Final Similar to the case questions at the end; some questions about facts Questions are pretty long; 100 questions in 3 hours Thursday before end of rotation; may have to go to clinic next morning depending on site 1. 2. 3. ● ● ● ● PHQ-2 has sensitivity of 96% and specificity of 70%; what does this mean ● It is a good screening tool for depression —> negative rules you out ● I think it is that 30% of depressed patients will answer the questions negatively ● PHQ2 questions: over the past 2 weeks have you 1) had little interest or pleasure in doing things 2) been feeling down, depressed or hopeless? ● If PHQ2 is positive then perform PHQ9 Question about the target heart range: know equation Target heart range= (220-age) * 0.7-0.8 Question about routine vaccines for a 9-month-old who is up to date Inactivated influenza 3rd dose of IPV if didn’t receive at 6 mos 3rd dose Hep B if didn’t receive at 6 mos 4. Question about woman on ACE inhibitor, aspirin, Ca channel blocker, beta blocker, and statin who wants to get rid of one, which one is safest to eliminate? ● Aspirin? It’s just cardioprotective whereas the other meds have a real purpose 5. Question about how to increase HDL ● Estrogen ● Mediterranean diet ● Diet & exercise ● Fibrates 6. Questions about diagnosis of knee pain and shoulder pain; gives range of motion measurements Knee Exam ● Lachman’s test: ACL stability ● Drawer sign: ACL (anterior) or PCL (posterior) integrity ● Valgus stress: MCL ● Varus stress: LCL ● McMurray: lateral meniscus (internal tibial rotation), medial meniscus (external tibial rotation) Shoulder Exam ROM ● Cervical spine ROM: evaluate for cervical pathology ● Active ROM shoulder: allows patient to show you what they can do without pain on their own ● Passive ROM shoulder: you are moving their arm for them and they tell you when they have pain ● Joint issue —> loss of active & passive ROM ● Muscle issue —> loss of active ROM Shoulder Exam Strength ● Empty Can or Jobes Test —> Strength of muscles surrounding shoulder ● Isolate each rotator cuff muscle —> resist internal (subscapularis) and external (infraspinatous/teres minor) rotation ● Push against wall —> winged scapula Shoulder Maneuvers ● Impingement test —> Neer, Hawkins Kennedy ● Stability testing ● Apprehension test ● Relocation test ● Speed’s test ● Yergason’s test ● Clunk test ● O Brien Test ● SLAP test 7. Preventative medicine type questions; person of certain age and past medical procedures; sometimes seemed like there were 2 possible right answers Screenings ● Colorectal Cancer: 50 - 75 yo ● Elevated BP: 18yo + ● Depression: 18 yo + ● Mammography: 50-74 yo, can do before 50 if high risk ● AAA: men 65-75 yo w/ hx of smoking ● Lipid panel: women 45 yo + w/ increased risk CAD ● T2DM: 40-70 yo who are overweight or obese ● Cervical cancer: 21-65 yo ● Lung Cancer: 55-80 yo w/ 30 pack yr smoking hx or have quit within 15 yrs Vaccines ● Tdap: 11-_ yo should get the shot, booster every 10yrs ● Pneumococcal 23: once prior to 65 yo, once again at 65 yo ● Influenza: annually everyone ● Zoster: 60yo +, Shingrix one dose CHD Prevention ● Daily Aspirin (low dose): prevents CVD & Colorectal cancer, 50-59 yo with 10%+ ASCVD risk and life expectancy of at least 10 yrs , 60-60 yo with 10%+ ASCVD risk ● 8. Know reasons why a person needs an x ray for ankle injury ● Ottawa Ankle rules are how you determine to do Xray or not ● 9. Know the 4 Ps related to helping distinguish chest pain a. Pleuritic, pulsating, positional, reproduced by palpation-> lower likelihood that the pain is due to ACS. also stabbing quality 10. Question about person with new onset dizziness, what type of imaging to do a. MRI 11. Question about interpretation of Dix-Hallpike maneuver – for vertigo dx ● Dix Hallpike: turn head 45 degrees then lean them back so head is extended over table, otolith that was dislodged should re-enter semicircular canal causing reproduction of the vertigo sx & nystagmus (positive test) ● Rx: meclizine, Epley Maneuver ● 12. Questions about components of SPIKES; Guy has one procedure and wants to know all information. During imaging, they find a renal tumor. Suspecting cancer, doc tells him everything that will happen step by step—go see other doc, tx for kidney thing, other tx for first problem, come back and see me, etc. Then at the end, only asks patient if that sounds good. a. I think it was the emotional component 13. Criteria for when to do strep rapid test ● Centor criteria: tonsillar exudate, tender anterior cervical lymphadenopathy, fever, and absence of cough. Each presents gets a 1; >3 is increased likelihood that they have strep throat. 14. Question about woman with black “mole” for 7 years, no itching, regular borders; what is the most concerning characteristic? ● ABCDE’s: asymmetry, border irregularity, color non-uniform, diameter >6mm, evolution, enlargement, or elevation over time. Enlargement is the most specific metric for metastatic melanoma, while diameter is the most sensitive. ● Depth of invasion is the most important risk factor for melanoma ● Nevi larger than 6 mm in diameter are more likely to be malignant than smaller nevi 15. Procedure to remove 1 cm skin lesion a. Biopsy, not Mohs because it is too small: Pts w/ nonmelanomatous skin cancer > 2 cm, lesions w/ indistinct margins, recurrent lesions, and those close to important structures [eyes, nose, mouth ] should be considered for referral for complete excision via Mohs micrographic surgery w/ possible plastic repair ● Surgical Excision is used for well defined <2cm lesions ● An Excisional Biopsy can be done as diagnostic and therapeutic technique 16. Young guy who is ginger and pale skin; gets sunburnt a lot, has lots of freckles; what to do for him? Dad had melanoma on his arm a. Educate: SPF 15 + , wide brim hat, shade as much as possible, tightly woven clothes, reapply sunscreen every 2-3hrs and after swimming 17. Question about childhood milestones; standing on one foot 8-10 seconds, writes name, knows 4 colors, draws person with 6 parts lots of stuff, but asks minimum age that child can do all the things listed. a. Answer choices were like 4, 5, 6, 7, or 8, so not easy to distinguish 18. Question about teen girl whose LMP was 3 weeks ago but was light; urine pregnancy test was negative last week; what test to do? a. Quantitative serum test v. qualitative v. urine 19. Asthma tx, already has albuterol a. Low Dose Inhaled Corticosteroid 20. Asthma symptoms severity a. Moderate persistent, mild persistent, etc. 21. T x for baby with colic a. No rx proven to work , continue breastfeeding 22. 11 year old male with pain that comes rapidly and wakes him up in the night; testicle is tender to palpation, no problems urinating a. Testicular torsion, emergency 23. EKG reading a. I thought it was irregular sinus rhythm… was definitely irregular, but thought there was some T wave elevation 24. Person with vision problems, high TSH and high T4 a. Pituitary tumor 25. Question about RUQ pain; pt had constipation right before; palpation caused pain in the region: positive Murphy sign [palpating liver while patient inhales; cessation of breathing is a + sign] is indicative of gall bladder pathology [cholecystitis] a. I think it was constipation 26. Kid that only drinks like 6-8 glasses of 2% milk a day; doesn’t like fruits and veggies; what might be a problem to address? a. Either the answer was anemia or it was nutritional assessment ● Drinking more than 24oz cow milk per day can lead to iron deficiency anemia ● Anemia screening done at 1 yo, Preschool entry, Kindergarten entry 27. One question about diabetic woman with pretty good A1C, but now foot tenderness; what should be next step ● Serum B12 —> can be low in patients on Metformin ● Foot exam to ensure no ulcer, Monofilament test ● Labs for Diabetic: HbA1c, finger stick glucose (if complaining of hyper or hypoglycemia sx), serum Cr, GFR, urine album:Cr, serum B12, lipid panel 28. Question about man who hurt his back while lifting; has decreased foot sensation, decreased Achilles reflex, & problems walking on toes (plantar flexion). ● S1 nerve root irritation ● Most common causes of back pain: 1) lumbar strain, 2) degenerative joint disease, 3) herniated disc 29. Question about what is suggestive of a disc herniation ● worse when sitting or bending ● better with standing & lying supine ● pain that shoots down the leg ● Paresthesias ● Muscle weakness (foot drop) ● Increased pain with coughing or sneezing ● Crossed leg raise test: raise asymptomatic leg, test is positive if pain increased in contralateral leg 30. Tx for a woman with sx like rheumatoid arthritis ● Colchicine or Ibuprofen 800? ● RA Rx: Exercise/PT, NSAIDs, low dose Corticosteroids, DMARDs (Methotrexate, Leflunomide, Hydroxychloroquine, Sulfasalazine) 31. Question about woman with gallbladder attack, received fluids and pain meds and observed; now not in pain; what is best next step? a. Expectant management or surgery or ursodiol ● Biliary colic —> expectant management ● Ursodiol is for dissolving gallstones and preventing future gallstones ● Cholecystectomy for cholecystitis 32. Question about the differences in women who use family med or OB for pregnancy care a. I think it was either “only trained OB should do a c-section” or “women who see OB instead of family end up having more c-sections” 33. Importance of EMR a. Maybe something about easily being able to transfer information to other providers 34. What is the reason for having a doula for a single pregnant person a. I think it was patient safety i. Other options were like ask for appropriate amount of pain meds 35. Kid with sx like strep or pertussis; what imaging would provide enough info for diagnosis a. X-ray : thumbprint sign? Epiglottitis 36. Different types of headaches ● Tension ● Migraine ● Cluster ● ● ● ● ● ● Medication overuse (analgesics) Meningitis Intracranial hemorrhage Brain tumor Traumatic brain injury ● 37. Tx for lady with occipital headache; ibuprofen provides some relief; what tx? a. I think increase ibuprofen dose ● Migraine: triptans, ergots, excedrin (acetaminophen/asa/caffeine), bubalbital, opioids ● Tension: ibuprofen, acetamenophen ● Cluster: ? 38. Questions about chest pain (seemed to be indicating anxiety) 39. Question about man with delirium, asks what is the cause a. Post residual volume was 400ml —> urinary obstruction 40. Question about man with dementia who is having delirium, no changes in urination, took Benadryl for allergy stuff, what is cause a. Diphenhydramine effect (remember Beer’s criteria) 41. Question about man who has been showing depressive sx after wife died. Has lasted 1.5 years; what tx? a. SSRI 42. Person with depression who doesn’t want medication a. CBT 43. Question about sx of baby who is small for gestational age a. Hypoglycemia ● Risks for SGA newborns: 1) Hypoglycemia —> poor feeding & listlessness, 2) Hypothermia —> poor feeding & listlessness, 3) Polycythemia —> ruddy skin & respiratory distress 44. APGAR score for emergency birth a. I think it was 3; Pulse was good, was breathing, everything else was bad ● Appearance, Pulse, Grimace, Activity, Respirations ● Score < 7 at 5 min —> continued resuscitation w/ re-assessment every 5 min up to 20 min 45. 46. 47. 48. ● NO BIRTH DATE CALCULATIONS NO DOMESTIC ABUSE STUFF NO ELDER ABUSE NO QUESTIONS ABOUT FETAL HEART RATE 49. Question about 50+ woman whose grandmother was diagnosed with breast cancer recently, drinks 2 glasses of wine daily, some other stuff; what is most concerning about her risk for breast cancer? a. Alcohol use-> important modifiable risk 50. Question about man with swelling in one leg from inguinal ligament down; very active a. I think it was venous insufficiency-> most likely DVT 51. Question about the first thing to do for DVT a. Doppler ultrasound of leg st 52. PHQ-2: 1 question: almost daily; 2nd question more than half the days; what is the next step? a. Do a PHQ-9 Ottawa Knee rules: x-ray series is only required for knee injury pts w/ any of these findings: 1. Age 55 or older 2. Isolated tenderness of the patella [no bone tenderness of the knee other than the patella] 3. Tenderness at head of fibula 4. Inability to flex to 90 degrees 5. Inability to bear wt both immediately and in the ED [4 steps; unable to transfer wt twice onto each lower limb regardless of limping]
