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Hello and welcome to PASPAC Podcast, your Audio Passport from Physician Assistant Student to Certified – and beyond! With your host, Rebecca Harrell, MPA, PA-C
Today, our destination is a high yield dive into the Family Medicine EOR topic blueprint
So, sit back, relax, and enjoy the show
Intro
We have a lot to cover today with Family Medicine high yields. We’ll go in descending order of the blueprint and touch on some of the highest yield topics with a rapid mixed review toward the end. As always, you’ll find the notes to this show on the website including all of our resources at the bottom.
Okay, let’s get to into it starting with Cardio, making up 15% of this EOR
Cardio
Your 35 year old patient comes into the ER for evaluation of recurrent chest discomfort and tightness at rest, typically in the mornings. She has a history of hypertension and currently uses both tobacco and cocaine recreationally. What do you suspect is the cause of her CP?
Prinzmetal Angina (aka Vasospastic Angina) is secondary to coronary artery vasospasms
This type of angina typically presents in a pattern respective of the circadian rhythm, usually from midnight to early morning
Patients will typically present younger than an ACS stim and have a history of stimulant prescriptions or sympathomimetic drugs, like sumatriptan and ergot-derivatives or recreational cocaine use
Differentiate from Stable Angina, which occurs with activity and is relieved with rest and from Unstable Angina or other types of ACS which will usually present in an older patient with a history of stable angina that then progresses.
Prinzmetal Angina can show transient EKG changes during an episode with transient ST elevation in multiple leads which normalizes after episode. Anginal events will also rapidly relieved with short acting nitrates as the vasospasm relax and dilate. Troponin will usually be normal in these patients, but they can be elevated if there is prolonged vasospasm.
Treat episode with SL Nitro for reduction of duration and advise on smoking cessation. Given increased risk for ASCVD progression, aggressive risk-factor modification is important, so consider initiating a Statin. Mainstay treatment for Prinzmetal angina is with Calcium Channel Blockers, such as Diltiazem and Amlodipine.
Avoid use of non-selective beta blockers, like Propranolol, as this can exacerbate vasospasms. Drugs that trigger episodes should also be avoided.
How does 2ND Degree Mobitz 2 Heart Block appear on EKG?
This will show as a fixed PR with QRS drop and typically widened QRS secondary to concomitant bundle branch block.
Bradycardia is more common with these than tachycardia
Mobitz 2 is 2/2 blockage below the AV node (Bundle of His, Perkinje, or lower)
Patients may complain of palpitations, dizziness, lightheadedness, syncope, or be completely asymptomatic
Mobitz 2 is more serious than Mobitz 1 as it is more likely to progress into a complete heart block.
Thus, treatment with immediate transcutaneous pacer and insertion of a permanent pacemaker if symptoms arise
AV Nodal blockers, such as CCBs, Digoxin, Beta-Blockers, and Adenosine, should be avoided in all heart blocks to prevent complete dissociation.
The other Heart Blocks are also high yield to recognize on EKG
1st Degree – prolonged PRI, no treatment
2nd Degree Wenkebach (Mobitz 1) – Progressive prolongation of PRI with dropped beat before pattern starts over. Less likely to progress into complete HB.
We discussed 2nd Degree Mobitz 2
3rd Degree or Complete HB – appears as complete dissociation between the P wave and QRS complex. It will look sporadic, but if you measure the distance between each P-P and each QRS-QRS, they will each be on their own fixed rate. These patients need a permanent pacer
Heart Block Rhyme – Princeton Surgical Group and Nurseslabs
“If the R is far from P then you have a First Degree
Longer, longer, longer drop – then you have a Wenkebach
If some Ps don’t get through, then you have a Mobitz II
If Ps and Qs don’t agree, then you have a third degree”
Your patient with history of IVDU comes into the ER due to new onset fever and rash with a persistent cough. Physical reveals painful nodules at the tip of his fingers, painless erythematous macules on his palms and soles, splinter hemorrhages of his nails, and fundoscopy shows exudative retinal lesions. What makes up the major criteria for suspected diagnosis?
The Duke Criteria for Infective Endocarditis includes both major and minor features.
Major criteria includes having 2 separate positive blood cultures for common IE organisms, such as Staph, Strep, HACEK group, or Enterococci OR 1 positive blood culture for C. burnetti +/- IgG antibody titer > 1:800.
Another major duke criteria is evidence of endocardial involvement by either positive echo showing vegetations, abscess, or partial dehiscence of prostatic valve OR NEW valvular regurgitation.
Minor criteria includes predisposition (ex. IVUD or Hx valve replacement), fever, vascular phenomena (Janeway Lesions, Splinter Hemorrhages), Immunologic phenomena like glomerulonephritis, Osler Nodes, Roth Spots or RF+, and/or microbiological evidence with blood cultures that are positive but do not meet major criteria.
Empiric treatment includes IV Vancomycin or Amp-Sulbactam plus an aminoglycoside like gentamicin. Patients with IVDU or prosthetic valve should have a cephalosporin added, such as Cefepime or Ceftriaxone.
High risk patients should receive prophylaxis for procedures, including dental procedures, with Amoxicillin 2g 30-60 minutes before appointment.
Your 62 year old male patient with a 30 PYH arrives to the clinic for routine physical and you note widened aorta when palpating his abdomen. Which of the following is the study of choice to diagnose suspected condition?
Abdominal Ultrasound is study of choice for Abdominal Aortic Aneurysms
Monitor annually if 3-4 cm, q6mos if 4-4.5cm and refer to vascular surgery if > 4.5 cm
If > 5 cm, symptomatic, or has grown > .0.5 inches in 6 months then you need to get a CT with contrast to prep for surgical intervention
Your 14 year old patient with history of Turner Syndrome is found to have BP of 140/90 with pulses bounding in upper extremities and faint in lower extremities. CXR reveals rib notching and a “Figure 3” sign. Which type of murmur is associated with your top differential?
Coarctation of the Aorta is a non-cyanotic L-R shunting congenital heart defect that most commonly occurs proximal to descending of aorta in patients with bicuspid aortic valves.
Though males are more commonly affected than females, CoA has been associated with Turner Syndrome (45, X0) and risk of intracranial aneurysms.
Patients are asymptomatic until the ductus arteriosus closes and may either present with symptoms of heart failure as an infant with lower extremity mottling, or if less symptomatic, will present later with symptoms in stem +/- LE claudication.
Murmur that you’re looking for here is a systolic ejection murmur at the left upper sternal border that radiates to the back and left axilla
Confirm suspected dx with Echo Color Flow Doppler
Treat neonates with prostaglandin E1 to keep PDA open and then surgical intervention once stable via balloon angioplasty, stenting, or surgical correction.
Which are the 4 components of Tetralogy of Fallot?
Pulmonary Stenosis, RVH, Overarching aorta, and VSD
“PROV it”
Tetralogy of Fallot is the most common cyanotic heart defect
Infants present with cyanosis with crying or feeding and toddlers might present with “Tet Spells” leading to squatting
Murmur heard is typically harsh systolic ejection murmur at left sternal border where the blood flows across the pulmonary outflow tract
What is the recommended treatment for patients with ASCVD score > 20%?
Preexisting CVD or LDL > 189 (score > 20%)
ASCVD score risk calculates a patient’s 10 year risk of CV events based on age, sex, BP, lipids, DM, smoking status, and meds
AACE Guidelines for goal LDL in an extreme ASCVD risk patient is LDL < 55
High density Statin (atorvastatin/rosuvastatin) should be initiated in these patients with a goal to reduce LDL by 50%
Your 67 year old male patient complains of pain in his calves when walking that improves with rest. Physical exams cool, shiny, and hairless lower extremities with diminished dorsalis pulses bilaterally. There are ulcer with a punched-out appearance over the top of a few of his toes and lateral malleoli. What is the gold standard diagnostic study for your top differential?
Contrast Angiography
This patient has evidence of peripheral arterial disease (PAD) and likely has claudication due to atherosclerosis of popliteal arteries.
Initial study of choice in these patients is an ABI with < 0.9 indicating >50% stenosis and <0.4 indicating ischemia.
Duplex ultrasound can also be helpful to evaluate the location/extent of disease
Management includes lowering CVD risk, increasing exercise, +/- ASA, and revascularization may be necessary.
Claudication may be relieved with Cilostazol which is a PDE inhibitor
Okay that wraps up our HY cardio for family medicine, be sure to stick around to the end for some more in our rapid review.
Time for some high yield Pulmonology, which makes up 12% of the EOR
Pulmonology
What is the triad of asthma pathogenesis?
Airway Inflammation
Bronchial Hyperresponsiveness
Reversible airflow obstruction
Asthma is usually seen in patients with other diagnoses included in the Atopic Triad which is made up of asthma, allergic rhinitis, and atopic dermatitis
Atopy is the strongest predisposing factor for asthma
Clinical presentation often includes nocturnal awakenings from coughing, SOB, and wheezing which on auscultation is usually a diffuse musical sound that is more apparent with expiration
Management recommendations has been changing, so be sure to stay updated on what current recommendations are in clinicals. Vs. what is expected to know for the exam.
Knowing how to differentiate intermittent, mild persistent, moderate persistent and severe persistent is important for exams due to the different treatment regimens for each. Because recs have been changing recently I don’t want to get into them too much for fear of steering future listeners wrong, so just make sure you’re staying up to date with what your professors and other AAPA and NCCPA sources tell you is high yield at the moment. Unfortunately, exams are typically about 2-3 years behind current recommendations, which can be frustrating, especially in Clinical Year.
Which hereditary disorder is associated with the develop of COPD in a young patient even without a history of smoking?
Alpha 1 Antitrypsin Deficiency
COPD is the overarching term for patient who have either Chronic Bronchitis (“blue bloater" presentation) and Emphysema (“Pink Puffer” presentation)
It is the 3rd leading cause of death In the US and is most commonly cause by cigarette smoking
COPD results from inflammation and airflow limitation with increased number of goblet cells, mucous gland hyperplasia, and fibrotic narrowing
This can be differentiated from asthma on spirometry due to the LACK of reversibility
CXR will be notable for hyperinflated lungs by visualization of ~ 11 posterior ribs, flattened diaphragm, and “barrel chest” noted on lateral CXR. Those with Emphysema may even have blebs visualized due to alveolar septae destruction.
Definitive diagnosis is with PFT showing FEV1 < 80% of predicted value and increased TLC
Treat with ICS+LABA to limit exacerbation and use oxygen therapy and smoking cessation to reduce mortality. Opioids can be used in palliative care to reduce sensation of dyspnea.
What should be co-administered with Isoniazid in order to decrease risk of peripheral neuropathy as an adverse effect?
Pyridoxine (Vitamin B6) should be administered with INH
Isoniazid is part of the RIPE mnemonic for treatment of TB.
Each of the RIPE drugs have unique adverse effects that love to be asked about on exams.
Rifampin results red/organ vision changes (“Rif-Vampin’)
Isoniazid – Peripheral Neuropathy
Pyrazinamide – (less HY) GI upset, arthralgias
Ethambutol – Optic neuritis with red-green color blindness, vertical nystagmus, and hyperuricemia can be seen. (E = Eyes)
Which CXR finding increases your suspicion of squamous cell carcinoma of the lungs?
Central solitary nodule with irregular borders
Lung cancer is the leading cause of cancer death among both men and women
Most common form is adenocarcinoma which arises in the periphery
Most aggressive form is small cell carcinoma, which typically arises centrally
Commonly also shows mediastinal widening and typically mets are already present on diagnosis
I remember which are central by pretending central is spelled with an S ("Sentral") and the S stands for Small Cell and Squamous Cell.
Clinical presentation is usually with cough maybe hemoptysis and always suspect cancer in a patient presenting with unintentional weight loss
SCC also may be associated with hypercalcemia whereas SCLC usually associated with paraneoplastic syndromes like Lambert-Eaten Myasthenic Syndrome.
Lung cancers may also present with hyponatremia from SIADH
Definitive dx is with biopsy
Treatment depends on staging for NSCLC and SCLC is treated with Chemo/Rad and whole-brain radiation
We’ll hit on some more pulm questions in our rapid review, but lets go ahead and move on with some GI/Nutrition, which makes up 11% of the EOR
GI/Nutrition
Your patient c/o pyrosis after meals which occurs a few times a week. He also has been having perception of reflux with acidic taste in his mouth. Additional symptoms reported are waterbrash and globus sensation. What is the first line treatment for suspected diagnosis?
In a patient with frequent symptoms, a step down therapy approach is typically preferred with the initiation of PPIs, such as omeprazole or Pantoprazole, in addition to lifestyle management.
In patients with fewer than 2 episodes weekly, a step up approach to treatment is indicated with lifestyle changes as first line, antacids to relieve symptoms on demand, Histamine 2 Receptor Antagonists, like Famotidine or Cimetidine, and even surface agents and alginates, like Sucralfate, to promote mucosal healing and protection
Your patient describes recurrent gnawing epigastric pain that radiates to her back that is usually alleviated with food but returns a few hours later and can even awaken her at night. Urea Breath Test is positive and you schedule her for a confirmatory EGD. Which medications should be started in this patient following her biopsy, if positive?
CAP – Clarithromycin, Amoxicillin, and Omeprazole +/- Bismuth x 14 d
Test of choice should be administered in all patients with H. Pylori induced Peptic Ulcer Disease 4 weeks after completion of therapy.
Screening for H Pylori can be done with urea breath test or fecal antigen testing, but biopsy is diagnostic.
Peptic Ulcer Disease is the most common cause of Upper GI bleed with the most common location being in the duodenum > stomach
Remember from last episode referencing the podcast Cram The PANCE's mnemonic “Dude, Give me Food”
Your 22 year old female patient complains of chronic, crampy abdominal pain which typically improves following a bowel movement. On the Bristol stool form scale she says they can range anywhere from 1-2 and 5-6 depending on the day. She has tried FODMAP diet in the past but has a hard time sticking to it and is hoping for management of her symptoms of abdominal pain and bloating. Which medication should be initiated?
Antispasmodic agents like Dicyclomine or Dicycloverine (Bentyl)
If she was more concerned with relieving constipation you could initiate osmotic laxatives like polyethylene glycol or even Lubiprostone, Linaclotide, or a bulking agent like psyllium
To relieve diarrhea, you can offer loperamide which is a Mu receptor agonist that slows down large bowel motility, bile acid sequestrants like cholestyramine, or serotonin 3 receptor antagonists like Alosetron
In patients with right sided colorectal cancer, what symptoms do they typically present with?
Chronic blood loss which can lead to iron deficiency anemia
Left sided lesions usually change the quality, quantity, and frequency of the stool
Symptoms related to CRC typically don’t appear until later in disease course, which is why screening is so important.
USPSTF suggests All patients ages 45-75 should receive screening with colonoscopy every 10 years being the best choice. If patients are not amenable to colonoscopy, you can do annual FIT tests, multitarget fecal DNA q3years, or CT colonography every 5 years.
In patient with (+) FM CRC in 1st degree relative, screening should begin at age 40 or 10 years prior to time of diagnosis in family member
In patients with Familial Adenomatous Polyposis, Sigmoidoscopy should begin at age 12 and every 1-2 years after that. If any abnormalities are found, colonoscopy is indicated.
What is a positive Murphy’s Sign and what does it indicate?
Palpation of the bladder during inspiration leads to a sudden cessation of breath and wincing (sign = sudden cessation of breath)
Indicates Cholecystitis, which is an obstruction of the cystic duct
Patient typically presents with colicky RUQ pain after eating fatty meals and may also have Boas sign present which is hyperesthesia inferior to right scapula.
Initial diagnostic test for cholecystitis/cholelithiasis is RUQ Ultrasound with the gold standard being the HIDA scan.
What is the most specific lab for acute pancreatitis?
Elevated lipase 3x upper limits of normal
Acute pancreatitis is most commonly caused by gallstones and then alcohol
Typically presents with sudden onset of sharp epigastric pain radiating to back that is worse with lying down and improved with leaning forward
Necrotizing Pancreatitis may show Grey Turner Sign (Flank Ecchymosis) or Cullen Sign (Umbilical Ecchymosis)
Ranson Criteria is one of the tools to predict severity
Treat by addressing underlying etiology, aggressive fluid resuscitation, and analgesics.
Okay, that’s enough GI – lets move onto EENT which makes up 8% of the EOR
EENT
Your 17 year old patient with history of Asthma comes into the office due to paroxysmal sneezing, runny nose, and bilateral itchy, pink eyes for the past couple weeks. Social history is unremarkable aside from recently adopting a new cat. Physical exam reveals infraorbital edema and darkening with accentuated folds below his lower lids. There is a transverse nasal crease and his nasal mucosa is pale bluish with turbinate edema with clear rhinorrhea visible. Given your suspected diagnosis, what is considered as the first line treatment?
Intranasal corticosteroids
This patient has allergic rhinitis as indicated by his history of atopy, symptoms, physical findings, and recent exposure to a new allergen.
First line treatment of allergic rhinitis is intranasal glucocorticoid steroids, like mometasone or fluticasone.
You could confirm diagnosis with a skin prick test as well.
Since this patient likely has allergic conjunctivitis too, you could consider giving him ophthalmic antihistamine drops, such as azelastine.
He should also be advised on proper use of nasal saline irrigation which could help decrease nasal allergens and also cleanse passageways of debris prior to inhaled med use.
If needed, additional therapies could be added on such as oral antihistamines, addition of antihistamine sprays or combination sprays with glucocorticoid and antihistamine
Since he has asthma, especially if the allergen is causing uncontrolled flares or persistent asthma symptoms, you could consider monoclonal antibodies like omalizumab or dupilumab, in addition to his asthma meds, to reduce symptoms and improve quality of life.
Your 7 year old patient is brought into the office due to ear pain and itching. He denies any known injury and his parents states this all started after returning from the beach. Physical exam reveals tenderness when manipulating tragus and auricle. Otoscopy reveals yellow debris in the inner ear with an erythematous canal. His TM appears erythematous, but there is a cone of light present and no air fluid level seen behind it. What diagnosis do you suspect?
Otitis Externa
this patient likely has otitis externa or “swimmer’s ear” given his tragal tenderness and painful, erythematous canal in the setting of recent beach trip.
The differential here is otitis media, which is unlikely in this patient given the lack of bulging or air fluid level seen with visualization of the TM. Also tragal manipulation is not likely going to increase pain in otitis media, the way it does in otitis externa.
A potentially fatal complication of otitis externa is malignant external otitis which is more commonly seen in the older diabetic population and occurs which the infection spreads from the skin to the bone/marrow spaces in the skull leading to severe otalgia and otorrhea that appears out of proportion to exam findings and physical exam shows granulation tissue at the bony cartilage junctions in the floor of the ear canal.
Treatment involves cleaning the canal and treatment with otic drops. In patients with mild severity and intact TM, acetic acid-hydrocortisone can be used 3-4x daily. If there is moderate disease, first line is an antibiotic otic drop that covers for both S. Aureus and Pseudomonas. Ciprofloxacin-hydrocortisone and neomycin-polymyxin B hydrocortisone are considered first line.
Your 56 year old patient has acute, painful swelling of under her chin with tenderness and overlying erythema. She states the pain is worse after eating and she thinks she can taste pus. Physical exam reveals expression of pus from Wharton's duct and fever of 100.4. What is the most common organism causing this patient’s suspected diagnosis?
Staph Aureus is the most common organism if an infection of salivary glands occur.
The most common cause of sialadenitis is inflammation due to salivary stasis and can be caused by viruses, such as mumps in parotitis, or autoimmune diseases like Sjogren Syndrome.
Diagnosis is made clinically but you may need to get an ultrasound or CT to rule out abscess or obstruction from a salivary stone.
Ludwig’s angina is a fatal differential here, which is the most common neck space infection, and leads to sublingual or submandibular cellulitis which will usually present as a patient with brawny neck edema and tongue protrusion or elevation.
Clinical interventions of a non-infected sialadenitis is with hydration, warm compression, massage of glands, and use of sialagogues to increase salivary flow
If infection occurs, like in our patient, anti-staph agents like Dicloxacillin may be prescribed.
Alright, we’ll hit on a couple more of those types of questions in our rapid review at the end but lets move onto some OBGYN, which makes up 8% of the EOR exam
OBGYN
Your 55 year old patient arrives to the OBGYN for her annual physical when you discover a palpable lump in her upper outer quadrant of her left breast. It seems to be hard, fixed, and was not present at her last physical. What should you do as initial work up?
Diagnostic mammography is used as initial work up, unless the patient is under 35 years old, in that cause you would choose ultrasound
Breast biopsy will ultimately need in this patient as she likely has breast cancer given the atypical nodule in the most common location of breast cancer tumor.
Core needle biopsy can be done or punch biopsy if Paget’s disease of the breast is suspected. Excisional biopsy can also be considered.
Your patient arrives to the OBGYN due to foul smelling vaginal discharge and irritation. Pelvic exam reveals thin, white, homogenous discharge and whiff test is positive. What is the pathogenesis of her diagnosis?
Bacterial Vaginosis is caused by alterations in the vaginal environment, which can lead to decrease lactobacillus leading to volatile amine production by new bacterial microbiota which raises the vaginal pH to above 4.5.
Most commonly associated bacteria in BV is Gardnerella vaginallis, though may are implicated.
It is high yield to be able to quickly differentiate BV from a yeast infection, trichomonas, or chlamydial/gonococcal infection based on physical exam and microbiology. So a comparison chart is your best friend here.
In BV, clue cells (which are vaginal epithelial cells studded with coccobacilli) are seen on saline wet mount.
Preferred treatment is with metronidazole PO or intravaginally with second line being Clindamycin vaginal cream.
Your 66 year old G5P5 female patient comes into OBGYN due to increase sensation of heaviness in her vagina with increased difficulty expelling urine. Physical reveals a hernia of her anterior virginal wall. What should be done to quickly relieve her symptoms?
Pessary Placement for this patient’s cystocele
Pelvic floor muscle exercises (aka Kegels) should also get started into order to build up strength back into her pelvic floor
Surgical intervention can be considered down the road if conservation fails
Differentials here include enterocele, which is typically from small bowel herniation into vaginal wall, rectocele evidenced by a posterior vaginal wall hernia, or even herniation of the uterus which would be seen on exam by bulging/protrusion of cervix father down into vagina.
Okay, enough of those for right now, lets get on to Rheum/ortho which makes up 8% of your EOR
Rheum/Ortho
Your 42 year old female patient with of thyroid disease presents with soft, red, tender, swelling in her MCPs, PIPs, and MTP which is typically worse in the morning and improves throughout the day. Physical exam reveals hyperextension of the PIP and flexion at the DIPs (swan neck deformity). Which test is diagnostic of suspected condition?
(+) Anti-cyclic citrullinated peptide antibodies is dx of Rheumatoid Arthritis
Screening can also be accomplished with positive RF (70%) and elevated inflammatory markers like ESR and CRP, which is supportive of disease, but not diagnostic
RA is the most common inflammatory arthritis most commonly caused by autoimmune destruction and typically affects women 40-50 years old
Synovitis is the most common presentation and you should be able to differentiate from OA by it’s unique feature of being worse with rest and improved with activity, vs. OA which is improved with rest and worse with activity
Joint deformity signs are also high yield. This stem describe a Swan Neck Deformity with hyperextended PIP and flexion of DIP, but there is also the Boutonniere sign which if flexion of PIP and extension of DIP, Bow-String Sign which is pronounced extensor tendons of dorsal hand, and then also classic bilateral ulnar deviation
Treatment is with DMARDs therapy such as Methotrexate
Your patient is a 40 year old male who arrives to your clinic due to painful and swollen first pedal digit. He reports he recently came back from vacation where he indulged in seafood and beer. What do you suspect to see on synovial fluid analysis using compensated polarized light microscopy?
This patient likely has gout which could be definitively diagnosed with negatively birefringence and needle-shaped crystals diagnoses on polarized light microscopy
Chronic gout can lead to tophi found on physical exam.
Differential is pseudogout which is positively birefringent with rhomboid shaped crystals visualized
Risk factors for gout include thiazide diuretics, high purine foods, and alcohol use.
Agent of choice for treating an acute flare is with NSAIDs, oral glucocorticoids, or Colchicine.
After a flare has resolved, the patient should be started on urate-lowering therapies, such as Allopurinol (preferred), Probenecid, or even Febuxostat.
Your 33 year old patient arrives to the office because of pain along his plantar region of the food that is worse immediately after stepping out of bed and later improves with walking or stretching his calf. If he sits for a long period of time, he’ll notice the pain again when he gets up. Physical reveals tenderness to palpation along the sole of his foot and calcaneus. What is the first line treatment of suspected diagnosis?
Treatment of plantar fasciitis starts conservatively with stretching exercises, avoidance of flat shoes or barefoot walking, and use of silicone shoe inserts at the heel
If conservative measures fail to provide relief, you can consider NSAIDs, or even injected glucocorticoids with a local anesthetic.
Want to differentiate this with a Morton's neuroma, which will be a patient complaining about an interdigital mass in foot that feels like a marble while walking and improves with massage.
The first line tx for this is with use of metatarsal shoe inserts and wearing shows with wider toe box.
Your 27 year old male patient arrives to the office concerned about lower back pain that is worse with rest and improves with movement. He denies any medical history and states his dad suffered from something similar but forgot what it was named. X-Ray reveals SI joint fusion and continuous fusion of lumbar spine. Which Presence of which protein surface antigen do you expect this patient to have on lab testing?
HLA-B27
Patients with Ankylosing Spondylitis typically are found to be positive with HLA-B27, which is also associated with other diseases making up the PAIR mnemonic, Psoriatic arthritis, IBD, and reactive arthritis (aka Reiter’s syndrome)
AS is the 2nd most common spondyloarthropathy, with the 1st most common being psoriatic arthritis
Treatment begins with NSAIDs and PT, with potential for TNF-alpha blockers. These patients should be referred to rheumatology.
Alright time for a couple Neurology questions which makes up 6% of your Family Medicine EOR
Neurology
Your 22 year old female patient arrives to your office to evaluate for potential seizures. She states that she has been having symptoms of lightheadedness with sweating, palpitations, and nausea prior to vision “tunneling” and then losing consciousness, usually occurring after being startled. What do you suspect patient’s diagnosis to be?
Vasovagal Syncope
This is a type of neurally mediated reflex syncope that occurs as a reflex to a trigger that leads to vasodilation and bradycardia which leads to hypotension systemically and cerebrally, leading to the classic prodrome with fainting
VVS is the most common cause of syncope in all ages
Want to ensure you’re able to differentiate this between a cardiac syncope, which usually has no prodrome, and seizure, which presents with postictal state and possible physical exam findings like injuries to lateral tongue from biting
Your patient comes into the office due to unilateral facial weakness which involves the forehead. No other focal neuro deficits are noted. What is the first line intervention for suspected diagnosis?
PO Prednisone
Patient has Bell’s Palsy which is the transient weakness of CN7 which is most commonly idiopathic, but also associated with inflammation or infection (like HSV or Lyme Disease).
Patient should be screened for Lyme Disease, especially if bilateral facial weakness, and treated if found to be positive. Should also look into the patient’s ear on exam to evaluate for presence of vesicles which may indicate etiology of Zoster or even HSV.
Glucocorticoids should be started in all patient’s with new onset of Bell’s Palsy. Antivirals can be considered if severe or suspicion of HSV etiology.
Remember, if the forehead moves YOU MOVE, because this likely indicates the patient is actually having a stroke.
Okay, those make up your heavy hitters on this blue print.
Lets get into some mixed review which will have more heavy hitters as well as include some high yield from the remainder of the blueprint.
Rapid Review
1. What is the first line treatment in mastitis?
a. Dicloxacillin
2. What makes up Samter’s Triad?
a. Asthma, ASA Sensitivity, and Nasal Polyps
b. Treat with Montelukast
3. What complication can arise from a patient who suffered from multiple febrile seizures?
a. Recurrent seizures in the future
4. What is the most common type of GI cancer?
a. Colorectal cancer (also is the 2nd mc cause of cancer death in US)
5. What is the diagnostic criteria between Stevens Johnson Syndrome and TEN?
a. SJS < 10% BSA
b. TEN > 30% BSA
c. Don’t confuse with Erythema Multiforme which presents with targetoid lesions that may involve palms and soles and has no fever and negative Nikolsky sign.
6. What is the most likely diagnosis for a patient complaining of a painless hard nodule on dorsal aspect of the wrist?
a. Ganglion Cyst
b. If its < 1 cm you can observe; Surgical Excision can be done if > 1 cm
7. Which valvular disorder is associated with midsystolic click heard at the apex?
a. Mitral Valve Prolapse
b. May also be associated with murmur of mitral regurgitation which is low-pitched holosystolic murmur which radiates toward the axilla
8. What can occur in a patient who uses daily inhaled corticosteroids that does not rinse mouth out afterwards?
a. Thrush or oral candidiasis
9. What is the most common location of invasive ductal carcinoma?
a. Upper outer quadrant
10. What is the screening study for Dementia?
a. Cognitive Impairment Testing
b. Diagnose type with Histology and MRI
11.How does trichomonas vaginitis typically present?
a. Cloudy, yellow-green frothy discharge with friable “strawberry cervix”
12. What is the treatment of choice in a patient with a thrombosed external hemorrhoid that presents in under 72 hours?
a. I&D
b. If non-thrombosed or > 72 hours, hemorrhoid cream, sitz bath, and stool softeners are recommended
c. Internal hemorrhoids can be treated with band excision
d. Difference between them is via location above vs. below the dentate line (higher = internal, typically non-painful; lower = external, typically painful)
13. What treatment decreases mortality in patients with risk of atherosclerotic cardiovascular disease?
a. Statins aka Hydroxymethylglutaryl-Coenzyme A Reductase Inhibitors
14.How does a patient with intussusception typically present?
a. ~18 months old with colicky pain and sausage shaped abdominal mass felt on exam +/- currant jelly stools. Child may frequently raise legs and flex hips for relief.
15. What are the only two interventions associated with decreased mortality in COPD?
a. Oxygen therapy and smoking cessation
b. If asked between one vs. the other, oxygen therapy is generally the answer but I have seen either one as the correct answer so need to differentiate if they’re talking about treatment (o2 therapy) vs. risk factor mitigation (smoking)
c. When in doubt, your best bet is probably choosing oxygen therapy
16.Which direction of an anal fissure typically corresponds with a systemic disease, such as IBD?
a. Lateral anal fissures
b. Typically, are posterior in patients without systemic disease
17. What does work up show in fibromyalgia?
a. All work up is negative
b. 11 + trigger points on physical exam
18. What is the difference in presentation between hordeolum and chalazion?
a. Hordeolum is typically painful with spontaneous drainage mc at or around eyelash follicle
b. Chalazion is typically painless and firm and found mc above eyelashes on upper lid
19. How does essential tremor present and what is the first line treatment?
a. Working tremor that worsens with stress and fine motor movements
b. Propranolol
20. How does right heart failure typically present?
a. Fluid overload throughout the body
b. Left = L for Lungs; Right = R for Rest
c. MCC RHF is LHF
21. What is the different between placenta previa and placenta abruption ?
a. Painless 3rd trimester bleeding in placenta previa
b. Painful 3rd trimester bleeding in placental abruption
22. What is the diagnostic criteria for chronic bronchitis?
a. Chronic, productive cough on most days for 3 months out of a year for at least 2 consecutive years
23. What is the treatment of a Brown Recluse Bite?
a. Initial tx is with wound care and pain control +/- tetanus prophylaxis if indicated
b. Abx should only be prescribed if signs of infection are apparent
c. In south America, Antivenom is recommended for patients with dusky center around bite or other signs of developing necrosis. However, this is unavailable in the US and first line still remains wound care practices.
d. Some advocate for use of Dapsone as treatment, but UTD does not recommend due to risk factors including aplastic anemia, methemoglobinemia, and potential hypersensitivity.
24. Which hypertension medication is most known as a risk factor for gouty flare?
a. Thiazide Diuretics
25. What is the most common cause of peptic ulcer disease?
a. Helicobacter pylori with close 2nd being use of NSAIDs
b. Rare etiology include overproduction of acid by a gastrin secreting tumor
26. What are some physical exam findings you might seen in patients with atopy?
a. Dennie Morgan lines
b. Hyperlinearity of palms
c. Eczema
d. Cobbelstoning of posterior pharynx and palpebral conjunctiva
e. Allergic salute and allergic shiners
f. Boggy Nasal Mucosa
27. What should be suspected in a patient with early satiety, postprandial fullness, bloating and vague abdominal pain in a patient with history of diabetes?
a. Gastroparesis
28. Which vitamin protects RBC membrane from oxidative damage in hemolytic anemias?
a. Vitamin E
29. What DEXA score is consistent with Osteopenia vs. Osteoporosis?
a. Osteopenia is -1 to -2.5
b. Osteoporosis is DEXA -2.5 or lower
c. If patient is between negative 2-2.25 you should be repeating DEXA every 2 years
30. What is Pott’s Disease?
a. TB of vertebrae leading to osteomyelitis and arthritis
31. What symptoms are associated with hyperprolactinemia?
a. Secondary Amenorrhea or oligomenorrhea
b. Galactorrhea
c. Decreased libido
d. Gynecomastia
32. What is Calot’s Triangle and what is found inside of it?
a. Cystohepatic triangle = inferior surface of the liver, cystic duct at right border and common hepatic duct at left. Inside the triangle is the cystic artery which needs to be ligated and divided to avoid injury during cholecystectomy
b. If you’re on a surgical rotation, know that some surgeons define the triangle as made up by the cystic duct to the right, common hepatic to the left, and cystic artery as the superior border. So, if they pimp you – give them both answers and they might be impressed.
33. What ABI result indicates ischemia?
a. < 0.4
34. What are some physical exam findings in seen in Cushing’s Disease?
a. Increased central adiposity, facial plethora, facial adiposity, increased adipose tissue in neck/upper pack, violaceous striae, hirsutism, easy bruising are some more high yield features to know.
35. ‘What populations are at high risk of giardiasis?
a. Childcare workers and those who just went camping who present with non-bloody diarrhea and vomiting
36. Which type of alopecia is described as discrete, smooth, circular areas of hair loss with visualization of exclamation point hairs on physical exam and a positive hair pull test?
a. Alopecia Areata, immune mediated disorder leading to recurrent, non-scarring hair loss.
37. What are two common screening tools used in MDD?
a. Beck’s Depression Inventory and PHQ-9
38. Which leukemia is the most common form of chronic leukemia in adults and presents with lymphadenopathy, splenomegaly, with peripheral smear showing smudge cell?
a. Chronic Lymphocytic Anemia
39. What is Pancoast Syndrome and how does it present?
a. Tumor in the superior sulcus leading to shoulder pain and Horner Syndrome (PAM = Ptosis, Anhidrosis, Miosis)
40. What side effect should be monitored for in patients with long term use of PPIs?
a. Vitamin Deficiency, especially Vitamin B12 Malabsorption
41. What is the suspected cause of developing Acanthosis Nigricans?
a. Insulin Resistance
42. How does Obstructive Sleep Apnea usually present?
a. A patient c/o fatigue, snoring, with excessive daytime sleepiness and morning headache
b. Physical usually shows an obese patient (highest risk factor) with enlarged neck circumference or patient with retrognathia and high arching high palate or enlarged tonsils/adenoids
43. What is the most common form of anemia overall?
a. Iron Deficiency Anemia (microcytic hypochromic anemia)
b. Ferritin is the most specific aspect of the iron study, which will be decreased in IDA
c. Differentiate from other high yield anemias like macrocytic megaloblastic anemias, such as B12 Deficiency or Folate deficiency anemia
44. What diagnostic study correlates with primary hyperthyroidism?
a. Low TSH, High Free T4/T3
45. What is the location of a Direct Inguinal Hernia?
a. Medial to inferior epigastric vessel (through Hesselbach’s Triangle)
b. Remember HT is made up of RIP = Rectus Abdominis, Inferior Epigastric, and Poupart’s aka Inguinal Ligament.
c. Scrotal involvement is not typically seen here as it is with Indirect Inguinal Hernia which is the most common type of hernia overall that results from hernia lateral to inferior epigastric vessel, traveling through the internal inguinal ring, and can involve the scrotum.
46. What is the diagnosis and treatment of a patient who complains of panic attacks every time she’s about to leave her house?
a. Agoraphobia, treat with SSRIs or even PRN benzos or hydroxyzine
b. Differentiate with Social Anxiety Disorder which is fear of social environments due to fear of ridicule or embarrassment
47. What is first line treatment for Lyme Disease in pregnant patients?
a. Amoxicillin (also first line in children)
b. 1st line otherwise is Doxycycline is first line
48. What vaccines can be started at 1 year checkup?
a. Live vaccines, like varicella and MMR (not combined)
49. What is the first line prescription for a patient with history of anaphylaxis with respiratory compromise?
a. IM Epinephrine 0.3 mg to lateral thigh, can repeat q5-15 mins PRN, consider IV if failure to respond.
50. What fractures are pathognomonic for nonaccidental trauma?
a. Metaphyseal aka bucket handle or corner fractures
b. Also suspect in patients with posterior rib fractures or multiple fractures and bruises at various stages of healing
51. What is the most common cause of Acute Pancreatitis?
a. Gallstones
b. Close second is alcohol
52.What is the difference between a threatened vs. inevitable abortion?
a. Threatened is diagnosed with vaginal bleeding < 20 weeks with closed os on ultrasound and presence of IUP
b. Inevitable is bleeding < 20 weeks with open os visualized and continued presence of IUP
c. Also be able to differentiate complete, partial, and missed abortion as well.
53.What is are some features of PTSD?
a. Hypervigilance/ hyperarousal is number one
b. Also, can report nightmares, flashbacks, intrusive thoughts, avoidance of trigger reminders which lead to considerable life dysfunction.
c. This should be lasting for over 1 month since initial trauma for dx of PTSD vs. < 1 month which would be dx as Acute Stress Disorder
54.How can you differentiate orbital cellulitis from preseptal cellulitis?
a. While they both cause ocular pain, orbital cellulitis causes pain directly linked with eye movements, proptosis, and possibly vision impairment
55.What is the most common cause of cystitis?
a. E. Coli
b. Patient’s UA will show positive leukocyte esterase and nitrates
c. Definitive Dx with Urine Culture and Sensitivity
d. Remember all pregnant patients with asymptomatic bacteriuria should be treated for UTI with nitrofurantoin x 7 days.
Woo, that wraps up our intense high yield family medicine EOR review. For note on this episode, including the sources and transcript, please head over to www.paspacpodcast.com . You an also find a whole bunch of information there geared toward whichever rotation you’re on right now or wherever you are on you PA journey
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