[Music] all right what's up guys so today we're gonna do a cram session for your family medicine shelf or for the family medicine component of your step 2 CK or for anyone who's just interested in listening to family medicine knowledge so first we're gonna talk about Triple A abdominal aortic aneurysm when do you start doing screening for that so it's in people aged 65 and if they've ever smoked you're gonna do an abdominal ultrasound for a triple-a what about for lung cancer screaming so anyone who is 55 years or older with a 30-pack year history of smoking who currently smokes or who or if they have quit within 15 years if they make for any of those criteria then you're gonna do a low-dose CT scan of the chest for a lung cancer so meanwhile I'm gonna take this opportunity to give you guys a little bit of advice for the family medicine shelf make sure you review the USPSTF guidelines the a and B rated ones these ones if you know them really well and review them you can search it online it'll help you live a lot of these questions are based off your knowledge of the guidelines alright so next is colonoscopy you do a colonoscopy for colon cancer screening starting at 50 years old and you do it every 10 years if they have someone in the family who was diagnosed with colon cancer before age 60 then you're gonna scream at 40 years old or 10 years before the family member got diagnosed with colon cancer whatever comes first so say someone in your family had colon cancer at 45 then you want to start a colon cancer screening at their five but say someone in your family got diagnosed at sixty ten before that is 50 so you will pick 40 years old because that one came first pap smears start at age 21 years old and happened every three years you can stop at age 65 mammograms USPSTF and ACOG which is the ob/gyn Society used to argue about this but lately I've been noticing that there's more of a consensus now and it's 40 years old starting at 40 years old and every year or two when do you start screening for osteoporosis 65 years old and you're gonna use a DEXA scan of the lumbar spine you want to give this zoster vaccine at 60 years old you want to give the HPV vaccine between 9 to 26 years old chlamydia and gonorrhea screening occurs in females who are sexually active in less than 24 years old HIV screening is done for anyone between ages 15 and 65 and so those are your major screenings and you should definitely try and commit this to memory so next is COPD there's mild moderate severe and very severe and how you categorize it depends on the fev1 and the fev1 is also the main metric for prognosis if you have a very low fev1 then your prognosis is poor so it starts with above 80% 50 to 80 30 to 50 and less than 30 so if it's your fev1 is over 80% you're gonna give someone with COPD albuterol which is a short-acting beta-2 mist between 50 to 80 which is moderate you're gonna add a long-acting beta agonist such as cell materal between 30 to 50 you want to add it inhaled steroid below 30 which is very severe this is when you start adding oxygen therapy there's also two other metrics that you can use for when patients will start needing oxygen therapy at home and that's if you're owed to saturation is less than 88 or your pao2 is less than 55 so forego doubt is basically a plastic presentation is a cute abrupt onset of severe pain of the metatarsal phalangeal joint of the foot which is the at the base of your big toe that part will become swollen and really red and extremely painful so painful that it might even wake the patient up in the middle of the night inside this joint is going to be filled with uric acid crystals which are negatively birefringence and the first thing you always want to do with the hot swollen joint is aspiration so when you do the joint aspiration that's where you'll find the uric acid crystals remember the positively birefringence crystals are also known as pseudo gout and those are the ones that have the calcium pyrophosphate crystals and they will be rhomboid shaped so forget you have a couple treatments for acute gout you want your first line is you want to treat it with the NSAIDs such as indomethacin or colchicine if you had to pick one of the other pick indomethacin first but here's a trick if the patient has any sort of kidney disease where their GFR is really low or their creatinine is high if they have CKD then these drugs are contraindicated and you want to proceed instead with the intra-articular steroid injection like I said any hot swollen joint needs to be aspirated because we fear of septic arthritis and if that's untreated it can be deadly but it can also destroy the joint very quickly someone with septic arthritis commonly happens in the knee or the hip and its secondary to systemic infections such as bacteremia and this person will have an extremely tender swollen joint that's really red and they won't be able to bear weight either on the hip or be able to bend the knee all very severe pain and they'll also have fever and leukocytosis so the first thing what you want to do is arthrocentesis take it out and when you analyze the joint fluid you'll see that usually a septic joint will have over 50 thousand white blood cells inflammatory joints are usually between ten to fifty thousand and that's more kind of like Dell or like rheumatoid arthritis and then septic joint will have 90% plus neutrophils and then with that you want to treat with IV antibiotics so for gout meds that you want to use for chronic treatment of gout and preventing future flares you can either treat with probenecid or allopurinol so in order to know how which one to use you can check the uric acid in the urine so basically if the urine uric acid is low then that means that there's a problem with excreting uric acid so you want to use probenecid which helps improve excretion and then allopurinol which is a xanthine oxidase inhibitor which prevents the formation of uric acid is used if the urine uric acid is really high that means that the body is making so much uric acid and it's spilling out into the urine so this is an excess production problem not a under excretion problem so then you can use allopurinol but for acute flares you always start off first line with the end said don't use pick the more long-term types of treatments such as allopurinol because that makes it worse in the short-term so initial prenatal care the first you should know about what type of things you want to work up for the first initial visit the visit at week around week 28 and the visit at around week 35 to 37 so the first visit you want to always do a CBC a urinalysis STD HIV hepatitis B a pap smear blood typing and rubella at weeks 28 you check for three things the CBC to check for anemia and then diabetes screaming and then the rhogam shot if they're Rh negative so diabetes screening remember you start off with the 50 gram oral glucose and after one hour if that's greater than 140 then you're advanced to the next stage which is the hundred gram glucose load and then that you measure hours one two and three if it's high and two out of the three hours then you diagnose gestational diabetes so at hours one it should be greater than 180 and then hours two is greater than 160 and hour 3 is greater than 140 180 160 140 and that can be plus or minus at some different sources give other numbers but usually in the question if they want to make it clearer it'll be way above those values like so hours one two and three if two out of the three are high in the 100 gram then that's just a tional diabetes so you want to check that at week 28 and then the rhogam shaw if the mom is Rh negative and remember the reason why you give the rhogam shot is it's an antibody that prevents the fetal red blood cells from being detected by moms immune system because if she sees those babies red blood cells that are possibly Rh positive then her antibodies might switch from IgM to IgG and that's bad news for the second baby and then in finally in week 35 to 37 that's when you do the group B strep test of and do a swab of the vagina and rectal area in the perianal area because if they show up for having a positive Group B Strep then that's when you give penicillin prophylaxis for hours before delivery for pap smears starting at age 21 you're gonna do them every three years and then there's three types of outcomes with the pap smear it can be askus low a grade or high grade and ascus means a typical squamous cells of undetermined significance if you have ascus then the next thing you want to do is an HPV test if that's positive then you proceed to colposcopy what if the mom is pregnant during the pap smear and she has askus then you basically take your chances and do the pap after birth because it's not likely she'll have cancer if it's low grade or high grade as an LS il RHS il then you're gonna proceed with the Koska P once you do the colposcopy that's when you do use the speculum and view the cervix under microscopy and then biopsy the lesions this can come back as cin 1 2 & 3 if it's cancerous then that's when you proceed with doing a hysterectomy for pap smears remember every three years and that 65 years old the Tdap vaccine is something that's given during pregnancy and that happens between weeks 27 to 30 six any live vaccines we'll have to wait until after the baby is born term is considered anything starting at 37 weeks and post term is starting at 42 weeks alright so pediatric milestones it's hard to remember anything like all of it but here are some of the key ones you should try to remember so at two months the baby can lift their head off the ground and Composition and then at four months the baby can roll over at six months the baby can sit up on their own at nine months the baby can crawl or cruise cruising meaning they can kind of get up and walk but they need to use the couch as like a crutch and they're gonna be using the couch to like keep themselves propped up and then at 12 months the baby can use one two three words other than mama dada two years old can has hundreds of words that they know to zeros and two-word phrases at three years old thousands of words three zeros and three word phases at five years old you can dress yourself and write your own name at six years old you can tie your shoes and identify left and right and also remember that in terms of like vision and hearing testing audiometry should start at four years old and same with vision testing it should start around that age as well if a kid is really young and they're cross-eyed you want to make sure that they go to the eye doctor because any early onset of strabismus can cause a kid to be an increased risk for amblyopia which basically means that there whatever eye is not focused is not getting enough stimulation to the visual cortex and this can lead to a blindness so you want to make sure that any kid who has true business or a congenital cataract needs to have vision testing and see an ophthalmologist at six months old the babies can start using toothpaste they can also start visiting the dentist by 1 year old breastfeeding happens exclusively until six months and then you can start introducing solids the first flu shot happens at six months the first live vaccine happens at one years old and that's the MMR vaccine if someone has constantly a runny nose due to allergies the first-line treatment is intra nasal steroids the main side effect of intra nasal steroids you should be aware of as epistaxis because the steroids can cause atrophy of the mucosa which predisposes to bleeding anything of a hemoglobin less than seven needs to be needs transfusion remember this what's the most common cause of folate deficiency alcohol abuse so if someone has acute gastroenteritis with hematochezia aka bloody diarrhea what's the next step stool analysis to check for white blood cells if there are white blood cells present this confirms that it's an inflammatory diarrhoea meanwhile any type of gastroenteritis make sure to rehydrate yeah make sure just to keep them hydrated with oral or IV fluids if they're hypotensive then IV fluids if they're normotensive then you can give oral rehydration therapy which is just glucose and the salt together be aware of the main common culprits of inflammatory diarrhoea and that's Campylobacter yak Salmonella Shigella and Yersinia most of the time these are treated with supportive care and you only give antibiotics if the patient is really young or immunosuppressed or very elderly other than that if you're an immuno competent person you don't want to treat with antibiotics and definitely you don't want to treat the diarrhea with anti diarrheal such as loperamide because that traps in the bacteria and you can make things worse by promoting diarrhea or letting it pass then the patient can excrete out all the bacteria remember one of the main complications is with a hack and Tarot hemorrhagic ecoli if you give someone antibiotics such as the fluoroquinolone this can preusse can progress to hemolytic uremic syndrome which leads to anemia thrombocytopenia and renal failure and you don't want that to happen if it does happen then you would treat it with dialysis if someone has chronic diarrhea means diarrhea lasting for greater than a month then you want to do a stool over and parasite analysis see death is Clostridium difficile it's a type of diarrhea that can happen most likely after taking broad-spectrum antibiotics it's also classically associated with clindamycin use and this to diagnose this um first the clinic science will be diarrhea and abdominal pain after taking antibiotics they might even have fever and leukocytosis what you want to do a toxin a and B analysis of the stool and then if it's confirmed that they have seeded you want to treat with oral vancomycin because if you give it IV it won't have good enough and iteration to the colon so if you give it orally it's more active in the colon so remember the two most common causes of viral watery diarrhea are norovirus and rotavirus these two in the vignette will usually be associated with cruise ships or classrooms so make sure if you see someone who has like a viral watery diarrhea with vomiting and diarrhea with acute onset and they were on a cruise or in areas close to other people such as classrooms this is Nora or rotavirus and the kids should stay home until that illness is resolved also rotavirus is common in the winter for osteoporosis when you do the DEXA scan at 65 years old that result will have a t-score if it's less than negative two point five if it's below that that's diagnosed as osteoporosis between negative one and two point five is considered osteopenia what's the first-line treatment of osteoporosis it's bisphosphonates such as a legend eight all right next is msk injuries so so you're gonna need to know the indications for an x-ray of an ankle when someone rolls it and this follows the Ottawa ankle rules so you want to do an x-ray if there's posterior malleolus tenderness or inability to bear weight immediately after injury any of those two and it's an indication for an x-ray of the ankle so hematuria is remember sometimes it can you can have microscopic hematuria which means it's invisible to the naked eye or proteinuria if this is the first time it's been detected on a urine dipstick then the next step is to repeat the urinalysis but with the repeat this time it should have a microscopic analysis because with the microscopic analysis this can be more specific red blood cell casts or if there are dysmorphic red blood cells so the microscopic analysis can give more information and then one of the key mysteries of your analysis is sometimes you'll have your analysis that has a lot of blood on dipstick but no red blood cells so what is that something that has a lot of blood but no red blood cells is usually a thorough mnemonic for rhabdomyolysis because rhabdomyolysis will have myoglobin which gets released and the myoglobin is detected as blood so for thyroid disorders remember the first line drugs you can use for hyperthyroidism or methimazole and Pokhara Cyril uracil and the main side effect on want you to remember is it can cause a granulocytes as' which means deficiency of granulocytes and remember granulocytes or your base fulfils use in the phils and neutrophils and these will be down and so if the patient a hyper thyroid patient who's being treated with this comes in with a sore throat or signs of infection then the most likely culprit is due to these medications causing a granulocyte OSIS so remember if a patient is pregnant that the thyroid hormone she's taking if she's hypothyroid and she's taking levothyroxine then with pregnancy the levothyroxine dose should be increased because when your estrogen levels are very high the thyroid binding globulin levels increase a lot and this kind of you can think of it as it kind of like sucks up all the ex sucks up all the medication and then binds to it and then basically you're gonna need more I read hormone to replace it and also it's always better for the mom to be a little bit hyperthyroid rather than you theory or hypothyroid because hypothyroidism and pregnancy can cause cretinism which is congenital hypothyroidism and this can be devastating for the kids development so next is a thyroid nodule the next step that you should do is a TSH level and an ultrasound so basically you want to do an ultrasound to assess for the nodule to see how many nodules there are get some information look at it to see if it's cystic or if it looks cancerous and also to measure the size the TSH will help you determine if they're hyper thyroid or youth thyroid if the TSH is low it means they're hyper thyroid most of the times thyroid nodules that are hyper thyroid it came a hot nodule usually they are not malignant but the cold nodules aka the ones that are you --they roid are the ones that are most likely to Fulop malignant so if someone is hyper thyroid with a fire-rate nodule the next step after that is you want to do a radio active iodine uptake and then from there if it's a diffuse uptake this is Graves disease if it is taken up in one area then that's called a toxic adenoma and if it's taken up in multiple patchy areas that's called a multinodular goiter which is multiple toxic adenoma if they have Graves disease then you can treat with pto and methimazole and see if it goes away and if they have a toxic adenomas or multinodular goiter then you can do radioactive iodine therapy which basically ablates the toxic thyroid nodules if there's a cold nodule aka it's not hyper thyroid and the nodule is greater than one centimeter then you wanna do a biopsy of that lesion a fine needle aspiration and to assess to see if it's cancerous or not if it's less than a centimeter then you can follow-up in six months after the biopsy and it's cancerous then the next step is surgical removal for fetal heart rate tracings remember for the fetal heart rate normal as between 110 and 160 if the fetal heart rate is above 160 for fetal tachycardia that means that the mom has an infection if the fetal heart rate is sinusoidal this means that the baby has anemia if the baby has a complete heart block then most likely mom has lupus and then in terms of accelerations you want to know that a good acceleration is a sign that the baby is healthy and to define acceleration as the 15 and 15 to + 20 rule which means if the heart rate raises by 15 and lasts for at least 15 seconds and you see two of those in 20 minutes that means the baby is healthy and it rules out hypoxia a non-stress test which is done when mom feels like there's reduced movement in the baby then you do a non-stress test and that's where you check for accelerations if you don't see any accelerations the 15 for in 15 2 and 20 then you proceed to a biophysical profile which incorporates more elements such as breathing tone movement and like amniotic fluid volume and if the score for that is less than 4 then you want to deliver but for now just remember what an acceleration is if you see 2 and 20 it means that the baby is healthy next is hypercalcemia calcium levels are usually between 8 to 10 anything higher than that is hypercalcemia and this is dangerous because it can lead to arrhythmias or coma it's very important to know what is the first-line treatment for hypercalcemia IV fluids if someone has hyponatremia this is a bit difficult but I'm gonna try and give you a spark note version of hyponatremia what in theory first you should always check tenacity so normal tenacity is 275 to 295 so you can be hypertonic if you're above that isotonic or hypotonic and then the hypertonic ones are usually due to elevated glucose levels and then the isotonic hyponatremia is are usually due to elevated proteins or fat but the hypotonic which is less than 275 is where it gets tricky because it subdivides further into fluid status so you can be hypervolemic euvolemic or hypovolemic hyponatremia you know common differentials for hypervolemic hyponatremia would be like CHF CKD but then for isotonic the two main ones would be primary polydipsia or SIADH and then for hypo bulimic would be like diuretics or vomiting what what I want you to know if someone has hyponatremia and they're hypovolemic without symptoms first-line treatment is normal saline if they have a severe hyponatremia with symptoms and the symptoms of hyponatremia would be like lethargy possibly coma and if sodium level is really low like 120 you want to treat with hypertonic saline 3% if they have euvolemic or hypervolemic hyponatremia the most common one is that you'll see in a question as someone with SIADH then the treatment will be water restriction so that's kind of like a quick sparknotes of what kind of fluid resuscitation you would use hypokalemia and hyperkalemia they both manifest with weakness as their main symptoms and then if the typo Klimek then you want to treat with oral potassium replacement and then for hyperkalemia check the EKG because hyperkalemia can present with EKG changes such as peaked t-waves and a wide QRS if you see that this page can have an arrhythmia at any moment so the first thing you want to give is calcium gluconate which stabilizes the cardiac membranes and then you can also give insulin which pushes potassium into the cell the correct answer with someone with hyperkalemia potassium over five with EKG changes the first thing is calcium gluconate acute bronchitis this is more of a diagnosis by exclusion it's mostly caused by a virus but it's different than other lung pathologies because it usually starts with a runny nose and no fever where's the other dangerous ones like pneumonia and stuff won't really have a runny nose and it's more just like a productive cough and fever so for acute bronchitis if you rule everything else out the treatment is just supportive care then you should know acute otitis media versus otitis externa versus otitis media with effusion so a qø tightness media is an infection of the middle ear and then this on otoscopy will show very puffed out red erythema das angry-looking eardrum and then this is caused by the main three bugs strep pneumo h flu and Moraxella those three are also the main culprits for pneumonia as well and also for bacterial sinusitis as well and for meningitis jab pneumo H flu are also the main culprits for meningitis and then the third one would be Neisseria meningitidis four and then that also has a rash which helps diagnose meningitis but anyways back to the ear pathologies otitis externa is usually associated with swimmers or diabetics and the main bug is Pseudomonas for acute otitis media you want to treat with amoxicillin otitis media with effusion is basically in the middle ear there is fluid bubbles behind the wall and then this is you treat it supportively so then MI there are three drugs you need to remember that decrease mortality and that's ace inhibitors beta blockers and aspirin you want to use ace inhibitors indefinitely because it prevents future ischemic events and left ventricular hypertrophy from remodeling after an mi so the main thing I want to talk about for MI is that if someone has stable angina which means that there's substernal chest pain that's worsened with exertion and relieved with rest and not getting any worse and it's kind of just every time they exercise they feel chest pain and it gets better this is stable angina what you want to do next is exercise stress test which is the exercise EKG if they have contraindications to exercise as a like maybe they've had a hip replacement or they're wheelchair-bound and they can't exercise then you can do a pharmacologic stress test but what is more important is when someone presents with an acute onset of chest pain that's happening right now or that has been getting worse so the first thing you want to do it someone who comes in with chest pain is you want to rule out acute coronary syndrome so the first thing you do is the EKG with troponin and acute coronary syndrome is defined as three different pathologies one is unstable angina the second is n STEMI and the third is STEMI so a STEMI is if you have C St elevations and two continuous leads so the ST segment is raised higher than one millimeter if you see that that's automatically a STEMI you don't even need to wait for the troponin this person goes straight to cath lab or if they have a new left bundle branch block with symptoms of MI they also go straight to cath lab and n STEMI an unstable angina are virtually indistinguishable upon presentation so you need serial troponin to differentiate and you're gonna do the troponin every few hours and what you do is you treat matically first with mona see - so morphine oxygen nitrates aspirin clopidogrel beta blockers ACE inhibitors statin and heparin if the serial troponin is come back elevated then this is an N STEMI if it doesn't then this is most likely unstable angina with these two you will not apply something called a Timmy score if the Timmy score is between zero to two you do a stress test it fits three or more then you want to go to the cath lab how do you apply the Timmy score coronary stenosis greater than 50% age 65 plus two episodes of angina in the last 24 hours three risk factors for cardiovascular disease such as obesity smoking hypertension hyperlipidemia diabetes etc greater than three of those aspirin usage troponin elevation or ast changes between 0 to 2 you're gonna do a stress test three or more they go to the cath lab also the definition of unstable angina you should know that it's considered chest pain that's been evolving worsening or occurs at rest coz stable angina when they're at rest they don't have chest pain but someone with unstable angina even at rest it'll hurt or the symptoms seem to be worsening unstable angina or NSTEMI apply the Timmy score STEMI doesn't need a Timmy score straight to cath lab so I hope that helps CKD what is the most likely cause of death from CKD cardiovascular causes what about for rheumatoid arthritis it's also cardiovascular causes because rheumatoid arthritis accelerates atherosclerosis CKD blood pressure goals is less than 140 over 90 women with diabetes mellitus are associated with getting candidiasis or vaginal yeast infections and you treat those with easels remember anyone who has asymptomatic vaginosis and a prank woman so vaginosis is gardnerella then you want to treat that with metronidazole because if it's left untreated it can lead to preterm delivery anyone who uses antibiotics and then has vaginal discharge afterwards think of Candida I kind of think of it as like the sea death of the vaginal infections for GI bleeding hematochezia if they're stable the first step is colonoscopy if they're unstable you want to give IV fluids and you wanna do an EGD because majority of those are from the upper GI for diverticulitis you treat it with fluoroquinolones and metronidazole diverticulitis will present that with left lower quadrant pain a history of constipation with fever and leukocytosis it's diagnosed by CT of the abdomen ulcerative colitis remember there's some key associations it's associated with colon cancer it also can cause toxic megacolon and it's also associated with primary sclerosing cholangitis this is very high yield an older person who presents with the microcytic anemia which means the MCV is less than 80 and they're anemic which means the human globin is less than 14 and males are less than 12 and females the next debt is colonoscopy this is huge make sure you remember this why do you do the colonoscopy because you want to rule out cancer rust-colored sputum is associated with strep pneumo Legionella is pneumonia plus diarrhea plus hyponatremia and it's associated with elderly smokers who hang out in areas with dirty air conditioning machines or areas with contaminated sources of water inpatient pneumonia is treated with a fluoroquinolone a healthy person who is treated with pneumonia outpatient for typical pneumonia is treated with amoxicillin for outpatient atypical pneumonia the first line is a macrolide like a zero Meissen the difference betwee typical and atypical pneumonia is based on chest x-ray findings a typical pneumonia will have low bar consolidation whereas a typical who have interstitial infiltrates the most common typical pneumonias are strep pneumo h flu and maxilla and the most common atypical pneumonia are mycoplasma chlamydia and Legionella how do you decide whether to admit someone to the inpatient hospital for pneumonia is supplied the curb 65 criteria confusion uremia respiratory rate that's tachypnic blood pressure that's hypotensive and age greater than 65 if they have true or greater of this then you want to admit them to the hospital to diagnose depression MC deep caps mood sleep insomnia guilt energy concentration appetite changes psychomotor changes and suicidality if they have 5 of the 9 symptoms greater than 2 weeks then you want to start them first-line on an SSRI and remember that it takes four to six weeks for SSRIs to start working so if they come in early and they haven't noticed changes yet tell them to hang in there be patient before it starts working and then if they start feeling better to continue it for at least nine months because you don't want to risk them going back into depression so you keep treating for at least nine months and then reassess later to see if you can wean off the antidepressants remember that people who have MI or strokes and have depression after that are three times more likely to die after giving birth the endometrium will keep shedding and this is called lochia and it's normal to see vaginal bleeding with lochia for at least a month contraindications to breastfeeding or HIV and chemotherapy mastitis is where you see erythema over the breast it can also look like cellulitis the first-line treatment is dicloxacillin this is due to cracks in the nipple and when the baby feeds oral bacteria infiltrates the cracks in the skin and then an abscess can also look like mastitis but on palpation there's fluctuant which means that it feels like there's fluid underneath and that's treated with antibiotics and incision and drainage breastfeeding happens from birth till six months exclusively and it benefits the baby a lot and prevents it from having infections and allergies later on in life and also it's good for the mom and reduces the chances of mom getting certain cancers CHF there's four types of heart failure based on the New York Heart Association class one two three and four so one is if there's no symptoms two is if their symptoms with activity three if there's no symptoms only when they're at rest and four is when there's symptoms at rest depending on each class you want to treat with different drugs and add different drugs so first class one it's an ACE inhibitor for class 2 you want to add a beta blocker for class three you add a diuretics such as spironolactone and class four is where you can add drugs that increase contractility and inotropy such as digoxin remember there are three heart failure drugs that can improve mortality and that's an ACE inhibitor a beta blocker and Sparano lactone which is a potassium sparing diuretic so CHF is diagnosed on echocardiogram if someone has a CHF exacerbation which means they're suddenly having a Q onset of shortness of breath with pulmonary edema the first-line treatment is furiosa mite which is a loop diuretic and that'll help alleviate a blood pressure and that will help drain out some of the fluid out of the lungs CHF usually presents with paroxysmal nocturnal dyspnea or orthopnea and that means when they lie down they feel like they have difficulty breathing OC peas are contraindicate in migraines with aura smokers or at 35 years or older because estrogens can increase the risk of DVT MI PE and stroke and it's prothrombotic it's contraindicated in these patient populations because it increases the risk of complications remember that OCPs protect against ovarian cancer endometrial cancer but it has a slight increased risk of breast cancer and then the copper IUD is the most effective form of emergency contraception and can be used with them five days of intercourse however its main side effect as man or Asha so it's contraindicated in patients who have many rajah first-line for hypertension or a calcium channel blockers ACE inhibitors and thighs Ides in african-americans you want to avoid ACE inhibitors as first-line so you want to use thighs Ides or calcium channel blockers because african-americans are predisposed to angioedema because ACE inhibitors prevent the breakdown of bradykinin and Brady kinase are similar to histamine which can cause angioedema anyone who has proteinuria the first line is ace inhibitors because ACE inhibitors remember they cause vasodilation of the afferent arteriole and this reduces pressure on the glomerulus and decreases the GFR which is protective and it's not so hard on the clam areolar unit hypertension is considered anything greater than 140 over 90 on three consecutive visits this is an indication for starting antihypertensives and if the blood pressure is not reached to the target goal which is under 140 over 90 after one month then you can increase the dose or add a second drug intussusception which is caused by telescoping of the ileum into the cecum and then this can cause irritation to the mucosa and possibly ischemia and this causes the mucosa to slough off and that produces currant jelly stools and colicky pain so and it'll most likely be in the right lower quadrant with intermittent abdominal pain the next up you want to do is an abdominal x-ray to rule out per for Asian intussusception is treated with an air enema versus a med got volvulus the mid got volvulus is an embryonic pathology where if you remember during embryology the intestines don't rotate counter-clockwise 270 degrees and it twists around the SMA improperly so basically the cecum is on the right upper quadrant and this predisposes to to twisting around the SMA and this causes a small bowel obstruction so the kid will present with bilious vomiting and constant abdominal pain versus intussusception which has colicky abdominal pain first thing you want to do is an abdominal x-ray to rule out / for a shin and then when you see that it's once you've ruled out perforation then the next thing you want to do is an upper GI series which is an x-ray with a barium swallow and it visualizes the esophagus stomach and duodenum what you'll see is a double bubble sign with some fluid after the double bubble or something called the corkscrew Simon jejunal atresia is caused by a vascular accident in utero mostly associated with maternal cocaine use and you'll see the triple bobl syín the double bubble sign is associated with Down's syndrome which is due to the duodenum failing to wreak analyze pneumomediastinum is something that you would see in esophageal perforation most commonly Boerhaave syndrome which is perforation of the Safa gas and it's most commonly caused by endoscopic procedures for Hubbs will present with pneumomediastinum on chest x-ray but also this patient will have fever and crepitus on palpation of the skin and you want to diagnose this with gastrografin swallow which will show the water soluble dye extravasated out of the esophagus and you don't want to do an endoscopy because this can make it worse once poor Hobbs is diagnosed then you treat it surgically so just to summarize constant abdominal pain you should think of midgut volvulus and colicky pain think of intussusception remember intussusception also has a couple associations and one is henoch-schonlein purpura can predispose to it and the second one the rotavirus vaccine is contraindicated and kids who have had interception in the past so with dementia make sure before you diagnose dementia to always rule out hypothyroidism or b12 deficiency first make sure you rule out all the reversible causes before you make the diagnosis first-line treatment for weight loss is lifestyle modifications such as diet and exercise and if that doesn't work then you can progress to orlistat and PCOS you can give metformin to help with weight loss bariatric surgery is indicated in patients who have a BMI of greater than 40 or a BMI of greater than 35 with comorbidities remember that after bariatric surgery certain complications or stole most enosis or dumping syndrome which is basically the food is transiting through the stomach too quickly and not being absorbed fast enough and this can cause diarrhea to treat it you want to eat small meals with high-protein migraine headache remember the pound's criteria pulsatile one day duration unilateral nausea and vomiting and debilitating but red flags for headaches would be a headache that's getting worse a headache that increases with valsalva or exercise or a headache that was associated with recent head trauma or a headache that awakens you from sleep other than that then you can diagnose a migraine headache first-line treatment for migraine headache is more conservative like getting exercise getting good sleep less caffeine less alcohol and erm but if it's a severe or refractory migraine then you want to give sumatriptan which is a serotonin agonist and then for migraine prophylaxis you can give beta blockers or TCAs so the next is very high yield is knowing what are the four types of patients that get statin therapy and so the first does any patient at all who has the LDL greater than 190 gets a statin any patient with a SC VD aka atherosclerosis Collor disease those who have peripheral artery disease or coronary artery disease will also get a statin any patients older than 40 with diabetes and LDL greater than 70 also gets a statin and any patients with the CVD risk greater than 7.5% with the LDL greater than 70 also gets a statin so those are the four patients that get us ten little things to also memorize are that niacin niacin is best at increasing HDL and fibrates are veste decreasing triglycerides but you don't really use any of those as first-line you might use a vibrate if the triglycerides are over a thousand and remember that super high triglycerides are associated with pancreatitis but the most common causes of pancreatitis are call stones and alcohol use so in terms of abuse any kid who has bruises on the thigh on the buttocks on the cheeks and varying ages you should suspect abuse posterior rib fractures or metaphyseal fractures are also suspicious for abuse and spiral fractures if you suspect child abuse try to talk to the child alone without the parents present and if you really suspect abuse then what you should do is separate the kid from their parents and admit them to the hospital for further workup and some of the further workup things you can do our fund escapee to look for retinol have ridges you can do a bones there survey to check for more fractures and you can also call Child Protective Services so hip conditions you should know the difference between Skippy and Lake a vapor theis disease versus septic arthritis versus transient synovitis so skip via slips capital femoral epiphysis and this is usually in an obese eleven-year-old and this is where the epiphysis has slipped off though you usually show you an x-ray photo and if you see that it slipped off they'll usually ask you what to do next and that's treated with surgical pinning versus leg calve a Perthes disease which is idiopathic avascular necrosis of the hip and this is just treated conservatively it's usually in a younger like six year old who's more skinny and then septic arthritis is a very hot and swollen red joint where the patient can't even bare anyway on it won't move it at all and it hurts a lot and the first thing you want to do is aspirate that joint the most common bugs are staph aureus and strep pyogenes the favorite test is a way to assess for ankylosing spondylitis it irritates the sacroiliac joint Faber stands for flexion abduction and external rotation and this is a way to but if you suspect ankylosing spondylitis on the Faber test the next step would be to do a lumbar and sacral x-ray which will show the bamboo patterning malignant hyperthermia is caused by calcium accumulating in the muscles due to Halo theme or succinylcholine and the treatment is supportive or dantrolene this should be contrasted with neuroleptic malignant syndrome and serotonin syndrome which also present with fever and rigidity but serotonin syndrome would be seen in a patient who's been taking antidepressants and neuroleptic malignant syndrome would be seen in a patient who's taking antipsychotics whereas malignant hyperthermia would be seen in a patient who just went under anesthesia aspiration pneumonia people who are at risk for this are people who can't really control their swallow or gag reflex so it would be like people who have had seizures people with dementia people who have had strokes people who are alcoholics and lose consciousness a lot or people who are mechanically ventilated these people are more likely to get aspiration pneumonia and what you'll see is inflict rates on the right lower lobe that can progress to abscesses which will show air fluid levels and you want to cover for anaerobes so you treat this with the so sin which is piperacillin Tazo back TM or clindamycin clindamycin covers and robes there's a little trick is that clindamycin covers anaerobes above the diaphragm and metronidazole covers anaerobes below the diaphragm DVT is when you have a deep venous thrombosis it'll present with a very tender and swollen calf and then if you suspect DVT the first thing you should do is start heparin and then bridge to warfarin this can also be treated with factor 10a blockers like rivaroxaban if there's a surgical site infection the skin around the sutures will be very red and err feminist and the patient will have fever and signs of infection and what you want to do is open the wound clean it out and let it drain and give antibiotics respiratory syncytial virus is one of the most common pediatric respiratory diseases and it's usually in kids less than two years old and it starts with upper respiratory symptoms such as nasal congestion and it progresses to wheezing and Eickhoff and the treatment here is supportive for adults normal breathing is anywhere between 12 and 20 breaths per minute but for kids less than two years old anything greater than 40 breaths per minute is to keep me up epiglottitis you should definitely know caused by H flu and it's vaccine preventible the kid will usually be drooling and having difficulty breathing and they'll assume the tripod form where they lean over with their palms on their knees to breathe better and stick they'll also stick their tongue out and the first thing you want to do is intubate that'll usually be the right answer and then croup is caused by para influenza virus this will present with the barking cough and Strider and you want to treat this with corticosteroids or nebulized epinephrine or what they call racemic epinephrine if the child has Strider at rest with respiratory distress so then sometimes croup can advance to something called bacterial tracheitis where their secretions start having more phlegm they start getting posi secretions at this point it's life-threatening and you want to intubate them and the bug is most likely staph aureus peritonsillar abscess is what you look for is the deviated uvula and difficulty swallowing also they will have a muffled voice fever and leukocytosis what you want to do is IMD and give antibiotics irritable bowel syndrome just thank alternating constipation with diarrhea and improvement after going to the bathroom if it's diarrhea predominant you can shoot with loperamide if it's constipation predominant then you can increase vibrant take this should be contrasted with celiac disease which happens in younger patients who will have diarrhea abdominal pain and weight loss but their diarrhea will be bulky greasy stools and this is due to malabsorption at the duodenum due to villous atrophy and this is a reaction to gluten so they'll have anti tissue transglutaminase anti and domicile or anti-gliadin antibodies and you want to treat this by avoiding gluten so remember that someone who comes with a cocaine overdose or cocaine toxicity with chest pain you don't want to give a beta-blocker because in theory this can cause unopposed alpha vasoconstriction which can cause an mi so the first thing you want to do with cocaine toxicity even with chest pain is IV benzodiazepines like lorazepam people who want to quit drinking alcohol the first-line drugs are a campers say and naltrexone first-line for quitting smoking would be a nicotine patch and nicotine gum and then the next line would be be appropriate or varenicline and tachycardia you can have a super ventricular tachycardia or ventricular tachycardia so super ventricular tachycardia happens above the AV node and ventricular happens below the AV node and on EKG the super ventricular tachycardias you'll just the QRS T qrst qrst and that QRS complexes are very narrow if they're stable first line is adenosine and if they're unstable then this cardioversion for a few tak what you'll see is just repeated QRS complexes but they look a little bit abnormal they look kind of like upside-down used and the QRS is will be really wide so the stable patient will get amiodarone if they're unstable then you want to also cardiovert high-yield whites you must know between cat bite a dog bite and human bite so a cat bite a deep puncture wound it'll most likely be Pasteurella same with the dog bite and you treat these with augmentin whereas a human bite is usually multi bacterial and it's usually the Hasek organisms like eikenella and you also treat this with augmentin and also people who have human bites should get Hep B and HIV prophylaxis the difference between T ia and ischemic stroke is T ia has symptoms that are resolved within 24 hours whereas stroke the symptoms do not resolve after 24 hours and still remain and stroke can be sub 2 into ischemic or hemorrhagic the majority of strokes are ischemic whereas the minority are hemorrhagic it's like 85% to 15% the greatest risk factor for stroke is hypertension so make sure you remember that you always give TPA within four and a half hours of the stroke so the first thing you want to do with suspected stroke is a head CT without contrast this is to rule out hemorrhage if they don't have hemorrhage then you proceed with TPA if they do have hemorrhage then this changes your management and you treat hemorrhagic stroke by maintaining blood pressure and keeping it lower so that they don't bleed out more and the first type of hypertensive drug you want to use is a calcium channel blocker like nifedipine after you treat the stroke then the next thing you want to do is look for the source so the three things you want to order or EKG and echo and carotid Doppler the carotid Doppler will look for atherosclerosis of the carotid arteries or any narrowing and this can shoot emboli up into the brain on the echo is test assessed for possible heart failure and it'll also look for thrombi and EKG is to assess for any or as Mia's or it possible mi which caused the stroke if you if you see that there is to no SACEUR the carotid artery greater than 70 percent the correct answer the next thing you want to do is a carotid endarterectomy HIV is a cd4 deficiency due to the HIV virus what once it becomes below 200 this is called AIDS and at 200 this is when you start with prophylaxis and you want to prevent p0 Veggie pneumonia and you treat this with TMP SMX if you don't then they could get p0 of matchin pneumonia which prevents with fever dry cough and interstitial infiltrates HIV the prodrome when you first get HIV it can present a lot like mono with the fever sore throat and malaise on top of that this patient will also have a rash and then at CD 450 you want to give Mac prophylaxis which is prophylaxis against Mycobacterium avium complex and you prophylaxis as a thorough Mason if they talk about ring enhancing lesions on the brain imaging think of primary CNS lymphoma which is seen in AIDS or Toxoplasma or a brain abscess but a brain abscess can happen in healthy individuals who have infections on the face like bacterial sinusitis or any type of sinus infection that can invade the brain what's the pathophysiology for palmar erythema / spider angiomas and people with liver disease such as cirrhosis well once you have cirrhosis your liver can't break down estrogen and these increased estrogen levels dilate the blood vessels and that leads to spider angiomas remember that if you have bilirubin urea bilirubin in the urine can only be found in its conjugated form you cannot urinate unconjugated bilirubin hyperbilirubinemia is anything greater than one if the direct portion is greater than 20% and this is called direct hyperbilirubinemia or conjugated hyperbilirubinemia below that is unconjugated or indirect hyperbilirubinemia they're both they both mean the same things anyone with painless jaundice that's a sign of pancreatic cancer the most common causes of ulcers are h pylori or NSAIDs if someone comes in with symptoms of GERD or gastritis or heartburn you can start them with empiric proton pump inhibitors but if they're from a foreign country where H pylori is endemic then you can start with the h pylori test but if they're from the United States then you start with a proton pump inhibitor and see if it gets better if it doesn't get better then you can test for h pylori or do an endoscopy patients with symptoms of GERD gastritis heartburn if they have alarm symptoms which means they've had dysphasia or a microcytic anemia which suggests chronic bleeding or weight loss these are called alarm symptoms and in that case you proceed with endoscopy to look for a possible cancer people often mix up spicy foods pausing ulcers but that's not true why C foods can make heartburn and indigestion worse and symptoms of GERD worse because the spiciness can irritate the lower esophageal sphincter and people might think that that is causing all sirs because the symptoms are similar but it doesn't cause ulcers it just exacerbates heartburn or indigestion but any sets and h pylori can definitely cause ulcers and remember in an old diabetic woman if she complains of upper abdominal pain this can be an atypical sign of a heart attack so you need an EKG chronic proton pump inhibitor use is also linked with CF and osteoporosis in the kid who is less than 30 days old with a fever you should suspect either meningitis or pneumonia and in this case you'll treat empirically with ampicillin and gentamicin and you should know what are the most common bugs for neonates and that's Group B Strep u coli and Listeria in adults the most common causes of meningitis or strata pneumo h flu and Neisseria meningitidis and you would treat them empirically with ceftriaxone and vancomycin so you need to know that small pox vs. chicken pox they can both have papules that show up but smallpox has the same stage of development all across the skin whereas chickenpox has successive crops of vesicles and papules that are of different ages and some will be new and some will be oscar ated and you need to know the difference between measles and rubella measles is also known as Ruby Ola and rubella is also known as German measles they present very similarly they both start with the rash that starts on the head and progresses down to the lower extremities but the differences are that measles has the four C's Kafka Raisa complex pots and conjunctivitis whereas rubella does not have the four C's and it has arthralgias both are vaccine preventable through MMR measles can progress to pneumonia or sspe subacute sclerosing pan encephalitis which is a brain infection that happens 10 years later and you treat it with vitamin b6 you need to know the difference between roseola and parvovirus roseola is fever that breaks what ends and men are rash follows whereas parvo virus is a slap cheek with the lacy reticular rash remember that if a pregnant mom gets parvo virus that the kid the fetus is predisposed to hydrops fetalis so for breast masses if the female is under 30 years old the next best step is ultrasound if it's over 30 years old then the next best step is mammogram and then any breast mass always has to be biopsied regardless of the imaging results on a unilateral nipple bleeding is suggestive of intraductal papillary and you should do a mammogram for that and remember mammogram screenings happen age 40 every year if there's a breast cysts you want to aspirate it and drain the fluid if it's yellow and completely drains then you follow-up in a month if not then you're gonna biopsy if the fluid is bloody make sure to send to a cytology PCOS the first lab test is a pregnancy test remember PCOS is characterized by an ovulation hirsutism and obesity and on ultrasound there'll be multiple cystic follicles of the ovary and if they are having problems with getting pregnant the first thing you want to suggest is weight loss and then hopefully weight loss will get their periods to normalize so diabetes is diagnosed by a fasting glucose of over 126 a random glucose of 200 plus with symptoms such as polyuria polydipsia polyphagia dehydration weight loss or a hemoglobin a1c of 6.5 what is considered controlled diabetes that's if the blood pressure is under 140 over 90 if the a1c is less than seven and if the cholesterol is less than 100 particularly the LDL remember that metformin is contraindicated in kidneys disease and CHF because it can cause lactic acidosis so in terms of low back pain majority of causes of low back pain or muscle strain but some red flags of low back pain would be night pain that's unrelenting which is suggestive of cancer pain at rest or six plus weeks know what the difference between disc herniation versus spinal stenosis they kind of have opposite presentations or desk herniation is worsened with any valsalva types of maneuvers like sneezing or coughing and it's improved with extension of the back like lying down but worsened with a bending forward and it will cause pain that radiates down the leg whereas spinal stenosis is actually better with flexion and worsened with extension and sometimes in vignettes they won't really say it so directly they'll say it and directly like a patient might feel better when they walk uphill but feel worse when they walk downhill and that is an indirect way of saying that the pain is worse with extension and then there's cauda equina syndrome which is when you have damage to the cauda equina and this presents with bowel incontinence urinary incontinence paresthesias around the perianal area and the legs and possibly paralysis and the next best step is to do an MRI and get ready for surgery and also a herniated disc is diagnosed clinically and you treat it conservatively with NSAIDs and Tylenol for one month and then if there's no improvement then you proceed with imaging such as an MRI and remember anyone who presents with lumbar muscle strain it's never the right answer to suggest bed rest it's always better to increase exercise and movement to keep yourself loose essential tremor is a tremor that increases with movement and is better at rest and it's treated with propanolol and it usually runs in the family also it improves with drinking alcohol Tourette's is treated with clonidine or guanfacine which are alpha-2 agonist or atypical antipsychotic remember this person needs to have a motor and vocal tic for greater than a year Huntington disease is the autosomal dominant disease on chromosome 4 it runs in the family and that causes early onset dementia with movement disorders and it's treated with Tetra benzene asthma comes in four flavors intermittent mild moderate and severe the intermittent is less than two days a week mild is three to seven days a week moderate is everyday and severe is multiple times a day and the intermittent you just treat with albuterol PRN but mild then you add a low dose steroid moderate you add a medium dose steroid and severe you add a high dose steroid to diagnosed asthma you will do a medically intest which is a muscarinic agonist and it narrows the bronchioles which exacerbates the asthma symptoms which helps with diagnosis remember Accu exacerbation of asthma and COPD have similar treatments with some differences so they both get oxygen and they both get IV or oral steroids like systemic steroids and bronchodilators but exacerbation of COPD you want to give antibiotics and you want to cover for COPD for Pseudomonas and you want to give them fluoroquinolone a patient with obstructive sleep apnea definitely in the vignette look at the PMI it'll be over 30 plus this person snores a lot at night with multiple episodes where they wake up in the middle of the night with problems breathing and throughout the day they feel very tired and when they wake up they don't feel like at rest and they might have headaches and lethargy and low-energy and possibly some signs of mood changes and then so if you suspect obstructive sleep apnea the next best step is a sleep study and you treat it with the CPAP remember that obstructive sleep apnea untreated can cause right-sided heart failure due to hypoxemic vasoconstriction of the pulmonary arteries osteoporosis the first-line treatment as bisphosphonates the greatest risk factor for osteoporosis is age also the greatest risk factor for breast cancer is also age so make sure you know what are the greatest risk factors like on the back of your hand cuz they like to ask these things like what's the greatest risk factor for stroke hypertension what is the first-line analgesic for cancer patients opioids what is the first language analgesic for people who have sickle cell crisis it is also opioids studies have shown that people underestimate the pain of sickle cell crisis chronic venous insufficiency look for the medial malleolus ulcer and then versus CHF can also have pitting edema of the lower bilateral lower extremities but in CHF it'll also include ascites and jvd and signs of heart failure such as pulmonary deema and possibly some heart murmurs no the different ear diseases like benign paroxysmal positional vertigo versus Meniere's disease versus vestibular neuritis which is also known as acute labyrinthitis so BPPV this is worse with random movements of the head like getting up from the bed it's exacerbated by random movements and you want to do the Dix Hall Pike maneuver to treat it which helps get the little stones in the semicircular canals out Meniere's disease has the triad of tinnitus hearing loss and vertigo and this is due to increased pressure in the endolymph and you treat it with diuretics and then vestibular neuritis is this is hearing loss and vertigo but it follows a viral upper respiratory tract infection an umbilical hernia self resolves the answer is usually reassure the parent unless it's over five years old then you do surgery but most of the time the correct answer is reassured remember on colon cancer screening if you find a polyp and you remove it the next time to follow-up is three years remember the most dangerous type of polyp is the villus polyp because it sounds like a villain and that's basically it for a family medicine so I hope that was helpful and yeah enjoy your studies and we'll see you in the next one