swollen?
Elevate it! Note in the plan
Patients with COPD: what should you ask them about their breathing?
Did they notice any wheezing?
What are some "good numbers to remember" for the diseases below?

1. Diabetes
2. Asthma
3. CHF
1. Diabetes: Hb A1c
2. Asthma: peak flow
3. CHF: Ejection Fraction
What is the "gold standard" for temporal arteritis?
A biopsy.
Why can a biopsy of temporal arteritis come back as a false negative sometimes?
Because the arteritis is intermittent along the artery.
When you are describing the lung on physical exam, what are the first thing that you comment on?
Don't jump right to the abnormal lung sounds. Comment about
- Chest wall expansion
- Air entry
- Chest wall abnormalities
Patient with COPD: essential question to ask about PMH.
Have you ever been hospitalized for your COPD before? Did you have to be intubated? Put on a ventilator? When was your last ER visit?
How do you determine if the difference between edema and extra adipose tissue?
Is the swelling old or new?
Chest pain questions:
How long does it take the chest pain to go away when it comes on? Sweating? Palpitations? Come on with exertion?
What is one way to evaluate a swollen finger?
Compare it to the other fingers!
How do you evaluate wounds on physical diagnosis?
Place, size, edges (sloping vs. smooth), color,
What are the different stages of wounds?
Stage I: skin broken
Stage II:
Stage III: muscle involved
Stage IV: bone involved

Description of this is important for determining if the wound needs to be debrided or not
What is something that you should put in your plan for a patient with liver/kidney failure?
"Dose according to liver/kidney failure"
"Avoid drugs that are excreted by the kidney/liver."
Something to assess about a patient's general well-being upon examination.
Whether the patient speaks in full sentences or not.
If you have a hernia, what is one important question to note? Why is it important to auscultate?
Is the hernia reducible or irreducible? Important to ausculate to see if you can hear bowel sounds.
What constitutes a positive Murphy's Sign?
Upon expiration, place your hand under the patient's right costal margin. Then ask them to breathe in. If the patient feels pain then this is part of a positive Murphy's Sign. The other part is doing the test on the left hand side and seeing no hypersensitivity upon inspiration. These two things constitute a positive Murphy's Sign.
Approximately how long would it take for a patient with a blood alcohol level of 300 to drop to normal levels?
About 24-30 hours.
Where should you start palpating when feeling for the liver?
Start really LOW and work your way up.
When should you be applying pressure when palpating the liver?
When the patient is expiring. Let up pressure when the patient is inhaling.
Which way does the diaphragm move on inspiration?
Down. The lungs expand and the diaphragm/liver moves down.
Maneuver for examining aortic regurgitation?
Have the patient lean forward. Ascultate the 2nd and 3rd left intercostal spaces with the stethescope diaphragm.
Best position to hear mitral disease?
Left decubitus position. Listen very lightly with the BELL listening for S3, S4, diastolic rumble.
If someone says "I have 3 drinks a day" you should ask what?
What types of alcohol do you prefer?
What is a type of gait characterized by favoring certain motions to avoid pain?
An antalgic gait.
If a patient has nausea and vomiting, what is the safest immediate course of action as far as their status is concerned?
Make them NPO --> look at some labs and buy some time.
How long do you usually have before symptoms come on if you ignore diabetes?
About 10 to 15 years.
If you see that someone is on prednesone, what is a question that you absolutely need to find out?
Why is this patient on prednisone?
What are some questions that you should ask patients with thyroid issues?
1. Determine if the patient is euthyroid, hypothyroid, or hyperthyroid.

2. Assessment of risk factors.
- Exposure to ionizing radiation.
- Family history

3. Assessment of symptoms of mass effect.
- Difficulty swallowing, hoarseness of voice, SOB when lying flat.
- Determine the rate of growth of the nodule or goiter (e.g, has your collar size changed)
What are some things that you should look for on physical exam in a patient with thyroid issues?
Vitals: HR, Weight

HEENT: Lid lag, proptosis, conjunctival irritation, loss of lateral 1/3 of eyebrows.

Neck: Thyroid: size, texture, nodules, bruits, Pemberton's Sign.

CV: Tachycardia, bradycardia,

Lungs: Rales

Neuro: Motor strength, reflexes, tremors

Skin: Moist/dry, brittle hair, vitiligo.

Psych: Affect, speech patterns.
What is Pemberton's Sign? What is it indicative of?
The development of:

- facial flushing
- elevation of jugular venous pressure
- inspiratory stridor

upon raising both arms above the head simultaneously

Indicates SVC syndrome secondary to thyroid goiter or tumor.
If TSH is ___, then the patient would proceed to what to determine what?
If the TSH is LOW, then the patient would proceed to a RADIOACTIVE IODINE UPTAKE (because there is a low risk of malignancy)

If the RAIU scan shows increased uptake, then you proceed with hyperthyroid workup.

If the RAIU scan is low or normal, then you do ultrasound --> fine needle aspiration.
If the TSH is ______ or ____, then the patient should proceed to ultrasound and possibly fine needle aspiration.
If the TSH is NORMAL or HIGH, then the patient should proceed to ultrasound and possibly fine needle aspiration.
Trousseau's Sign
Inflate BP cuff at a point greater than the systolic blood pressure and hold it there for three minutes. In the absence of blood flow, the patient's hypocalcemia will cause spasm of the hand and forearm muscles (obstetrician's hand)
Chvostek's Sign
tap facial nerve anterior to ear --> contraction of ipsilateral facial muscle.
What does POLYuria mean?
It means increase in the AMOUNT of urine, not the frequency
Fever
Flank pain

Which is more indicative of pyelonephritis?
Fever is seen more often than CVA tenderness!
A woman who notices blood in her urine. What is a question that you need to ask?
Is she menstruating?
"Pus always suggests __(bug)__"
"Pus always suggests S. aureus"
What type of infection is associated with wrestling?
"Herpes gladitorum" herpes simplex from wrestling mats.
Folliculits, furuncles, carbuncles --> ?

Cellulitis --> ?
Folliculits, furuncles, carbuncles --> S. aureus

Cellulitis --> 95% GAStrep
Descriptive term for the appearance of the skin in:

Graves disease
Inflammatory breast cancer
Pseudoxanthoma elasticum
peau d'orange or "skin of an orange"
Beta hemolytic strep loves _____.
Beta hemolytic strep loves EDEMA.
Basic data concerning bites by pets
1% of all ED visits

Children > adults

Frequency: dog bites > cat bites

Infection: cat bites (35%) > dog bites (10%)
Cat bite with immediate sx: what organism?
Pasturella multicoda
Cellulits: offending bug, treatment
95% strep, 5% staph
Cefazolin, nafcillin, or vancomycin
Cat bite: ABX
Ampicillin (every 4-6 hrs)
Ceftriaxone (daily)
Dog bite: ABX
Vancomycin
What should you do rule out GAS necrotizing fascitis?
Look for crepitus (only 1/3 sensitive)

Get a plain film and look for gas
Penetrating injury --> worried about what bug --> type of infection --> what surgical procedure would you do?
Penetrating injury --> beta hemolytic strep --> cellulitis --> debridement
Crushing trauma --> worried about what bug --> type of infection --> what surgical procedure would you do?
Crushing trauma --> Clostridia --> myositis --> amputation
Foot care advice for diabetics
Look at your feet everyday.

If you can't because of retinopathy, have someone else look at your feet for you.

If you are inflexible, get a mirror
Do most tumors cause fever?
No, not really

Tumors that do: Lymphomas, renal cell carcinoma, and any tumor in the liver
What are the tumors that cause fever?
Lymphomas, renal cell carcinoma, and any tumor in the liver.
What makes for a good sputum culture?
Lots of PMNs, not a lot of squamous cells, lancet shaped cells inside PMNs
How should you go about getting a sputum sample?
You should watch the patient give it!
How can you differentiate between a pleural effusion vs. consolidation?
Usually can differentiate by ultrasound or CT
"If you are standing around discussing an x-ray for more than 3 minutes, it's time to get a CT scan." Dr. Glew
***
"If a patient's racial identity is ot relevant to issues, don't include it in the opening, include it in the social history." Dr. Glew
***
How much does a CT scan cost?
$1500 - $2000
GERD can cause coughing and wheezing
***
What are some states that can present with a natural left shift?
Steroid use, pregnancy
Post auricular adenopathy
Mononucleosis
Dose of ACEi and cough
Cough increases with dose, esp at 40-60 mg/day
Extremely important study of diabetes: DCCT (Diabetes Control and Complications Trial) NEJM 1993: 329: 977-986
***
BMI =
Weight in kg / (height in meters)^2
What are the odds of an American having diabetes in 2010?
1 in 3
Diabetes control: metformin vs. exercise
Meformin reduced complications by 30%, exercise reduced by 60%!

Exercising 30 minutes a day was the most effective
What are the units used to measure serum glucose in the EU? How do you convert?
mmol/L.

To convert from mg/dL, divide by 18 g/mol.
What is a way that you can distinguish between an insulin overdose vs. an insulinoma?
Insulin overdose: will see no C-peptide

Insulinoma: will see increased C-peptide
What tissues in the body don't need insulin?
Brain, heart, erythrocytes
"Insulin is like the key that unlocks the door and lets glucose into your body." - Dr. Mordes
***
Above what level does your serum glucose need to be before you are seeing glucose in the urine?
Above 180 mg/dL
Why do we say that a fasting glucose level of 126 mg/dL is diagnostic for diabetes? Why this number?
Because it is based on the European system

7.0 mmol/L = 126 mg/dL
126/18 = 7.0
Post-prandial glucose levels are the first to be elevated
***
As of December 2009, what Hb A1c is diagnostic for diabetes?
> or = to 6.5%
How long do RBC stick around?
about 3 months
Community acquired pneumonia: onset
Usually acute
"cough of a few weeks" = pneumonia?
Not usually, usually is more acute. Might suspect TB
"afebrile" = pneumonia?
no, usually presents with fever
pneumonia: weight loss
Don't usually see weight loss with pneumonia.
Factors that should prompt consideration of TB in the DDx
1. Hx of postive tuberculin test or disease.

2. Contact with known or suspected tuberculosis case

3. Presence of fibrotic lung lesions or upper lobe scars compatible with inactive TB

4. Immigration from countries with high risk for TB.
What is vitamin B6 used for in the treatment of TB?
Used to decrease the amount of neuropathy associated with INH.
Upper lobe infiltrate on CXR + foreign born, what do you do?
Isolation w/ N95 mask, order smears.
A pt says that they have an allergy to local anesthetics. One time after injection they becames sweaty and tachycardic. What is going on?
This is most likely not a true allergy, but is a normal reaction to epinepherine that is included in the local anesthetic solution. Could also be a hypersensitivity reaction to the preservative (often PABA, methylparaben, propylparaben)
How do you locate the femoral nerve?
It is at the level of the inguinal ligament. Intentionally touch the nerve with the needle to create a paresthesia. DO NOT inject anesthetic into the nerve, this is very painful.
How do you locate the sciatic nerve to do an injection?
Hook needle up to nerve stimulator and try to evoke motor activity
Where is a good place to inject to block the brachial plexus?
Just superior to the clavicle where it passes over the first rib.
How do people with a blood sugar of 120-160 feel?
Fine, no sx usually. But definite increase in AE from diabetes.
Dr Mordes on diabetes: "For what you need, you ain't got enough."
***
Dr. Mordes: "People with diabetes, not 'a diabetic'"
***
Steps to placing an IV catheter.
1. Get all the equipment you need.
2. Bevel up
3. Shallow angle in
4. Hold needle thingy in place and slide catheter in.
5. Take needle thingy out
6. Take touriquet off.
6. Place tape sticky side up under the butterfly and then wrap around (don't cover puncture site).
7. Put saline flush syringe on. Pull back to get air out. Then flush by putting air in.
Steps to intubate
1. Get all the equipment that you need, make sure that laryngeoscope light works.

2. Put middle finger in between teeth then use thumb and index fingers to scissor mouth open.

3. Put blade in on right side with blade at a right angle to sweep tongue out of the way.

4. MAC blades are designed so that the tip goes in the velicula (in between the epiglottis and the tongue). Miller blades are used to go on top of the epiglottis and physically move it away (more helpful in kids).

5. Pull up and out at an angle (don't ratchet back or you will break teeth!) to visualize vocal chords.

6. Keep looking at the chords and have someone pass the endotracheal tube to you.

7. Insert the tube up until 23 or so. Inserting too deeply will cause the tube to go into the main stem bronchi.

8. Inflate the balloon.

9 Connect the bag

10. All set!
How much do insulin pumps cost?
3000-5000 dollars!
Which requires ATP: cardiac contraction or relaxation?
Relaxation!
A drug's lipid solubility correlates well with its what?
Its average amount of adverse effects.
Why should you not discontinue beta-blockers abruptly?
It can cause a hyperadrenergic state.
Nitrates for angina are very lipid soluble so they can be given:
transdermally! Also sublingually to avoid the liver.
How do nitrates relieve angina?
Nitrates work by increasing pulse pressure and LVEDP. They cause peripheral dilation, but they don't expressly dilate the stenosis. Nitrates work via NO.
Nitrates should not be taken with what other drug?
Viagra! Can cause too much hypotension.
675. IMS (Immediate Memory Span)
Most of us only have 7 digits +/- 2. This is why phone numbers are not 10 digits long!
People with HTN and meds
have a lower risk of becoming demented than those that do not
Common thing that people do that increases the risk of getting Alzheimer's
Smoking!
"Doughy" abdomen
Tuberculous peritonitis
Viridians strep NOT strep viridians
***
A good way to remember to get lab data to patients
Have them call you later
"I'd rather be bitten by a dog's anus than by a human mouth."
Dr. Glew
Foot puncture wound
P. aeruginosa
Medicaid will not pay for
home ABX
Culture negative pyarthrosis
Suspect Lyme
Don't pierce cartiledge!
Not a great blood supply. Hard to cure if it gets infected
Never start parenteral IV without
blood cultures
anemia + neuropathy of posterior columns
B12 (folate deficiency does not do this!)
Too many egg whites can cause...
a biotin deficiency!
People affected by fava beans are usually from what part of the world?
Meditteranean!
vLow citrulline, ornithine =
Urea cycle disorder
Allopurinol is not
an acute txt for gout
presents 10 years earlier than the diagnosis of Huntington's
Depression
One of the only infections that can give you lymphocytosis
Pertussis
If someone has had HA x 6 mo, then it is probably not
temporal arteritis.
Jaw claudication after eating
temporal arteritis.
Aspirin and acetaminophen are good for HA, but have to
Take them early!
Equal, nutrisweet contains this
Aspartame
Stop chewing sugarless gum =
headache due to sudden lack of aspartame
Temporal focal meningoencephalitis
Herpes encephalitis (get them on acyclovir!)
Herpes encephalitis: tx
Acyclovir
Herpes encephalitis has a predeliction for which lobes
Temporal
A normal EEG does not rule out
seizure
Mental status exam
Can ask about sports, TV, etc.
If stool osmolarity is >400 then
diluted with urine
If stool osmolarity is < 290 then
diluted with H2O
Nearly 30% of all deaths from CAD are attributable to
smoking
Smoking is protective for
Parkinson's!
Head pain in the elderly
Think Giant Cell Arteritis
Patient who can't see straight ahead needs
the most urgent care
ROS for macular degeneration
"Any warpage or distortion?"
The shoulder can come out of socket after a stroke
Often pec major is the only muscle working, and holds arm to the body.
If arm hurts after stroke
Put in pocket
Dressing with hemiparesis: which arm goes in first?
The bad arm!
amoxicillin + EBV = ?, amoxicillin + CMV = ?
amox + EBV = rash, amox + CMV = no rash
Uncommon to have _______ _____ as a child in the tropics
Chicken Pox
Smallpox scabs are infectious for how long?
"Forever" . Worry about smallpox in mummies!
Causes terrible back pain
Endocarditis! Smallpox!
Why should you foam after removing gloves?
Because there can be microperforations
To get max antiseptic effect from alcohol wipes
Let alcohol dry on skin
Everyone over the age of __ aspirates once a night
45
Osteomyelitis of the vertebrae/disk begins on the
anterior side
Tumors of the vertebrae start in the
body of the vertebra
What happens if a vertebral disk is destroyed?
The vertebrae will fuse on its own
What is nice about fluoroqinolones?
Using cleansing towelettes
c/c tetra and doxy: excretion
Tetra: renally excreted, doxy: hepatic/fecal
Corticosteriods stabilize the
BBB
How many neurons do you lose in a minute in stroke
1000000
tPA is
neurotoxic!
Men have a ___ higher risk of stroke than women
19%
Af Amer are ___ as likely as whites to have stroke
2x
Most powerful risk factor modifier in stroke
HTN
If you have a second concussion within a week of having the first it could be
catastrophic
If you have TIA you inc the risk of
MI
White dot in the retinal vessels
Hollenhorst (cholesterol) plaque
Hemorrhagic stroke vs. ischemic stroke
Hemorrhagic stroke will usually do much better.
What can you put on the brain to induce seizure?
Penicillin!
"Deserve 1 imaging study"
Pts with migraine
Sunset sign
Aqueductal stenosis
Wilson's disease: diet
No lobster! Too much copper!
Largest tumors in the body come from the
Ovaries!
Spotty periods after menarchy because
GnRH periodicity not well established
Any time there is no FSH
Females lose follicles
What do OTC "ovulation indicators" look at?
At urinary LH
HCG given to infertility pts to
mimic LH and tigger ovulation
Peaking of HCG correllates with peaking of
nausea
Possibly preg pt with enlarged uterus and open cervix =
bad
99% of ectopic pregs are in the
fallopian tubes
Scopolamine vs diphenhydramine: amnesia
Scop does cause amnesia, diphen does not
Peripheral circulating DA can cause
HypoTN, nausea
What happens when you pet a dog
Both yours and the dogs oxytocin go up!
Ok to say to a psych patient
"It doesn't make sense to me, but...ok"
"Soft signs" you see in schizophrenia
Tap on forehead --> will blink repeatedly. Stroke along the side of the mouth --> rooting response?
Seroquel (quetiapine) can help you...
sleep, and gain weight
Meds for alzheimer's allow grandparents to
remember their grandparent's names for 3 extra months (that's all)
Most middle aged men should take ____ once a day for protective CV effects
Aspirin
Migraines are NOT caused by ..... Instead they are thought to be caused by....
...vasodilation of the vessels of the meninges. ...probably due to dysfunction of 5-HT receptors
What is the cause of St. Anthony's fire? What was the ancient treatment?
Ergot (grows on rotting rye). Was to make a pilgrimage. Worked because you eneded up eating the grain of a different region.
What if sumitriptan doesn't work for migraine?
Then you might want to reconsider your diagnosis
Most data on pregnancy and radiation exposure comes from
Hiroshima and Nagasaki
Hallucinations while going to sleep and while waking up
Hypnogogic hallucinations, usually not pathological
Grief bereavement
"Not going to feel better for two years"
the "Tie Sign"
For mania. Pt might be manic if starts making comments about someone's tie. a half-joke
Depression eval, what lab test should you check?
TSH
what percentage of MS patients are depressed?
50% This is much more than with other neurodegenerative disorders, so we think there is something inherent to the disease that makes depression more common.
L-sided stroke --> ?, R-sided stroke --> ?
L-sided stroke --> depression, R-sided stroke --> mania
People that are depressed have "heart rate variability"
***
People that cut themselves are more likely to
complete suicide. Also those that take more than 70 pills
An emotional plea is effective sometimes
***
Physicians and suicide
Attempt less often, complete more often
How many grams of EtOH is in 1 beer?
10 g
Excessive phone calling correllates well with
Mania
If pt has ascities and fever
Check to see if the ascities is infected!
ECRP can cause
Pancreatitis!
Natural remedy for hepatitis
Milkthistle
Bereavement: worse for men or women?
Men
Diarrhea was thought to be
An excessive form of the desire to giving to others.
Agoraphobia often made better by
Having a sympathetic companion along with the person.
Extinction
Decrease undesired behavior by ignoring it.
2 issues with extinction
Have to be able to deal with escalation of the event

have to be able to provide "non contingent" attention.
"try to avoid using benzos in your medical practice"
Dr. Hobart
Mitral value prolapse: panic attack
Inc risk of panic attack
Alcohol: panic attacks
Alcohol use can cause worse panic attacks.
Caffiene : panic attacks
Some people can have caffiene induced panic attacks
Self help for panic attacks
Exercise, especially w other people. . Regular sleep, getting up at reg hours.
Age of children : anxiety in mother
Age of children may bring back memories of when parents were abused.
Benzo : alcohol
Act on the same receptors.
MA is one of the worst states in divertion of prescribed meds
Dr. Barton
Alcohol, barbituates, benzos, others (methaqualone "qualudes")
All have potential cross reactivity
Opiod withdrawl
Not life threatening
drug craving
hyperalgesia, mydriasis
N/V ab cramps
insom, anxiety
F, sweating
piloerection
Legally drunk
0.08%. 0.15 or 0.2% if tolerant
Most persons prescribed opiods for chronic pain do not become abusers.
***
Diacetylmorphine
Heroin.
Opiod detox meds
Clonidine for autonomic signs
otreotide for gi symptoms
may be followed by naltrexone therapy.
Suboxone
Naloxone is in to prevent shooting it up. Will precipitate withdrawl.

Suboxone = naloxone + buprenorphine
One of the biggest problems with buprenorhine
Acute pain is very difficult to manage.
Why is methadone less abuseable than heroin?
It is very long acting, much less rush and assoc craving
Cns depressant withdrawl
Craving, irritability insomnia, tachycardia, htn, hallucinations
Disulfram
Don't take nyquil! Contains alcohol.
Naltrexone oral vs IM
Oral = pennies per day
IM = hundreds of dollars a month.
Two forms of cocaine
Hydrochloride salt: inhaled IV
Alkaloidal base: crack, smoked. Faster high.
Cocaine withdrawl
Craving, sleepy, unhappy, depressed, bradycardia
mild compared to opiod withdrawl
Amphetemes
Have appetite suppression affects, become refractory to this in about 2 weeks.
Dronabinol
Medicinal marijuana! Elderly people don't like associated affects.
Marajuana wihtdrawl
Insomnia, restlessness, nausea. Almost imperceptible.
Not an analgesic, but may be affective in atypical pain syndromes
Two types of psychadelics
5-HT2 agonists: LSD, etc.
NMDA antagonists: Ketamine, PCP

No withdrawl
Sharpies contain
Toluene! Can get high off of this.
Inhalants
Most are non halogenated alkanes, cause arr, sz. Brain damage, liver, kidney damage
Nicotine withdrawl
Insom, irr, anx, wt gain

can use bupropion (Xyban), varenecline (wmost effective, wt gain)
People and animals HATE how DA blockers make them feel
Unless they are being txtd for hallucinations
Inhalant withdrawl
Cns depressants: sz, irritability, major problems are irreversible organ damage.
Is an addict in pain
Some clinicians will inject a syringe of saline3 ethical?

never tell what it is and what the dose is: ask "how did this help"

If not comfortable in prescribing huge loads of opiods for acute on chronic pain, get a pain consult.
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
A Samoan third gender type
Fa-afafine
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
A Samoan third gender type
Fa-afafine
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
A Samoan third gender type
Fa-afafine
Reconstructed penises
Doesn't grow, need multiple surgeries.
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
Reconstructed penises
Doesn't grow, need multiple surgeries.
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
Reconstructed penises
Doesn't grow, need multiple surgeries.
Conversion therapy for homosexuality
Doesn't work.
A Samoan third gender type
Fa-afafine
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
Conversion therapy for homosexuality
Doesn't work.
Conversion therapy for homosexuality
Doesn't work.
Reconstructed penises
Doesn't grow, need multiple surgeries.
Putting a lemon in your mouth
Autoerotic asphyxiation. Makes you wake up before you die.
A Samoan third gender type
Fa-afafine
Conversion therapy for homosexuality
Doesn't work.
A good way of explaining androgen insensitivity to a child.
You are a girl because all the cells of your body only respond to "girl" hormones.
Reconstructed penises
Doesn't grow, need multiple surgeries.
Conversion therapy for homosexuality
Doesn't work.
A Samoan third gender type
Fa-afafine
Reconstructed penises
Doesn't grow, need multiple surgeries.
Conversion therapy for homosexuality
Doesn't work.
If you can go up and down a flight of stairs without arrhythmias
then you can return to sexual activity
If have arrhythmias
Don't drink, eat heavy meals, or be with strange partners
Frequentcy of oral sex
Increases with educational level!
If a patient wants to practice oral sex on a male
Dr rogoff suggests using a dairy queen ice cream
Vagina is analagous
To the scrotum. Not so much innervation.
Dealing with vaginismus
Instruct them to use tapered candles. Put it until you feel comfortable, then move to a larger size.
Squeeze (Sieman's) technique
Squeeze both sides of glands. Count 1, 2, 3. To delay premature ejaculation.
Masturbation correlates with
Increased education
Most comfortable position for people with abdominal issues.
Rear entry.
Good position for men with premature ejaculation.
Woman on top.
What if you are in the delivery room and you can't tell the sex of the baby?
Don't just make your best guess. Talk about good things and ease parents into "it looks like the genitals are not developed yet"
Toddlers in the bed
If you are a single parent and you let your toddler stay in bed with you and you get a new partner, you will have to "evict" the newborn.
Nudity with children
It's ok if you are ok with it. If you are uncomfortable with it, they will notice.
Primal scene with kids
Kids think that mommy and daddy are having a fight! Tell kid that everyone loves each other.
High spinal cord injury
Flaccid high and spastic lower. Increased erections?
SSRI
Anorgasmia -> loss of libido. "bathed in seratoin," become insensitive to serotonin
Pt is 12-13 weeks preg and has PID...
Probably not... May have C or G but progesterone in preg keeps cervical mucus thick
Perihepatic adhesions between liver and diaphragm (Fitz-Hugh-Curtis syndrome)
HIGHLY indicative of prior PID!
Increased susceptiblity to UTIs during preg due to
Inc progesterone slows motility of the smooth muscle of the urinary tract leading to Inc risk of infection.
Screening tests at pregnancy
HBV, syphilis, rubella, GC/CT, GBS, should offer HIV to All women. As needed: evaluation for HCV, HSV, varicella. HIV: w txt can go from 25% -> <1%
How does pregnancy affect women with HIV?
Does not affect the progression of the disease.
What is the worst thing that a preg woman with HIV can do?
Stop her meds because she is preg! Viral loads will go up, Inc risk of transmission.
WITS study
Women and Infant Transmission Study. Giving meds to dec transmission of HIV from mom to baby. Zidovudine!
Increased risk of vaginal prolapse
Use of forceps
Pushing in labor for over 2 hours
Too long, at risk for pelvic floor trauma.
Reversible causes of incontinence in the elderly
Delirium
Infection
Atrophic urethritis & vaginitis
Pharmacological causes
Psychological causes
Excessive fluid secretion
Restricted mobility
Stool impaction
C/c female vs male brains
Female brains are about 5% smaller. The brain grows independently from the body - people with bigger bodies don't usually have bigger brains.
Neonates and elderly have low stomach acid...
...some drugs need acid to be absorbed. Ketoconazole is one. If pt is taking a PPI, take ketoconazole with coke (acid)!
Cholestyramine binds to...
....many other drugs
Absorption of fluoroquinolones inhibited by...
...divalent cations. Bind and chelate out.
Duration of effect controlled by what
Half life AND absorption
10 of morphine orally is...
...3 given IV
Procardia XL (nifedipine)
May see tablet shell in stool
Don't crush enteric coated drugs
They get really smushy and can't through a feeding tube.
Clindamycin liquid, Claritin liquid
Taste terrible!
Warfarin + TMP-Sulfa =
BAD INR will shoot up
Child with guttate psoriasis - check for
Previous strep A infection
DDx for nail pitting
1. Psoriasis
2. Alopecia areata
Difference bet tinea corporis and pityriasis rosea
Herald patch of pityriasis rosea: scale is on the inside of annular ring. Tinea corporis: scale is on the outside of the annular ring.
Most important DDx for PItyriasis rosea
Secondary syphilis
Pityriasis rosea treat
Can give erythromycin even though thought to be a viral disease!
Lichen planus is itchy, but...
...pts don't seem to itch plaques!
Lichen planus is itchy, but...
...pts don't seem to itch plaques!
Oral lichen planus is assoc w...
...hepatitis C!
Oral lichen planus is assoc w...
...hepatitis C!
History of ezcema
593 Aetius, "boiling out or over"
History of ezcema
593 Aetius, "boiling out or over"
What is atopy?
Tendency toward hayfever, allergic rhinitis, asthma or atopic dermatitis.
What is atopy?
Tendency toward hayfever, allergic rhinitis, asthma or atopic dermatitis.
What is the atopic march?
Atopic derm --> asthma --> allergic rhinits
What is the atopic march?
Atopic derm --> asthma --> allergic rhinits
Severe atopic dermatitis in infants is usually due to...
...a food allergy
T or F: a child can have atopic dermatitis without being itchy.
False. AD = itching
Atopic dermatitis saying
"the itch that rashes, rather than a rash that itches"
Neomycin and bacitracin can cause...
...allergic contact dermatitis in children.
Timecourse of initial exposure and contact dermatitis
7-10 days bc no tcell memory yet
Dermatitis below umbilicus
Allergy to nickel in jeans button!
Wheals =
Hives
If you circle a "wheal" in a pt w urticaria, will the lesion be in the same location tmw?
No, lesions are very migratory. Helps with dx.
2 big offenders for anaphylaxis w urtcaria
Peanuts, latex
Foods that cross react with latex
Bananas, kiwi, avocados, chesnuts! Avoid if have latex allergy!
Most common complaint that PTA have that present to a PCP.
Back pain and musculoskeletal issues.
What is the normal range of motion of the knee?
There is no normal. Examine the pts uninvoled knee to see what normal is for that pt. Usually 130-135
Knee "locking"
Means that you can't extend knee. To pts may mean many things. One of the mos common presenting sx of meniscal tear.
What is the difference between a fracture and a break?
There is no difference!
To classify a fracture
Which bone?
Where in the bone is the fracture?
Displaced or not?
Fracture pattern?
Comminuted? (lots of little pieces)
open or closed? (if open go directly to OR)
Does the fracture involve the articular surface?
Callus is a...
...good thing! Highly vascularized new bone formation.
Moron is...
...a made up word that was originally used bc it was thought to be inoffensive. Bc it had no previous meaning! But didn't work...
Moron is...
...a made up word that was originally used bc it was thought to be inoffensive. Bc it had no previous meaning! But didn't work...
Children: questions to evalulate developmental function
"how does she indicate wants and needs?"
"What kinds of things does she like to play with?"
Children: questions to evalulate developmental function
"how does she indicate wants and needs?"
"What kinds of things does she like to play with?"
"intellectually disabled"
1. Significantly subaverage intellectual function.
2. Deficits in adaptive behavior.
3. Occuring during developmental period (before age 18)

if you get in a car crash at 17 years in 364 days - you may qualify for an intellecual disability.
Potty training happens when?
Most trained by 3 or 4 years.
"intellectually disabled"
1. Significantly subaverage intellectual function.
2. Deficits in adaptive behavior.
3. Occuring during developmental period (before age 18)

if you get in a car crash at 17 years in 364 days - you may qualify for an intellecual disability.
Potty training happens when?
Most trained by 3 or 4 years.
Sedated "coma end of things" vs. Seizing: which neurotranmitters?
GABA is coma. Glutamate is the seizing end of things.

Only one enzyme that really governs GABA/glutamate balance.

Barbituates, benzos lean you toward the GABA end of things.
Mydriasis
MyDriasis = Dilated
Don't cause pipping pupils
Meperidine, propoxyphene, diphenoxylate/atropine, and pentazocine, sometimes tramadol
Effect of respiratory rate

Benzo:
Ethanol:
Barbituates:
Opiods:
Benzo: unchanged
Ethanol: unchanged
Barbituates: dec
Opiods: dec
C/c maculopapular rash vs. Palpable purpura
Mp rash is blanchable pp is not
Scabies how many mites?
Usually about 12 mites! Unless norweigen scabies = thousands of mites.
Koebner phenomenon
Think psoriasis
Remembering decimal points
Always lead and never trail
2006 report found unnecessary polypharmacy in
15-20% of patients on 4-6 patients
The five rights of writing prescriptions
Patient
dose
route
time
medications
Becareful about using corticosteroids with eczema because
A fungal infection can look like Eczema. Giving steroids with fungal infection can make feel better but problem worse.
If pts with psoriasis stop corticosteroids
The psoriasis comes right back. Can use calcipotriene to prevent remission.
Usually give methotrexate with
Folate to prevent bone marrow side effects.
Phototherapy for psoriasis
"narrow band" around 312 nm
-cept
-mab
-umab / -ximab
Signifies receptor analogs. Work by binding-up cytokines.

-mab signifies monoclonal antibody against receptor. These work by blocking the cytokine receptors on lymphocytes. (-umab indicates human abs, -ximab indicates animal abs)
Doctor has to have a special registration for what dermatological med?
Isotretionoin (accutane). Have to do IPLEDGE. One month off accutane and you are safe to get pregnant again.
If you have dryness between your toes, there is something else going on.
First require pts to treat tinea pedis with topical. Then work on the onychomycosis. If don't do this then infxn of nails recurrs from tinea pedis. Don't need new shoes. 6 wk treatment for fingernails, 12 wk treatment for toenails. Generally safe, now don't really check any labs before prescribing.
Herpes zoster often causes skin to be tender before breakout
If treat with acyclovir or valacyclovir early enough, can prevent post herpetic neuropathy.
Permethrin (Elimite)
For scabies or head lice. Need to prescribe permethrin TWICE so that can eradicate both scabies bugs and eggs. Need to rx two doses seven days apart. If wait too long then hatch and then lay eggs. If too soon then permethrin won't be able to kill eggs.
Doctor has to have a special registration for what dermatological med?
Isotretionoin (accutane). Have to do IPLEDGE. One month off accutane and you are safe to get pregnant again.
If you have dryness between your toes, there is something else going on.
First require pts to treat tinea pedis with topical. Then work on the onychomycosis. If don't do this then infxn of nails recurrs from tinea pedis. Don't need new shoes. 6 wk treatment for fingernails, 12 wk treatment for toenails. Generally safe, now don't really check any labs before prescribing.
Herpes zoster often causes skin to be tender before breakout
If treat with acyclovir or valacyclovir early enough, can prevent post herpetic neuropathy.
Permethrin (Elimite)
For scabies or head lice. Need to prescribe permethrin TWICE so that can eradicate both scabies bugs and eggs. Need to rx two doses seven days apart. If wait too long then hatch and then lay eggs. If too soon then permethrin won't be able to kill eggs.
ADHD correlates with
Maternal smoking!
ODD (oppositional defiant disorder) often responds to same meds as...
...ADHD drugs
Sugar in kids.
Does not cause hyperactivity.
Appetite suppression with methylphenidate
Have a big breakfast before you take your methylphenidate.
Drug holidays with methylphenidate?
Not recommended to stop on weekends, summer. Can have cardiac symptoms.
Pregnant women are the most at risk for intimate partner violence.
"During pregnancy and the first year of a child's life a woman is more likely to die from a domestic homicide than any other cause of death. " Chang 2005
Getting the partner out of the room.
You have control to say: "I need to examine your wife alone."
Ways to frame questions about domestic violence
Many patients I see are coping with an abusive relationship, so I start by asking about it directly.

Follow lead in with specifics:

"At any time has a partner hit, kicked, or otherwise hurt or frightened you?"

"Do you have guns at home? Where's the ammunition?"
Patient tells you about domestic violence.
"I believe you. We can help you."
Batterer/perpetrator: what is not useful
Couples counseling is not only not useful but can escalate the violence.

Anger management txt does not get to the core issue
Most at risk for domestic violence when...
...when victim is trying to leave! So just leaving is often not possible. It's more like you need to totally escape.
You have to report domestic violence to the police. T or F?
False.
You don't get a severe myopathy from
Any type of vasculitis ?
If ALT or AST is elevated for no reason
Could be a myositis!
Don't do an EMG on all limbs...
...save one limb for a muscle biopsy. Usually thigh.
Corporal punishment is not abuse if...
...no marks are left
Exposure of sexual material to children is...
...sexual abuse
Exposure of fetus to substances during pregancy
Automatically neglect
Spanking
Isn't a very effective way of parenting, but hasn't been shown to be particularly detrimental.
Section 51A
Section 12
51A: for abused children. MA gives more power to the state. If you "have reasonable cause to believe" that there is abuse, you must immediately report orally or written report within 48 hours.

No mandated reporter has ever been convicted for not reporting.

Not reporting = one thousand dollars
Reporting frivolously = one thousand dollars.

DCF has to decide to investigate or not. If investigate then have to substantiate or not. The threshold for what has been substantiated has risen with hard economic times.


12: when you send someone to the ED for psych eval.
If you really want to know what is going on with the patient
Ask the nurses before they sign out in the morning!
Ask for feedback directly
Tell me three things I can approve on.
What patIents want FP quote
Affabilty availability ability in that order
Don't sit on the same aide as the attendings at
Surgical grand rounds
Muscle spasm of the back
Usually causes generalized back pain with diffuse burning pain not past knee. Radiculopathy presents with shooting pains past knee.
Remember that ibuprofen + diabetes
Not so great because the patient might have renal involvement.
For lower back pain
Get a diagnosis! Osteoarthris, etc.
With radiculopathy
Vibratory would be first to go.
Colon cancer
Prevents more with constipation more than diarrhea
Some people get a low grade fever with
Dehydration
What viruses are associated with symmetrical arthritis
Parvovirus and HCV, HBV, HAV in acute phase
If have HCV you can't use what med for RA
methotrexate
Cryoglobulinemia is assoc with
RF factor and HCV
Of someone comes into your office with all the sx of RA with positive RF
Must be present for at least 6 weeks
Chinese pharmaceuticals
Often have all kinds of other meds thrown in
The percentage of people taking cam therapies
50%
Regulation of dietary supplements
Dietary supplement health and education act ( DSHEA 1994)

Orrin Hatch and herbal factories in Utah. Lobbies got DHEA passed. Gave manufacturer the responsibiltiy.

Also Food, Drug, and Cosmetic Act is what gives the FDA it's power. But doesn't apply to dietary supplement, becuase it's not food.

FDA can't investigate unless there is direct proof of harm.
Ayurvdic medications
Frequently cause arsenic, lead, mercury
Homeopathic dilution
24x 60% chance that there is 1 molecule of remedy in the bottle
Echinacea is more potent in
Germany. Regulated in Germany. More potent.
St johns wort and transplant
Induces intestinal. CYP3A4 can lead to decreased tacrolimus and cyclosporine concentration.
Brazilian weight loss remedy
Contains lead
Spice toxicity
Contains lead. Usually from little Indian markets in India. Also herbal teas.
Medical foods
Not required to be regulated, review, or approved! But there is a drug insert.
Remember, if you want to fight big pharma, going to supplements
Often the supplement companies are owned by big pharma!
Malar rash vs acne rosea
Acne rosea does not spare the nasolabial folds.
Lupus in Latin
Means wolf. Malar rash looks like wolf
Toxic rape seed oil in Spain in 1970s. Polyvinyl exposure. Gadolinium exposure.
Scleroderma!
Skin biopsy in scleroderma
Don't really need to do. If do it, do in inconspicuous area.
Most specific antibody for lupus?
Sm abs. About 30% of pts have this but it is specific for lupus.
A major side effect of anti-TNFs
Reactivation of TB! Reactivation of hep B in chronic carriers.
Lethargic
obtunded
stuporous
LethArgic - wake up when call
obtunded - wake up when shake
stuporous - need painful stimuli to wake
Serious recurrent symptoms reported by only one person
Suspect munchausen's by proxy
Munchausen's by proxy
Don't confront! The parent with run with the child.

Need to alert dcf to be present when confront.
Older patients with parnoid ideation
May just be that they can't hear, so they think that everyone is whispering about them!
Delirium vs. Dementia
Delirium
1. Sudden onset
2. Fluctuating level of arousal. Can go from somnolence to agitation. Dementia usually doesn't vary.
Delirium vs. Dementia
Delirium
1. Sudden onset
2. Fluctuating level of arousal. Can go from somnolence to agitation. Dementia usually doesn't vary.
IOP has significant
Diurnal variation!
People with cutting in central areas.
More indicative of psychosis.
A white t-shirt has an SPF of
SPF 10
What does a dermatologist say about sunlight and vitamin D?
Just get it from a dietary supplement!
Even though psoriasis is very itchy, you don't see
Eosinophils!
If can completely extend your elbow
There is no excess in the joint
Gout vs. Pseudogout can you see on x-Ray?
Can see calcium pyrophosphate of pseudogout.
What kind of biopsy do you do with a melanoma?
Excisional biopsy. NOT a shave biopsy - need to see whole depth.
Identifying an ixodes tick
Have BLACK legs
Helpful practice for those with personality disorder
Tell pts to "check it out" and to ask people about their emotions/ what they meant.
The 11th step of alcoholics anonymous
Meditation and prayer
Diabetic acidosis vs. Alcoholism acidosis
Alcohol inhibits gluconeogenesis and so alcoholism ketoacidosis presents with hypoglycemia
TG excess and chylomicrons vs. VLDL
TG excess comes from diet --> chylomicrons

from liver--> VLDL

refrigerator test VLDL more milky and with plasma. Chylomicrons float to the top.
Minocylene can cause
Drug induced lupus. Get antihistone antibody screen
Heavy menses with hyper thyroid or hypo thyroid?
HYPOthyroidism !
Rule of twos with WBCs
0-200 normal
200-2000 non inflammatory
2000 and above is inflammatory
Presdnisone and mood
Can cause restlessness and a racing mind.
When blood glucose fluctuates
Vision can become blurry because of water coming in and out of the lens of the eye. People think that prescription is changing.
Ankylosing spondylitis management tips
Sleep on back, not curled up. Do back extention exercises.
Criteria For inflammatory back pain vs. Mechanical
1. Age of onset is under 40 years
2. Insidious onset
3. Duration greater than 3 months
4. Association with morning stiffness (>1 hr)
5. Improvement with exercise
Table for memorizing types of insulin
Peak/Duration

Glargine: none/>24 hours
NPH: 6/12
Regular: 3/6
Lispro, Aspart: 0.5/3

everything is approx half of that above it.
Delusional disorders are characterized by
Defined by an "encapsulated" delusion. Pt usually otherwise fine. Characteristically only one delusion. Doesn't usually have visual hallucinations.
Lewy body dementia
Characterized by visual hallucinations. Pt otherwise fine. ?
How to approach energy healing
Do you pray? Do you mind if I say a little prayer for your leg?
EKG Changes with pericarditis
Pericarditis can trigger ST elevation "All over the place" - Dr. Cuenoud
Cold sweat happens because
The pt has a vagal reaction and the body is compensating to the hypotension by activating the sympathetic system
Anteroseptal MI: which leads?
V1 - V2
Anterior MI: which leads?
V2 - V5
Anterolateral MI: which leads?
V5, V6
ST depression is sometimes falsely positive, but
ST elevation is rarely falsely positive
Ca blockers are good for ____ but not good for _____
Not good for MI
Good for esophageal spasm
What is a person's mortality rate if they have chest pain for more than 1 hour and recieve no intervention?
30-40% mortality
Does a pt with angina have a normal EKG?
Yes when there is no pain and "maybe" when there is pain.
What are the eight steps to evaluating an EKG?
1) Rhythm
2) Rate
3) Nature of PR
4) Duration of PR
5) Duration of QRS
6) Duration of QT
7) T wave
8) Other
/ 457
Term:
Definition:
Definition:

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