1
Q
Critères parkinsonisme
A
Bradykinésie + soit (rigidité ou tremblement au repos)
2
Q
Ddx syndrome parkinsonien
A
Paralysie supranucléaire progressive
Dégénérescence corticobasale
Atrophie multisystémique
Démence à corps de Lewy
3
Q
Parkinsonisme secondaire - 2 causes
A
Vasculaire
Médicamenteux
Trauma/lésion cérébrale
Métabolique/toxique (Wilson, hémochromatose…)
Infection (encéphalite, toxoplasmose)
4
Q
Autres symptômes du Parkinson
A
Pré-symptomatique: Micrographie, modification de al voix, hyposmie, dépression, somnolence, anxiété/dépression
5
Q
Démarche en Parkinson?
A
Retard au démarrage, lent, petits pas, demi-tour décomposé, diminution ballant des bras
6
Q
Dx clinique du Parkinson
A
Parkinsonisme (donc 2 des 3 critères)
Pas de critère d’exclusion
Pas drapeaux rouges
7
Q
Démence à corps de Lewy
A
1) Fluctuation fonctions intellectuelles (attention, souvenirs, compétences visuospatiales)
2) Hallucinations visuelles
3) Trbl comportement sommeil paradoxal
4) Parkinsonisme
8
Q
Corps Lewy VS PD: différence onset?
A
PD: démence se présente >1an après symptômes (VRAIMENT TARD)
Démence Corps Lewy: démence peut apparaître avant symptômes moteurs
9
Q
Tremblements au repos?
A
Sos parkinsonisme
10
Q
Tremblements ua mouvement/action
A
Essentiel, physiologique
Cérébelleux
dystonique
Médicamenteux
Métabolique
Etc
11
Q
Acteurs à impliquer Parkinson?
A
Nous
IPS
Nutrition
Groupes: Parkinson Canada
Neurologue, urologue
PHyio/ergo
12
Q
Tx Parkinson sauf LEvodopa
A
1) Inhibiteurs MAO-B (rasagiline, selegiline, safinamide). ES: céphalées, nausées
2) Amantadine - rarement utilisé. ES: livedo reticularis, OMI
3) Anticholinergiques si tremblements dérangeants sans bradykinésie, trbl marche significatifs. ES: trbl mémoire, confusion, halluciatninos, bouche sèche
13
Q
Tx classique Parkinson (2) avec ES
A
Levodopa. ES: dyskinésie, nauséée, somnolence, étouridssement, céphalée,HTO
Agonists dopamine. ES: NMS, akinésie, trbl contrôle impulsion
14
Q
Problèmes comorbides à tjrs suivre pour PD?
A
Statut fonctionnel (AVQ/AVD)
ES médications
Dépression
Démence
Chutes
Constipation
Trouble sommeil
15
Q
Infertilité: définition
A
Absence de conception après 12 mois de coit non-protégé, 12-15% couples en âge de reproduction
Primaire = déjà eu conception, secondaire = jamais eu conception
16
Q
Histoire pour infertilité?
A
- Antécédents personnels et fam, médication, habitudes de vie
- Histoire gynécologie-obstétricale avec histoire menstruelle (STI, PID, surgeries, dysmenorrhea, dyspareunia, regular cycles)
- Habitudes sexuelles : Fréquence et moment, temps d’essai
- Durée d’infertilité, investigations faites, résultats d’examens
- Symptômes d’affection (thyroïdien,SOPK, hyperprolactémie, trouble alimentaire, insuffisance ovarienne) , etc.
- Revue de système
- ITSS
Hommes:
- Occupation (radiation, heat, chemical)
- HDV
- Problèmes érectiles et éjaculatoires
- ATCD de trauma, infections génitales, surgeries, tx of genital organs
- Causes idiopathiques : Pantalon / culotte serré, exposition à la chaleur, marijuana
17
Q
Physical exam for fertility?
A
- Thyroid and breast exams (signs of galactorrhea)
- Abdominal and pelvic pain
- Male exam
- Genital signs of symptoms
18
Q
Signes de l’ovulation
A
- Présence de menstruations régulières q 28 à 35 jours
- Syndrome prémenstruel
- Changement de la glaire en milieu de cycle
- Douleurs ovulatoires (Mittelschmerz)
- Courbe de température
19
Q
Conseils non-pharmaco infertilité
A
- Perdre poids (si IMC > 30)
- Cesser de fumer
- Cesser drogues et alcool
- Prendre des suppléments d’acide folique (1 - 5mg die) et multivitamines
- Éviter les lubrifiants spermotoxiques
20
Q
Infertilité algorithme femmes
A
PRISES DE SANG (CBC, TSH, proges etc)
1) Confirmation si ovulation (courbes température, détection LH urinaire/test ovulation, dosage prosgetérone sérique, biopsie endomètre)
2) Examen tubaire: hystérosonographie, hsytérosalpingographie, laparoscopie
2) Examen endométrial: Hystérosalpingographie, hystérosonographie, biopsie endomètre
21
Q
Ddx infertilité - femmes
A
1) Tubaire
2) Ovulatoire (SOPK, hypoT4, hyperPROL, tumeurs hypophysaires, insuffisance ovarienne précoce, Cushing, tumeurs sécrétant androgènes)
3) Endométrial
4) Cervical
22
Q
Ddx perte de poids
A
- Malignancy
- GI (PUD, celiac, IBD)
- Psychiatric (depression, eating disorders)
- Endocrine (hyperthyroidism, diabetes, adrenal insufficiency)
- Infectious (HIV, viral hepatitis, tuberculosis, parasite)
- Chronic disease (heart failure, renal failure, autoimmune)
- Neuro (stroke, dementia)
- Medications/substances
23
Q
HPI for weight loss
A
- Pattern of weight loss
- Intentional vs. Unintentional (r/o eating disorder)
- Dietary history
- GI symptoms (N/V/D, dysphagia, abdominal pain, early satiety)
- Malignancy (fever, fatigue, chills, night sweats)
- Psychiatric (depression, mood)
- Medication, Alcohol, Drugs
- Social (Income, Activity) and Function (Dementia)
24
Q
Définition perte de poids
A
5% over 6-12 months
25
Rapid antidotes in poisoning?
1) Dextrose can be given 50mL of D50W, if no IV access can give Glucagon 1mg IM
2) Oxygen, 100% O2 in carbon monoxide poisoning
3) Naloxone in life-threatening is 2mg initially up to 10mg, or if non-life-threatening 0.1mg initially doubled every two minutes up to 10mg
4) Thiamine (B1) given 100mg IV/IM/PO with 25g dextrose (50mL of D50W) to prevent Wernicke's encephalopathy (suspect thiamine deficiency in malnutrition (alcoholics, anorexics, hyperemesis of pregnancy)
26
Safety to avoid child poisoning?
- Keep items locked and out of reach/sight
- Keep in original containers (safety lids)
- Don’t take medications in view of children
- Don't refer to medicine as “candy”
27
Classic poisoning substances with antidotes
Antipsychotics (acute dystonic reaction) -> Benztropine, diphenhydramine
Anticholinergic -> Physostigmine salicylate (Antilirium)
Organophosphates, Carbamates (Cholinergic) -> Atropine, Pralidoxime
Digoxin -> Digoxin immune Fab (Ovine, Digibind). Consider MgSO4 to stabilize if delay in digoxin antibodies
Iron -> Deferoxamine (Desferal)
TCA (Cardiotoxicity, convulsion, coma)-> Sodium Bicarbonate 1-2mEq/kg
Cocaine, Methamphetamins, amphetamines (sympathomimetic) -> Rapid cooling, Benzos, Fluids + Nitroglycerine infusion
Cyanide -> Hydroxocobalamin 5g, Sodium nitrite 300 mg., Sodium Thiosulfate 12.5g, 100% oxygen
28
What to ask if ingestion/poisoning?
Patient often unreliable – use collateral sources (paramedics, police, family, friends, pharmacist)
Who - patient's age, weight, PMH (alcoholism, renal or hepatic disease)
What - name, dosage of medications (including OTC) or substances, coingestants, amount
When
Where - Injection or ingestion
Why - intentional vs unintentional
Commonly ingested nontoxic substances
Personal care products: Soap, shampoo, lipstick, lotion, perfume (low alcohol), eye makeup, toothpaste, deodarant
Household items: Thermometers (glass potentially harmful), pen ink, crayons, chalk, candles, pencils/erasers, laundry detergent, fabric softener, bleach
29
Timeline for activated charcoal, 1-2 g/kg?
Contraindications?
1-2h
Non-toxic ingestion
High-risk of aspiration
Specific types of stuff: caustic acids/alkalis, alcohols, lithium, heavy metals
30
Work-up for intoxication?
CBC
Lytes, Glucose
Hepatic/renal function
UA
Serum osmolarity
VBG + lactate
Serum drug levels (Tylenol, Salicylates, Ethanol)
Pregnancy Test
31
Osmolar gap formula
Measured serum osmolarity - (2Na + Gluc + Urea)
32
What increases osmolar gap?
Methanol
Ethylene glycol
Sorbitol
PEG
Propylene glycol
Glycine
Malcose
33
5 toxidromes?
Anticholinergic
Cholinergic
Opioids
Sedatives-Hypnotics
Sympathomimetic
34
Acetaminophen Intox? Antidote?
Toxic 150 mg/kg (7.5-10g for an adult)
Labs: >4h Tylenol Level on Rumack-Matthew Normogram, ALT/INR
N-acetylcysteine (NAC, Mucomyst) indications:
1) known time and above treatment line
2) uknown time ing or >24h/chronic
3) any signs of liver injury
35
Indications for inpatient tx/hospitalisation in depression patients
Active SI/HI
Psychotic features
Major impact on functioning)
36
Patients at higher risk of depression
Comorbid medical d/o (CAD, hypoT4)
Comorbid psychiatric d/o (anxiety, SUD)
Low SES
Post-partum women
Chronic pain patients
37
In who/which behaviours should I be screening for depression?
Multiple visits with unexplained symptoms
Work/relationship dysfunction
Weight/sleep/energy/memory/cognitive complaints
Comorbidity (IBS, obesity, CVA, cancer)
Substance abuse
38
Definition criteria of depression
≥ 5 (with either depressed or decreased interest) for >2w with change in functioning
- Sad (depressed mood most of the day)
- Interest (loss)
- Guilt
- Energy
- Concentration, memory
- Appetite
- Psychomotor agitation/retardation
- Sleep (mostly end of night, early mornings)
- Suicidal ideation
- Other criteria
- Causing significant distress/impairment (change in functioning, occupation/social/other) - functioning impairment with impact on QoL
- Not caused by other psychiatric condition (manic, hypomanic, schizoaffective disorder, schizophrenia, delusional disorder, schizophreniform or others)
- Not caused by organic pathology or substance uses
39
Antidepressants for depression with anxious features
Paroxetine, Sertraline, Venlafaxine
40
Antidepressants for psychotic features
Quetiapine
41
Antidepressants with sleep disturbance
Mirtazapine, Quetiapine, Trazodone
42
Treatment for depression - non-pharmaco
Regular exercise - group physical activity programs
Adequate food intake
Adequate sleep
Avoid substance use
Stress management techniques
Behavioral activation
Thérapie (CBT, ITP)
43
Treamtent depression - indication for pharmacological tx
- Past history of moderate/severe depression
- Long period (>2y) of subthreshold depressive symptoms
- Persistent symptoms after other interventions (ex CBT/IPT)
- Moderate/severe depression in combination with CBT or IPT
- Mild-moderate-severe depression but no access to CBT
44
Monitoring response and modify appropriately treatment in depression?
If >20% improvement at 2-4w, continue treatment and reassess at 6-8w
If <20% improvement at 2-4w, increased dose OR switch to another medication
DONC la réponse serait tjrs de augmenter dose max, si partial response tu peux ajouter adjunct (genre quetiapine), si aucune répnose tu changes d'agent complètement.
45
Symptômes de sevrage SSRI
- FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal)
- Typically resolves in 1-2 weeks
- Worse with Paroxetine, Venlafaxine
46
Conditions médicales à r/o pour dépression
- Adrenal insufficiency, hypercortisolism, hypothyroidism, diabetes
- Mononucleosis
- Multiple sclerosis, Huntington disease, Parkinson disease, systemic lupus erythematosus
- Obstructive sleep apnea
- Stroke, traumatic brain injury
- Vitamin B12 insufficiency
47
2 choses à penser absolument si pt se présente avec dépression
r/o abus de substance
r/o abus domestique
48
Déf dysthymie (PDD)
1) humeur dép quais toute la journée, plus d'un jour sur deux, pendant au moins 2 ans
2) 2 ou plus de: appétit, sommeil, fatigue, faible estime de soi, trbl concentration, désespoir (PAS PERTE INTÉRÊT, PAS IS, RETARD/AGITATION, PAS TRISTESSE)
3) pas de période de 2 mois sans les 2 du critère 2
49
Adjustment d/o definition
1) Emotional/behavioral sx responding to a stressor wichin 3 months
2) Marked distress/significant impairment
3) Does not meet criteria for another mental disorder/exacerbation of preexisting
4) NOt normal bereavement
5) When stressor over, does not persist more than 6 months
50
Which symptoms should I ALWAYS ASK ABOUT when depression?
Maniac
Psychotic
Suicidality
51
Risk factors for anxiety
Family history of anxiety
Personal history of anxiety/mood disorder
Childhood stressful life events or trauma
Female
Chronic medical illness
Behavioral inhibition
52
Screening questions for GAD?
During the past 2 weeks, have you been bothered by
1) Feeling worried, tense, or anxious most of the time?
2) Not being able to stop or control worrying
53
Screening questions for panic d/o
In the past month, have you on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy even in situations where most people would not feel that way?
Did the spells peak within 10 minutes?
Have you spent more than a month in fear of having another attack or about the consequences of the attack?
54
Ddx for anxiety
Medical (palpitations, chest pain, dyspnea/trouble breathing, etc).
Cardiovascular: Myocardial Infarction, Arrhythmia, CHF, valvulopathy
Respiratory: Pulmonary Embolism, Asthma/COPD
Endocrine: Hyperthyroidism, hypoglycemia
Metabolic: Vitamin B12, porphyria
Neurologic: TBI
Psychiatric comorbidities
Medication-induced
Substance-induced: Intoxication (caffeine, stimulants) or withdrawal (benzodiazepines, alcohol)
55
Differentiate between distress (fear, nervousness, worry) and anxiety disorder
LEADING TO A MALADAPTIVE BEHAVIOUR, THOUGHT AND COGNITIONS AND POORER PERFORMANCE
56
What should I screen for in anxiety d/o? What should I always ask?
all other comorbid psychiatric conditions: mood d/o (depression, bipolar so MANIA), psychotic d/o, personnality d/o
SUBSTANCE USE D/O
dangerosity
FUNCTIONAL IMPAIRMENT
57
Treatment for anxiety
1) Self-management
2) Community resources
3) Therapy
4) Pharmacotherapy
1) Relaxation, breathing control skills, physical activity, self-help books, internet-based CBT
2) Support groups, SW
3) CBT, psychotherapy
4) another question honey
58
Pharmaco tx for GAD
Duloxetine, escitalopram, paroxetine, sertraline,venlafaxine
59
Tx for social anxiety d/o
CBT
Exposure therapy
Beta-blockers before presentations
Escitalopram, paroxetine, sertraline
60
Antidepressant chez enfants/ados
fluoxetine
61
Work-up pour r/o organic disease en anxiety
- CBC
- Electrolytes, Fasting glucose
- TSH, LFTs
- Lipid profile
- UA, urine toxicology for substance abuse
- EKG for arrhythmia
62
High-risk group for substance use?
Mental health comorbidities (depression, ADHD, schizophrenia, etc)
Chronic disability
Family or personal hx of SUD
Associated symptoms (functional decline, confusion, delirium, syncope)
Associated medical problems
Prescription medication that are commonly misused (opioids, sedatives, hypnotics, anxiolytics, stimulants)
63
Outil pour screen SUD?
CAGE
Have you ever felt you had to cut down on your drinking?
Do you get annoyed by criticism of your drinking?
Do you ever feel guilty about drinking?
Do you ever take an early-morning/eye opener drink?
64
Definition de SUD
1) Pattern of using a substance resulting in clinically significant impairment/distress
2) 2 or more of the following within a 12 MONTH PERIOD: impaired control, social impairment (obligations, family, work, relationships, gave up activities), risky use (driving, sex,), pharmacological indicators like withdrawal/tolerance
65
Harm-reduction strategies in SUB
Needle exchange
Driving and driving
Immunizations in ITSS
66
Method to dsscuss a change in habits
1) Ask (frequeny, amount, etc)
2) Advise: you should stop, do you wanna hear about the benefits/risk
3) Assess: are you ready to change (pre-contemplation not ready, contemplation im thinking about it, preparation actively planning a quit, action involved in a quit attempt, maintenance)
4) Assist: barriers? strategies? resources, medications?
5) Arrange FU
67
When a patient comes in with functional decline
confusion
delirium
THINK ABOUT
SUBSTANCE USE DISORDER
68
Signs of substance use in adolescents
- School failure
- Isolation, negative symptoms
- Behavior change
- Dangerous behaviors
69
Opioid-use disorder: what to do periodically? what to discuss?
1) Reassess clinical problem to make sure they still need the medications
2) Assess other substance use
3) Safety recommandations (do not share meds, store meds in safe location, do not receive meds from other sources)
4) Avoid use of sedatives/depressants
5) Monitor for symptoms, FUNCTION, adherence
70
Différences entre UA vs NSTEMI vs STEMI
UA: tropos neg
NSTEMI/STEMI: tropos pos
Changements ECG pour UA/NSTEMI, ST Elevations pour STEMI
71
Populations qui se présentent sans classique DRS?
Et définition DRS
Pression rétrosternal, pire avec l'effort, moins pire avec repos
Populations: gériatrique, femmes, diabétiques
72
Facteurs de risque CMP ischémique
Age
Homme
IRC
Diabète
MCAS
Family history
Tobacco
Physical activity
Nutrition (mediterranean, DASH)
73
What tests to rule out cardiomyopathie ischémique? Si suspicion clinique élevée et si ECG/Tropos N
Test à l'effort
MIBI à l'effort
Échocardio à l'effort
74
CMPi stable: gestion des symptômes? Principes du traitement
1) Changements d'habitudes de vie (tabac, roh, perte poids, exercise, DM/DLP/HTA)
2) Thérapie antiplaquettaire selon
3) Médications antiantineuses: BB (2 ligne CCB, nitrates)
75
QUestions à poser pour le suivi des patients avec MCAS?
1) Contrôle des symptpomes, IMPACT SUR LA VIE
2) adhérence aux médications
3) Modification des habitudes de vie
4) Dépistage des complications
76
Classes NYHA
Class 1: Pas de limitation
Class 2: Slight limitation (SOB/fatigue) during moderation exertion/stress
Class 3: symptoms with MINIMAL EXERTION with normal daily activity
Class 4: inability to carry out physical activity
77
Meds in acute coronary syndrome?
O2
Nitro
Morphine - only if refractory pain to nitro
Antiplaquettaires: ASA 320 x1 with either Plavix/Ticagreol 600/180 x1
Anticoagulants: 48h to 7 d, depending on when is coronarography. Hep (invasive) VS LMWH (conservative)
BB - within 24h if no signs of HF
Statin - later
IECA - later
78
DB: screen who/when?
Use de FINDRSICK
If low-mod-risk, no screen indicated, reassess RF annually
High risk: screen q3 years
Very high risk: screen q6-12mo (FHx DMT2, non-white, low SES, hx HDM/preDB, CV RF, associated diseases (PCOS, OSA), drugs a/w DB (atypical AP, HAART, glucocorticoids))
79
Dx of DB?
FPG > 7.0 (6.1-6.9)
A1c > 6.5% (6 - 6.4)
2hPG > 11.1 or random > 11.1 (7.8 -11)
2 TESTS DIFFERNET OCCASIONS
or 1 test + symptomatic
80
If HbA1c < 1.5% from target at dx, what do you do?
If HbA1c > 1.5%?
If symptomatic hyperglycemia?
Lifestyle x 3 months then MTF
MTF
Insuline +- MTF
81
Targets in DB?
< 6.5 if low risk of hypoglycemia
< 7 most adults
7.1-8.5 if recurrent hypoG, limited life expetancy, elderly, dementia
82
Labs at dx DB?
FSC
Lytes + Creat
Lipid profile
TSH
ALT
UA
ACR (2 positive = proteinuria)
ECG
83
What other rx to start (other than glucose control) for DB?
Statin (always)
ACEi/ARB (if ACR >2, CV RF)
SGLT-2 (CAD, PAD, carotid disease, not at target)
ASA (CAD, PAD, carotid disease)
84
Follow-ups/exams to do in DB?
Neuropathy: qyear monofilament exam, with foot care qyear
Retinopathy: opto qyear
Nephropathy: ACR qyear
Lipids qyear
ECG q3-5y
85
DKA
- Advise patient it exists
- Stop meds if stress/infection/unwell/etc.
- Management: FLUIDS, insuline + glucose, serial glucose/gas with lactate. Insuline until anion gap closed.
86
Screen who for HTA?
Anobody older than 18yo
Consider in older than 3yo
87
Cut-offs for HTN dx?
MAPA 135/85 daytime (or 130/80 24h)
OR
Home BP 135/85
88
What to ask periodically for HTN patients?
PMHx/FHx of CVD, HTN, DB
Lifestyle (diet, exercise, habits)
HPI:
- daytime sleepiness, morning h/a
- LLE, dyspnea, CP
- Stroke sx
- PAD sx
- h/a, tinnitus, dizziness, palpitations, epistaxis
89
Initial work-up for HTN dx
- CBC, Lytes + Creat/GFR
- Calcium
- FBG/HbA1c, lipid profile
- TSH
- ECG (LVH, CAD, arrhythmias)
- Urinalysis (proteinuria)
90
Causes of secondary hypertension?
- Renal (Renovascular HTN (renal artery stenosis, polyarteritis nodosa, fibromusuclar dysplasia of renal arteries), Polycystic kidney disease (vasculitis of small/medium vessels), Renal failure (any disease impairing GFR), Glomerulonephritis, SLE, Renal tumors, Atrophic kidney)
- Endocrine (hyperaldosteronism, cushing, pheochromo, hyperT4, HyperPTH)
- OSA
- Meds (sympatomimetic, corticos, nsaids, contraceptives)
- Drugs (amphetamines, cocaine, caffeine, NSAIDs)
91
Who should we investigate for secondary HTN?
What are the investigations?
1) Young, abrupt onset, high diastolic, recurrent hypertensive crisis, or refractory
2) Lytes, CBC, TSH, VBG, UA, cortisol, calcium, PTH, polysomnography, doppler renal arteries, serum metanephrines
92
Lifestyle changes for HTN?
Exercise (150 min/week)
Weight loss
Decrease ROH
Smoking cessation
Diet: DASH, sodium < 200 mg, K increase
93
Target for treatments?
High-risk: 120
DM: 130/80
Low-risk: 140/90
94
First line for HTN treatmen?
If DM/CKD: ACEi/ARB
If black: Thiazide diuretics
If nothing: CCB (Amlo)
95
Lifestyle changes when pregnant?
Folic acid (low-risk: 0.4 mg, moderate: 1 mg ad 12 weeks, high risk: 4-5 mg DIE - include Methotrexate/MTF/Sulfa, hx of fetus with neural tube defect/birth defect like facial cleft, heart diseaase, limb defect. FHx of NTD. Epilepsy. IDDM. Obesity. IBD/GI malabsorption, celiac dz, advanced hepatitis condition. Dialysis. Social components.
MEDICATIONS: stop retinoids/Vit A, ACE/ARB, Warfarin, Sulfa/Trimothoprim, Tetracycline, NSAIDs
Smoking cessation
ROH cessation
Undercooked meats, unpasteurized foods
Avoid cat litter
96
What should we establish in ALL PREGNANCIES?
Desirability
97
Who are the high-risk pregnant patients?
(psychosocial AND medical)
Teens
Domestic Violence Victims
Single parents
Drug abusers
Impoverished women/low SES
HIV
IVDU
Diabetic
Epileptic
Environmental exposures
Travelling
Family genetic history
98
99
Chronic conditions to ask about in new pregnancy?
Diabetes (important because good glycemic control essential for good organogenesis)
Hypertension (a/w preterm birth, placental abruption, IUGR, pre-eclampsia
Asthma
Thyroid disease
Thrombophilia
Seizure disorders
Herpes
Hep B
Abnormal cytologies
100
Blood tests first tremester pregnancy?
FSC + Groupe Rh + recherche d'anticorps
TSH
Glyc à jeun
Rubéole
Syphillis
Hep B
VIH
A/C Urine
Considérer électrophorèse Hgb si méditerranean region
101
In anybody who is sexually active what should we talk about?
Fertility
Delayed child bearing more and more because accessible contraception, women in post-secondary education, etc.
Should be evaluated after 6 months of unprotected sex if older than 35 yo.
102
Definition of PROM
Risk factors
Management
Rupture of membranes BEFORE labor (premature PROM = before 37w)
RFs: amniocentesis, cervical insufficiency/cerclage, prior PPROM/preterm birth, vaginal bleed, abruption, multiple pregnancy, polyhydramnios, smoking, STI, BV, low SOS
Management:
- NO DIGITAL EXAM
- Sterile speculum, pooling, ferning, nitrazine, culture for STI/GBS
- Admission
- Oxytocin, +/- abx
103
Definition of hypertensive d/o of pregnancy
1) HTN: before 20 w
2) Gestational HTN: after 20w
3) Preeclampsia: 140/90 with proteinuria, OR hypertension with severe features of preeclampsia (end-organ-damage: decreased PLTs, high creat, pulmonary edema, high AST/ALT, h/a, visual symptoms)
4) Eclampsia: seizures
104
Who is at risk for preeclampsia?
Nulliparity
OBesity
FHx of PE
Age 35 and up
Low SES
African American
Previous PE
Multifetal gestation
Pre-existing medical conditions (HTN, DB, renal disease)
Autoimmune disease
105
Management of pre-eclampsia
Goal BP 140/90 (Nifedipine, Labotalol)
MgSO4 as prophylaxis (severe PE, non-severe PE with sypmtoms, HELLP)
Delivery
106
Dystocia definition?
Causes?
First stage: 4h of < 0.5 cm/hr dilation OR no cervical dilation >2h
Second stage: >1h active pushing without descent
Causes: 4 P
- power - oxytocin
- passenger - reposition
- passage - ensure bladder empty
- psyche - pain/anxiety
Anagelsia, hydration, rest
Amniotomy
Oxytocin
Assisted vaginal birth
C-section
107
Complications in labour? 4
Abruption
Uterine rupture
Shoulder dystocia
Non-reassuring fetal monitoring
108
Abruption: RF and management
RF: previous abruption, smoking, hypertension, PE, PROM, chorioamnionitis, COCAINE, polyhydramnios, abdo trauma)
50% of cases result in DIC
Échographie pour localiser placenta
O2, DLG, bolus, monitoring
Si pas d'atteinte fétale, induction avec monitoring. Si atteinte fétale: accouchement d'urgence.
109
Uterine rupture
RF: previous rupture/CS/vertical hysterectomy/IOL with misprostol.
If unscarred uterus, RF are: trauma. Weakness of myometrium. Dystocia with prolonged labor. Uterotonic drugs. Placenta Accreta. Multiparity. Multiple gestations.
OR VERY FAST
110
Shoulder dystocia: RF
Suspected macrosomia
Diabetes
GA more than 42w
Multiparity
Previous hx of dystocia
Previous macrosomia
Weight gain
Obesity
Prolonged labour
Operative vaginal delivery
Labour induction
Epidural anesthesia
111
Shoulder dystocia management
ALARMER
Ask for help, stop pushing
Lift legs in McRobert's
Anterior shoulder disimptation (suprapubic pressure)
Rotate posterior shoulder like screw (Wood's)
Manual removal posterior arm (cal lead to fracture0
Roll onto all fours
Episiotomy
112
PPH: definition, causes
Definition: 500 cc vaginal, 1L CS
Causes:
Tone (uterine atony, distended bladder, infection)
Trauma (lacerations)
Tissue (retained products)
Thrombin (coagulopathy)
113
PPH Management
*ask for help, IVs, fluids, O2, monitoring, Foley*
1) Bimanual fundal massage
2) Oxytocin
3) TXA 1g over 10min
4) Uterotonics: Hemabate, Misoprostol, Methylergonovine
5) Intrauterine tampoande with balloon
6) surgery
114
PP blues vs depression
Blues: onset day 3-10, anxiety, irritability, decreased concentration, sleep disturbance. LESS THAN 2 WEEKS
Depression: within 1y
2w or more of symptoms
RFs: previous depression, poor social support, poor financial support, stressfull live events during pregnancy, treat SSRI/psychotherapy
115
Problems with breastfeeding
1) Inadequate milk production:
- problems with breast like previous surgeries, radiation, endocrine
- delay in lactogenesis (obesity, HTN, PCOS)
- medications (oxytocin, SSRI, estrogen)
- offering only one side per feeding
2) Poor milk extractoin
- infrequent feeding
- inadequate latch-on
- maternal-infant separation
- use of supplemental formula
116
General treatment for problems with breastfeeding
1) Position and latch (C-shape, baby's chin below areaola lips wide open)
2) Lactation consultant
3) Rx: Domperidone although no data
4) Antibiotic ointment (Mupirocin, Bethamethasome)
117
Risk factors for breast cancer
FHX of breast cancer
Previous benign breast lesions
Previous personal hx of breast cancer
Ovarian Cancer
Hormonotherapy/OCP
BRCA mutation carrier
Early menarche
Late menopause
Nulliparity
118
Features on FHx increasing likelihood of BRCA1/2 hereditary cancer syndrome?
Hx breast cancer in more than one 1st degree
Hx bresat cancer male family member
Ashkenazi Jewish descent
Hx of ovarian cancer
Positive BRCA mutation carrier in the family
Low age onset of breast cancer
119
Red flags for neck pain
Trauma
Cancer or constitutional symptoms
Infectious symptoms, Immunosuppression or IVDU (Epidural abscess, discitis)
Neurological signs/symptoms (cord compression, demyelinating process)
Severe ripping neck pain, unstable (carotid/vertebral dissection)
Chest pain, SOB, diaphoresis (MI)
History of rheumatoid arthritis (atlanto-axial disruption)
120
SOS diagnosis in neck pain?
Malignancy
Carotid dissection
MI (referred pain)
Pseudotumor cerebri (referred pain)
Discitis
121
Modifiable RF in OMA?
Second-hand smoke
Drinking supine position
Daycare
Crowded living conditions
Bottle feeding (not breastfeeding)
122
Indications for tubes in OMA
Speech delay
Hearing loss
Atelectasis of TM/retraction
Persistent effusion
Recurrent OMA
123
Abdo pain in children: non-GI causes?
DKA
UTI
Pneumonia
124
Classes for migraines prophylaxis
Beta-blockers
CCB
Antidepressants TCAs
Anticonvulsivants
125
Contact avec varicelle: on donne quoi aux gens à risque? Gens normaux?
Immunoglobuline
Rien
126
Glucose control targets in GDM?
5-6 fasting
6-8 2h-post meal
127
Questions à poser si ingestion de substance?
- Who - patient's age, weight, PMH (alcoholism, renal or hepatic disease)
- What - name, dosage of medications (including OTC) or substances, coingestants, amount
- When
- Where - Injection or ingestion
- Why - intentional vs unintentional
128
How to enhance elimination of a poisoning substance?
Dialysis
Forced diuresis
Acidification/alcalinization of urine
129
Tylenol ingestion: what labs do we do?
AST/ALT
INR/PT/PTT
Plaquettes
130
Antidote Tylenol?
NAC
Mucomyst
N-acétylcystéine
131
Complications des troubles alimentaires (en catégorie)
(endocrino, cardiaque, GI x2,
Ostéoporose
Arythmies cardiaques
REflux
Syndrome Mallory-Weiss
Suicide
132
Quels facteurs liés au mode de vie pourraient entraîner une dysfonction hypothalamo-hypophysaire primitive et une anovulation subséquente?
Stress excessif
Exercise excessif
Régime alimentaire excessif/trbl alimentation
133
Causes endocrino pour anovulation en infertilité?
Cushing
TSH
PCOS
Hyperprolactinémie
134
Optimisation non-pharmaco de fertilité?
Cesser roh, tabac, cafféine
Relations sexuelles fréquentes toutes 72h
Perte poids
Chaleur testicules
135
Crises épiléptiques chez pt connu/pas connu, causes?
GROSSESSE
Non-compliance
VITAMIN D & E
Vasculaire (stroke, bleed, hypertensive encephalopathy)
Infectious causes
Trauma
Autoimmune (NMDA, SLE)
Métabolique (hypoG/hyperG, hypoNa/K/Ca, TSH, LFTs, Urée)
Idiopathique (épilepsie de novo)
Néoplasie
Drugs
Eclampsia/pseudoseizures
136
Habitudes de vie pouvat provoquer convulsions chez patient connu?
Alcool, drogues
Stress
Manque sommeil
137
FRs pour hépatites? Quoi demander à l'histoire
IVDU/nasal drug use
Unprotected sex
Piercings, tattoos, contaminated needles
Blood transfusion
People with jaundice
138
If a h/a treatment works, it exlucdes serious pathology?
NO
139
If treating chronic h/a or relapsing h/a, can I use barbiturate/narcotics?
NO
140
Investigation if h/a, neg CT scan and suspected SAH?
LP
141
Criteria migraine
1) 5 episodes lasting 4-72h
2) 2/4 of (pulsatile, unilateral, mod-severe pain, worse with activity)
3) 1/2 of (photo/sonophobia, nausea/vomiting)
142
Definition tension h/a
1) 10 episodes/month (less than 1 day)
2) 30min-7 days duration
3) 2/4 of (pressure/tightening, mild-mod, bilateral, not worsened by activity)
4) 1/2 (no N/V, no sono/photo)
143
Definition cluster
1) at least 5 crisis
2) 15-180 min untreated of severe deep excruciating unilateral orbital/supraorbital/temporal pain
3) one of ispilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness,miosis, ptosis
144
Definition medication over h/a
more than 15 d of h/a per month
use of either more than 15d of analgeics
145
RED FLAGS in h/a
SNOOPS
Systemic (fever, weight loss, scalp tenderness)
Neuro (confusion, decreased LOC, seizure, pappilledema, focal sx)
Onset (sudden, worse of life, refractory)
Older (50yo)
Progression/pattern (new, different pattern)
Papilledema
Postular aggravation (ICP)
Secondary RF (immunosuppressed, malignancy, early morning, known aneurysm, previous stroke, anticoagulants, precipitated Valsalva, fever)
IMPACT ON FUNCTIONNING !!!!!
146
If suspicion of SAH, what should I do as a work-up?
C- (100% sensitive in first 6h)
LP if too late
IRM/angio IRM
147
Non-pharmaco management/recommandations of h/a
Headache diary
Avoid triggers (not eating, tobacco, weather, sleep hygiene, specific foods like old cheese, fermented things, nitrites meats, alcohol, coffee, chocolate)
REGULAR EXEDRCISE
Stress management reduction
148
Treatment of migraines
1) First line: Tylenol, NSAIDs (Naproxen/Advil)
2) TRIPTANS - always try at least 2-3 before saying it does not work
149
Contraindications to Triptans
Migraine hémiplégique, basilaire, ophthalmoplégique
ICT, AVC
MCAS, MVAS
HTA non contrôlée
Arrhythmies cardiaques
Insuffisance hépatique grave
150
3rd line for migraine?
Antiemetics
Ergotamines (Cafergot) - same CI as triptans
Ubropegant (new) - to consider of CI for triptans
Dexaméthasone
Valproic Acid
151
Indications for prophylaxis migraines
4 migraines/month
Lasting more than 12h
Recurrent interfering with daily activities
Non-response to tx
Menstrual tx
152
Contraindications to BB for migraine prophylaxis
MVAS
Raynaud
Hypotension
Bradycardia
BAV
+/- asthma
153
Durationof prophylaxis rx for migraine?
Try at least 3 months
If it works, continue max 6-12 months
Then taper down progressively
154
Tx Cluster h/a?
Acute: O2
Triptans
Other rx: Corticos, ergotamine, occipital nerve block
Neuro early on
155
Screening cancer colorectal?
50-74yo
FIT q2 ans ou flexible sigmoidoscpy q10 ans
156
Cancer colorectal: si
1) 1er degré avec cancer <60 ans
2) 2 parents 1er degré peu importe l'âge
3) parent 1 & 2e même côté famille
COLOSCOPIE Q5 ans
Dès 40 ans OU 10 avant plus jeûne âge de diagnostic
157
Cervical cancer screening
25-60 yo, PAP q3 yr
ASCUS en bas de 30 ans: repeat at 6-12 mo
ASCUS above 30 ans: VPH, + colpo, neg PAP 12 mo
158
Prostate cancer
No screening recommended - DISCUSS DRE/PSA with patient
APS < 1.5: repeat 2-4 yr
APS 1.5-4: repeat 1-2 yr
APS > 4: repeat 8 weeks, <4: repeat 1-2 yr, > 4: UROLOGY
159
Breast cancer screening?
50-74 yo q 2-3y with mammography
any cancer (1st or 2nd degree) > 50: same
ANY CANCER (1st or 2nd deg) > 50: annual at 40yo
160
Lung cancer screening?
5-74yo with ≥30 py smoking history (current or quit <15y ago)
Low-dose CTq 1y-3y max
(Task Force Guidelines)
161
AAA screening?
men 65-80 yo
one-time abdo US
162
How to manage dyspnea in pall care?
Position (turn, sit up, elevate head of bed)
Air circulation (fan), oxygen PRN
Manage cough, secretions, anxiety (relaxation therapy)
Opioids (eg. morphine 1mg PO), benzodiazepines, bronchodilators
163
Non-pharmacological management of pain in pall care
- Massage / Physical therapy
- Pet therapy
- Acupuncture
- Relaxation / Hypnotherapy
- Aromatherapy / Music therapy
- Heat/Cold
164
RF for opioid abuse
Young age
Hx of preadolescent sexual abuse,
Hx of depression
Hx of ADD/OCD
Bipolar d/o
Schizophrenia
PMHx of alcohol abuse/illegal drug abuse/prescription drug abuse
FHx of alcohol abuse
Illegal drug abuse
165
Side effects of opioids
Constipation
Nausea
Sedation
Urinary retention
Neurotoxicity (hallucinations, allodynia, myoclonus, seizures, delirium)
166
Management of nausea in pall care
1) Non-harmaco: cut some intolerant foods, control odeurs, restrict intakes, small frequent meals, cool fizzy drinks, avoid lying flat after eating, acupuncture
2) Pharmacological
- Metoclopramide (prokinetic)
- Ondansetron
- Antihistamine (dimenhydramine)
- Anticholinergic (scopolamine)
- Antipsychotic (Haldol)
- Cannabinoids
167
Tx of anorexia in pall care?
Favorite foods
Small frequent meals
Rx: Dex 4 PO BID, progesterone, metoclopramide, mirtazapine
168
Fatigue in pall care?
Steroids
Metamphetamines
169
Pharmaco mngt secretions in pall care?
Glycopyrrolate
Scopolamine
Atropine
170
Safety plan pour suicide? 5 points
Keep environment safe
Recognize early warning signs
Ways to cope PERSONNALY
Identify people to contact
Identify places to go
171
In a trauma in the emergency, think about what as possibly the cause?
Suicide attempt
172
Which drugs to ask for when suspected drug overdose in the ER?
ASA
Tylenol
173
Risk factors for anxiety?
Family history of anxiety
Personal history of anxiety/mood d/o
Childhood stressful life events/trauma
Female
Chronic medical illness
Behavioral inhibition
174
DEFINITION GAD
1) Excessive anxiety/worry more days than not for 6 months
2) Difficult to control the worry
3) 3 or more of: easily fatigued, irritability, muscle tension, decreased concentration, decreased sleep, restlessness
4) IMPAIRED FUNCTION
175
Panic d/o definition
1) Recurrent unexpected panic attacks
2) 4 or more of (palpitations, sweating, dyspnea, trembling, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization, losing control, fear of dying)
3) at least 1 attack followed by 1 month of either persistant concern/worry about attack OR significant malapdative change genre avoidance
176
Which medications have a mortality benefit in patients with CAD post-MI?
Aspirin/Clopidogrel
Beta-blockers within 24h
Ace-i within 24h
Statin
177
What rx to start during ACS? After stabilization of the patient
MONA
Morphine
O2
Nitro
Aspirine
178
Dx of DB
1 test pos + symptoms OR 2 tests pos diferent moments/diff tests
HbA1c 6,5%
FPG 7
2hPG 11.1
Random glucose 11.1
179
PreDB?
HbA1c 6-6.4
FPG 6.1-6.9
2hPG 7.8-11
180
Indications to start Insulin right away?
Symptomatic hyperglycemia
Metabolic decompensation (DKA/HHS)
181
What 2nd line medication to start if
1) patient has clinical CVD?
in DB
1) SGLT-2
182
Targets for DB patients: BP and LDL
130/80
<2 or decrease by 50%
183
Tx of hypoglycemia if
1) conscious
2) unconscious
1) 15g carbohydrates, D50 1 amp (25g)
2) Glucagon 1 mg SC or IM
184
Complications of DB, micro and macrovascular
1) Micro: neuropathy, nephropathy, retinopathy
2) Macro: CAD, PVD, AVC
185
Weight loss medications in DB^
GLP-1
SGLT-2
186
Weight gain medications in DB^
Insuline
Sulfonylureas
187
Antihyperglycemic medications contraindicated in CKD?
Biguanides
SGLT-2 inhibitors
Thiazolidinediones
Alpha-glucosiade inhibitors
188
Prescription for Insulin
DC all PO hypoglycemics except MTF
Glucometer
Lancets x100
Test strips x100
Injection pen
Needles
Insulin (Lantus 10u qHS)
Sharp Container
Alcohol swabs
189
HTN threshold for dx
1) NABP x1 in office
2) AOBP x1 in office
3) daytime ambulatory BP monitor (MAPA jour)
4) 24h ambulatory BP monitor (MAPA 24h)
5) home BP series patient
1) 180/110
2) 180/110
3) 135/85
4) 130/80
5) 135/85
190
Threshold to start medications:
Low-risk: 160/100
Mod-risk: 140/90
High-risk/DB: 130/80
191
What is considered high-risk patients in HTN guidelines?
>50 yo AND sBP > 130 AND one of those:
1) older than 75
2) clinical CVD
3) CKD
4) FRS > 15%
192
BP target for
1) DB
2) High-risk
3) Mod-risk
4) Low-risk
1) 130/80
2) 120/XX
3) 140/90
4) 140/90
193
What meds increase BP?
Sympathomimetic drugs
Corticosteroids
COCs
NSAIDs
Antidepressants
Atypical antipsychotics
Decongestants
Stimulants (methylphenidate, amphetamines)
194
What meds to treat hypertensive emergency?
Nitroprusside/nitroglycerine
Labetalol/Esmolol
CCB (Clevidipine, Nicardipine)
Dopamine-1 agonist (Fenoldopam)
195
Meds irritating the stomach/RF for ulcers
ASA
NSAIDs
TYlenol
Bisphosphonates
SSRIs possibly
GLUCOCORTICOIDS
196
Which ulcer causes risk of gastric cancer?
GASTRIC ULCERS
197
Eradication therapy for H Pylori?
PPI
Clarithromycine
Amoxicilline
198
Complications of gastric/duodenal ulcers?
Gastric cancer
Bleeding
Ulcer perforation
Fistulas
Gastric outlet obstruction
199
Types of treatment for IBD
REMISSION
1) 5-ASA (5-aminosalicylates) - Sulfasalazine, Mesalamine)
2) Glucocorticoids
MAINTENANCE
1) 5-ASA
2) Immunomodulator( Azathioprine, 6-Mercaptopurine, Methotrexate)
3) ANti-NTF (infliximab)
4) Probiotics
200
Extra-intestinal manifestations of IBD
1) Arthritis (peripheral arthritis, ankylosing spondylitis, sacroileitis)
2) Dermato (aphtous somatitis, erythema nodosum, pyoderma gangrenosum)
3) Ocular (episcleritis, scleritis, uveitis)
4) Primary sclerosing cholangitis
201
Possible tx in IBS?
Exercise
Diet (low FODMAP)
PEG, psyllium
Antispasmodics, TCAs
202
Abdo pain in children
1) <1yo
2) 1-5 yo
3) 5-12yo
4) >12yo
1) Food protein allergy, colic, constipation. NEC, VOLVULUS, PYLORIC STENOSIS, INTUSSUSCEPTION.
2) UTI, constipation. USP, APPENDICITIS, MECKEL
3) UTI, constipation, functional. DKA, GONADAL TORSION, APPENDICITIS, IBD.
4) Gastroenteirits, pneumonia, PANCREATITIS, PID, DKA, ECTOPIC PREGNANCY.
203
Drugs that have interactions wiht COC
Antiepileptics (phenytoin, topiramate, carbamazepine)
Antibiotics (Rifampin)
Antivirals (HIV)
St-John's Wort
204
Contraindications progesterone:
- Known or suspected pregnancy. However, pregnancies conceived in individuals taking POPs have not been associated with adverse effects.
- Known or suspected breast cancer.
- Undiagnosed abnormal uterine bleeding.
- Benign or malignant liver tumors (hepatoma), severe cirrhosis, or acute liver disease.
205
Types of emergency contraception
Copper IUD (up to 5-7 days)
Ella (Ulipristal acetate) - up to 5 days, good for higher BMI
Plan B (Levonorgestrel) - up to 3 days
Combined OCP - up to 3h (Yuzpe)
Contraindications pregnancy
Or pelvic infection/cervicitis
206
Symptomatic management de TP?
Antipsychotic low-dose schizotypal
SSRIs for avoidant
207
CFPC Exam
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