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Textbooks, Family Medicine: Essential Family Medicine, First Aid for Family Medicine BoardsTextbooks, Clinical Skills: Swartz Physical Diagnosis, Physical Diagnosis Secrets, OMT Review--------------------------------------------------------------------------------------------------------------------------------------------Common Problems in Family MedicineAbdominal: Peptic Ulcer Disease, Cholecystitis, Constipation/Diarrhea, Irritable Bowel Syndrome, GastritisAches/Pains: Back Pain, Neck Pain, Shoulder Pain, Sprains/Strains, Bursitis, Osteoarthritis, GoutCAD: Angina, Congestive Heart FailureChest Pain: Costochondritis (Tietze Syndrome), Gastroesophageal Reflux/Hiatal HerniaDysuria: Urethritis, Cystitis, Pyelonephritis, STD, ProstatitisGeneral: Depression/Anxiety, Diabetes Type II (NIDDM), Hypertension, Metabolic SyndromeGynecologic: Incontinence, Menopausal Syndromes, Menstrual Disorders, PID, Vaginitis, Cervicitis, FamilyPlanning, ContraceptionHeadache: Tension, MigrainePreventative: Immunizations, Weight Management/Exercise, Smoking Cessation, School/Sports/OccupationalPhysical, Well Child Assessment, Well Adult Assessment, Women's Health AssessmentLower RTI: Pneumonia, BronchitisSkin Problems: Dermatitis, Eczema, Common Rashes/Viral Exanthems, Common Benign Skin Lesions, CommonDermatological MalignanciesSOB: Emphysema, COPD, AsthmaSubstances: Tobacco, Alcohol, Prescription Drugs, Illicit DrugsUpper RTI: Allergic Rhinitis, Otitis Media, Pharyngitis/Sore Throat, Sinusitis, Viral URIVomiting: GastroenteritisViolence: Family Violence, Sexual Violence, Child Abuse, Senior AbuseMiscellaneous: Medication Compliance, Anticipatory Guidance/Family Life Cycle Issues, Referral and Consultation--------------------------------------------------------------------------------------------------------------------------------------------Emergency Medicine Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Class of drugs that may cause syndrome of muscle Antipsychotics (neuroleptic malignant syndrome). rigidity, hyperthermia, autonomic instability, and extrapyramidal symptoms. Side effects of corticosteroids. Acute mania, immunosuppression, thin skin, osteoporosis, easy bruising, myopathies. Treatment for DTs. Benzodiazepines. Treatment for acetaminophen overdose. N-acetylcysteine. Treatment for opioid overdose. Naloxone. Treatment for benzodiazepine overdose. Flumazenil. Treatment for neuroleptic malignant syndrome and Dantrolene. malignant hyperthermia. Treatment for malignant hypertension. Nitroprusside. Treatment of atrial fibrillation. Rate control, rhythm conversion, and anticoagulation. Treatment of supraventricular tachycardia. If stable, rate control with carotid massage or other vagal stimulation; if unsuccessful, consider adenosine. Causes of drug-induced SLE. INH, penicillamine, hydralazine, procainamide, chlorpromazine, methyldopa, quinidine. Macrocytic, megaloblastic anemia with neurologic B12 deficiency. symptoms. Macrocytic, megaloblastic anemia without neurologic Folate deficiency. symptoms. A burn patient presents with cherry-red flushed skin Treat CO poisoning with 100% O2 or with hyperbaric and coma. SaO2 is normal, but carboxyhemoglobin is O2 if poisoning is severe or the patient is pregnant. elevated. Treatment? Blood in the urethral meatus or high-riding prostate. Bladder rupture or urethral injury. Test to rule out urethral injury. Retrograde cystourethrogram. The most common organism in burn-related infections. Pseudomonas. Method of calculating fluid repletion in burn patients. Parkland formula.
Radiographic indications for surgery in patients with Free air under the diaphragm, extravasation of contrast, acute abdomen. severe bowel distention, space-occupying lesion (CT), mesenteric occlusion (angiography). Acceptable urine output in a trauma patient. 50 cc/hr. Acceptable urine output in a stable patient. 30 cc/hr. Cannon "a" waves. Third-degree heart block. Signs of neurogenic shock. Hypotension and bradycardia. Signs of ↑ ICP (Cushing's triad). Hypertension, bradycardia, and abnormal respirations. ↓ CO, ↓ pulmonary capillary wedge pressure (PCWP), Hypovolemic shock. ↑ peripheral vascular resistance (PVR). ↓ CO, ↑ PCWP, ↑ PVR. Cardiogenic (or obstructive) shock. ↑ CO, ↓ PCWP, ↓ PVR. Septic or anaphylactic shock. Treatment of septic shock. Fluids and antibiotics. Treatment of cardiogenic shock. Identify cause; pressors (e.g., dopamine). Treatment of hypovolemic shock. Identify cause; fluid and blood repletion. Treatment of anaphylactic shock. Diphenhydramine or epinephrine 1:1000. Supportive treatment for ARDS. Continuous positive airway pressure. Signs of air embolism. A patient with chest trauma who was previously stable suddenly dies. Trauma series. AP chest, AP/lateral C-spine, AP pelvis.--------------------------------------------------------------------------------------------------------------------------------------------Cardiovascular Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Classic ECG finding in atrial flutter. "Sawtooth" P waves. Definition of unstable angina. Angina is new, is worsening, or occurs at rest. Antihypertensive for a diabetic patient with proteinuria. ACEI. Beck's triad for cardiac tamponade. Hypotension, distant heart sounds, and JVD. Drugs that slow AV node transmission. β-blockers, digoxin, calcium channel blockers. Hypercholesterolemia treatment that leads to flushing Niacin. and pruritus. Murmur: hypertrophic obstructive cardiomyopathy Systolic ejection murmur heard along the lateral sternal (HOCM). border that ↑ with Valsalva maneuver and standing. Murmur: aortic insufficiency. Diastolic, decrescendo, high-pitched, blowing murmur that is best heard sitting up; ↑ with ↓ preload (handgrip maneuver). Murmur: aortic stenosis. Systolic crescendo/decrescendo murmur that radiates to the neck; ↑ with ↑ preload (Valsalva maneuver). Murmur: mitral regurgitation. Holosystolic murmur radiating axillae or carotids. Murmur: mitral stenosis. Diastolic, mid- to late, low-pitched murmur. Treatment for atrial fibrillation and atrial flutter. If unstable, cardiovert. If stable or chronic, rate control with calcium channel blockers or β-blockers. Treatment for ventricular fibrillation. Immediate cardioversion. Autoimmune problem occurring 2-4 weeks post-MI. Dressler's syndrome: fever, pericarditis, ↑ ESR. IV drug use with JVD and holosystolic murmur at the Treat existing heart failure and replace the tricuspid left sternal border. Treatment? valve. Diagnostic test for hypertrophic cardiomyopathy. Echocardiogram (showing thickened left ventricular wall and outflow obstruction). A fall in systolic BP of > 10 mmHg with inspiration. Pulsus paradoxus (seen in cardiac tamponade). Classic ECG findings in pericarditis. Low-voltage, diffuse ST-segment elevation. Definition of hypertension. BP > 140/90 on three separate occasions 2 weeks apart.
Eight surgically correctable causes of hypertension. Renal artery stenosis, coarctation of the aorta, pheochromocytoma, Conn's syndrome, Cushing's syndrome, unilateral renal parenchymal disease, hyperthyroidism, hyperparathyroidism. Evaluation of a pulsatile abdominal mass and bruit. Abdominal ultrasound and CT. Indications for surgical repair of abdominal aortic > 5.5 cm, rapidly enlarging, symptomatic, or ruptured. aneurysm. Treatment for acute coronary syndrome. Morphine, O2, sublingual nitroglycerin, ASA, IV β- blockers, heparin. What is metabolic syndrome? Abdominal obesity, high triglycerides, low HDL, hypertension, insulin resistance, prothrombotic or proinflammatory states. Appropriate diagnostic test? A 50-year-old man with Exercise stress treadmill with ECG. angina can exercise to 85% of maximum predicted heart rate. Appropriate diagnostic test? A 65-year-old woman Pharmacologic stress test (e.g., dobutamine echo). with left bundle branch block and severe osteoarthritis has unstable angina. Target LDL in a patient with diabetes. < 70. Signs of active ischemia during stress testing. Angina, ST-segment changes on ECG, or ↓ BP. ECG findings suggesting MI. ST-segment elevation (depression means ischemia), flattened T waves, and Q waves. Coronary territories in MI. Anterior wall (LAD/diagonal), inferior (PDA), posterior (left circumflex/oblique, RCA/marginal), septum (LAD/diagonal). A young patient has angina at rest with ST-segment Prinzmetal's angina. elevation. Cardiac enzymes are normal. Common symptoms associated with silent Mls. CHF, shock, and altered mental status. The diagnostic test for pulmonary embolism. V/Q scan. An agent that reverses the effects of heparin. Protamine. The coagulation parameter affected by warfarin. PT. A young patient with a family history of sudden death Hypertrophic cardiomyopathy. collapses and dies while exercising. Endocarditis prophylaxis regimens. Oral surgery—amoxicillin; GI or GU procedures— ampicillin and gentamicin before and amoxicillin after. The 6 P's of ischemia due to peripheral vascular Pain, pallor, pulselessness, paralysis, paresthesia, disease. poikilothermia. Virchow's triad. Stasis, hypercoagulability, endothelial damage. The most common cause of HTN in young women. OCPs. The most common cause of HTN in young men. Excessive EtOH.--------------------------------------------------------------------------------------------------------------------------------------------Dermatology Rapid Review – First Aid For USMLE Step 2 (3rd, Le) "Stuck-on" appearance. Seborrheic keratosis. Red plaques with silvery-white scales, sharp margins. Psoriasis. The most common type of skin cancer; the lesion is a Basal cell carcinoma. pearly-colored papule with a translucent surface and telangiectasias. Honey-crusted lesions. Impetigo. A febrile patient with a history of diabetes presents Cellulitis. with a red, swollen, painful lower extremity. Positive Nikolsky's sign. Pemphigus vulgaris. Negative Nikolsky's sign. Bullous pemphigoid.
A 55-year-old obese patient presents with dirty, velvety Acanthosis nigricans. Check fasting blood glucose to patches on the back of the neck. rule out diabetes. Dermatomal distribution. Varicella zoster. Flat-topped papules. Lichen planus. Iris-like target lesions. Erythema multiforme. A lesion characteristically occurring in a linear pattern Contact dermatitis. in areas where skin contacts clothing or jewelry. Presents with a herald patch, Christmas-tree pattern. Pityriasis rosea. A 16-year-old presents with an annular patch of Alopecia areata (an autoimmune process). alopecia with broken-off, stubby hairs. Pinkish, scaling, flat lesions on the chest and back; Pityriasis versicolor. KOH prep has a "spaghetti-and-meatballs" appearance. Four characteristics of a nevus suggestive of Asymmetry, border irregularity, color variation, and melanoma. large diameter. A premalignant lesion from sun exposure that can lead Actinic keratosis. to squamous cell carcinoma. "Dewdrops on a rose petal." Lesions of 1° varicella. "Cradle cap." Seborrheic dermatitis. Treat with antifungals. Associated with Propionibacterium acnes and changes Acne vulgaris. in androgen levels. A painful, recurrent vesicular eruption of Herpes simplex. mucocutaneous surfaces. Inflammation and epithelial thinning of the anogenital Lichen sclerosus. area, predominantly in postmenopausal women. Exophytic nodules on the skin with varying degrees of Squamous cell carcinoma. scaling or ulceration; the second most common type of skin cancer.--------------------------------------------------------------------------------------------------------------------------------------------Endocrinology Rapid Review – First Aid For USMLE Step 2 (3rd, Le) The most common cause of hypothyroidism. Hashimoto's thyroiditis. Lab findings in Hashimoto's thyroiditis. High TSH, low T4, antimicrosomal antibodies. Exophthalmos, pretibial myxedema, and ↓ TSH. Graves' disease. The most common cause of Cushing's syndrome. Iatrogenic corticosteroid administration. The second most common cause is Cushing's disease. A patient presents with signs of hypocalcemia, high Hypoparathyroidism. phosphorus, and low PTH. "Stones, bones, groans, psychiatric overtones." Signs and symptoms of hypercalcemia. A patient complains of headache, weakness, and 1° hyperaldosteronism (due to Conn's syndrome or polyuria; exam reveals hypertension and tetany. Labs bilateral adrenal hyperplasia). reveal hypernatremia, hypokalemia, and metabolic alkalosis. A patient presents with tachycardia, wild swings in BP, Pheochromocytoma. headache, diaphoresis, altered mental status, and a sense of panic. Should α- or β-antagonists be used first in treating α-antagonists (phentolamine and phenoxybenzamine). pheochromocytoma? A patient with a history of lithium use presents with Nephrogenic diabetes insipidus (DI). copious amounts of dilute urine. Treatment of central DI. Administration of DDAVP ↓ serum osmolality and free water restriction. A postoperative patient with significant pain presents SIADH due to stress. with hyponatremia and normal volume status.
The percentage of cases within one SD of the mean? 68%, 95.4%, 99.7%. Two SDs? Three SDs? Birth rate? Number of live births per 1000 population in one year. Fertility rate? Number of live births per 1000 females (15–44 years of age) in one year. Mortality rate? Number of deaths per 1000 population in one year. Neonatal mortality rate? Number of deaths from birth to 28 days per 1000 live births in one year. Postnatal mortality rate? Number of deaths from 28 days to one year per 1000 live births in one year. Infant mortality rate? Number of deaths from birth to one year of age per 1000 live births (neonatal + postnatal mortality) in one year. Fetal mortality rate? Number of deaths from 20 weeks' gestation to birth per 1000 total births in one year. Perinatal mortality rate? Number of deaths from 20 weeks' gestation to one month of life per 1000 total births in one year. Maternal mortality rate? Number of deaths during pregnancy to 90 days postpartum per 100,000 live births in one year.--------------------------------------------------------------------------------------------------------------------------------------------Ethics Rapid Review – First Aid For USMLE Step 2 (3rd, Le) True or false: Once patients sign a statement giving False. Patients may change their minds at any time. consent, they must continue treatment. Exceptions to the requirement of informed consent include emergency situations and patients without decision-making capacity. A 15-year-old pregnant girl requires hospitalization for No. Parental consent is not necessary for the medical preeclampsia. Is parental consent required? treatment of pregnant minors. Doctor refers patient for an MRI at a facility she owns. Conflict of interest. Involuntary psychiatric hospitalization can be The patient is a danger to self, a danger to others, or undertaken for which three reasons? gravely disabled (unable to provide for basic needs). True or false: Withdrawing a nonbeneficial treatment is True. ethically similar to withholding a nonindicated one. When can a physician refuse to continue treating a When there is no rationale for treatment, maximal patient on the grounds of futility? intervention is failing, a given intervention has already failed, and treatment will not achieve the goals of care. An 8yo child is in a serious accident. She requires Treat immediately. Consent is implied in emergency emergent transfusion, but her parents are not present. situations. A son asks that his mother not be told about her A physician can withhold information from the patient recently discovered cancer. only in the rare case of therapeutic privilege or if the patient requests not to be told. A patient's family cannot require the physician to withhold information from the patient. Conditions in which confidentiality must be Real threat of harm to third parties; suicidal intentions; overridden. certain contagious diseases; elder and child abuse. Involuntary commitment or isolation for medical When treatment noncompliance represents a serious treatment may be undertaken for what reason? danger to public health (e.g., active TB). A 10-year-old child presents in status epilepticus, but Treat because the disease represents an immediate her parents refuse treatment on religious grounds. threat to the child's life. Then seek a court order.--------------------------------------------------------------------------------------------------------------------------------------------Gastrointestinal Rapid Review – First Aid For USMLE Step 2 (3rd, Le) The most likely cause of acute lower GI bleed in Diverticulosis. patients > 40 years of age.
A patient presents with sudden onset of severe, diffuse Emergent laparotomy to repair perforated viscus. abdominal pain. Exam reveals peritoneal signs, and AXR reveals free air under the diaphragm. Management? Diagnostic modality used when ultrasound is equivocal HIDA scan. for cholecystitis. Risk factors for cholelithiasis. Fat, female, fertile, forty, flatulent. Inspiratory arrest during palpation of the RUQ. Murphy's sign, seen in acute cholecystitis. The most common cause of SBO in patients with no Hernia. history of abdominal surgery. The most common cause of SBO in patients with a Adhesions. history of abdominal surgery. Diarrhea: Most common organism Campylobacter Diarrhea: Recent antibiotic use Clostridium difficile Diarrhea: Camping Giardia Diarrhea: Traveler's ETEC Diarrhea: Church picnics/mayonnaise S. aureus Diarrhea: Uncooked hamburgers E. coli O157:H7 Diarrhea: Fried rice Bacillus cereus Diarrhea: Poultry/eggs Salmonella Diarrhea: Raw seafood Vibrio, HAV Diarrhea: AIDS Isospora, Cryptosporidium, Mycobacterium avium complex (MAC) Diarrhea: Pseudoappendicitis Yersinia A 25-year-old Jewish man presents with pain and Crohn's disease. watery diarrhea after meals. Exam shows fistulas between the bowel and skin and nodular lesions on his tibias. Inflammatory disease of the colon with ↑ risk of colon Ulcerative colitis (greater risk than Crohn's). cancer. Extraintestinal manifestations of IBD. Uveitis, ankylosing spondylitis, pyoderma gangrenosum, erythema nodosum, 1° sclerosing cholangitis. Medical treatment for IBD. 5-ASA agents and steroids during acute exacerbations. Difference between Mallory-Weiss and Boerhaave Mallory-Weiss—superficial tear in the esophageal tears. mucosa; Boerhaave—full-thickness esophageal rupture. Charcot's triad. RUQ pain, jaundice, and fever/chills in the setting of ascending cholangitis. Reynolds' pentad. Charcot's triad plus shock and mental status changes, with suppurative ascending cholangitis. Medical treatment for hepatic encephalopathy. ↓ protein intake, lactulose, rifaximin. First step in the management of a patient with an acute Establish the ABCs. GI bleed. A four-year-old child presents with oliguria, petechiae, Hemolytic-uremic syndrome (HUS) due to E. coli and jaundice following an illness with bloody diarrhea. O157: H7. Most likely diagnosis and cause? Post-HBV exposure treatment. HBV immunoglobulin. Classic causes of drug-induced hepatitis. TB medications (INH, rifampin, pyrazinamide), acetaminophen, and tetracycline. Hernia with highest risk of incarceration—indirect, Femoral hernia. direct, or femoral?
Microcytic anemia with ↓ serum iron, ↓ total iron- Anemia of chronic disease. binding capacity (TIBC), and normal or ↑ ferritin. Microcytic anemia with ↓ serum iron, ↓ ferritin, and ↑ Iron deficiency anemia. TIBC. An 80-year-old man presents with fatigue, Chronic lymphocytic leukemia (CLL). lymphadenopathy, splenomegaly, and isolated lymphocytosis. Suspected diagnosis? The lymphoma equivalent of CLL. Small lymphocytic lymphoma. A late, life-threatening complication of chronic Blast crisis (fever, bone pain, splenomegaly, myelogenous leukemia (CML). pancytopenia). Auer rods on blood smear. Acute myelogenous leukemia (AML). AML subtype associated with DIC. M3. Electrolyte changes in tumor lysis syndrome. ↓ Ca2+, ↑ K+, ↑ phosphate, ↑ uric acid. Treatment for AML M3. Retinoic acid. A 50-year-old man presents with early satiety, CML. splenomegaly, and bleeding. Cytogenetics show t(9,22). Diagnosis? Heinz bodies? Intracellular inclusions seen in thalassemia, G6PD deficiency, and postsplenectomy. An autosomal-recessive disorder with a defect in the Glanzmann's thrombasthenia. GPIIbIIIa platelet receptor and ↓ platelet aggregation. Virus associated with aplastic anemia in patients with Parvovirus B19. sickle cell anemia. A 25-year-old African-American man with sickle cell O2, analgesia, hydration, and, if severe, transfusion. anemia has sudden onset of bone pain. Management of pain crisis? A significant cause of morbidity in thalassemia Iron overload; use deferoxamine. patients. Treatment?--------------------------------------------------------------------------------------------------------------------------------------------Infectious Disease Rapid Review – First Aid For USMLE Step 2 (3rd, Le) The three most common causes of fever of unknown Infection, cancer, and autoimmune disease. origin (FUO). Four signs and symptoms of streptococcal pharyngitis. Fever, pharyngeal erythema, tonsillar exudate, lack of cough. A nonsuppurative complication of streptococcal Postinfectious glomerulonephritis. infection that is not altered by treatment of 1° infection. Asplenic patients are particularly susceptible to these Encapsulated organisms—pneumococcus, organisms. meningococcus, Haemophilus influenzae, Klebsiella. The number of bacteria on a clean-catch specimen to 10^5 bacteria/mL. diagnose a UTI. Which healthy population is susceptible to UTIs? Pregnant women. Treat this group aggressively because of potential complications. A patient from California or Arizona presents with Coccidioidomycosis. Amphotericin B. fever, malaise, cough, and night sweats. Diagnosis? Treatment? Nonpainful chancre. 1° syphilis. A "blueberry muffin" rash is characteristic of what Rubella. congenital infection? Meningitis in neonates. Causes? Treatment? Group B strep, E. coli, Listeria. Treat with gentamicin and ampicillin. Meningitis in infants. Causes? Treatment? Pneumococcus, meningococcus, H. influenzae. Treat with cefotaxime and vancomycin.
What should always be done prior to LP? Check for ↑ ICP; look for papilledema. CSF: Low glucose, PMN predominance Bacterial meningitis CSF: Normal glucose, lymphocytic predominance Aseptic (viral) meningitis CSF: Numerous RBCs in serial CSF samples Subarachnoid hemorrhage (SAH) CSF: ↑ gamma globulins MS Initially presents with a pruritic papule with regional Cutaneous anthrax. Treat with penicillin G or lymphadenopathy; evolves into a black eschar after 7– ciprofloxacin. 10 days. Treatment? Findings in 3° syphilis. Tabes dorsalis, general paresis, gummas, Argyll Robertson pupil, aortitis, aortic root aneurysms. Characteristics of 2° Lyme disease. Arthralgias, migratory polyarthropathies, Bell's palsy, myocarditis. Cold agglutinins. Mycoplasma. A 24-year-old man presents with soft white plaques on Candidal thrush. Workup should include an HIV test. his tongue and the back of his throat. Diagnosis? Treat with nystatin oral suspension. Workup? Treatment? Begin Pneumocystis jiroveci (formerly P. carinii) ≤ 200 for P. jiroveci (with TMP-SMX); ≤ 50–100 for pneumonia prophylaxis in an HIV-positive patient at MAI (with clarithromycin/azithromycin). what CD4 count? Mycobacterium avium–intracellulare (MAI) prophylaxis? Risk factors for pyelonephritis. Pregnancy, vesicoureteral reflux, anatomic anomalies, indwelling catheters, kidney stones. Neutropenic nadir postchemotherapy. 7–10 days. Erythema migrans. Lesion of 1° Lyme disease. Classic physical findings for endocarditis. Fever, heart murmur, Osler's nodes, splinter hemorrhages, Janeway lesions, Roth's spots. Aplastic crisis in sickle cell disease. Parvovirus B19. Ring-enhancing brain lesion on CT with seizures. Taenia solium (cysticercosis). Organism: Branching rods in oral infection Actinomyces israelii Organism: Painful chancroid Haemophilus ducreyi Organism: Dog or cat bite Pasteurella multocida Organism: Gardener Sporothrix schenckii Organism: Pregnant women with pets Toxoplasma gondii Organism: Meningitis in adults Neisseria meningitidis Organism: Meningitis in elderly Streptococcus pneumoniae Organism: Alcoholic with pneumonia Klebsiella Organism: "Currant jelly" sputum Klebsiella Organism: Infection in burn victims Pseudomonas Organism: Osteomyelitis from foot wound puncture Pseudomonas Organism: Osteomyelitis in sickle cell patient Salmonella A 55-year-old man who is a smoker and a heavy Legionella pneumonia. drinker presents with a new cough and flulike symptoms. Gram stain shows no organisms; silver stain of sputum shows gram-negative rods. What is the diagnosis? A middle-aged man presents with acute-onset Lyme disease, Ixodes tick, doxycycline. monoarticular joint pain and bilateral Bell's palsy. What is the likely diagnosis, and how did he get it? Treatment? A patient develops endocarditis three weeks after S. aureus or S. epidermidis. receiving a prosthetic heart valve. What organism is suspected?
DO NOT DISTRIBUTE - 10 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
--------------------------------------------------------------------------------------------------------------------------------------------Musculoskeletal Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Back pain that is exacerbated by standing and walking Spinal stenosis. and relieved with sitting and hyperflexion of the hips. Joints in the hand affected in rheumatoid arthritis. MCP and PIP joints; DIP joints are spared. Joint pain and stiffness that worsen over the course of Osteoarthritis. the day and are relieved by rest. Genetic disorder associated with multiple fractures and Osteogenesis imperfecta. commonly mistaken for child abuse. Hip and back pain along with stiffness that improves Suspect ankylosing spondylitis. Check HLA-B27. with activity over the course of the day and worsens at rest. Diagnostic test? Arthritis, conjunctivitis, and urethritis in young men. Reactive (Reiter's) arthritis. Associated with Associated organisms? Campylobacter, Shigella, Salmonella, Chlamydia, and Ureaplasma. A 55-year-old man has sudden, excruciating first MTP Gout. Needle-shaped, negatively birefringent crystals joint pain after a night of drinking red wine. Diagnosis, are seen on joint fluid aspirate. Chronic treatment with workup, and chronic treatment? allopurinol or probenecid. Rhomboid-shaped, positively birefringent crystals on Pseudogout. joint fluid aspirate. An elderly woman presents with pain and stiffness of Polymyalgia rheumatica. the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR. An active 13-year-old boy has anterior knee pain. Osgood-Schlatter disease. Diagnosis? Bone is fractured in a fall on an outstretched hand. Distal radius (Colles' fracture). Complication of scaphoid fracture. Avascular necrosis. Signs suggesting radial nerve damage with humeral Wrist drop, loss of thumb abduction. fracture. A young child presents with proximal muscle Duchenne muscular dystrophy. weakness, waddling gait, and pronounced calf muscles. A first-born female who was born in breech position is Developmental dysplasia of the hip. If severe, consider found to have asymmetric skin folds on her newborn a Pavlik harness to maintain abduction. exam. Diagnosis? Treatment? An 11-year-old obese African-American boy presents Slipped capital femoral epiphysis. AP and frog-leg with sudden onset of limp. Diagnosis? Workup? lateral view. The most common 1° malignant tumor of bone. Multiple myeloma.--------------------------------------------------------------------------------------------------------------------------------------------Neurology Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Unilateral, severe periorbital headache with tearing and Cluster headache. conjunctival erythema. Prophylactic treatment for migraine. Antihypertensives, antidepressants, anticonvulsants. The most common pituitary tumor. Treatment? Prolactinoma. Dopamine agonists (e.g., bromocriptine). A 55-year-old patient presents with acute "broken Broca's aphasia. Frontal lobe, left MCA distribution. speech." What type of aphasia? What lobe and vascular distribution? The most common cause of SAH. Trauma; the second most common is berry aneurysm. A crescent-shaped hyperdensity on CT that does not Subdural hematoma—bridging veins torn. cross the midline. A history significant for initial altered mental status Epidural hematoma. Middle meningeal artery. with an intervening lucid interval. Diagnosis? Most Neurosurgical evacuation. likely source? Treatment? CSF findings with SAH. Elevated ICP, RBCs, xanthochromia.
DO NOT DISTRIBUTE - 11 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
DO NOT DISTRIBUTE - 12 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
DO NOT DISTRIBUTE - 13 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
Breast cancer type that ↑ the future risk of invasive Lobular carcinoma in situ. carcinoma in both breasts.--------------------------------------------------------------------------------------------------------------------------------------------Pediatrics Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Nontender abdominal mass associated with elevated Neuroblastoma. VMA and HVA. The most common type of tracheoesophageal fistula Esophageal atresia with distal TEF (85%). Unable to (TEF). Diagnosis? pass NG tube. Not contraindications to vaccination. Mild illness and/or low-grade fever, current antibiotic therapy, and prematurity. Tests to rule out shaken baby syndrome. Ophthalmologic exam, CT, and MRI. A neonate has meconium ileus. CF or Hirschsprung's disease. Bilious emesis within hours after the first feeding. Duodenal atresia. A two-month-old baby presents with nonbilious Correct metabolic abnormalities. Then correct pyloric projectile emesis. What are the appropriate steps in stenosis with pyloromyotomy. management? The most common 1° immunodeficiency. Selective IgA deficiency. An infant has a high fever and onset of rash as fever Febrile seizures (roseola infantum). breaks. What is he at risk for? Immunodeficiency: A boy has chronic respiratory Chronic granulomatous disease infections. Nitroblue tetrazolium test is positive. Immunodeficiency: A child has eczema, Wiskott-Aldrich syndrome thrombocytopenia, and high levels of IgA. Immunodeficiency: A four-month-old boy has life- Bruton's X-linked agammaglobulinemia threatening Pseudomonas infection. Acute-phase treatment for Kawasaki disease. High-dose aspirin for inflammation and fever; IVIG to prevent coronary artery aneurysms. Treatment for mild and severe unconjugated Phototherapy (mild) or exchange transfusion (severe). hyperbilirubinemia. Sudden onset of mental status changes, emesis, and Reye's syndrome. liver dysfunction after taking aspirin. A child has loss of red light reflex. Diagnosis? Suspect retinoblastoma. Vaccinations at a six-month well-child visit. HBV, DTaP, Hib, IPV, PCV. Tanner stage 3 in a six-year-old girl. Precocious puberty. Infection of small airways with epidemics in winter RSV bronchiolitis. and spring. Cause of neonatal RDS. Surfactant deficiency. A condition associated with red "currant-jelly" stools. Intussusception. A congenital heart disease that causes 2° hypertension. Coarctation of the aorta. First-line treatment for otitis media. Amoxicillin × 10 days. The most common pathogen causing croup. Parainfluenza virus type 1. A homeless child is small for his age and has peeling Kwashiorkor (protein malnutrition). skin and a swollen belly. Defect in an X-linked syndrome with mental Lesch-Nyhan syndrome (purine salvage problem with retardation, gout, self-mutilation, and choreoathetosis. HGPRTase deficiency). A newborn girl has a continuous "machinery murmur." Patent ductus arteriosus (PDA).--------------------------------------------------------------------------------------------------------------------------------------------Psychiatry Rapid Review – First Aid For USMLE Step 2 (3rd, Le) First-line pharmacotherapy for depression. SSRIs. Antidepressants associated with hypertensive crisis. MAOIs. Galactorrhea, impotence, menstrual dysfunction, and ↓ Patient on dopamine antagonist. libido.
DO NOT DISTRIBUTE - 14 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
A 17-year-old girl has left arm paralysis after her Conversion disorder. boyfriend dies in a car crash. No medical cause found. Defense mechanism: A mother who is angry at her Displacement husband yells at her child. Defense mechanism: A pedophile enters a monastery. Reaction formation Defense mechanism: A woman calmly describes a Isolation grisly murder. Defense mechanism: A hospitalized 10-year-old begins Regression to wet his bed. Life-threatening muscle rigidity, fever, and Neuroleptic malignant syndrome. rhabdomyolysis. Amenorrhea, bradycardia, and abnormal body image in Anorexia. a young female. A 35-year-old man has recurrent episodes of Panic disorder. palpitations, diaphoresis, and fear of going crazy. The most serious side effect of clozapine. Agranulocytosis. A 21-year-old man has three months of social Schizophreniform disorder (diagnosis of schizophrenia withdrawal, worsening grades, flattened affect, and requires ≥ 6 months of symptoms). concrete thinking. Key side effects of atypical antipsychotics. Weight gain, type 2 DM, QT prolongation. A young weight lifter receives IV haloperidol and Acute dystonia (oculogyric crisis). Treat with complains that his eyes are deviated sideways. benztropine or diphenhydramine. Diagnosis? Treatment? Medication to avoid in patients with a history of Neuroleptics. alcohol withdrawal seizures. A 13-year-old boy has a history of theft, vandalism, Conduct disorder. and violence toward family pets. A five-month-old girl has ↓ head growth, truncal Rett's disorder. dyscoordination, and ↓ social interaction. A patient hasn't slept for days, lost $20,000 gambling, Acute mania. Start a mood stabilizer (e.g., lithium). is agitated, and has pressured speech. Diagnosis? Treatment? After a minor fender bender, a man wears a neck brace Malingering. and requests permanent disability. A nurse presents with severe hypoglycemia; blood Factitious disorder (Munchausen syndrome). analysis reveals no elevation in C-peptide. A patient continues to use cocaine after being in jail, Substance abuse. losing his job, and not paying child support. A violent patient has vertical/horizontal nystagmus. Phencyclidine hydrochloride (PCP) intoxication. A woman who was abused as a child frequently feels Depersonalization disorder. outside of or detached from her body. A man has repeated, intense urges to rub his body Frotteurism (a paraphilia). against unsuspecting passengers on a bus. A schizophrenic patient takes haloperidol for one year Tardive dyskinesia. ↓ or discontinue haloperidol and and develops uncontrollable tongue movements. consider another antipsychotic (e.g., risperidone, Diagnosis? Treatment? clozapine). A man unexpectedly flies across the country, takes a Dissociative fugue. new name, and has no memory of his prior life.--------------------------------------------------------------------------------------------------------------------------------------------Pulmonary Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Risk factors for DVT. Stasis, endothelial injury, and hypercoagulability (Virchow's triad).
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Criteria for exudative effusion. Pleural/serum protein > 0.5; pleural/serum LDH > 0.6. Causes of exudative effusion. Think of leaky capillaries. Malignancy, TB, bacterial or viral infection, pulmonary embolism with infarct, and pancreatitis. Causes of transudative effusion. Think of intact capillaries. CHF, liver or kidney disease, and protein-losing enteropathy. Normalizing PCO2 in a patient having an asthma Fatigue and impending respiratory failure. exacerbation may indicate? Dyspnea, bilateral hilar lymphadenopathy on CXR, Sarcoidosis. noncaseating granulomas, ↑ ACE, and hypercalcemia. PFTs showing ↓ FEV1/FVC. Obstructive pulmonary disease (e.g., asthma). PFTs showing ↑ FEV1/FVC. Restrictive pulmonary disease. Honeycomb pattern on CXR. Diagnosis? Treatment? Diffuse interstitial pulmonary fibrosis. Supportive care. Steroids may help. Treatment for SVC syndrome. Radiation. Treatment for mild, persistent asthma. Inhaled β-agonists and inhaled corticosteroids. Treatment for COPD exacerbation. O2, bronchodilators, antibiotics, corticosteroids with taper, smoking cessation. Treatment for chronic COPD. Smoking cessation, home O2, β-agonists, anticholinergics, systemic or inhaled corticosteroids, flu and pneumococcal vaccines. Acid-base disorder in pulmonary embolism. Hypoxia and hypocarbia (respiratory alkalosis). Non–small cell lung cancer (NSCLC) associated with Squamous cell carcinoma. hypercalcemia. Lung cancer associated with SIADH. Small cell lung cancer (SCLC). Lung cancer highly related to cigarette exposure. SCLC. A tall white male presents with acute shortness of Spontaneous pneumothorax. Spontaneous regression. breath. Diagnosis? Treatment? Supplemental O2 may be helpful. Treatment of tension pneumothorax. Immediate needle thoracostomy. Characteristics favoring carcinoma in an isolated Age > 45–50 years; lesions new or larger in pulmonary nodule. comparison to old films; absence of calcification or irregular calcification; size > 2 cm; irregular margins. Hypoxemia and pulmonary edema with normal ARDS. pulmonary capillary wedge pressure. Sequelae of asbestos exposure. Pulmonary fibrosis, pleural plaques, bronchogenic carcinoma (mass in lung field), mesothelioma (pleural mass). ↑ risk of what infection with silicosis? Mycobacterium tuberculosis. Causes of hypoxemia. Right-to-left shunt, hypoventilation, low inspired O2 tension, diffusion defect, V/Q mismatch. Classic CXR findings for pulmonary edema. Cardiomegaly, prominent pulmonary vessels, Kerley B lines, "bat's-wing" appearance of hilar shadows, and perivascular and peribronchial cuffing.--------------------------------------------------------------------------------------------------------------------------------------------Renal/Genitourinary Rapid Review – First Aid For USMLE Step 2 (3rd, Le) Renal tubular acidosis (RTA) associated with abnormal Type I (distal) RTA. H+ secretion and nephrolithiasis. RTA associated with abnormal HCO3– and rickets. Type II (proximal) RTA. RTA associated with aldosterone defect. Type IV (distal) RTA. "Doughy" skin Hypernatremia. Differential of hypervolemic hyponatremia. Cirrhosis, CHF, nephritic syndrome. Chvostek's and Trousseau's signs. Hypocalcemia.
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2) Body fat "distributions" by waist circumference (WC) and waist-to-hip ratio (WHR) are much better markers forcardiovascular risk than the body mass index (BMI) alone. In fact, a WC <100 cm practically excludes insulinresistance.3) An acute difference in systolic pressure >20 mmHg between the two arms usually indicates aortic dissection(complicated by aortic regurgitation in cases of more proximal dissection). If chronic, it indicates instead asubclavian artery occlusion or a subclavian steal syndrome.4) An ankle-to-arm systolic pressure index (AAI) <0.97 identifies patients with angiographically provenocclusions/stenoses of lower extremities arteries with 96% sensitivity and 94-100% specificity. Most patients withclaudication will have AAI values between 0.5 and 0.8, whereas those with pain at rest will have values <0.5.Indexes <0.2 are associated with ischemic or gangrenous extremities.5) Paired, transverse, white nail bands in the second, third, and fourth fingers (Muehrcke lines) suggest chronichypoalbuminemia, occurring in more than three quarters of patients with nephrotic syndrome (<2.3 gm/100mL) butalso in liver disease and malnutrition.6) In a study of 118 subjects with acrochordons (skin tags), 41% had either impaired glucose tolerance or overt type2 diabetes.7) Ten percent of patients with vitiligo have serologic or clinical evidence of autoimmune disorders; the mostcommon are thyroid diseases, especially hypothyroidism of the Hashimoto variety. Diabetes, Addison's, perniciousanemia, alopecia areata, and uveitis (Vogt-Koyanagi syndrome) also are frequent.8) Twenty percent of patients with acanthosis nigricans (AN) have an aggressive underlying neoplasm-agastrointestinal (GI) adenocarcinoma in 90% of cases, and a gastric in 60%. Still, most patients with AN have justobesity and insulin resistance.9) To separate icterus from the brownish color normally present in the bulbar conjunctiva of dark-skinnedindividuals, ask the patient to look upward. Then inspect the inferior conjunctival recess. This should be entirelywhite in nonicteric subjects, since the brownish discoloration of these individuals is the result of sunlight exposure.10) Earliest signs of nonproliferative diabetic retinopathy include microaneurysms and dot intraretinal hemorrhages,with progression of disease characterized by an increase in number and size of microaneurysms and intraretinalhemorrhages (both dot and blot). Soft exudates are not as predictive, and hard exudates even less.11) Diagonal earlobe creases in adults are an acquired phenomenon and a significant independent variable forcoronary artery disease. Hair in the external ear canal also seems to be associated with coronary artery disease.12) Findings that can best separate patients with and without strep throat are (1) pharyngeal or tonsillar exudates, (2)fever by history, (3) tonsillar enlargement, (4) tenderness or enlargement of the anterior cervical and jugulodigastriclymph nodes, and (5) absence of cough.13) Multiple white, warty, corrugated, and painless plaques on the lateral margins of the tongue (hairy leukoplakia)represent an Epstein-Barr-induced lesion typical of HIV infection, even though this can also occur in severelyimmunocompromised organ transplant patients. If present, it carries a worse prognosis for HIV progression.14) Pemberton's maneuver (reversible superior vena cava obstruction caused by a substernal goiter being "lifted"into the thoracic inlet as a result of arm raising) is a nonspecific finding that may be encountered in patients withsubsternal thyroid masses, lymphomas, or upper mediastinal tumors.15) The average size of a thyroid nodule detected on exam is 3 cm. In fact, the larger the nodule, the more likely itsdetection (with <1 cm nodules being missed 90% of the time; <2 cm nodules 50% of the time).16) Findings most suggestive of hyperthyroidism include lid retraction (likelihood ratio [LR] = 31.5), lid lag (LR =17.6), fine finger tremor (LR = 11.4), moist and warm skin (LR = 6.7), and tachycardia (LR = 4.4). Findings morelikely to rule out hyperthyroidism are normal thyroid size (LR = 0.1), heart rate <90/minute (LR = 0.2), and nofinger tremor (LR = 0.3). Older hyperthyroid patients exhibit more anorexia and atrial fibrillation; more frequentlack of goiter; and overall fewer signs, with tachycardia, fatigue, and weight loss in more than 50% of patients (andall three in 32%).17) Findings more strongly suggestive of hypothyroidism are bradycardia (LR = 3.88), abnormal ankle reflex (LR =3.41), and coarse skin (LR = 2.3). No single finding, when absent, can effectively rule out hypothyroidism.18) Clinical breast exam (CBE) has low sensitivity for the detection of breast masses, high specificity, and accuracythat can be increased by (1) longer duration of exam (at least 3 minutes per breast); (2) higher number of correctsteps (a systematic and vertical search pattern, thoroughness, varying palpation pressure, use of three fingers, fingerpads, and circular motion); and (3) examiner experience (previous training with silicone models).19) A brisk arterial upstroke with a widened pulse pressure indicates aortic regurgitation (AR). A brisk arterialupstroke with a normal pulse pressure instead indicates either the simultaneous emptying of the left ventricle into ahigh pressure bed (the aorta) and a lower pressure bed (like the right ventricle in patients with ventricular septaldefect, or the left atrium in patients with mitral regurgitation) or hypertrophic obstructive cardiomyopathy (HOCM).
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20) The alternation of strong and weak arterial pulses despite regular rate and rhythm (pulsus alternans) indicatessevere left ventricular dysfunction, with worse ejection fraction and higher pulmonary capillary pressure. Hence, itis often associated with an S3 gallop.21) Visible neck veins in the upright position indicate a central venous pressure >7 cmH2O and thus are pathologic.22) In chronic heart failure, jugular venous distention represents an ominous prognostic variable, independentlyassociated with adverse outcomes, including risk of death or hospitalization. The presence of S3 is similarly (andindependently) associated with increased risk.23) Presence of either end-inspiratory crackles or distended neck veins has high specificity (90-100%) but lowsensitivity (10-50%) for increased left-sided filling pressure due to either systolic or diastolic dysfunction.24) Positive abdominojugular reflux has equally high specificity (but better sensitivity, 55-85%) for increased left-sided filling pressure. S3 gallop, downward and lateral displacement of the apical impulse, and peripheral edemaalso have high specificity (>95%) but low sensitivity (10-40%). Of these, only the S3 and the displaced apicalimpulse have a positive likelihood ratio (5.7 and 5.8, respectively).25) In patients presenting with dyspnea, an abdominojugular reflux argues in favor of bi-ventricular failure andsuggests a pulmonary capillary wedge pressure >15 mmHg. Conversely, a negative abdominojugular reflux in apatient with dyspnea argues strongly against increased left atrial pressure.26) Posturally induced crackles (PICs) after myocardial infarction (MI) carry an ominous significance, reflectinghigher pulmonary capillary wedge pressure, lower pulmonary venous compliance, and higher mortality. After thenumber of diseased coronary vessels and the patient's pulmonary capillary wedge pressure, PICs rank third as mostimportant predictor of recovery after an acute MI.27) Ischemic heart disease patients with S3 have a 1-year mortality that is much higher than those without it (57%versus 14%). The same applies to a displaced apical impulse (39% versus 12%).28) Leg swelling without increased central venous pressure (CVP) suggests bilateral venous insufficiency ornoncardiac edema (hepatic or renal).29) The Valsalva maneuver has excellent specificity and sensitivity (90-99% and 70-95%, respectively) fordetecting left ventricular dysfunction, either systolic or diastolic.30) The PPP (proportional pulse pressure-arterial pulse pressure divided by the systolic blood pressure) has excellentsensitivity (91%) and specificity (83%) for identifying low cardiac index (CI). A PPP <0.25 has a positive likelihoodratio of 5.4 for CI of 2.2 L/min/m2.31) Patients with distended neck veins, dyspnea/tachypnea, tachycardia, and clear lungs should be thought of ashaving tamponade; thus, their pulsus paradoxus must be measured.32) A pulsus paradoxus >21 mmHg has good sensitivity and excellent specificity for tamponade. It also may bepalpable.33) A paradoxical increase in venous distention during inspiration (Kussmaul's sign) is not a feature of tamponadebut does occur in 30-50% of patients with "pure" constrictive pericarditis; 90% of patients with constrictivepericarditis also have a retracting apical impulse.34) A loud S1 should always alert the clinician to the possibility of mitral stenosis and should thus prompt a searchfor its associated diastolic rumble.35) An audible physiologic splitting of S2 is age dependent, present in 60% of subjects younger than 30 and 30% ofthose older than 60.36) Wide splitting of S2 usually reflects a delayed closure of the pulmonic valve because of either a right bundlebranch block or pulmonary hypertension.37) S2 that remains audibly split throughout respiration, both in the supine and upright positions, with a consistentinterval between its two components, argues in favor of an atrial septal defect.38) S2 that becomes audibly split only in exhalation, while remaining single in inspiration (paradoxical or reversedsplitting), means pathology until proven otherwise. This is usually an increased impedance to left ventricularemptying (aortic stenosis, coarctation, or hypertension), a left bundle branch block, or a transient, left ventricularischemia.39) A loud and ringing S2, rich in overtones and tambour like ("drum" in French), indicates a dilation of the aorticroot. When associated with an aortic regurgitation murmur, it suggests Marfan syndrome, syphilis (Potain's sign), ora dissecting aneurysm of the ascending aorta (Harvey's sign).40) S3 is such an accurate predictor of systolic dysfunction (and elevated atrial pressure) that its absence argues infavor of an ejection fraction >30%.41) In patients with congestive heart failure, S3 is the best predictor for response to digitalis and overall mortality. Itcorrelates with high levels of B-type natriuretic peptide (BNP), and if associated with elevated jugular venouspressure, it predicts more frequent hospitalizations and worse outcome. S3 is also the most significant predictor of
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cardiac risk during noncardiac surgery. If preoperative diuresis is not instituted, it can also predict mortality. Finally,the presence of S3 in mitral regurgitation reflects worse disease (i.e., higher filling pressure, lower ejection fraction,and more severe regurgitation).42) S4 reflects an increase in late ventricular diastolic pressure (hence a diastolic dysfunction); but, in contrast to S3,it reflects normal atrial pressure, normal cardiac output, and normal ventricular diameter.43) S4 can be heard in as many as 90% of patients with MI, but eventually resolves. Presence of S4 at more than 1month after MI does predict a higher 5-year mortality rate.44) An early systolic (ejection) sound indicates normal ejection of blood through an abnormal aortic valve (i.e.,bicuspid), normal ejection of blood into a stiffened and dilated aortic root (i.e., hypertension, atherosclerosis, aorticaneurysm, or aortic regurgitation), or forceful ejection of blood into a normal aortic root (high output states likeaortic regurgitation).45) An aortic ES in patients with aortic regurgitation (AR) argues in favor of valvular AR, possibly due to a bicuspidvalve.46) In mitral valve prolapse (MVP), clickers stay clickers and murmurs stay murmurs. This may have implicationfor prophylaxis.47) One tenth of all rubs are associated with a pericardial effusion. In fact, rubs can occur in up to one fourth oftamponade cases. Hence, measure pulsus paradoxus in all patients with a rub.48) All right-sided auscultatory findings (except the pulmonic ejection sound) get louder on inspiration (RiveroCarvallo maneuver).49) A murmur that intensifies with Valsalva or squatting-to-standing is due to either HOCM or MVP.50) A longer diastolic pause (such as that following a premature beat) intensifies the murmur of aortic stenosis butnot that of mitral regurgitation.51) A benign "functional" murmur should be systolic, short, soft (typically <3/6), early peaking (never passingmidsystole), predominantly circumscribed to the base, and associated with a well-preserved and normally splitsecond sound. It should have an otherwise normal cardiovascular exam (i.e., no bad company); and it oftendisappears with sitting, standing, or straining (as, for example, following a Valsalva maneuver).52) A "bad" systolic murmur instead should be long, loud (in fact, pathologic by definition if loud enough togenerate a thrill), late peaking, nonlocalized, and associated with a soft-to-absent S2 that does not normally split. Italso should be accompanied by other abnormal findings/symptoms ("bad" company).53) The murmur of aortic sclerosis is the most common systolic ejection murmur of the elderly, affecting 21-26% ofpersons older than 65 and 55-75% of octogenarians and carrying a 40% increased risk of myocardial infarction.54) Presence of an early systolic (ejection) click in aortic stenosis (AS) usually indicates a valvular AS, typically dueto a congenitally bicuspid aortic valve.55) Some patients with AS may exhibit a dissociation of the systolic murmur into two components, with mediumfrequencies transmitted to the base and high frequencies to the apex, almost mimicking MR (Gallavardinphenomenon).56) Findings arguing most strongly in favor of AS are a reduced/delayed carotid upstroke, a mid-to-late peak of themurmur, a soft-to-absent A2, a palpable precordial thrill, and an apical-carotid (or brachioradial) delay. Conversely,lack of radiation to the right carotid artery argues most strongly against AS. A normal rate of rise of the arterialpulse argues also against the presence of significant AS, but only in the young.57) The best bedside predictors for severity/clinical outcome of AS are (1) murmur intensity and timing (the louderand later-peaking the murmur, the worse the disease); (2) a single S2; and (3) delayed upstroke/reduced amplitude ofthe carotid pulse (pulsus parvus and tardus). Still, no single physical finding has both high sensitivity and specificityfor detecting severe valvular obstruction.58) Presence of an audible S4 in AS reflects severe left ventricular hypertrophy (with a transvalvular pressuregradient >70 mmHg), but only in younger patients (older subjects may already have a "normal" S4). Yet, a palpableS4 always reflects severe disease.59) In cardiac auscultation, the louder (and the longer) the murmur, the worse the underlying disease. The onlyexception is severe aortic stenosis with decreased cardiac output.60) Plateau mitral regurgitation (MR) murmurs are more likely to be rheumatic, whereas murmurs that start inmidsystole and "grow" into S2 are more likely to be due to either mitral valve prolapse or papillary muscledysfunction.61) The acute MR murmur is often early systolic (exclusively so in 40% of cases) and is associated with S4 in 80%of the patients.62) Valvular aortic regurgitation (AR) tends to be loudest over the Erb's point (left parasternal area), whereas "root"AR is loudest over the aortic area (right parasternal area).
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63) The Austin-Flint murmur may occur in more than 50% of moderate to severe AR cases, usually requiring aregurgitant volume of at least 50mL.64) A palpable pulsus bisferiens usually reflects moderate to severe aortic regurgitation (with or without aorticstenosis).65) A difference in systolic pressure ≥60 mmHg between upper and lower extremities (Hill's sign) has highspecificity and a very high positive likelihood ratio for severe aortic regurgitation, but a sensitivity of only 40%. Sodo a diastolic blood pressure ≤50 mmHg and a pulse pressure ≥80 mmHg.66) Traube pistol shot sound(s) and Duroziez double murmur have sensitivity of 37-55% for AR and specificity of63-98%. Neither predicts severity.67) The alternate reddening and blanching of the fingernails, coinciding with each cardiac cycle and easilyvisualized by lightly compressing the nail bed with a glass slide (Quincke's pulse), is one of the many peripheralsigns of AR, albeit a nonspecific and vastly discredited one.68) You diagnose aortic regurgitation in diastole, but you assess its severity in systole (through the presence of aflow murmur and possibly an ejection click). Conversely, you diagnose mitral regurgitation in systole, but youassess its severity in diastole (through the presence of an S3 and possibly a diastolic flow rumble).69) Tachypnea is so frequent in pulmonary embolism (92% of patients) that a normal respiratory rate arguesstrongly against the diagnosis.70) Unlike orthopnea, platypnea (an obligatory "supine respiration") is usually due to a right-to-left shunt. This canbe either intracardiac or intrapulmonary (typically bibasilar and common in cirrhotic patients-hepatopulmonarysyndrome).71) Abdominal paradox has high sensitivity (95%) and good specificity (71%) for impending respiratory failure,usually preceding arterial blood gases' deterioration.72) Upward inspiratory motion of the clavicle in excess of 5 mm is a valuable sign of severe obstructive disease,correlating with FEV1 of 0.6 L.73) The distance between the top of the thyroid cartilage and the suprasternal notch (laryngeal height) is a strongpredictor of postoperative pulmonary risk if ≤4 cm.74) The forced expiratory time (FET) is the best bedside predictor of the severity of airflow obstruction. FETo >6seconds corresponds to an FEV1/FVC <40%. Conversely, FETo <5 seconds indicates an FEV1/FVC >60%.75) Crackles (and rhonchi) that clear with coughing suggest airflow obstruction. Conversely, crackles that appearafter coughing (post-tussive crackles) argue in favor of tuberculosis.76) Bronchial breath sounds reflect patent airways in a setting of absent alveolar air, with replacement by media thatbetter transmit higher frequencies, such as liquids or solids (consolidation). If unaccompanied by crackles, theyargue in favor of a pleural effusion.77) Late inspiratory crackles can be detected by careful auscultation in 63% of young and healthy nursing students(in 92% if using an electronic stethoscope with high-pass filtration).78) Timing of crackles predicts the site of production, with early inspiratory crackles reflecting bronchitis, mid-inspiratory crackles reflecting bronchiectasis, and late inspiratory crackles reflecting interstitial fibrosis or edema.79) In asbestosis and idiopathic pulmonary fibrosis, the number of late inspiratory crackles correlates with diseaseseverity.80) In patients with pneumonia, crackles and diminished breath sounds appear first; bronchial breath sounds andegophony develop 1-3 days after onset of symptoms (i.e., cough and fever), and dullness to percussion (plusincreased tactile fremitus) occurs even later. This time lag usually allows for x-ray to preempt diagnosis, thusmaking exam often irrelevant.81) Wheezing on maximal forced exhalation has such a low sensitivity and specificity for asthma (57% and 37%,respectively) to be completely unreliable for diagnosing subclinical airflow obstruction.82) Wheezes are neither sensitive nor specific for airflow obstruction. Although unforced wheezing argues stronglyfor chronic airflow obstruction, it can be absent in 30% of patients with FEV1 <1 L. It may also resolve in acuteasthmatics whose FEV1 remains at 63% of the predicted value. In fact, in status asthmaticus, wheezing is the least-discriminating factor in predicting hospital admission or relapse.83) Wheezing intensity does not correlate with severity of obstruction. Only pitch and length of wheezes are usefulpredictors of airway narrowing. Higher-pitched and longer wheezes reflect worse obstruction.84) Bowel sounds lack sensitivity and specificity for intestinal obstruction, being decreased or absent in only onequarter of cases. Hence, they are clinically useless.85) Lateral expansion of an abdominal mass ≥3 cm with pulsation suggests an abdominal aortic aneurysm. In casesof small aneurysms (3-5 cm in diameter), the finding is very specific, with the few false positives usually reflecting atortuous aorta (yet, the finding is also poorly sen-sitive, detecting only one of five cases). In patients with large
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aneurysms (>5 cm), sensitivity increases to four out of five patients. In fact, lack of expansile pulsation in a thinpatient should strongly argue against the presence of a large aneurysm.86) Palpation of the liver edge is an unreliable way to estimate hepatic consistency. In fact, half of all palpable liversare not enlarged, and half of truly enlarged livers are not palpable.87) A pulsatile liver edge may represent transmission of aortic pulsations through an enlarged liver but usuallyindicates one of two conditions: (1) constrictive pericarditis or (2) tricuspid regurgitation (TR). An inspiratoryincrease in the magnitude of pulsations will be typical of TR (especially in held mid-inspiration/end-inspiration), butnot of constrictive pericarditis. Pulsatility in a setting of hepatomegaly instead is such a good indicator ofconstrictive peri-carditis (present in 65% of patients) that its absence argues strongly against the diagnosis.88) A painful arrest in inspiration triggered by palpation of the edge of an inflamed gallbladder (Murphy's sign) is agood test for cholecystitis, with sensitivity and specificity of 50-80% (specificity usually a little higher thansensitivity).89) A palpable and nontender gallbladder in icteric patients strongly suggests that the jaundice is not due tohepatocellular disease, but to an extrahepatic obstruction of the biliary tract, more likely neoplastic. Albeit not toosensitive, this finding is highly specific.90) In patients with splenomegaly, (1) concomitant hepatomegaly suggests primary liver disease with portalhypertension; (2) concomitant lymphadenopathy excludes primary liver disease and makes instead hematologic orlymphoproliferative disorders more likely; (3) massive splenomegaly (or left upper quadrant tenderness) also arguesin favor of a myeloproliferative etiology; and (4) Kehr's sign (referred pain or hyperesthesia to the left shoulder)suggests impending splenic rupture.91) Half of all patients with renovascular disease have a systolic murmur, whose significance depends on locationand characteristics. Overall, posterior murmurs are specific but not sensitive; anterior murmurs are sensitive but notspecific; anterior bruits (i.e., continuous murmurs) are both specific and sensitive.92) Combining all bedside maneuvers provides a good bedside tool for the diagnosis of ascites, with overallaccuracy of 80%. Still, the amount of volume necessary for these maneuvers to become positive (500-1000 mL) ismuch larger than that detected by ultrasound alone (100 mL).93) Generalized adenopathy suggests a disseminated malignancy (especially hematologic), a collagen vasculardisorder, or an infectious process. Adenopathy presenting with fever usually suggests infection or lymphoma.94) A palpable supraclavicular node carries a 90% risk of malignancy for patients older than 40 years, and a 25%risk for younger patients.95) A cranial nerve (CN) III palsy that spares pupils (i.e., ptosis and external rotation of the globe, but symmetricand equally reactive pupils) suggests diabetes, but also vasculitides and multiple sclerosis.96) In a meta-analysis of almost 2000 patients, the signs with highest likelihood ratios for predicting neurologicrecovery after a cardiac arrest were, at 24 hours: absent corneal reflexes (LR 12.9); absent pupillary reflexes (LR10.2); absent motor response (LR 4.9); and absent withdrawal to pain (LR 4.7). At 72 hours, absent motor responsepredicted death or poor neurologic outcome.97) Many traditional findings in carpal tunnel syndrome, including Phalen, Tinel, and flick sign have low sensitivityand limited or no value.98) A positive straight-leg-raising test indicates nerve root impingement, usually by a herniated disk. It has highsensitivity (91%) but low specificity (26%), thus limiting its diagnostic accuracy. The "crossed" straight-leg raisingtest instead has low sensitivity (29%) but high specificity (88%). Hence, use them together.99) A composite examination for anterior cruciate ligament (ACL) injuries has sensitivity >82% and specificity>94%, with an LR of 25.0 for a positive examination and 0.04 for a negative one. Overall, a positive Lachman testargues strongly in favor of ACL tear, whereas a negative is fairly good evidence against it. The anterior drawer isthe least accurate test.100) A composite examination for posterior cruciate ligament (PCL) injuries has sensitivity of 91%, specificity of98%, and LRs of 21.0 (for a positive exam) and 0.05 (for a negative one). The posterior drawer test is the mostreliable indicator, with mean sensitivity of 55%.--------------------------------------------------------------------------------------------------------------------------------------------Quick Osteopathic Review – OMT Review (3rd, Savarese)--------------------------------------------------------------------------------------------------------------------------------------------Somatic Dysfunction DefinitionSomatic Dysfunction (SD) is impaired or altered function of related components of the somatic system: skeletal,arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.Visceral (Viscerosomatic) Dysfunction is impaired or altered mobility or motility of the visceral system and relatedfascial, neurological, vascular, skeletal and lymphatic elements.
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Autonomics Organ Parasympathetic Sympathetic Eye Pupil Constricts (miosis) Dilates (mydriasis) Eye Lens Contracts for near vision Slight relaxation for far vision Glands (nasal, lacrimal, parotid, Stimulates copious secretion Vasoconstriction for slight secretion submandibular, gastric, pancreatic) Sweat Glands Sweating on palms of hands Copious sweating (cholinergic) Decreases contractility and Increases contractility and conduction Heart conduction velocity velocity Bronchiolar Smooth Muscle Contracts Relaxes Thin secretions, decreased Thick secretions, increased number of Respiratory Epithelium number of goblet cells goblet cells GI Smooth Muscle Lumen Contracts Relaxes GI Smooth Muscle Sphincters Relaxes Contracts GI Secretion & Motility Increases Decreases Arterioles, Skin & Visceral Vessels None None Arterioles, Skeletal Muscle None Relaxes Bladder Wall (Detrusor) Contracts Relaxes Bladder Sphincter (Trigone) Relaxes Contracts Penis Erection Ejaculation Vasoconstriction of afferent arterioles, Kidneys Unknown decreased GFR, decreased urine volume Ureters Maintains normal peristalsis Ureterospasm Liver Slight glycogen synthesis Glycogenolysis (glucose into blood) Uterus Body (Fundus) Relaxation Constricts Uterus Cervix Constricts RelaxesParasympatheticsCN III (midbrain): Ciliary ganglion, pupils.CN VII (pons): Sphenopalatine ganglion, lacrimal and nasal glands.CN VII (pons): Submandibular ganglion, submandibular and sublingual glands.CN IX (medulla): Otic ganglion, parotid gland.CN X (medulla): Heart, bronchial tree, esophagus lower 2/3, stomach, intestine, liver, gallbladder, pancreas, kidneyand upper ureter, ovaries, testes, ascending and transverse colon.S2-S4: Pelvic splanchnic, lower utter and bladder, uterus, prostate, genitalia, descending colon, sigmoid, rectum.Cranial Nerves Somatic Efferent Cranial Nerve Exits Cranium Clinical Correlation Dysfunction Afferent CN I sphenoid, frontal, Cribriform plate Altered sense of smell SVA Olfactory ethmoid CN II Optic canal sphenoid, occiput Visual changes SSA Optic CN III Superior orbital Diplopia, ptosis, sphenoid, temporal GSE, GVE-P Oculomotor fissure accommodation problems CN IV Superior orbital sphenoid, temporal Diplopia GSE Trochlear fissure CN V1 Superior orbital Decreased sensation to sphenoid, temporal GSA, SVE Trigeminal fissure eyelid and scalp CN V2 sphenoid, temporal, Foramen rotundum Tic Douloureux GSA, SVE Trigeminal maxillae, mandible
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CN V3 Deceased sensation to Foramen ovale sphenoid GSA, SVE Trigeminal mandible CN VI Superior orbital sphenoid, temporal Diplopia, esotropia GSE Abducens fissure Internal acoustic SVE, GSA, CN VII sphenoid, temporal, meatus, Stylomastoid Bell palsy SVA, GVA, Facial occiput foramen GVE-P CN VIII Internal acoustic sphenoid, temporal, Tinnitus, vertigo, hearing SSA, SSE Auditory meatus occiput loss CN IX Decreased gag, decreased SVE, GSA, Jugular foramen temporal, occiput Glossopharyngeal taste GVA, GVE-P Headaches, arrhythmias, SVE, GSA, CN X Jugular foramen temporal, occiput GI upset, respiratory SVA, GVA, Vagus problems GVE-P CN XI Foramen magnum, Trapezius or SCM temporal, occiput GSE Accessory Jugular foramen tenderness CN XII Hypoglossal canal occiput Dysphagia GSE HypoglossalCranial Nerve Efferent & Afferent ContributionsGSE: General Somatic Efferent, motor to somatic voluntary skeletal muscles.GSA: General Somatic Afferent, sensory to skin, joints, muscle and tendon receptor endings, nasal and oral cavity.GVE: General Visceral Efferent, motor to smooth muscles (in general, skin, blood vessels), secretomotor to glands.GVA: General Visceral Afferent, sensory to gut and derivatives, pharynx, blood vessels, glands and internal organs.SSA: Special Visceral Afferent, special senses of vision, auditory sensation and vestibular apparatus.SVA: Special Visceral Afferent, chemical senses of taste and by analogy smell.SVE: Special Visceral Efferent, motor to voluntary skeletal muscles derived from branchial arches.Neurologic Testing Dermatome Deep Tendon Vertebral Levels Muscle Strength Reflex Grading Levels Reflexes C6: Thumb, Radial T2/3 Body: Sternal 5: Full ROM, gravity 4/4: Brisk + Clonus C5: Biceps Nerve Notch + full resistance (UMN)
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not a sufficient indication. Patient is positioned such that the dysfunctional joint engages the restricted barrier and aquick thrust—high velocity—over a very short distance—low amplitude—is applied by the practitioner* ME: A direct technique in which the physician engages the initial resistance to a barrier—the feather edge—andasks the patient to provide a counterforce away from the barrier. Forces are generally light—excessive force is acommon error. The active contraction by the patient acts to mobilize a joint directly or by providing a postisometricrelaxation period whereby tissues can be further stretched.* ART: Gentle, repetitive, and passive motion of a joint into its restricted. Examples include Spencer technique forthe shoulder and rib raising.* MFR: A direct or indirect approach to releasing tension in muscles (myo)and fascia (fascial). With a direct approach, tissue barriers are engaged rhythmically, or engaged and held. With anindirect approach, tissues are taken to a place where the least amount of tension exists and held until an inherentrelease occurs.* Strain and CS: Treatment consists of positioning the patient to eliminate the tenderness and tension—a position ofease—and holding this for 90 seconds. More than 200 specific points found anteriorly and posteriorly. Usuallydiscrete, fingertip size, tense, and edematous. Patient will typically wince because of exquisite tenderness ofsignificant points. Tenderpoints typically in tendons or muscle belly. They may also be found in other myofascialtissues. If multiple tenderpoints are found, treat the most tender point first. Points are often away from a point oftrauma. For example, tenderpoints on the chest wall with back pain, or points in the antagonist muscle of atraumatized muscle. If pain is associated with trauma, position of treatment matches the position of trauma and isassociated with maximal comfort.* BLT: An indirect approach where tensions of the ligaments and membranous structures are balanced by jointpositioning. This allows an inherent release in the tissues. Active movement by the patient—often breath—iscommonly used to assist with the release.* FPR: A form of indirect treatment—positional release—in which a facilitating force is added to decrease theamount of treatment time needed. Facilitating force is compression and or torsion. Used for both tissue texturechange and joint restriction secondary to myofascial tension. Treatment always begins with putting joint into aneutral position then adding a facilitating force.Cranial Assessment* Craniosacral flexion: midline bones flex, paired bones externally rotate.* PRM = CNS + CSF + dural membranes + cranial bones + sacrum.* Dural attachments: foramen magnum, C2, C3, S2.* SBS: articulation of sphenoid with occiput.* CRI = 10-14 cycles per minute.* Factors decreasing CRI: stress, depression, chronic fatigue, chronic infections.* Factors increasing CRI: exercise, systemic fever, OMT.* Vault Hold: index on greater wing of sphenoid, middle on zygomatic processes of temporal, ring on mastoidprocesses of temporal, pinky on squamous portion of occiput, thumbs cross on head.* Torsion: AP axis, physiologic. Named for greater wing of sphenoid. If superior on right, right torsion.* Sidebending/Rotation: 2 parallel vertical axes, physiologic.* Sidebending of SBS cause sphenoid and occiput to rotate inferior to that side, hand feels fuller on that side (SBRLor SBRR).* Flexion/Extension: physiologic. Flexion is SBS cephalic, extension is SBS caudal.* Vertical: 2 transverse axes, pathologic. Named for direction of sphenoid movement. Superior vertical strain, handsmove inferiorly.* Lateral: 2 vertical axes, pathologic. Named for direction of sphenoid movement. Sphenoid right is right lateralstrain, index fingers point to left.* SBS Compression: severely decreased CRI usually due to trauma, especially to the back of the head. a.k.a."bowling ball head"* Craniosacral flexion, detailed: midline bones flex, paired bones externally rotate, sacrum moves posterior(counternutation), ASIS widens, AP diameter of cranium decreases, transverse diameter increases.* Fingers spread apart and abduct, sphenoid anteriorly rotates, basiocciput moves anteriorly and superiorly, foramenmagnum moves superiorly, condyles spread laterally.* Occiput and sacrum move in the same direction. Sphenoid moves opposite of the sacrum.Cervical Assessment & Counterstrain Points* OA is Type I Mechanics: The side of the deeper sulcus is the OA rotation side. Flex and extend the occiput todetermine ease of motion.
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* Forward Torsions: L on L, R on R* L on L: R deep sulcus, L posterior ILA, +SeFT on R, Neg spring test.* R on R: L deep sulcus, R posterior ILA, +SeFT on L, Neg spring test.* Backward Torsions: L on R, R on L* L on R: R deep sulcus, L posterior ILA, +SeFT on L, Pos spring test.* R on L: L deep sulcus, R posterior ILA, +SeFT on R, Pos spring test.* L Uni: L deep sulcus, L posterior ILA, +SeFT on L, Neg spring test.* R Uni: R deep sulcus, R posterior ILA, +SeFT on R, Neg spring test.* Bi Flexed: L&R deep sulci, L&R posterior ILA, Neg SeFT, Neg spring test.* Bi Extended: L&R shallow sulci, Pos spring test.* +SeFT side is opposite sacral axis.* L5 Rotation is opposite sacral rotation.* L5 Sidebending is same as sacral axis.* Low ilium SI/anterior sacral TP on superior surface of pubes.* Iliacus TP lower abdomen deep in fossa.* Inguinal ligament TP at pubes attachment.* Sacral Axes (CRAIN): Cranial (Superior Transverse, S2). Respiratory (Superior Transverse, S2). Anatomic(Middle Transverse). Innominate (Inferior Transverse).Pelvis Assessment & Counterstrain Points* Standing Flexion Test (StFT): +StFT implies Iliosacral > Sacroiliac S.D.* +StFT side determines side of dysfunction.* Anterior Innominate Rotation: ASIS inferior, PSIS and ischial tuberosity superior. Ipsilateral leg appears longer.* Posterior Innominate Rotation: ASIS superior, PSIS and ischial tuberosity inferior. Ipsilateral leg appears shorter.* Superior Innominate Shear: Ischial tuberosity, ASIS, PSIS, and medial malleoli superior on same side.* Inferior Innominate Shear: Ischial tuberosity, ASIS, PSIS, and medial malleoli inferior on same side.* Abducted Pubes: pubic tubercles are wider than usual (lax symphysis).* Adducted Pubes: pubic tubercles are closer than usual (compressed symphysis).* Superior Pubic Shear: pubic tubercle is higher on side of +StFT.* Inferior Pubic Shear: pubic tubercle is lower on side of +StFT.* Inflare: shorter distance between ASIS and umbilicus on side of +StFT.* Outflare: longer distance between ASIS and umbilicus on side of +StFT.* Piriformis TP in middle of gluteus, check for externally rotated leg.* Sacrospinous ligament divides the greater and lesser sciatic foramen.Chapman Reflex Points* Sinuses: Below proximal 1/3 clavicle.* Ears: Above proximal 1/3 clavicle.* Pharynx: Below 1st rib/manubrium junction.* Pylorus: Sternum.* Stomach Acid: 5th intercostal on left at costal cartilage.* Stomach Peristalsis: 6th intercostal on left at costal cartilage.* Liver: 5th intercostal on right at costal cartilage.* Liver, Gallbladder: 6th intercostal on right at costal cartilage.* Pancreas: 7th intercostal on right at costal cartilage.* Heart: 2nd intercostal space at sternal border. T2 intertransverse space.* Upper Lung: 3rd intercostal space at sternal border. T2 intertransverse space.* Lower Lung: 4th intercostal space at sternal border. T3 intertransverse space.* Adrenals: 1 inch lateral and 2 inches above the umbilicus. T11 intertransverse space.* Kidneys: 1 inch lateral and 1 inch above the umbilicus. L1 intertransverse space.* Appendix: Tip of 12th right rib.* Colon: Iliotibial band in mirror image of colon layout. Cecum at right hip, transverse 1/3 colon at right knee,transverse 2/3 colon at left knee, sigmoid at left hip.* Bladder: Triangle around umbilicus.* Prostate: Iliotibial band posterior margin.Upper Extremity Assessment & Counterstrain Points* Radial Head: Anterior radial head is a supination dysfunction, so restricted in pronation. Posterior radial head is apronation dysfunction, so restricted in supination.
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evidence that self examination improves mortality. Why do we recommend it then? Because it is cheap and easy.Recommendation is monthly self breast exam starting at age 20 done 7-8 days after end of menses.* Physician breast exam is recommended annually starting at age 40. Mammogram recommended annually from 50-75 years of age. Most physicians between age 40-50 recommend mammogram every 1-2 years. Some newerevidence is pushing toward mammograms starting at age 50, not 40. Can get a physician breast exam every threeyears between the age of 20 and 40.* Cervical cancer screening is done at age 21. Previous guidelines were age 18 or sexual activity. Pap smear is themajor modality of screening and should be done annually until there are three negative Pap smears. After threenegative Pap smears in a row, you can screen every 2-3 years until age 65.Traveler Health* 44yo executive comes to your clinic prior to traveling to Thailand for business. He has no significant past medicalhistory and is only here to see you because his company will not let him travel until he is seen by a physician. Thepatient appears agitated and demands your recommendations immediately.* Consider vaccinations: hepatitis A, hepatitis B, malaria prophylaxis, traveler's diarrhea.* For hepatitis B vaccination, ask patient if they plan to engage in any sexual activity with the local population. Ifthey will, they should be immunized against hepatitis B. If patient will be functioning in close proximity to thepopulation, such as working as a nurse, they should be immunized.* For hepatitis A vaccination, immunize if patient is going to an endemic area. Endemic areas for hepatitis A are anynon-industrialized nation (rural India, Middle East, North Africa, South Africa). If patient is planning to eat anddrink in those areas, they should be vaccinated.* Generally you want to see patients for travel medicine one-month prior to them taking the trip.* Say patient shows up and needs hepatitis A but is two weeks from their trip. You can give immunoglobulin inaddition to the vaccination. So you give them passive immunity with Ig, give vaccination, then give second shot ofhepatitis A vaccination when they return from the trip.* Hepatitis A immunoglobulin given if patient is departing within two weeks.* For a patient traveling to a malaria endemic area, what is the prophylaxis? For Caribbean or Central America, yougive chloroquine. Mnemonic is "C" for Caribbean, Central America, Chloroquine. For everywhere else, they shouldget mefloquine due to chloroquine resistance. Alternative regimen is atovaquone and proguanil for patients going toa mefloquine-sensitive or chloroquine-resistant area.* For traveler's diarrhea, you can give loperamide to help with diarrhea if there is no fever and no blood in the stool.If the patient has fever with blood in stool, give fluoroquinolone (ciprofloxacin). You can give the patient themedication for the trip, but make sure they know only to take it if they have a fever and blood in their stool.* Caution patients not to eat unwashed vegetables and fruits, even in a fancy restaurant. Should only drink bottled orboiled water to avoid traveler's diarrhea.* Enterotoxigenic Escherichia coli (ETEC) is the most common cause of traveler's diarrhea.Immunizations* 52yo man comes to your clinic for a health maintenance evaluation. His recent colonoscopy showed no evidenceof carcinoma. His recent serum fasting glucose, serum cholesterol, and blood pressure measurements were all withinnormal limits. The patient has a history of smoking and continues to smoke two packs per day. He was diagnosedwith COPD three years ago. What is your recommendation for this patient?* For this patient, we should do fecal occult blood testing if he has not had one within a year. There is no indicationfor colonoscopy because he just had one. You should address this patient's immunization status.* In the U.S., up to 70,000 adults die a year secondary to preventable infectious disease. The simple act of providingan immunization when recommended can seriously improve the mortality and morbidity of a lot of patients. Youshould consider this in any patient you see, regardless of what specialty you choose for your career.* In patients who are pregnant or immunosuppressed, we generally do not give live vaccines.* Live vaccines are varicella, MMR (measles mumps rubella), yellow fever, polio (live not given anymore).* Varicella is given in any adult who has no history of varicella (chicken pox) infection.* MMR is given in any adult born after 1956, give them a booster vaccination.* MMR is the only live vaccination that is safe in HIV-positive patients, given they have no symptoms.* Pregnant females should never get a varicella or MMR vaccine.* Hepatitis A is universally recommended, but high risk is chronic liver disease and would not be able to tolerate anacute infection or if they are traveling to an endemic area.* Hepatitis B is for patients exposed to blood, young sexually active patients, or those with chronic liver disease.* Tetanus given every 10 years in the adult population after their initial series of shots.* Influenza in universally recommended annually. Previous guidelines were after age 50 or young if chronic disease.
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* You give influenza every year because the virus is different each year, so previous immunity may not cover.* Pneumococcal vaccine given at age of 65 if no co-morbidities. Given before 65 if co-morbidities, especiallyasplenic, immunosuppressed, smokers, asthma, COPD, emphysema, American Indians, Alaska Natives.* If patient receives their pneumococcal vaccine before the age of 60, they should be re-vaccinated at the age of 65.* Any smoker age 19-64 should receive the pneumococcal vaccine with smoking cessation counseling.* Any patient with chronic lung problems age 19-64 should get the pneumococcal vaccine.Smoking Cessation* 25yo man comes to clinic for evaluation of stuffy nose and fever. You diagnose pharyngitis and give himantibiotics. Over the course of the interview, the patient states that he smokes three packs of cigarettes per day andhas been doing so for the past seven years.* Smoking is the cause of about 1 in every 5 deaths in the United States.* If you can get your patient to stop smoking, you have accomplished a tremendous amount in the prevention oflung disease, cancer, and other smoking-related causes of death.* There are 5 steps to smoking cessation (5 A's): Ask, Advise, Attempt, Assist, Arrange.* Ask the patient at every visit about their smoking.* Advise the patient to stop smoking at every single visit. Just the advice from a doctor has been shown to increasethe rate of smoking cessation. You have a positive influence on your patients.* Attempt to identify those patients who want to quit.* Assist the patient by setting a quit date and providing pharmacologic support, either patch or gum or bupropion.* Arrange for follow-up with the knowledge that most patient require several quit attempts to finally stop. At thatpoint, discuss why they relapsed and what can be done differently. Encourage them to try again, try again, and tryagain. The more attempts a patient makes, the more likely they are to quit.* The importance of smoking cessation cannot be overstated.Diabetes, Cholesterol, & Hypertension Screening* 45yo man comes to your office anxious about his health. When questioned further he states that the source of hisanxiety is his family medical history. Five years ago his mother was diagnosed with diabetes and high cholesterol.He is worried about his health and risk of heart disease. Physical exam is within normal limits.* Screen for diabetes when you have risk factors for diabetes. Risk factors are obesity and family history.* Diagnosis is random glucose > 200 or fasting blood glucose > 126 on two occasions.* There is no clear recommendation for screening for diabetes unless risk factors are present.* Cholesterol screening for males starts at age 35 and females from the age of 45.* There is no clear recommendation for how often a screening cholesterol should be taken. If a patient has multiplerisk factors for atherosclerotic disease, they should be followed more closely with cholesterol screening.* Hypertension screening should occur at every visit and at least every two years.Alcohol Abuse Screening* 55yo man comes to your office for evaluation of a sore throat. Upon further discussion you know that the patientwas recently fired from his job and is having marital problems at home. The patient has no significant past medicalhistory and physical exam is within normal limits. He attests to drinking 3 shots of whiskey every day after work.* CAGE questionnaire is used to screen for alcohol abuse. Cut down, Annoyed, Guilty, Eye opener.* Have you ever tried to cut down on your drinking?* Do you get annoyed when people talk about your drinking?* Do you ever feel guilty about the amount of alcohol you drink?* Have you ever taken a drink as an eye-opener to wake you up in the morning?* A CAGE score of 2/4 is considered a positive screen.* How much is too much? Men may be at risk for alcohol-related problems if their alcohol consumption exceeds 14standard drinks per week or 4 drinks per day, and women may be at risk if they have more than 7 standard drinks perweek or 3 drinks per day.* A standard drink is one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.* In the above 55yo, the patient is having trouble functioning in their normal social context. They are havingproblems at work and at home. They are using alcohol as an escape, showing signs of drug abuse.Physical Abuse Screening* 27yo woman is brought to the Emergency Department complaining of right arm pain. When asked how shesustained the injury she states that she fell down the steps in front of her house. The patient appears anxious andnervous. On physical exam you notice various lacerations that are 2cm wide on her buttocks.* As physicians, we can prevent injury and death by counseling our patients about safe practices and behavior.* Any patient under the age of 65, the number one cause of death is traumatic injury. It can be not wearing a seatbelt
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in the car, not wearing a helmet on a bike, playing with firearms, drinking and driving, physical abuse.* An effective way to screen for abuse is to ask patients simply and clearly: Have you ever been threatened bysomebody close to you? Have you ever been hit or bitten by anyone close to you? Up to 10% of the time, patientswill answer yes and will identify themselves. Simply by asking the question, you can do a lot of good.* The area of preventive medicine is not very glamorous. It is not about giving thrombolytic therapy to save apatient who is having an MI. It is about giving medication to prevent the MI in the first place.* Preventative medicine is less glamorous, but much more effective.* Address health issues, cancer screening, immunization status, counsel about alcohol abuse, ask about physicalabuse, counsel about safe behavior, counsel about smoking cessation.--------------------------------------------------------------------------------------------------------------------------------------------Kaplan Videos (2001) – Medico Legal Cases with Dr. Steven Daugherty, MD--------------------------------------------------------------------------------------------------------------------------------------------* It is important to have a set of rules to apply to these types of questions. You will likely see questions you have notstudied before, so having rules to apply to any question will make them easy to answer.* The answer on an exam may not be what you've seen in real life. The exam is not about what everybody does inreal life, they are about what everybody should be doing in real life.* Note: This is not legal advice on how to practice medicine.Karen Ann Quinlan Case (Substituted Judgment)* Karen Ann Quinlan case gave rise to the rule of substituted judgment.* Karen Ann was a young woman living in NJ, in her early 20s and was out driving with her friends looking for funone Saturday evening. Another driver was out drinking, ran a stop sign, and crashed into Karen Ann's car. Severalof her friends died and Karen Ann was left in a persistent vegetative state.* Doctors examining Karen Ann said they could keep her on life support almost indefinitely but she is unlikely toregain consciousness and certainly not much quality of life.* When the father heard this prognosis, he said lets disconnect life support and let nature take its course.* This case ended up in court because there was no clear rule; it should never end up in court today.* The court listened to the doctors and what the father said and went with their wishes. Life support was terminated.Miraculously, Karen Ann lived 3-4 months without life support then subsequently died.* The important part is that the father got to make the decision because if Karen Ann had sat up and had a "lucidmoment" she would have said what the father said. The father did not get to make the decision because he was thedad, he got to make the decision because he was the best representative of what Karen Ann's own wishes were.* The father was the best window to the wishes of the patient.* It is not about next of kin. It is never about next of kin. Next of kin does not matter. Substituted judgment matters.* A man is brought into the Emergency Department with his partner, a homosexual companion with whom he hasbeen living for the past 10 years. The man is at the end-stages of HIV dementia. He has all the symptoms includinglack of cognitive capacity and inability to express his wishes in any way. If you treat this man aggressively, you cankeep this man alive for about 2 months. Without aggressive treatment, the man will die in about two weeks. Howaggressively should you treat this patient?* The partner says they do not know, but remembers the patient saying that he did not want to drag this thing out. Sothe partner thinks we should not do anything and let nature take its course.* Then the patient's family come into the hospital. Mom, father, aunt, uncle, family dog Spot. The whole family inunison says do everything possible to keep their loved one alive "as long as possible."* It is not clear still. Now you find that because of the man's lifestyle he has been estranged from his family forseveral years. Now it is clear to listen to the partner and not the family. (In real life, it may be risky to go againstfamily wishes to keep a patient alive even if they have the worst substituted judgment for the patient.)* Answer choices that say go to court are generally not the right answer. The basic rule on the exam is you as thephysician makes the call.Brother Fox Case (Best Interest Standard)* Eichner v Dillon (Brother Fox Case) gave rise to the rule of best interest standard.* This case is about someone who was never competent. So in the eyes of the law, there was no substitutedjudgment because the patient never wanted anything. Guessing at wishes when functionally the patient never hadwishes is pretty difficult. Substituted judgment does not apply here.* Best interest standard means you act as a dispassionate rational decision maker weighing the benefits and burdensof any problem, doing what any rational person would do. If benefits are great and burdens few, you act. If benefitsfew and burdens great, you do not act.* So you're saying I do not know what you in particular want, but I'm doing what most people would want in this
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same situation. This is the best interest of the patient and no one else.* If the decision maker has strong philosophical beliefs that preclude a decision being made, they are consideredirrelevant when using the best interest standard. Personal beliefs cannot come into play.* The person making the decision is irrelevant, because any person using the best interest standard should come tothe same decision.* In general, physicians do not make decisions for patients. This is an exception. It is not because of your position,your expertise, it is because you are just as good as anybody else with the best interest standard.* If you're stuck with the best interest standard, think about laying all the evidence out in front of a randomcommunity jury of 12 people. What they would tell you to do, is what you do.Infant Doe Case (Parents Cannot Withhold Life-Saving Treatment)* Infant Doe Case gave rise to the rule of parents cannot withhold life- or limb-saving treatment from their child.* Infant Doe was the third child born to a happy mother and father. This child was born with a whole list of medicalproblems including gross mental retardation, Down syndrome, tracheoesophageal fistula.* Unless the fistula was operated on, the child would certainly die.* The surgery team said they could do the surgery, but even if it was successful the child would live out its life in acustodial state without any of the things we think of as human life. The surgery team said they were 50/50 at best ondelivering the best outcome for this child.* The parents heard this and said not to operate, letting nature take its course. The hospital doctors agreed.* The local county prosecutor disagreed. He said it was his job to defend the helpless, which this child is. He sued toforce treatment and lost. He appealed to the Indiana Supreme Court and lost again. He was getting together hisappeal to go to the U.S. Supreme Court but the child died.* So are there clear extraordinary circumstances where a parent can withhold life-saving treatment, clearly there are.If this case troubles you, angers you, disturbs you, you are not alone.* The court used the best interest standard, saying the benefits were few and burdens great so no surgery.* So, parents cannot withhold life- or limb-saving treatment from their children. The exception is when the bestinterest standard says otherwise.Roe v Wade (Patients Make Medical Decisions)* Roe v Wade gave rise to the rule of patients (not doctors) make medical decisions.* Roe v Wade is known to the public as the abortion legalizing decision, but this is wrong on many levels. Abortionhas always been legal in some of the United States. Roe v Wade said states could not make abortion illegal in thefirst trimester. States may, if they wish, decide if abortion is legal or illegal in the last two trimesters.* Abortion is not an exam issue because the laws that govern abortion differ radically across the 50 states.* This case was about the rights of mother's own body versus the rights of an unborn child. This goes to the heart ofwho makes medical decisions in the United States, and that is patients not doctors. This is fundamental and differsfrom many other countries in the world.* If you think you are better educated and better informed thus can make decisions for patients you will be getting alot of questions wrong because it is not the doctor's decision to make.* Your job is to come to the patient like a waiter. Here's the menu, I'd recommend the triple bypass today. In ademocracy the patients make the laws. Most people would like to decide for themselves when faced with a decision.If you're a doctor and don't like what the patient decides, too bad, it's their decision to make.* If the mother is ill and you want to do something for the sake of the child, courts have held that you cannot unlessthe mother says it is alright. If the mother is bleeding profusely and the fetus is in the 9th month and will die withouta blood transfusion, but the mother says no blood, do you give it to her? No, she said no.* Another case involved a fetus that had the cord wrapped around its neck three times, mother refused C-section.Court said its mother's right even though team thought the baby and the mother would die. Team prepared and therewas a happy ending where both lived. So again, you believe the baby will die without intervention it does not matterbecause it is not your decision to make.Tarasoff Case (Duty To Warn And Protect)* Tarasoff v Regents of U of CA gave rise to the rule of duty to warn and duty to protect.* Student at the University of California went to the university counseling center because they were feeling distress.During the counseling cession, student said I'm so mad at another student I'm going to go out and kill them. Thenthe student left the counseling cession.* The counselor was so concerned that she called the police and said she had a student that was threatening to harmanother student. The police picked up the student who visited counseling, but the student said I was just talkingduring counseling no big deal. Since no crime was committed the police let the student go.* The student then went out and killed the person they said they were going to kill.
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* The counselor, the counseling center, and the University were found liable for millions of dollars. The counselordid one thing she should do (call the police) but did not warn the potential victim.* There is a duty to warn by letting people know they are in danger and a duty to protect by acting to stop the harmfrom happening if you can at all do so.* You are seeing a middle-aged man for essential hypertension for several years. He comes in for a standardcheckup, you check his BP, do a physical, and adjust his medications. When he's getting dressed and about to leave,he pauses, looks back, and says, "Doctor, I don't know why I'm telling you this but I have to tell someone, when Ileave here I'm going to go kill my wife" then walks out the door. You notice a bulge that looks like a large revolverin his pants pocket. What should the physician do next?* If you said go for the phone, you just got the question wrong. You should be following the patient out the door.But doesn't the patient have a gun? Rule for the exam, we don't care about you (the doctor). The exam doesn't careif you get sued, shot, maimed, they only care about the patient. You're not expected to tackle the patient and wrestlethe gun away, but you're expected to be able to talk the patient down from this situation.* Say patient gets away. Now call the police. Then call the wife. But what do you say to the wife when you call?* Tarasoff 2 Case says if you tell the wife that her husband is coming home to kill her, and she greets him at thedoor with a shotgun and kills him, then you the doctor are liable.* So clearly what you say to the wife on the phone is important. What goal do you want to achieve here. I want herto be safe and I want to know that she is safe. You can do that by getting the patient to your office.* So say, "I need to talk to you about something very urgent and I need you to come right now. Drop everything youare doing and come to my office immediately."* Why not tell the patient to go to the police station? Because you don't know that she actually went to the policestation. Why not tell the patient to go to the neighbor and wait for the police? Because you don't know whathappened yet. If the potential victim is at your office you can go with her to the police together.--------------------------------------------------------------------------------------------------------------------------------------------Kaplan Videos (2001) – Medico Legal Rules with Dr. Steven Daugherty, MD--------------------------------------------------------------------------------------------------------------------------------------------Rule #1: Competent Patients Have The Right To Refuse Medical Treatment* If the patient is incompetent, you still need permission but not from the patient, from the surrogate or guardian.You don't make decisions, patients do.* Here are some "exceptions" people use: Life is the greatest good, once lost it is irreplaceable. I must intervenebecause if I don't the patient will die and that's the greater good. I must intervene because to not intervene is likehelping the patient commit suicide. Protection of third parties, I must save this woman's life else her children will allbe orphans and for their sake I must intervene. I took an oath, based on this oath I must intervene.* These were listed because none of them work on the exam or in real life. If you thought these were goodexceptions to the rule, then you're wrong. A competent patient has the absolute right to refuse treatment.* The patient will die without a blood transfusion in an hour. The alert patient says, "I don't want a bloodtransfusion." The outcome of this case is that the patient dies. They have the right to refuse.Rule #2: Assume Competence* It is not the job of the patient to prove to you that they are competent. You must have clear court designation orbehavior evidence that they are incompetent. If you don't, then they are competent.* If you are presented with a case and wondering if you're in the gray area, "is this patient competent or not?" thenthey are competent. They are either completely incompetent, or are considered competent. There is no gray area.* Schizophrenic patient for 15yrs, in and out of treatment facilities for the past 5 years, he is on a large does ofhaloperidol several times a day. Is he competent? Of course. What does diagnosis have to do with competency, thatis a medical decision. Competence is a legal decision and you are not qualified to determine competence.* Woman has Alzheimer dementia for the past 5 years. She has been in a nursing home care facility for the past 15months. Is she competent? Yes.* What blood alcohol level do you need to determine incompetence? None, competence is not a blood test. You lookat the behavioral evidence.* Patient comes in and is drunk. Are they competent? You assume competence.* Suppose you're working late in the ED and an ambulance roles in, the patients arm is crushed with nerves stickingout and blood shooting out. You realize this person repeatedly slashed their arm with a knife in a suicide attempt.The man is conscious, as you're trying to stop the bleeding he says "No, let me go, I want to die." Do you let himdie? No. Trying to kill yourself is clear behavioral manifestation of incompetence.* The schizophrenic patient is talking to you, eyes roll back, starts to giggle, then falls to the floor and rhythmicallybeats his head against the floor. Competent? No. Any random 10 people you picked off the street would say this
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person is incompetent.* If you think someone is incompetent, you can't just do whatever you want. You need permission from the closestsurrogate or guardian.Rule #3: Avoid Going To Court* For exams, going to court is a bad answer. The examiner figures if they watch you make a decision they arelearning something about you. If you toss problems off to someone else, they learn nothing about your capacity. So,make the call.* You have a child that is 7yo with juvenile onset diabetes. The child is not an emergency, but if not treated theywill die in several months. The patients, because of religious beliefs, refuse to have the child treated. Instead they aregoing to take the child back home and pray for the child's recovery with their religious community. This is theexception when you go to court. The court will take over medical guardianship of the child and make medicaldecisions. It is not because we don't like the parent's religion, that is irrelevant. It is because we don't believe in theparent's decision. Parents are not allowed to withhold life- or limb-saving treatment from the child.* Say this is an emergency but the parents say no. Do you act. Yes of course, they cannot withhold.* Do you need a court's approval to terminate life support. No, make the decision. The court says, "Look, youpassed all your exams, right? You know what the rules are and we're really busy. Stop bothering us and make thedecision. Leave the hard ones for the court."Rule #4: Use Subjective Standard, Then Substituted Judgment, Then Best Interest Standard* Use subjective standard (advanced directive), then substituted judgment, then best interest standard.* Advanced directive means if the patient is unable to communicate right now, then we're going to do what thepatient said before they were in this state. This is clear historical verbal or written wishes.* Say the patient never said what they wanted. Now we use substituted judgment (Karen Ann Quinlan). You neversaid what you wanted but I know you, so I'll tell people what you want.* Say no one knows the patient or what they want, then we use the best interest standard (Brother Fox). This is thelast step. We sit and weight what most people would want and make a decision based on that.* It's been a busy night in the ED and at the end of the shift an 87yo woman is brought in by her adult daughter whohas been caring for her at her own home. The 87yo woman is in an apparent coma, persistent vegetative state.Examination and neurological consultation suggests that this woman is unlikely to ever regain consciousness butcould probably be kept alive on life-support for several years. You wonder how aggressively to treat this patient soyou start talking to the daughter. The daughter is visibly distressed and breaks down crying, you wait, give her atissue, she composes herself, and you start again. The daughter says I don't want to make this decision, I don'tknow, I don't know. You ask what she thinks her mother would want. She says mother never talked about what shewanted, if I had to decide I'd say do nothing aggressive because mom didn't want to be a burden on people, but I'mjust not sure. Now comes the mother's adult son, who has been estranged, living 2000 miles away, but raced to thehospital upon hearing about the condition. He got there via his private jet and helicopter, landing on the hospital. Heis able to pay for this lifestyle because he does well as a malpractice attorney suing physicians for bad medicaldecisions. The son points out that you haven't done anything to treat his mother, you haven't even done the standardprotocol interventions that are done in these circumstances, and he insists that you begin treating. Now what?* So what options? Listen to the daughter, listen to the son, sit with them both and come to a decision, go to court,talk to the hospital ethics committee, talk to the hospital legal committee, call the chief attending physician. Theanswer is listen to the daughter. We do not have clear subjective standard because the patient did not write anythingdown. Now we're at substituted judgment and who do you believe has the best substituted judgment, daughter.* Say the son pulls out a letter written by the mother. It says she wishes they will do everything to help her. Now wehave clear subjective standard, so who cares what the son or daughter say, this is the patient's wishes.Rule #5: The Physician May Rely On Advanced Directives* If the patient is incompetent, the physician may rely on advanced directive.* Advanced directive can be oral.* Prior to going into surgery, you are going through the procedure with the patient and making sure they understandthe details because you believe this enhances patient recovery. As you're going over the procedure one last time, thepatient grabs your arm and looks into your eyes seriously, saying, "Doctor, I've thought about this and I knowyou're going to do your best but if something happens during surgery I don't want to be kept alive on life-support,just pull the plug." You assure the patient everything will be fine and you've done this hundreds of times before.Then something horrible happens during surgery and they end up in a coma. The family hears about this conditionand identifies the country's leading specialist in this kind of comatose patient. They come to you saying that thespecialist is flying in first-class from across the country. At this point, what should the physician do. Answer is pullthe plug. Wait wait, there were no witnesses for this conversation. You also forgot to chart the conversation because
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you were so busy so there is no documentation. Yes, still pull the plug. Wait, won't you get sued? Absolutely. Notonly will you get sued but you'll lose big time, your house is gone, your car is gone, your license is gone, you'reflipping burgers. If you're thinking how do I protect myself legally on the exam, you're not going to get the answer.* When should you have a conversation with the patient about a living will? The answer is as soon as you begin tobe their physician. You don't have conversations about these things when they are at the threshold of difficultmedical procedures. You don't have this conversation when they hear the word cancer, they're not listening. Youhave the conversation early when they are able to think and reflect, making the best decision for themselves.* Health Power of Attorney (POA) is a person speaking with the patient's voice, just like the patient.* So patient goes under for surgery and says pull the plug if something happens. They go into a coma and the POAsays do everything. You do everything because it is the last conversation with the patient that matters and the mostrecent conversation (by the POA, same as patient) was keep them alive.* Say living will reads "Do everything to keep me alive" and POA comes in and says pull the plug. What do youdo? You pull the plug.* The Health POA has on the spot facts about what should be done. The dates on the documents are irrelevant. If theHealth POA was designated 2 years ago and the willing will was 2 weeks ago, we listen to the Health POA. HealthPOA is like a trump card.Rule #6: Feeding Tubes Can Be Withdrawn At The Patient's Request* Feeding tube is considered a medical treatment and can be withdrawn at the patient's request.* A competent patient has the right to refuse even life-saving food and hydration.* The willpower needed to starve yourself to death is incredible and very few people have that.* Cruzan case, feeding tube was removed, patient continued to live.* What about anorexia nervosa? A 15you refuses food and water. What do you do? Feed them. Why? The patient isa minor so what they say does not matter. Most cases of anorexia are in the teen years.* Say patient is 19yo with anorexia nervosa and is refusing food and water. Outcome is go to court. Anyone wouldrecognize this is a clear syndrome, the court will say she is not competent, and they will take over medicalguardianship of the patient.Rule #7: Do Nothing To Actively Assist The Patient To Die Sooner* What is acceptable and not acceptable for euthanasia? Not doing something at the patients request is acceptable.Not giving food, medications, blood, that is fine because it is the patient's decision. Actively doing anything tospeed up the time of death is unacceptable, don't do this. No you can't leave morphine syringes on the table andwalk out of the room.* One common question, "Doc, if I knew I had a way out it would help so much more with the pain. If you couldjust write me a prescription for something…" Do not do this. Don't even give the patient pain medication where youknow you're getting close to the respiratory depression threshold and causing death.* Give the patient as much pain medication as they can stand. Do more than you think you should; if you say thepatient is terminal and there is nothing more than can be done you're lying. You can always give them comfort andpain relief. But, do this in a way that does not kill the patient.* In real life, if you do an intervention like give pain medication and they end up dying, this is considered dualintervention or dual consequence and we forgive you. On the exam, don't go there.Rule #8: The Physician Decides When The Patient Is Dead* You've been treating a patient for several months doing all the standard and even some non-standardinterventions. Yet, the patient continues to be in a persistent come and does not show any response. You believethere is no hope of improvement and your colleagues agree. You believe any further intervention with this patient isa waste of valuable medical resources. You wish to terminate treatment with the patient. The family says no, theywant you to keep treating even though they agree there is no benefit from the intervention. What do you do, keeptreating. Decisions to terminate treatment (or start treatment) are not yours to make.* You've been treating a coma patient for several months without any improvement or chance of recovery. A reviewof the data shows the EEG over the past 48hrs has been flat line. You confront the family and they say they know aspecialist who is not flying in to consult on their loved one. What do you do? Call time of death. You do not get todecide when to terminate treatment, but you get to decide when you have a patient and a corpse. You had flat-lineover 48 hours when you only need it over 24 hours. The patient is dead. Make the call, terminate life support.* It is not futile in the sense that the treatment is not working, it is futile in the sense that the patient is dead and thatis your decision to make.Rule #9: Never Abandon A Patient* If a patient wants you as their doctor, do you have to take them? No. But once you take a patient you cannotabandon them. What is the patient is completely annoying. "Unless you improve your manner with me I can no
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pregnant minor may be emancipated during pregnancy but no longer emancipated after giving birth depending onthe state.* What about a 16yo who dropped out of high school but has a job and is contributing to the family and paying alltheir bills. Are they emancipated? Yes.* Partial emancipation applies to any child (usually age 16-17) that gives them the right to make medical decisionsin four area only. They are substance abuse, prenatal care, treatment for STDs, and birth control.* These exceptions exists because they are obvious public health concerns. We're worried that a 16yo would bescared to tell his parents about her STD and simply not get treated. If he can get treatment for himself without hisparents knowing then he is more likely to get treatment and thus we protect the public.* 16yo female patient that you've had for 10 years. She comes for a physical exam prior to summer camp. You findnothing remarkable on exam and as you're filling out the forms she says, "When I go to summer camp I'm going togo with my new boyfriend and we've decided to start having sex. I want to do the responsible thing and don't wantto become pregnant so can you give me birth control pills and not tell my parents." What should the physician do orsay next? The right answer is not to write her a script and send her on her way. Yes, you can write her a script andno you shouldn't tell the parents. The correct answer is counseling, advice, use of barrier protection for STDs.Rule #12: Parents Cannot Withhold Life- Or Limb-Saving Treatment From A Child* A mother and her 17yo girl are brought in by ambulance to the hospital after an automobile accident. Both arealert, conscious, and bleeding profusely. Unless both receive a transfusion within an hour they will both die withintwo hours. The mother refuses blood transfusion citing her religious beliefs. The daughter refuses blood transfusionas well, citing her own participation in these religious beliefs. You take the daughter away from the mother to makesure she isn't being influenced and the daughter continues to refuse. Do you transfuse the mother? No. Do youtransfuse the daughter? Yes.* A mother brings in a child with a deep bleeding cut on her forearm. The cut would require about 20 stitches,although you could take care of it with butterfly closure bandages and compresses. Yet that would leave an unsightlyscar that might possibly impede the use of her arm in her elderly years. The mother refuses you permission to stitchthe arm. Do you stitch? No. This is not life- or limb-threatening.Rule #13: Anything That Varies Widely Across The United States Cannot Be Tested* Abortion issues differ widely so do not get tested.* 12yo girl comes in and wants an abortion but doesn't want you to tell her parents. Can you do the abortion? No,there is no state that you can do an abortion on a 12yo without parental consent.* They get around this by backing the age down to the point where everyone is consistent.Rule #14: Good Samaritan Laws* Good Samaritan laws are an attempt to make the world a better place, they try to get physicians to do what theyought to do by stopping to help people in non-medical settings when those people need care.* The law does not say you have to stop to help. Say you see a horrible accident on the highway, blood everywhereand people screaming. You drive by. Will you get in trouble? No.* The law is meant to take away a barrier that people use to not stop and help. In the United States, for better orworse, you can be sued any day by anybody for anything. If that's the case, why would you stop to help?* What the Good Samaritan law does is shields you from that liability if you stop to help. If you stop to help and dowhat is reasonable, you are shielded from legal liability even if every patient you touch dies.* You are shielded as long as four things hold true:* 1) Your actions are within your level of competence. If you've been a dermatologist for decades then opted to doon-the-spot brain surgery at the scene of an accident, that's probably over the line.* 2) You use accepted procedures. This is not the time to try new things.* 3) You have to stay if you stop. You can't be giving CPR then say, "Ow my back, I'm outta here." You arecommitted until you are relieved by competent medical personnel (e.g. ambulance).* On the exam, you should get in the ambulance and ride with them to the hospital because it is ethically the rightthing to do. Is it possible that something could happen in the ambulance where you could save the patient and theEMTs/Paramedics could not? Yes, so don't abandon your patients.* 4) You cannot get paid or compensated. Once you get paid it is fee-for-service and all the regular liability lawswill come into play.* You splint a guy's broken arm and he pulls out a wad of cash to give you as thanks. Don't take it. If you do, it'sfee-for-service and not Good Samaritan. How about he says he owns the new restaurant downtown and you shouldvisit with your buddies for a free meal. Don't take the meal. How about a package shows up at your door two weekslater and it's a Rolex watch with a card from the patient. Don't accept the watch. The amount does not change theanswer. Do not give this up casually, keep the shield.
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* It's 7:15pm and your office closes at 7pm. Your office sign is turned to closed and you are doing paperwork. Youhaven't locked your doors yet and a man stumbles into your office with a large butcher knife stuck in his abdomen.He passes out in the lobby. Do you have to help this man? Yes, he made it into a medical setting.* It's 7:15pm and you just left your office. You see a man outside on the sidewalk with a large butcher knife stuck inhis abdomen. Do you have to help him? No, he's not in a medical setting. This isn't what we want you to do ofcourse, but it is how the legal system works.* You are flying in an airplane and the stewardess comes over the speaker to say, "Is there a doctor, we need adoctor in first class." Do you have to go help? No.* You are not forced to help but the Good Samaritan law tries to remove the barrier if you want to help.Rule #15: Confidentiality Is Absolute* You don't tell anybody anything about any patient period.* Never discuss a patient anywhere where you can be overheard. Err on the side of not telling.* A husband and wife always come in together for the husband's visits. One day the husband comes alone becausethe wife is doing errands. She calls later to ask about the visit because she is usually there. Can you tell her about thevisit? No. You cannot even tell her if the husband kept the appointment. That fact that he was there or not isconfidential and the fact that you are someone's doctor or not is confidential.* You get a subpoena to come testify about a patient next Thursday. Do you show up next Thursday. Yes. Do youtestify? No, a subpoena is easy to get and you should not burst patient confidentiality. Say because of patientconfidentiality you cannot discuss the matter. You can only tell if there is a threat of harm to the patient or others.Not only can you break confidentiality in that exception, you must break confidentiality.* Your male patient has been diagnosed with Gonorrhea and is being treated. He says please don't tell my wifebecause he got this during an affair and he doesn't think his marriage would survive the strain. What do you do?This is a mandatory reportable public disease, so you have to report it to public health. The notion that the wife willnot find out is not in the cards. The wife will find out from public health. The discussion should be about how wetell the wife because she will find out. The husband says he'll go tell the wife and leaves. Is that the right answer?Probably not. How about you call and say, "This is Dr. so-and-so, you don't know me but have you ever consideredbeing tested for Gonorrhea?" Nope, wrong answer. Best way to do this is bring them both together into the office,she finds out, she gets informed and gets advices from you.* Husband has HIV, does the wife find out? Yes, spousal notification is the law.* With any infectious disease, encourage the patient to bring in their significant other so you can tell them about thedisease. Voluntary notification is generally recommended, where the patient notifies their partner. In some states, thephysician has the right to call the partner, in some other states they prefer the physician not tell.* A man makes a living as a bus driver but you find an eye condition as part of a physical exam. You think this eyecondition would make driving a bus dangerous. He says please don't tell my boss. Do you tell the boss? Yes,prevent harm from happening.Rule #16: Patients Should Be Given A Chance To State DNR And Physicians Should Follow Them* If the DNR says no pulmonary resuscitation, can you do cardio resuscitation? Yes. The DNR says what you cannotdo and you can do whatever else. Generally it means don't call for the crash cart.* If someone has DNR, does that mean you don't perform scheduled surgery? Of course you do the surgery.* If someone has DNR, do you stop the antibiotic drip? No, you continue regular medical care. You just do not doheroic measures to bring them back from the brink.Rule #17: Doctors Don't Commit The Mentally Ill, Courts Commit* Doctors do not make the decision to commit a mentally ill patient and that patient is entitled to a jury trial beforethey are committed.* Committed means the patient is assigned to a locked treatment facility and cannot come and go as they please.* This is not a jail, treatment must be available.* The patient can refuse treatment. I go to talk to my schizophrenic patient today and give them their haloperidol,but they say, "No, I don't want that." They said no, you can't force it. You go ahead and treat if they let you treat.* A committed patient still has the right to transact business, get married, get divorced, vote, drive on a day pass.Rule #18: Physicians Can Detain* Emergency detention is allowed in most states for 48 hours in some states and at most 72 hours in most states.* Can you hold a patient against their will if it will prevent harm from happening to themselves or others? Yesabsolutely, this is therapeutic privilege.* Children are not allowed to be detained unless they are an imminent danger to self or others, unless they areunable to care for their daily needs, or unless the parents have no control over the child.* Example would be a child that starts fires and breaks windows everywhere they go and the parents cannot do
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anything about it, then we can protect the child and others by detaining them.Rule #19: If A Health Care Professional Puts Anyone At Risk, Remove Them From The Risk* Examples would be infectious disease. The doctor has tuberculosis, do you want them seeing patients? No.* This covers substance abuse too. Your coworker has an alcohol abuse problem, should they be treating patients?No, take whatever action necessary to prevent that from happening.* A colleague is very depressed. Should they be treating patients? No, take action to stop them from treating.* You think your colleague is completely incompetent. Should they be seeing patients? No. How do you make thathappen? If you're a resident, you can go to the program director and discuss it. If it's a freestanding physician out inpractice then you go directly to the state licensing board to make the report. Your loyalty on this exam is to thepatient. It is not to yourself or other physicians.* If a physician is HIV positive, do they have to tell their patients? It depends on if it is relevant. Say you're aradiologist or psychiatrist, then it doesn't matter if you have no patient contact. How about a surgeon? Yes. Thatwould be a risk to discuss during informed consent.* A fellow physician has a substance abuse problem. You report them to the licensing board. Then what? Refer tothe local treatment facility? No. The right answer is you personally take the physician on as a patient. You go withthem to the facility.Rule #20: Focus On The Best Ethical Conduct* Think "What would Mother Teresa do in this instance?" Whatever you decide is the answer you choose.* It's not about reflecting on real life, it's not about what the lawyers want you to do, it's about what the exam-writers want you to do.--------------------------------------------------------------------------------------------------------------------------------------------Kaplan Videos (2001) – Epidemiology with Dr. Steven Daugherty, MD--------------------------------------------------------------------------------------------------------------------------------------------Screening Tests* Screening tests are about secondary prevention and are about prevalence (not incidence).* Sensitivity involves how good a test is at finding disease in a population; detection of disease.* 100% sensitivity means every person with disease was found by a test.* Rule: True on top for every calculation.* Sensitivity (Sn) = True Positive / (True Positive + False Negative)* A sensitivity of 80% is pretty good, chance would be 50% so at 80% we're not doing too bad.* Specificity involves the detection of health.* Specificity (Sp) = True Negative / (True Negative + False Positive)* Mnemonic: for sensitivity (SN) the false Negative is on the bottom, for specificity (SP) the false Positive is on thebottom. SPIN and SNOUT: Specificity rules disease IN, Sensitivity rules disease OUT.* It is very difficult to get a test with high sensitivity and specificity. In practice, we pick tests that either have highspecificity or have high sensitivity, but usually not both.* Screening should start with a test that has good Sensitivity, then confirm with a test that has good Specificity.* So which do you want, good specificity or good sensitivity? Well it depends on what you're trying to achieve.* Suppose there is a horrible infectious disease out there but we have a great way to treat it. Would you want a testthat is sensitive or specific? Here we want sensitivity to make sure we catch all the cases.* Suppose there is a disease we can treat, but the treatment is a little dangerous and pretty painful. In this case wewant specificity so that we aren't subjecting healthy people to the painful treatment.* A patient comes to you and says they think they got HIV. You do the screening test and it comes back positive.Now you have to tell the patient the news. As a side note, you should both be sitting and you should be talking to thepatient either face-on or slightly offset, but not side-by-side. So what do you tell the patient? You say, the test saysyou have HIV. The patient will ask, are you sure? You say: the positive predictive value for the test.* Every time you get a positive lab result you should ask yourself if you believe the test result.* Positive Predictive Value (PPV) = True Positive / (True Positive + False Positive)* You could get a lab result back on an exam and be asked what should the physician do? If you calculate the PPVand decide the test is garbage, it will completely change what you do with the test result.* A female patient comes in to see you for fertility trouble. Now she returns because she missed a period and wantsa pregnancy test. The pregnancy test comes back negative. You have to deliver the news and the patient asks if youare sure? You say: the negative predictive value for the test.* Negative Predictive Value (NPV) = True Negative / (True Negative + False Negative)* Accuracy = (True Positive + True Negative) / N, N is the total for the table* If prevalence is 50%, which is common, then accuracy is (Sensitivity + Specificity) / 2
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* Suppose that disease prevalence increases. What effect does that have on sensitivity? It stays the same. Sensitivityand specificity are properties of the test, so they will not change with changes in prevalence.* Suppose that disease prevalence increases, what happens to positive predictive value? PPV increases. Say youhave a group of people where 50% have a disease and you have another group of people where disease is one in amillion. If you got a positive from each group, which would you believe? The 50% group. How about a negative?You would believe the one in a million group. So prevalence has to affect the PPV and NPV.* This is the reason we tend not to screen entire populations because by definition your prevalence is going to below, thus your PPV will be bad. So we focus our screening on areas where we think there is a higher likelihood ofdisease because our PPV will be higher.* The bimodal "double hump" diagram is used to help decide where a screening test cutoff should be made.* The bimodal diagram is meant to show a hump for healthy people and a hump for diseased people. The majority ofthe hump to the left of the middle line is the true negatives (healthy) and to the right is the true positives (diseased).The mistakes are in the little triangles that overlap into the larger hump sections. The ones to the left on the negativeside of the line are false negatives and the ones to the right on the positive side of the line are false positives.* A new screening test is applied to a representative 1000 people in a population. Based on the data presented in thetable, calculate the requested screening test measures. The first thing to do when encountering a 2x2 table is to makesure everything is in the right order. Focus on the denominator first. If asked about sensitivity, just look for thenumber divided by TP + FN. For PPV, look at the number divided by TP + FN. For accuracy, look at the total (N)for the denominator, then look at TP + TN for the numerator. Prevalence is disease out of total population.* The CDC would like to decrease the cutoff for a screening test from X to Y. X was at the point where the twobimodal curves crossed. What will happen? True positive tests will increase and false positive tests will increase.PPV will decrease since we have more false positives. The accuracy of the test will be reduced. The sensitivity isconcerned with classifying diseased people, so the sensitivity will increase. If the number of positive test resultsincreases and those people go to follow-up, there will be an increase in the number of follow-up patients.* Now say there is a little bit of cross-over between two bimodal curves and they ask what the sensitivity of the testis. If you split a curve in half, you would be at 50% sensitive. If you drew a horizontal line just outside the tail of thecurve, you would be at 100% sensitivity. So, at the point where the curves cross you are between 50% and 100%sensitive. If the overlap tail is small, you're probably closer to 100% sensitive.* There is a screening test with sensitivity of 80% and specificity of 90%. Disease prevalence is 10%. What is thePPV for this test? You have to construct a 2x2 table, assume you have 1000 people (pick a nice round number). Nowwork backwards, so you have 100 diseased people (10% prevalence) and 900 healthy. Out of 100 diseased people,TP must be 80 and FP must be 20. Then TN is 90 and FN is 810. PPV is then 80 / 170, so just below 50%.Research Designs: Observational Studies* The developers of the exams know not everyone is going to become a researcher. They realizes however that allphysicians will be consumers of research and should be able to interpret research studies. Does this study have bias?Is what this pharmaceutical representative telling me accurate? What about a patient that shows up with a study theyprinted off the Internet after seeing it in the news? You should be able to understand if the study applies to thepatient and why.* Whenever presented with a question on research, ask yourself if this is an observational study (writing down whathappened) or an experimental study (an intervention such as medication or surgery).* Observational studies are the first type we do in medicine. They are done in a specific order.* Case report is an observational study that is a description of a single patient. N = 1 in a case report. This is how werealize something is possible in medicine. The first time we learned about HIV was a single case report.* Case series is an observational study that is a bunch of patients with something in common. This helps us get aclear list of symptoms or signs for a disease. However, there is no control group.* Cross-sectional study is simply a prevalence study. This observational study is to figure out how many people inan entire population have the disease right now. We do not get incidence or a measure of causality. We havechickens and eggs but no temporal sequence so we don't know what came first.* Case-control study is cases of disease compared with control (no disease). We get these people together and lookback into time retrospectively for the presence or absence of some precursors. The goal is to determine what theprecursors are for the disease. We do not get a measure for the prevalence of disease since we just pick a group ofpeople. We also do not get incidence because we are starting with disease. We do get a measure of causality.* There is a sudden and widespread cholera epidemic. No common water source can be found. How do you do astudy to figure out the problem? You do a case-control study, get people together and interview them aboutabsolutely everything you can think of. Then you look between the two groups for differences and those differencesare likely precursors to disease. When this study was done, all the patients with cholera were found to love mangos.
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The mangos are washed at the point of shipping, so that was the source. People were told not to eat mangos and thecholera epidemic was stopped.* Cohort study is an observational study that is the most elaborate, time-consuming, and expensive. Thus, we do itlast after the case report, case series, cross-sectional study, and case-control study. A cohort study is the exactopposite of a case-control study. It starts with people who have risk factors then follows them forward in time to seewho does or does not develop disease. This gives you a measure of incidence of disease. You do not get a measureof prevalence. You do get the best measure of causality because you are in the right temporal sequence with causethen effect afterwards.* Cohort studies give incidence data. We analyze data as relative risk (division) and attributable risk (subtraction).* Relative Risk = Incidence In Exposed / Incidence In Unexposed* Relative risk is a ratio of incidence rates. Say infant mortality for African Americans is 20 per 1000 live births.Say infant mortality for Caucasians is 10 per 1000 live births. These are incidence rates. What is the relative risk forAfrican Americans versus Caucasians? RR is 20/10 = 2, twice as likely. What about Caucasians versus AfricanAmericans? RR is 10/20 = 0.5, half as likely.* Relative risk answers the question how much more likely.* Attributable risk answers the question how many more cases.* Attributable Risk = Incidence In Exposed - Incidence In Unexposed.* In the previous case, 20 - 10 = 10. So 10 more African American babies died per 1000.* You should be much more concerned with attributable risk. You don't treat probabilities, you treat cases.* Relative risk is important from a statistical point of view, it gives you statistical significance, p-value.* Attributable risk is how you get a gauge of clinical significance, how many more cases you are likely to see.* Number Needed To Treat (NNT) is how many people you have to treat (medication, surgery, etc) to make oneperson better. This is linked to the incidence rate; it is the inverse of the incidence rate.* If the incidence is 1 in 1000, we have to treat 1000/1 = 1000 people to make 1 better.* If incidence rate is 10 per 1000, NNT is 1000/10 = 100.* NNT = 1 / Incidence* We analyze case-control study data with odds ratio.* Looking at a 2x2 table does not tell you the type of study, you have to see where they got the data from. Say we goout right now and look at who has and who does not have lung cancer, then who is or is not a smoker. What type ofstudy is this? Cross-sectional. Say we look at smokers and non-smokers then follow them for a few years to see whogets lung cancer. That is a cohort study. Say we look at people with lung cancer and those without, then go back intheir history and figure out who was a smoker. That is a case-control study. All could be shown on a 2x2 table.* Odds means ratio by definition. Odds of having lung cancer is a/c then not having lung cancer is b/d. The oddsratio is the ratio of those odds, (a/c) / (b/d) = (a*d) / (b*c).* The 2x2 from left to right, top to bottom is a b c d. A study about smokers and lung cancer would have the "a" cellas smokers who have lung cancer. "a" cell is always disease with risk factor. "d" cell is diagonal from "a".* Odds ratio mnemonic is AD (present time, like 2000AD) over BC (past time, dinosaurs in BC time).* Odds ratio is sometimes read "smokers are 9.5x more likely to get lung cancer" but it should be read "people withlung cancer are 9.5x more likely to have been smokers." You did not start with smoking and predicted lung cancer,you started with lung cancer then went back and found smokers.Research Designs: Experimental Studies* Research in medicine that is experimental is labeled clinical trials.* To see if a drug makes people better, we should give it to people and see if they get better? Wrong; we have tocompare that group to a group of people who did not get the drug and see if those people get better.* A control group is a group of people who get everything except for the intervention being investigated.* The three phases of clinical trials are what the U.S. Food and Drug Administration (FDA) requires a drug to passso that they can be prescribed in medical practice.* Phase I tests how well the drug performs with healthy volunteers. Does it harm or not harm healthy people?* Phase II is the first time we use real patients, a small group of them. We are trying to figure out if the drugs worksto a point, but really we care about the correct dosage for the drug, what the protocol should be for giving the drug.We get some outcome data but the goal is to get information to setup for the Phase III trial.* Phase III trial is where the clear decision is made about whether the drug works and if we should be using it onpatients that have the particular disease. It is characterized by a large group of patients because we are looking forefficacy (how well does the drug work) and side effects. You won't find side effects emerging with a small group ofpatients. If a drug passes a Phase III trial, meaning we get statistical significance relative to a control group, then thedrug is available for the FDA to certify and we can prescribe it in clinical practice.
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* Phase IV clinical trial is when the drug is being prescribed but we are keeping track of what is happening. It is notreally a clinical trial per-se but more record-keeping of what is happening.* Randomized controlled clinical trial (RCT) is the verging on the best kind of research. Randomized meanswhether the patient ends up in the intervention or the control side is completely up to chance.* Say you setup a trial about antidepressants. For each person that comes into your clinic, you assign them to onegroup, the next person to the other group, and back-and-forth. Is this randomized? No. To be randomized means anyperson has an equal chance of being in either group and all combinations are possible. So if you walk in behindsomeone then you would not end up in the same group, however being in the same group has to be a possibility forrandom assignment.* A better way to randomly assign people would be to shuffle a deck of cards then flip a card for each person. If thecard is red they go to group A and black they go to group B. Theoretically the first 26 people could be in the samegroup. That is a random assignment.* Double-blind randomized clinical trial is the best type of research we can do. Double blind means the subjects donot know if they are getting the intervention or in the control group. Also, the researchers who have contact with thesubjects do not know if they are in the intervention or the control group. So both the patients and researchers cannotbe biased, the patients do not respond differently and the researchers do not treat the patients differently.* True or False: in a double-blind randomized clinical trial nobody knows who is in the intervention or the controlgroup. False, somebody has to know. The true statement is that the subjects and the researchers who have contactwith the subjects do not know. Someone, like a lab technician or computer analyst, has a coded list.* If RCT are the gold standard, why don't we just run those all the time? Well, because they are expensive and timeconsuming. So we focus our resources on things that are likely to show good outcomes. That is why we do all theobservational studies ahead of time, that way we get good evidence that it is useful to move on into the experimentalstudies.* Say we have a drug that is likely to add a few years to a patient's life. We could give the drug to all those with thedisease, but that wouldn't be good research. We have a conflict of what we need from research and what we cantolerate with ethics. The solution is a crossover design study.* Crossover study starts with two double-blind randomized groups. At the beginning, group A gets the real drug andgroup B gets a placebo that looks like the real drug. At some point, unknown to the patients or researchers, weswitch the groups so that group A is now getting the placebo and group B is getting the real drug. In this study,every patient in the study gets the drug at some point thus we have no untreated patients. We also have a comparisonbetween the groups at each point and we can compare the individuals themselves when they are on or off the drug.So we have good research design and research ethics satisfied.--------------------------------------------------------------------------------------------------------------------------------------------Kaplan Videos (2001) – Biostatistics with Dr. Steven Daugherty, MD--------------------------------------------------------------------------------------------------------------------------------------------Descriptive Statistics* Central tendency is measured by the mean, median, mode. Mean is the average. Median is the middle number, halfnumbers above and half below. Mode is the most common number, what you have the most of.* In a normal distribution, the mean equals the median equals the mode.* Positive skew is when the tail of the curve points to the right. Negative skew is when the tail points to the left.* Positive skew: mean > median > mode. Start at tail an go inward in that order, alphabetical order.* In a skewed distribution the mean is most sensitive to extreme values, so it is pulled toward the tail. The mode isthe least sensitive to extreme values.* Negative skew: mean < median < mode. Again, start at the tail and go inward. The mean is pulled most toward theextreme values.* You can tell if a distribution is skewed by comparing the mean to the median. If the mean > median, we have apositive skew. If mean < median, we have a negative skew. If mean = median, we have a normal distribution.* For most normal distributions, the measure of central tendency that we use is the mean because it is the mostintuitive for people. For a skewed distribution the mean is not the best measure, use the median as the measure forcentral tendency.* When looking at salary (skewed distribution), you would want to use the median. Say most electrical engineers ear$75,000/year but a few guys earn $2 billion/year. That would really skew the mean, but the median would be closerto the actual salary that you would earn.* Now that we have central tendency, we want to know about the spread. How wide or narrow is the distribution?* The most common and intuitive measure of spread is range, which is the highest - lowest score. It is a poormeasure of the spread however. The range ignores most of the data we have, concentrating on 2 numbers.
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* Suppose there is an exam today and a similar test next week. Your score is likely to shift between the two tests.Your score is going to shift in a predictable direction if you are at the extremes, they shift toward the mean. This iscalled regression towards the mean. It means that extreme values when re-measured will be less extreme.* Say you took Step 1 and got a really high score. You are more likely to get a lower score on Step 2, not becauseyou got dumber, but because of regression toward the mean.* Suppose you have a patient that has the highest blood pressure you have ever seen in your clinical career. You leapinto action, give them strong medication, get them to exercise, put them on a diet, and schedule to see them againone week later. Now one week later, the blood pressure is substantially lower than before. What accounts for thisreduction in blood pressure? Not the drugs, not the exercise, not the diet, it is regression toward the mean. It issimply an artifact of measurement.* Since the extreme score are the least stable of all the scores, we can see that the range is a poor measure of spread.* So how should we measure spread? Lets take each score (x) and subtract the mean (xbar) and sum them. Thisshows us how close or far from the mean each score is, so we get the average deviation from the mean. This soundsgood on paper but doesn't work well in practice because we always get zero. For each number above the mean thereis a similar number just as far below the mean. If we square that match, we don't get numbers zeroing out. But nowwe have to account for the number of people, so we divide by the sample size - 1. Don't worry about the -1, it is adegree of freedom and just adjusts for the mean.* Standard Deviation = sqrt((SUM (x - xbar)^2) / (N - 1))* Yes, it looks like a complicated formula, but we did the talk so you understand why the formula was created.* As the sample size increases, the standard deviation increases, true of false? False, the standard deviation shouldnot change with sample size. We always divide by the sample size in the formula.
* In a normal distribution, what percentage of cases fall within +/- 1 standard deviation? 68%.* Memorized these numbers: +/-1 SD = 68%. +/- 2 SD = 95.5%. +/-3 SD = 99.7%.* What percentage of scores fall between 0 and +1 SD? 34%. We calculate that by dividing +/- 1 SD (68%) by 2.* Say the average for a test is 500 and standard deviation is 100 (e.g. COMLEX). If you scored 600, what percentileare you? Here you are +1 SD above the mean. That means you are 34% above the mean (50%), which is 84%ile.This means you scored better than 84% of everyone taking the test and only worse than 16%.* What percentage of cases in a normal distribution fall above one standard deviation below the mean? That wouldbe 34% + 50% or 84%.* What percentage of cases in a normal distribution fall below two standard deviations below the mean? This isroughly 2.25%. We know that +/- 2 SD is 95.5% leaving 4.5% leftover on each tail. We only need half of that.* IQ Distribution: Average = 100, Standard Deviation = 15.* What percentage of the population has an IQ below 70? 2.25%. What about > 130? 2.25%.
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* Say USMLE Step 2 has a theoretical mean of 200 and standard deviation of 20. If you score a 240 on the exam,what percentile are you at? You are at the 97.75%ile. What if you score 180? That is 16%ile.* Say that 95% of people scored on a test between 150 and 250 on a test given to the general population. What is the84%ile for this test? Can we assume this is a normal distribution if the test is given to the general population? Sure.So we know +/-2 SD of people are between 150 and 250, so the mean must be 200 in the middle. To get to the84%ile we need mean + 1SD. If 2 SD = 50 then 1 SD = 25, so 84%ile is 200 + 25 = 225.* What would you estimate the 16%ile to be in the previous case? That is the mean -1 SD, so 200 - 25 = 175.Inferential Statistics* Inferential statistics are taking some information and inferring from that information what the whole rest of theworld must be like. It is because of inferential statistics that we can do science and research or decide what drugsyou should or should not be giving your patients. You make a leap from a study on a group of people and infer howthe drug would work on anyone getting it.* Say you have a class of 200 students and want to know how they did as a whole. But, you're in a hurry so yourandomly take 6 students and calculate the mean. Will that mean be exactly the same mean as the whole class?Doubtful. But, is it likely to be close? Sure.* With inferential statistics we give up precision (knowing the exact number) and get a degree of confidence orcertainty about what the exact number is probably.* Confidence intervals are how we do research in medicine and you have to understand confidence intervals tounderstand basically any research article you get.* Say class starts at 8am. But you come strolling in 5mins late but you think you're on time. You know the numberisn't exact but you're in the ballpark.* Confidence Interval (CI) = Xbar +/- Z (S / sqrt(N))* The part in the parenthesis is called the standard error (SE). So do you want this to be a large number or smallnumber? Small number, you want the error to be as low as possible. The SE is essential a measure of the quality ofyour estimate. S is the standard deviation and N is the number of people.* The smaller the standard deviation the better your estimate, the larger the SD the worse the estimate. As thesample size gets larger the standard error gets smaller. Thus, we put SD on top and N on the bottom for SE.* The one thing you can modify for standard error is the sample size. This is your way to reduce the error.* Say a group of obstetricians wants to do a new study comparing a new birthing method with the current method.You ask what the sample size is and they say 4. Is this study doing to reach significance? No way, the reality you getfrom a sample size of 4 is so skewed compared with the general public that you won't be able to make an inference.* Z is the standard score or Z-score. Read carefully here, there is a standard deviation, standard error, standard score.* Standard score (Z) implies the mean (Xbar) = 0 and SD = 1 because these numbers are easy to work with. So if thenumber is positive it is on the right side of the mean, and negative is on the left side of the mean. SD of 1 means thatthe Z-score is in standard deviation units.* If your Z-score is +1, you are 1 SD above the mean. If your Z-score is -1.6, you are 1.6 SDs below the mean.* Say we want 95% of our scores within 2 SD of the mean. We could go +/- 2 for our Z-score, but that's 95.5%. Toget 95%, we tuck it in to Z-score = +/- 1.96. 99% of cases for Z-score = +/-2.58.* Z = 1.96 for a 95% confidence interval. Z = 2.58 for a 99% confidence interval.* When you're in the hurry during the middle of an exam, use approximates Z = 2 for 9% and Z = 2.5 for 99%.* Say Xbar = 60%, S = 9%, and N= 9. What is the 95% CI for that estimate of the mean? CI = 60 +/- 2 (9/sqrt(9)),which is 60 +/- 6. This means if you got all the data and not just the 9 people, you would likely find the real mean tobe between 54 and 66. Are we completely certain the mean is between 54 and 66? No, we're 95% certain. Is themean most likely to be 60 in the middle? No, it is just as likely to be 54 as it is 60 or 66. This is a flat probabilitydistribution, so any number inside is as good as any other number in the confidence interval.* Confidence interval is our window to reality. We have a set of data representing a small group and we want toinfer what that data would look like for everyone, so the confidence interval is our best guess.* Say 187 people are polled regarding who they want the next president to be, AG or W. AG gets 38% and W gets44%. The margin of error is 3% for the poll (assume this is 95% CI). Can you say with 95% confidence that W isleading? So AG is as high as 41% and as low as 35%, and W is as high as 47% and as low as 41%. They could bothbe 41%, so no you cannot say that W is leading the poll because there is overlap.* Rule: Any overlap in a confidence interval means no difference.* It would be better to choose a drug that has a more predictable response pattern than a drug that has better effectbut less predictable response. So look for a smaller standard deviation to get the more predictable response.* How do you determine if a relative risk number is significant? Look at the confidence interval. The critical numberis 1.0. The relative risk will always occur within the confidence interval given. See if the confidence interval
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contains the number 1.0. If the confidence interval contains 1.0, it is not significant. If the interval is outside 1.0,then it is significant. Why is 1.0 the critical value? We divide to get the relative risk, so if the risk in group A is thesame as the risk in group B we would get a relative risk of 1, meaning the groups are the same. To prove they aredifferent, show the outcome of the relative risk is outside of 1.* A relative risk > 1 with confidence interval not including 1 indicates increased risk.* A relative risk < 1 with confidence interval not including 1 indicates decreased risk.* The relative risk does not matter unless the confidence interval matters, so make sure the CI does not include 1.* This is all the same for odds ratio. You can tell if an odds ratio is significant if the CI does not include 1.Statistical Probability* You flip a coin 4 times and it comes up heads every time. If you think the next flip will more likely be tails sinceyou are due for a tails, you fell for the gambler's fallacy. What came before has nothing to do with what will happenbecause the coin flips are independent events.* What is the chance of getting two heads in a row (joint probability)? We multiple. Probability of heads and heads,the and means multiply. Chance of getting heads is 50%, so 50% times 50% is 25% change of 2 heads in a row.* What is the chance of getting 4 heads in a row? (50%)^4.* You flip a coin and it came up heads. What do you know? You know the coin came up heads and that it did notcome up tails. On a single event, heads and tails are mutually exclusive. If one occurs the other cannot occur.* What is the chance of getting heads or tails on a single flip? Or means add. 50% for heads + 50% for tails is 100%chance of getting either heads or tails on a single flip.* Mutually exclusive in Venn diagram would be two circles that do not overlap. Non-mutually exclusive in Venndiagram would be two overlapping circles, you can be part of both circles at the same time.* Joint probability of circle A and B if they are mutually exclusive is A + B. What about when you have non-mutually exclusive? If you add A + B you counted the overlap twice, once for A and once for B. The overlap area isA times B, so this is the correction factor. The formula then for overlapping circles is A + B - A*B, the chance ofgetting A, B, or both. What is the chance of getting A or B but not both? A + B - 2*A*B.* Say the chance of meeting someone who is obese is 30% and the chance of meeting someone with diabetes is10%. What is the chance of meeting someone who is either obese or has diabetes, but not both? Using A + B -2*A*B, we get 30% + 10% - 2*(30%*10%) = 40% - 6% = 34%. What is the chance of meeting someone who isobese, or someone who has diabetes, or someone who is obese with diabetes? 37%.* What is life expectancy following surgery? You are being asked about the median survival time, or when 50% ofpeople have died.* For a given surgery, say 90% live to one year, 75% live to two years, and 50% live to three years. The lifeexpectancy following surgery is thus 3 years (50% mark). If you live to two years, what is the chance that you willmake it to three years? 50% / 75% = 2/3 = 67%. This is a conditional probability problem, similar to the questionabout two trains heading toward each other and asking when they will meet.Statistical Logic* The problem with statistics is that most people think instinctually the exact opposite of what the statistics.* You cannot prove something with logic. You can't say that a drug works. But, you can disprove something so youcan disprove that the drug doesn't work. Sounds pretty backwards but that's how it works.* Say there is a new anti-diarrhea medication and we want to research if it works. So, we take a group of people withexplosive diarrhea and randomize them to either control or the group that gets the medication. One group gets thepill and the other gets the placebo but neither the participants nor researchers contacting the patients know whichpill. Now, we have to lay out the null hypothesis.* The null hypothesis is the opposite of what we want to find. If we want to know if the drug works, the nullhypothesis is that the drug does not work. Don't worry about one-tailed versus two-tailed null hypothesis.* For our study, the null hypothesis would be that the group getting the anti-diarrhea medication fails to resolve theirdiarrhea before the control group.* Data gets fed into a computer. What happens in the computer? Who cares for now. The output will be some letters,like t (t-test), F (F-test), r (correlation coefficient), or x^2 (chi squared). Just ignore those for the exam, honestly.The one letter you should focus on is p (p-value). This is your key value for making statistical decisions.* The p-value is both the standard and a summary of the empirical evidence that you compare to the standard.* The p-value is set before the research begins. When you aren't sure what to do, you do what everyone else doeswhich is p ≤ 0.05. For a 95% CI, you are right 95% of the time. The 5% is the percent of the time that you arewrong, so it corresponds exactly to p ≤ 0.05.* If p = 0.02, are we under or over the bar? We are under the bar, which is good. This means we can reject the nullhypothesis. We want to reject the null hypothesis because it is the opposite of what we are looking for.
DO NOT DISTRIBUTE - 47 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
* Is it possible that in our study the drug works but it won't work for the rest of the world? Not likely but possible.So you have to realize that the decision you make here could be wrong, a Type I or alpha error.* Type I Error means you rejected the null hypothesis but you should not have. You decided that the drug works butin reality it is garbage. You will never know for sure that you made a Type I error, but you will know the chance orprobability that you made a Type I error. The chance that you made a Type I error is the p-value.* If p = 0.02, there is a 2% chance of a Type I error. So out of 100 times we will be wrong twice. But, this is howstatistics and medicine work. We have to go ahead and keep making decisions anyhow.* Type I Error (alpha error) = p-value, the alpha criterion.* If p = 0.13, we are above the bar so we cannot reject the null hypothesis. Should we accept the null hypothesis?No. We fail to reject the null hypothesis. Never accept the null hypothesis. The same holds for court where the jurydoes not find you innocent, they say there is not enough evidence to convict you.* If p=0.13, can we have a Type I error? No because you have to reject the null hypothesis to get a Type I error.* Type II error is when you did not reject the null hypothesis but you should have. In your study the drug wasgarbage but in the real world the drug is fantastic. What is the chance that you made a Type II error? You don'tknow and there is no information to tell you.* Type II Error (beta error) = you don't know.* In general, which is worse, a Type I error or a Type II error? A Type I error, which is why the p-value is soimportant. A fault of commission is something you did that you shouldn't have done. A fault of omission issomething you didn't do that you should have done. It's considered worse in general to fault with commission.* It is worse to give patients a drug that will not help them (and might hurt them) than to fail to find a drug thatwould help them. Primum non nocere = first do no harm.* You are given a drug with p = 0.02 in clinical research. A patient comes in and you prescribe the drug. The patientasks you what the chances are that the drug will work for them. The answer does not deal with the p-value. It doesnot tell you the percentage of patients who will benefit, the chance your patient will benefit, or the chance that sideeffects happen. You can look in the research article for a table that shows how many people got better when giventhe drug along with how many people did not get better when given the drug.* Power is capacity to find a difference if there is a difference to find.* Beta = 1 - Power = Type II Error* What is the simplest thing you can do to increase statistical power? Increase sample size, N.* A researcher found p=0.15 with statistical power of 70%. What is the chance of a Type II error? 30%.Statistical Analysis* The type of statistical test that you run depends on the type of data you have. The world is not made of numbers, itis made of things. We have to convert those things into numbers and we do that by scaling. Once you recognize thetype of scale you have, you know the type of statistical analysis you should do.* Nominal or Categorical data is grouping things into clusters. The most common nominal variable is gender, maleand female. So male and female, how many nominal variables? One, gender. Gender is a single nominal variablewith two groups.* Interval data is along a scale, where things are measured at equally graded intervals. From interval data we can getmeans and standard deviation. Can we computer the mean of gender, not so much. How about the mean of theheight of students in a class, yea.* When you're talking about what something is, that is nominal data. When you're talking about how much ofsomething you have, that is interval data.* Pearson correlation is for interval data with two variables (most likely).* Chi squared is for all nominal data (most likely).* t-test for nominal and interval data combined (most likely).* If you want to compare the heights of men and women. What statistical test should we use? We have men andwomen, which is nominal data, and height, which is interval data. So t-test.* If you want to compare height to weight, how would you do that? You have two types of interval data so do aPearson correlation.* Say you want to do a simple study where one group gets a drug and the other group does not. Then see who isbetter or not better at the end of the year. How would you analyze that data? You have all nominal data so do a chisquared analysis.* Correlation coefficient (R) ranges from a possible -1 to +1. The closer to +1 or -1 the better. The cleaner the lineor trend you have on a graph the stronger the correlation. Positive correlation is direct and negative correlation isinverse. Would you expect a positive or negative correlation between height and weight? Positive. How aboutnumber of minutes exercised per week and blood pressure? Negative.
DO NOT DISTRIBUTE - 48 -Study Notes – Family Medicine & Physical ExamJames Lamberg 28Jul2010
* A t-test only works when you have two groups. Say you want to compare the heights of three different animals,then you cannot do a t-test. Mnemonic is "t for two". If you have more than two groups you do an analysis ofvariance (ANOVA).* Chi squared is for all nominal data so you will likely see a table, like a 2x2 or 3x3.* Again, Pearson correlation is for interval data, chi squared is for nominal data, and t-test is for nominal andinterval data combined with two groups. If you have more than two groups, use ANOVA.--------------------------------------------------------------------------------------------------------------------------------------------