ABIM 2015 - General IM

Question 1

The degree to which the investigator’s conclusions are supported by a research study is called the study’s?

Answer 1

INTERNAL Validity

Question 2

The generalizability of an investigator’s conclusions beyond the internal confines of the research study is called the study’s?

Answer 2

EXTERNAL Validity

Question 3

In therms of what specifically is the error for a given study shown?

Answer 3

Confidence Interval (CI) - usually 95%

Question 4

What does it mean when there is a “wide” Confidence Interval?

Answer 4

It means that the research study has less certainty and precission

Question 5

What causes a research study’s Confidence Interval to be less precise or less certain (“wide”)?

Answer 5

Small sample size

Question 6

The probability of detecting the difference between two groups when a difference exists is affected by a small sample size and is called?

Answer 6

Power of a study

Question 7

Non-random errors that occur in a research study are called what?

Answer 7

Bias (can occur in selection of patients, measurement and analysis)

Question 8

What type of bias exists when patients chosen for a study group have characteristics that can affect the results of a study?

Answer 8

Selection Bias

Question 9

A third factor that influences BOTH exposure (treatment) and outcome (false conclusion: “smokeless tobacco in the form of snuff poses a greater risk for developing CAD than cigarette smoking” could occur because being MALE which is associated with a higher risk of CAD, is more likely among snuff users than cigarette smokers (male and female) thus distorting the cause-effect relationship. This factor is known as?

Answer 9

Confounder (MALE)

Question 10

How can confounders be minimized in research studies?

Answer 10

By using a randomized study design

Question 11

What type of study determines patient selection, treatment and analysis from the outset in order to minimize errors and bias by blinding patients, treating physicians and investigators?

Answer 11

EXPERIMENTAL Study

Question 12

What is the objective of an EXPERIMENTAL Study?

Answer 12

To prove that the “new” therapy is “non-inferior” to existing therapies (but is cheaper, more convenient to take, etc.)

Question 13

True differences between studied subjects can be masked if the sample size is too small, what is this called?

Answer 13

Low-power

Question 14

If a study has great precision and internal validity however the treatment protocol is difficult to implement outside of the research setting, the study lacks what?

Answer 14

Generalizability (External Validity)

Question 15

What is a study design called when randomization of patients is UNETHICAL or UNFEASIBLE however by its design, data can be compared in the same group of patients both BEFORE and AFTER the intervention?

Answer 15

Quasi-Experimental Study

Question 16

What are studies called when instead of randomizing individual patients, entire GROUPS of patients are randomized?

Answer 16

Cluster-Randomized Study

Question 17

In what types of studies does the study investigator have no role in assigning individuals to interventions but rather just compares the effects of exposures or treatments among two or more observed groups?

Answer 17

Observational Study

Question 18

What are the weaknesses of Observational studies over Experimental studies specifically because in Observational studies, the investigator “observes differences among treated or exposed groups and has therefore NO role in randomizing them?

Answer 18

Confounding error and Bias

Question 19

The ability to include a broader spectrum of disease (rather than very narrow spectrum of disease (well designed Randomized Control Studies), disease exposures that are rare and where treatments are administered in a “REAL WORLD” environment rather than in a lab, is the advantage of what type of study?

Answer 19

Observational Study

Question 20

What types of studies are COHORT and CASE-CONTROL?

Answer 20

Observational Studies

Question 21

The study that compares the outcomes of GROUPS forward in time (prospectively) or backward in time (retrospectively) with and without exposure or treatments NOT initiated by the investigator (rates of lung cancer between smokers and non-smokers) is called what?

Answer 21

Cohort Study

Question 22

Which type of Cohort study, prospective or retrospective, minimizes a certain type of bias?

Answer 22

Prospective Cohort Studies (minimize “recall” bias - inaccurate recall of past events)

Question 23

This type of study RETROSPECTIVELY compares the EXPERIENCE of patients who HAVE a disease with those who do not have the disease (patients with and without lung cancer can be compared with respect to their exposure to asbestos)?

Answer 23

CASE (disease)-Control Study

Question 24

What study design is best for studying RARE diseases or those that occur many years after specific exposures?

Answer 24

CASE (disease)-Control Study

Question 25

Being EXCLUSIVELY a RETROSPECTIVE study, Case-Control Study, much like retrospective Cohort Studies are susceptible to what type of bias?

Answer 25

Recall Bias (those patients WITH disease may be more likely to remember previous exposure than those without disease)

Question 26

Which Observational Study design assesses BOTH for exposure and disease at the SAME TIME POINT rather than prospectively or retrospectively?

Answer 26

Cross-Sectional Study

Question 27

This Observational Study is merely a REPORT of clinical outcomes in a group of patients?

Answer 27

Case Series (group of patients rather than a “case report” involving only one patient)

Question 28

Because a Case-Series Study is merely a REPORT of clinical outcomes in a group of patients, it lacks a CRUCIAL part of a study design that prevents it from DRAWING ANY CONCLUSIONS about the effectiveness of a treatment, what is that crucial part without which, no real conclusion can be drawn regarding the effectiveness of a treatment?

Answer 28

Control Group

Question 29

This type of study compares outcomes in AGGREGATE, of TWO different POPULATIONS (countries, socioeconomic groups)?

Answer 29

Epidemiological Study

Question 30

What is the ECOLOGICAL FALLACY, a specific study error of Epidemiological Study?

Answer 30

Erroneously ASSUMING that population-level associations imply individual-level associations

Question 31

This type of study design SUMMARIZES EXISTING experimental OR observational studies in a rigorous way (they pose a FOCUSED clinical question, exhaustive review of published literature, QUALITATIVE or QUANTITATIVE combination of the results and a narrative summary of the STRENGTHS and LIMITATIONS of the analysis?

Answer 31

Systematic Reviews

Question 32

The Systematic Review Study that QUANTITATIVELY combines data (not qualitatively) is known as what?

Answer 32

A Meta-Analysis

Question 33

What is the strength of systematic reviews?

Answer 33

Their ability to combine the data of MANY small studies thus minimizing the impact of RANDOM ERROR

Question 34

What type of study is considered the HIGHEST QUALITY sources of evidence, followed by the QUALITATIVE Systematic Review > RCT (experimental study) > Cohort Study (observational) > Case Control Study (observational)?

Answer 34

Meta-Analysis

Question 35

This type of study is intended to produce evidence that can help PATIENTS, PHYSICIANS and POLICY MAKERS better understand the EFFECTIVENESS, BENEFITS and HARM of treatments or procedures?

Answer 35

Comparative Effectiveness Research

Question 36

This error occurs when SYSTEMATIC differences between groups affect the outcome of a study?

Answer 36

Bias

Question 37

In this study design, patients receive one of two interventions (one often being a placebo) , it is the strongest study design for determining causation, EXPENSIVE, time-consuming, limited follow-up and has a limited number of outcomes with limited generalizability. What study design is this?

Answer 37

Experimental Study: Randomized Controlled Trial (RCT)

Question 38

In this study design, patients are grouped (ex. nursing unit) rather than being assigned randomly, used when randomization of patients is unethical or not feasible, challenging to analyze. What study design is this?

Answer 38

Experimental Study: Cluster-Randomized Trial

Question 39

In this study design, a review of data is collected before and after an intervention, used when randomization of patients is unethical or not feasible, patients are NOT RANDOMIZED, needs to be adjusted for possible confounding. What study design is this?

Answer 39

Experimental Study: Quasi-Experimental Study

Question 40

In this study design, outcomes of groups using an OBSERVED assignment are studied, can DETECT associations but not always cause-effect relationships, can study multiple outcomes over a long period of time, has both retrospective and prospective designs, requires complicated statistical techniques, prospective designs can be expensive and take many years, selection and measurement of exposures and outcomes bias exists> What study design is this?

Answer 40

Observational Study: Cohort Study

Question 41

This study design compares only PAST exposures in patients with and without disease, it is useful for rare diseases or exposures however has a high risk for selection and measurement (especially recall) bias, confounding and cannot assess incidence or prevalence. What study design is this?

Answer 41

Observational Study: Case-Control Study

Question 42

An intervention that reduces the rate of disease from 20% to 10% has a RELATIVE RISK (RR) Reduction of what? It has an ABSOLUTE RISK REDUCTION (ARR) of what? It has a NUMBER NEEDED TO TREAT (NNT) of what?

Answer 42

RR: 50% (reduction from 20% to 10%)
ARR: 10% (the actual reduction 20%-10%=10%)
NNT: 1/ARR; 1/10% (which is 1/0.10)=10

Question 43

The NUMBER of patients NEEDED to receive TREATMENT for ONE additional patient to be expected to benefit from the intervention?

Answer 43

Number Needed to Treat (NNT) - the lower this number, the better

Question 44

How are Number Needed to Treat (NNT) and the Absolute Risk Reduction (ARR) related?

Answer 44

NNT=1/ARR

Question 45

The NUMBER of patients NEEDED to receive TREATMENT to expect ONE of them to be HARMED from the intervention?

Answer 45

Number Needed to Harm (NNH)

Question 46

How are Number Needed to Harm (NNH) and the Absolute Risk Increase (ARI - same as ARR) related?

Answer 46

NNH=1/ARI

Question 47

Defining the risk of an exposure or treatment in ABSOLUTE terms (ARI) and calculating the NNT/NNH does what?

Answer 47

Provides the BEST way to understand the MAGNITUDE of DIFFERENCE in the sample (effect size)

Question 48

What statistical value allows one to asses how likely ANY DIFFERENCE seen in a study is due to chance alone?

Answer 48

The P value

Question 49

What does a P value of LESS than 0.05 (P

Answer 49

It means that there is a less than 1 in 20 chance of coming up with the results found in the study trial by chance alone (null hypothesis) and that there is an actual difference between the treatments studied

Question 50

When does a study produce HIGHLY Statistically Significant Results (P

Answer 50

When they have many patients; It can mean that although highly significant STATISTICAL differences are found, they may not be CLINICALLY important (a very large NNT to see that difference)

Question 51

The ability of a test to DETECT a disease IF it is PRESENT is called?

Answer 51

SENSITIVITY (does not vary with the prevalence of disease)

Question 52

The ability of a test to EXCLUDE a disease IF the disease is NOT PRESENT is called?

Answer 52

SPECIFICITY (does not vary with the prevalence of disease)

Question 53

In a given population, 80% of the people HAVE a disease, what is that disease’s PREVALENCE?

Answer 53

80%

Question 54

What statistical tests are AFFECTED by the PREVALENCE of a disease when taking into account a given test’s specificity and sensitivity?

Answer 54

Positive Predictive Value (PPV) and Negative Predictive Value (NPV)

Question 55

The PROBABILITY that subjects with a POSITIVE screening test result truly DO HAVE the disease is called what?

Answer 55

Positive Predictive Value (PPV)

Question 56

The PROBABILITY that subjects with a NEGATIVE screening test truly DON’T have the disease.

Answer 56

Negative Predictive Value (NPV)

Question 57

(The probability of a pt WITH the condition having a POSITIVE test result)/(The probability of a pt WITHOUT the condition having the same POSITIVE test result) is?

Answer 57

Positive Likelihood Ration (LR+)

Question 58

(The probability of a pt WITH the condition having a NEGATIVE test result)/(The probability of a pt WITHOUT the condition having the same NEGATIVE test result) is?

Answer 58

Negative Likelihood Ratio (LR-)

Question 59

Sensitivity/(1-Specificity)=?

Answer 59

Positive Likelihood Ratio (LR+), where the scale is 0-1

Question 60

(1-Specificity)/Sensitivity=?

Answer 60

Negative Likelihood Ratio (LR-), where the scale is 0-1

Question 61

LR >1?

Answer 61

An INCREASED likelihood that the condition IS PRESENT

Question 62

LR

Answer 62

A DECREASED likelihood that the condition IS PRESENT

Question 63

LR=1?

Answer 63

The test result does NOT change the probability of the test at all (i.e. useless test)

Question 64

How do pre-test odds and post-test odds relate to the Likelihood Ratio?

Answer 64

Pre-test odds x LR (LR+ is used if result of test is positive and LR- is used if result of test is negative) = Post-test odds
Post test odds x 100 = Post-test Probability (as a percentage)

Question 65

Pre-test probability/(1-Pre-test probability)=?

Answer 65

Pre-test odds

Question 66

What is VALUE in healthcare defined by?

Answer 66

OUTCOMES achieved (rather than procedures performed or services rendered)

Question 67

(TP+FN)/(TP+FP+FN+TN)=?

Answer 67

PREVALENCE (number of patients in the population who HAVE the disease)

Question 68

TP/(TP+FN)=?

Answer 68

SENSITIVITY (Patients WITH the disease who have a POSITIVE test)

Question 69

TN/(FP+TN)=?

Answer 69

SPECIFICITY (Patients WITHOUT the disease who have a NEGATIVE test)

Question 70

TP/(TP+FP)=?

Answer 70

POSITIVE PREDICTIVE VALUE (PPV) - number of patients who have tested POSITIVE who actually HAVE the disease (INCREASES with INCREASING PREVALENCE)

Question 71

TN/(TN+FN)=?

Answer 71

NEGATIVE PREDICTIVE VALUE (NPV) - number of patients who have tested NEGATIVE who actually DO NOT HAVE the disease (INCREASES with DECREASING PREVALENCE)

Question 72

SENSITIVITY/(1-SPECIFICITY)=?

Answer 72

POSITIVE LIKELIHOOD RATIO (LR+) - the likelihood that a POSITIVE test result would be EXPECTED in a patient WITH the disease compared with the likelihood that a POSITIVE test result would be EXPECTED in a patient WITHOUT the disease

Question 73

(1-SENSITIVITY)/SPECIFICITY=?

Answer 73

NEGATIVE LIKELIHOOD RATIO (LR-) - the likelihood that a NEGATIVE test result would be EXPECTED in a patient WITH the disease compared with the likelihood that a NEGATIVE test result would be EXPECTED in a patient WITHOUT the disease

Question 74

The odds that a patient HAS the disease BEFORE the test is performed?

Answer 74

PRE-TEST ODDS

Question 75

The odds that a patient HAS the disease AFTER the test is performed?

Answer 75

POST-TEST ODDS

Question 76

Number of patients WITH the disease BEFORE the test is performed?

Answer 76

PRE-TEST PROBABILITY

Question 77

Number of patients WITH the disease AFTER the test is performed?

Answer 77

POST-TEST PROBABILITY

Question 78

These types of tests should be reserved for identifying COMMON conditions, with well-understood natural histories, that have SIGNIFICANT NEGATIVE consequences and for which EARLY detection provides clinical benefits that lead to INCREASED SURVIVAL and IMPROVED QUALITY of LIFE compared to identification at a LATER SYMPTOMATIC stage?

Answer 78

Screening Tests

Question 79

What type of STUDY is the BEST for determining the EFFECTIVENESS of screening tests in reducing morbidity and mortality?

Answer 79

Experimental Study: Randomized Controlled Trial (RCT)

Question 80

What type of BIAS occurs when a screening test leads to an EARLIER identification of a condition and an “APPARENT” improvement in 5-year survival but does NOT actually result in improved mortality?

Answer 80

Lead-Time Bias

Question 81

What type of BIAS occurs when the VARIABLE RATE of PROGRESSION of a condition is NOT accounted for (a patient with a prolonged, asymptomatic phase such as in a slowly-progressing cancer, has a greater likelihood of being identified in a screening test than a patient with a more rapidly-progressing cancer, resulting in an “apparent” but NOT ACTUAL survival benefit?

Answer 81

Length-Time Bias

Question 82

Identification of cancers that are NOT destined to progress thereby INFLATING “survival” statistics

Answer 82

Overdiagnosis

Question 83

Whom should be SCREENED for Depression, EtOH misuse, Obesity and HTN?

Answer 83

ALL Adults

Question 84

What patients WITHOUT increased cardiovascular risk should be SCREENED for Lipid Disorders?

Answer 84

ALL Men ≥35

Question 85

What patients WITH increased cardiovascular risk should be SCREENED for Lipid Disorders?

Answer 85

ALL Women ≥45

Question 86

ALL ADULTS with a sustained BP ≥135/80 mm Hg should be SCREENED for?

Answer 86

Diabetes Mellitus Type II

Question 87

What patients should be SCREENED for Osteoporosis?

Answer 87

ALL Women ≥65 OR younger women with fracture risk greater than that of a 65 yo white woman without additional risk factors

Question 88

What patients should be SCREENED for AAA?

Answer 88

ONE-TIME screening with Abdominal US for ALL MEN 65-75 yo who have any h/o smoking (past or present) - NOT FOR WOMEN (whether smoked or not)

Question 89

What patients should be SCREENED for HIV?

Answer 89

All PREGNANT women and ALL those at an increased risk

Question 90

What patients should be SCREENED for Hep B?

Answer 90

ALL Women at their FIRST prenatal visit

Question 91

What patients should be SCREENED for Chlamydia infection?

Answer 91

ALL Women ≤24 who are SEXUALLY ACTIVE OR ALL women ≥24 who are at an increased risk (multiple partners)

Question 92

What patients should be SCREENED for Gonorrhea?

Answer 92

ALL women ≥24 who are at an increased risk (multiple partners)

Question 93

What patients should be SCREENED for Asymptomatic Bacteriuria?

Answer 93

ALL PREGNANT women at 12-16 weeks gestation OR at their FIRST prenatal visit (whichever comes first)

Question 94

What patients should be SCREENED for Syphilis?

Answer 94

ALL PREGNANT women and ALL patients at an increased risk (multiple sexual partners)

Question 95

What Women should be SCREENED for Breast Cancer and WHEN and how FREQUENTLY?

Answer 95

ALL Women 50-75 yo EVERY 2 YEARS (starting at the age of 40 should be individualized for risk)

Question 96

What Women should be SCREENED (PAP-Smear) for Cervical Cancer?

Answer 96

ALL those ≥21, EVERY 3 YEARS OR, for women 30-65, who want to LENGTHEN their screening, ok to do it EVERY 5 YEARS IF COMBINED with HPV testing

Question 97

If a woman has NOT had a HIGH-RISK PAP-Smear and undergoes Hysterectomy, when do you SCREEN for Cervical Cancer?

Answer 97

You Don’t

Question 98

What patients do you SCREEN for Colon Cancer?

Answer 98

ALL ALDULTS 50-75 yo (routine screening)

Question 99

Are PERIODIC Health Examinations (“yearly physical”) recommended?

Answer 99

NO

Question 100

How OFTEN should an adult with a BP of

Answer 100

Every 2 years

Question 101

How OFTEN should an adult with a SBP of 120-139 mm Hg and DBP of 80-89 mm Hg be SCREENED for HTN?

Answer 101

YEARLY

Question 102

What is the MOST IMPORTANT risk factor for the development of BREAST CANCER in women?

Answer 102

Age

Question 103

Family history of BREAST CANCER, multiple family members with BREAST CANCER and development of BREAST CANCER in those family members at a YOUNG age as well as the presence of MULTIPLE PRIMARY TUMORS suggests what?

Answer 103

An INHERITED Syndrome

Question 104

Which GENETIC mutation has the HIGHER risk for developing BREAST CANCER by the age of 70, BRCA-1 or BRCA-2?

Answer 104

BRCA-1 (65% vs. 45% with BRCA-2)

Question 105

If concern exists for an inherited syndrome in a patient, what should be done besides counseling?

Answer 105

Referral to a GENETICIST

Question 106

What should Post-Menopausal women with a ≥1.66 risk of developing breast cancer in the next 5 years be offered?

Answer 106

A 5-YEAR course of either tamoXIFEN or raloXIFENe

Question 107

What should be recommended to a woman s/p PAP-Smear with “unsatisfactory” cytology?

Answer 107

Immediately REPEAT the test

Question 108

What should be recommended to a woman s/p PAP-Smear with “ATYPICAL squamous cells of undetermined significance”?

Answer 108

Either of these is acceptable:

1. COLPOSCOPY referral
2. Obtain HPV DNA test and refer for COLPOSCOPY if POSITIVE
3. REPEAT PAP-Smear in 6-12 months

Question 109

What should be recommended to a woman s/p PAP-Smear with ANYTHING other than “ATYPICAL squamous cells of undetermined significance” OR unsatisfactory” cytology?

Answer 109

COLPOSCOPY referral

Question 110

Should a patient who presents with benign prostatic hyperplasia (BPH) symptoms prompt screening for prostate cancer?

Answer 110

NO (no screening method is recommended by the USPSTF)

Question 111

A patient’s recall of ONLY which two (2) vaccines should be considered “valid”?

Answer 111

Influenza and Pneumococcus (for ALL other vaccines, either re-vaccinate according to age or obtain serology)

Question 112

Which are the four (4) LIVE Attenuated Vaccines?

Answer 112

MMR, Influenza (intranasal only), Herpes Zoster, Varicella (not for immunocompromised and pregnant patients)

Question 113

ALL Adults should be Vaccinated with what four (4) vaccines?

Answer 113

Influenza, Tdap (Tetanus, diphtheria, pertussis), Varicella, MMR

Question 114

Who should receive the Herpes Zoster vaccine?

Answer 114

ALL adults ≥60 yo

Question 115

Who should receive the Pneumococcal vaccine?

Answer 115

ALL adults ≥65 (or those ≥19 with risk factors - immunocompromised, asplenia, chronic kidney disease, malignancy, cardiovascular, HTN, DM, pulmonary disease, liver disease, smokers, alcoholics, CSF leaks, cochlear implants)

Question 116

Who should receive the HPV vaccine?

Answer 116

ALL men and women 11-26 yo

Question 117

Who should receive the Meningococcal vaccine?

Answer 117

Adolescents, persons living in dorms, military and those with HIV or asplenia

Question 118

Who should receive the HAV vaccine?

Answer 118

ALL children, travelers to endemic areas, homosexual men, promiscuity, illicit drug users and persons with chronic liver (having HBV or HCV does not constitute disease, they must have liver dysfunction) or kidney disease, DM

Question 119

Who should receive the HBV vaccine?

Answer 119

ALL children, Health Care workers and persons with chronic liver disease

Question 120

What VACCINE should ALL pts with HIV get?

Answer 120

Meningococcal Vaccine

Question 121

What VACCINES should Health Care Workers get?

Answer 121

HBV, MMR (second dose), Varicella (if born before 1980)

Question 122

Which HIV patients CAN receive Live Attenuated Vaccines (MMR, Varicella, Herpes Zoster and Intranasal-Influenza)?

Answer 122

Those with CD4 counts ≥200

Question 123

In whom are INACTIVATED vaccines contraindicated?

Answer 123

Those with ALLERGIES to the vaccines

Question 124

What needs to be done if a patient received two of the three required shots needed to complete a vaccination?

Answer 124

Resume where that patient left off and give the THIRD shot

Question 125

A patient with a SERIOUS ACUTE disease wants to be vaccinated, what do you do?

Answer 125

DO NOT VACCINATE until illness resolves (ok to vaccinate if mild to moderate illness -URI, even with fever)

Question 126

What should be done if MULTIPLE vaccines are given at the same time?

Answer 126

Give at different SITES

Question 127

What is the process by which we require a NEW influenza vaccine yearly?

Answer 127

Antigenic DRIFT

Question 128

In whom is it ok to give the LIVE Attenuated Influenza vaccine?

Answer 128

ALL patients 2-49 yo WITHOUT medical conditions that make them susceptible to Influenza or its complications

Question 129

What patients CANNOT use EITHER LIVE Attenuated NOR INACTIVATED Influenza vaccines?

Answer 129

Those who developed Guillain-Barre after Influenza infection and those with severe EGG allergies (anaphylaxis)

Question 130

What are the components of the Influenza vaccine?

Answer 130

Influenza A & B as well as H1N1

Question 131

Varicella vaccination (as well as ALL other LIVE Attenuated vaccines) in pregnant women is contraindicated. When should a woman be able to become pregnant after the administration of a LIVE Attenuated vaccine?

Answer 131

ONE (1) MONTH (counsel for possible birth defects if before)

Question 132

Which patients should be RE-VACCINATED with the pneumococcal vaccine EVERY 5 YEARS?

Answer 132

Immunocompromised, Kidney failure and Asplenic (functional - sickle cell or anatomic) patients
ALL adults given the vaccination BEFORE age 65, give a BOOSTER at age 65

Question 133

What patients should receive the Meningococcal vaccine every 5 years?

Answer 133

Those with ASPLENIA and Complement deficiencies

Question 134

When should a patient consult a physician before starting an exercise program?

Answer 134

Cardiovascular disease or HTN, musculoskeletal disorder or symptoms of chest pain and dizziness when exercising in the past

Question 135

What is smoking considered?

Answer 135

A disease (not a habit)

Question 136

What is the LEADING cause of ILLNESS and DEATH in the US?

Answer 136

Smoking

Question 137

What are the two effective medical interventions for smoking cessation?

Answer 137

1. Bupropion + Nicotine Replacement

2. Varenicline + Nicotine Replacement (superior)

Question 138

Can patients on MAOI’s, those with eating disorders or seizures be on BUPROPION?

Answer 138

NO

Question 139

16 oz beer, 5 oz wine, 1.5 oz (one shot) of spirits?

Answer 139

A STANDARD Alcoholic beverage

Question 140

40% of Malpractice payments in 2003 were for what?

Answer 140

Diagnostic Errors

Question 141

When should a patient’s medication reconciliation take place during their hospital stay?

Answer 141

THROUGHOUT and at DISCHARGE with PRINTED LIST

Question 142

Diagnosing a patient based on what is most easily AVAILABLE in the physician’s mind (because of a recently seen patient with similar symptoms, etc.) rather than what is most probable, is known as what type of a diagnostic error?

Answer 142

Availability Heuristic

Question 143

Settling on a diagnosis EARLY in the diagnostic process despite data that refute the diagnosis or indicate another diagnosis is known as what type of a diagnostic error?

Answer 143

Anchoring Heuristic

Question 144

Formulating a diagnosis based on the application of pattern recognition (a patient’d presentation fits a “typical” case therefore it must be that case is known as what type of a diagnostic error?

Answer 144

Representativeness Heuristic

Question 145

Does a diagnosis of DEMENTIA or MENTAL ILLNESS mean that a patient is incapable of making health care decisions?

Answer 145

NO!!

Question 146

What should be done if a patient or proxy wants to have FUTILE treatments administered?

Answer 146

Request ETHICAL and LEGAL consultations

Question 147

WHEN is the only time where it is ETHICALLY permissible to give a terminally-ill patient a treatment that may HASTEN their DEATH?

Answer 147

ONLY when the PRIMARY INTENT is THERAPEUTIC

Question 148

Is the ACTIVE administration of a drug with INTENT to cause DEATH legal?

Answer 148

ABSOLUTELY NOT (regardless of consent)

Question 149

Whom can a physician disclose information to regarding a patient?

Answer 149

Staff involved in patient’s care and other persons specifically designated by the patient ONLY

Question 150

In which two (2) situations can patient confidentiality be broken?

Answer 150

1. Communicable diseases

2. Pt is a risk of harm to themselves or others

Question 151

What are the three (3) key components of ERROR disclosure? (certainly can and should obtain legal counsel advice prior to error disclosure)

Answer 151

1. Provide the FACTS
2. Express REGRET
3. Formal APOLOGY

Question 152

Should GIFTS or other ITEMS of material value be accepted by physicians by pharmaceuticals, medical device vendors or biotech companies?

Answer 152

NO

Question 153

Should educational presentations controlled by industry be given?

Answer 153

NO

Question 154

When should a physician accept a drug sample?

Answer 154

For patients who lack financial access to medications

Question 155

A service which addresses PAIN, SUFFERING and QUALITY of LIFE across ALL stages of treatment and DOES NOT exclude life-prolonging treatment and rehabilitation?

Answer 155

Palliative Care

Question 156

When should HOSPICE care be offered?

Answer 156

When a patient reaches the final weeks or months of life, when harm from life-prolonging therapies exceed benefit and when therapies are discontinued

Question 157

How should CANCER-related pain be initially treated?

Answer 157

With NSAIDS, OPIOIDS and RADIATION therapy

Question 158

Which long-acting opioid has been reported to cause arrhythmia and QT-prolongation?

Answer 158

Methadone (requires baseline, 30-day and regular follow-up ECG)

Question 159

Why should meperidine (demerol) be avoided as an analgesic?

Answer 159

Seizures, confusion and mood alterations (especially in kidney disease)

Question 160

Can opioids CAUSE pain?

Answer 160

YES, rarely “opioid-induced hyperalgesia” where increased dosages exacerbate pain

Question 161

What bowel regimen should ANY patient starting an OPIOID analgesic agent?

Answer 161

Stool SOFTENER + LAXATIVE

Question 162

Since fatigue caused by cancer and chemo/radiation therapy agents CANNOT be relieved by rest, what should be recommended?

Answer 162

Energy conservation, Biofeedback and Exercise program

Question 163

Which is the FASTEST acting and POWERFUL opioid analgesic that is also available in extended release and should ONLY be used in patients that have not done well with MORPHINE or weaker opioids?

Answer 163

FENTANYL

Question 164

What are the two most powerful analgesic agents used?

Answer 164

FENTANYL and Hydromorphone

Question 165

What two (2) agents are used in cancer-related dyspnea?

Answer 165

Opioids and Benzodiazepines

Question 166

What disease are ß-agonists, morphine, pulmonary rehabilitation and oxygen used in, for the purpose of dyspnea symptom relief?

Answer 166

COPD

Question 167

What is considered “chronic” nausea?

Answer 167

Nausea ≥1 week

Question 168

What are Metoclopramide, Ondasetron, Dronabinol and Dexamethasone used for in cancer patients?

Answer 168

Anti-emetics

Question 169

What two (2) medications can increase appetite in cancer patients?

Answer 169

Megestrol and Corticosteroids

Question 170

What are the preferred antidepressants for use in end-of life patients?

Answer 170

TCAs and SSRIs

Question 171

How is delirium treated in end-of-life patient however can exacerbate delirium in pts with dementia?

Answer 171

Sedatives such as Haloperidol and Benzodiazepines

Question 172

Does morphine cause respiratory depression in patients who are in pain?

Answer 172

NO

Question 173

What is considered “Complicated Grief” in family members who have lost a loved one?

Answer 173

Grief >6 months

Question 174

What would you ask a patient during a visit if you wanted to uncover possibly uncomfortable issues which the patient would benefit from discussing?

Answer 174

Ask if they had “OTHER” concers

Question 175

What should be considered in a patient who presents with multiple symptoms in different parts of the body?

Answer 175

Depression, Anxiety, Somatization

Question 176

A patient presenting with complaints of PAIN should be screened for?

Answer 176

Depression, Anxiety and Substance Abuse

Question 177

PRIOR to starting pain therapy for a patient who c/o pain, what BARRIERS must be excluded?

Answer 177

BEHAVIORAL (low motivation, unrealistic expectations, continued EtOH/Drug use); SOCIAL (lack of support, cultural/language barriers and financial issues); SYSTEMS (formulary/coverage restrictions), difficulty accessing behavioral health care

Question 178

Treatment of neuropathic pain such as burning, shooting or stabbing is best treated with what agents?

Answer 178

Gabapentin, pregabalin, TCA’s, SNRIs, (DULOXETINE, venlafaxine) TRAMADOL, opioids and carbamazepine

Question 179

Treatment of muscle pains such as seen in fibromyalgia with tender trigger points (neck, shoulders, arms, lower back, hips, extremities) is best done with what agents?

Answer 179

TCA’s (amitriptyline, imipramine, nortriptyline, doxepin, clomipramine), MILNACIPRAN (specifically for fibromyalgia)

Question 180

Treatment of inflammatory pains such as from joints in RA is best done with what agents?

Answer 180

NSAIDS, DMARDS, TCA’s

Question 181

Treatment of mechanical/compressive pain such as BACK pain, NECK pain, MUSCULOSKELETAL pain is best done with?

Answer 181

NSAIDS, acetaminophen, TCA’s, SNRI’s (duloxetine-Cymbalta)

Question 182

What is the goal of treatment of patients with Chronic Non-Cancer Pain (CNCP)?

Answer 182

Improvement of function and quality of life (exercise, rehabilitation, cognitive-behavioral therapy, pharmacological therapy and massage - low back pain, fibromyalgia, knee osteoarthritis)

Question 183

What other disease state tends to coexist in patients with chronic pain?

Answer 183

Depression - must be treated (if major depression - by psychiatrist)

Question 184

These two herbals have been shown to be effective for the treatment of HA and back pain as glucosamine, chondroitin and others have NOT?

Answer 184

Feverfew (HA) and Willow bark (back pain)

Question 185

Which OPIOID medication has been shown to be efficacious in moderate-to-severe CHRONIC pain and has SSRI properties as well?

Answer 185

TRAMADOL (therefore caution when using together with SSRIs as it can cause SEROTONIN SYNDROME)

Question 186

Use of these analgesic agents is contraindicated in patients with current PUD, chronic KIDNEY disease (CKD) or HF?

Answer 186

NSAIDs

Question 187

If an NSAID must be used in a patient with cardiovascular risk, which should it be?

Answer 187

Naproxen

Question 188

What is the ideal pharmacologic combination therapy for a patient with POST-herpetic neuralgia and diabetic neuropathy pain?

Answer 188

Nortriptyline + Gabapentin

Question 189

In what patients do you want to consider OPIOID analgesia?

Answer 189

Those with MODERATE-to-SEVERE pain who did not respond well to non-opioid analgesia) acetaminophen, NSAIDS, TCAs

Question 190

Are opioids beneficial in patients with inflammatory or mechanical/compression pain (spinal)?

Answer 190

NO

Question 191

What is considered “acute” cough?

Answer 191

Cough

Question 192

In acute bronchitis, how long can cough last for and what is the time-frame for resolution of bronchitis?

Answer 192

5 days; 3-8 weeks

Question 193

How do you test for Bordetella pertusis and how do you treat?

Answer 193

Nasopharyngeal aspirate/swab; treat with macrolides (erythromycin)

Question 194

Should a non-elderly, immunocompetent patient with an uncomplicated URI or Bronchitis be treated with an antibiotic?

Answer 194

NO

Question 195

How soon after starting therapy with an ACE-I do 15% of patients develop a cough?

Answer 195

1-week

Question 196

What should be done in a patient (15%) who started ACE-I therapy and developed a cough?

Answer 196

STOP the ACE-I, don’t start a different ACE-I (will resolve in

Question 197

What is the best and closest alternative to an ACE-I if the ACE-I must be discontinued due to COUGH, etc.?

Answer 197

ARB

Question 198

What meds are best used for supportive treatment for patients with acute cough (common cold, etc.)?

Answer 198

Antihistamines (-“adine” -“amine” -“azine”), decongestants, ipratropium bromide, cromolyn and naproxen

Question 199

What types of antihistamines are generally weak and not effective?

Answer 199

Non-sedating ones

Question 200

When should ß2-agonists (-“terol”) be used to treat cough?

Answer 200

ONLY when WHEEZING is present

Question 201

What is considered “subacute” cough and what is this generally due to?

Answer 201

3-8 weeks, usually POST-INFECTIOUS

Question 202

What is considered “chronic” cough and what generally causes this?

Answer 202

Cough >8 weeks, usually by Upper Airway Cough Syndrome (post-nasal drip), asthma and GERD

Question 203

Best initial diagnostic test for chronic cough is?

Answer 203

CXR

Question 204

What is considered empiric therapy for Upper Respiratory Cough Syndrome (post-nasal drip) which causes chronic cough (>8 weeks)?

Answer 204

Antihistamines + decongestants

Question 205

If a patient’s symptoms with chronic cough abate after 2-4 weeks of inhaled bronchodilator and corticosteroids, ONLY the SHOULD the be diagnosed with?

Answer 205

Asthma (because bronchoprovocation testing can have false-positive results)

Question 206

What two agents can be used for patients in whom disease-specific cough therapy fails?

Answer 206

Codeine or Dextromethorphan (centrally acting)

Question 207

How is the approach of cough treatment different for Immunocompromised patients?

Answer 207

Definitive work-up is indicated as well as EMPIRIC antibiotics during diagnostic period

Question 208

What are the two most common causes of HEMOPTYSIS and what amount is considered LIFE-threatening?

Answer 208

Infection (bronchitis, bronchiectasis, PNA, tuberculosis, Goodpasture syndrome, Granulomatosis with polyangiitis - Wegener granulomatosis) and Malignancy; >200 mL/day

Question 209

What should be done for a patient with hemoptysis?

Answer 209

CXR and if needed, chest CT or Bronchoscopy

Question 210

How long must FATIGUE persist for to be diagnosed as CHRONIC FATIGUE SYNDROME?

Answer 210

> 6 months (with memory impairment, sore throat, tender lymph nodes, muscle/joint pain, HA, unrefreshing sleep and post-exertional malaise)

Question 211

Can patients with substance abuse, eating disorders, underlying psychiatric disorders or severe obesity (BMI ≥45) be diagnosed with Chronic Fatigue Syndrome?

Answer 211

NO!! (if they have fatigue ≥6 months it is “idiopathic chronic fatigue”

Question 212

Post-viral infection (Parvovirus B19), childhood trauma or pre-existing psychiatric disorders are all thought to be associated with?

Answer 212

Chronic Fatigue Syndrome (CFS)

Question 213

Is routine laboratory testing for symptoms of dizziness helpful?

Answer 213

NO!!

Question 214

Vascular disease/stroke, mass lesions of the brainstem/cerebellum, MS, migraines and seizures all have this SYMPTOM in common which causes dizziness?

Answer 214

VERTIGO

Question 215

Aminoglycosidetoxicity with Tobramycin, Neomycin, Gentamicin can all cause what neurological symptom?

Answer 215

VERTIGO

Question 216

What maneuver can DISTINGUISH between Central and Peripheral vertigo?

Answer 216

Dix-Hallpike maneuver (POSITIVE for BPV if BRIEF nystagmus is present WITHOUT latency, otherwise likely central etiology)

Question 217

The TRIAD of Vertigo + UNILATERAL low-frequency hearing loss + Tinnitus is seen in what condition?

Answer 217

MENIERE disease

Question 218

What maneuver can be used to TREAT BPV (benign positional vertigo)?

Answer 218

Epley maneuver (used because MEDS are typically NOT effective for BPV)

Question 219

What are the three (3) medication types used to treat SYMPTOMS of Vestibular Neuronitis (vestibular neuritis/labyrinthitis) which is caused by viral infection?

Answer 219

Antihistamines, Benzodiazepines, Phenothiazines (-“azine” - used as antiemetic)

Question 220

How long does vertigo last in BPV?

Answer 220

SECONDS

Question 221

How long does vertigo last in Meniere disease, TIA, Migraines?

Answer 221

MINUTES

Question 222

How long does vertigo last in Vestibular neuronitis/labyrinthitis, stroke, MS?

Answer 222

DAYS (if longer , likely psychogenic - i.e. bullshit)

Question 223

Dix-Hallpike maneuver demonstrates immediate nystagmus (without latency) that lasts ≥1 MINUTE?

Answer 223

CENTRAL disease (not BPV)

Question 224

Can BPV present with vertical nystagmus?

Answer 224

No, NEVER (if it’s vertical, it’s central)

Question 225

What is a side effect of treatment of VERTIGO that is NOT a result of BPV?

Answer 225

Sedation

Question 226

Caffeine and Salt restriction together with Diuretic therapy are used in the treatment of VERTIGO in which associated condition?

Answer 226

Meniere disease

Question 227

Are neurological symptoms present in VERTIGO due to Vestibular Neuronitis or BPV?

Answer 227

NO! (only in Meniere diease or other central causes - bleed)

Question 228

What is the BEST test to assess for VERTIGO due to a Central etiology possibly caused by a vascular insult such as ischemia, infarction or hemorrhage?

Answer 228

MRI with angiography

Question 229

Dysequilibrium is caused by what generally?

Answer 229

Defective sensory input (vision, vestibular), impaired propioception or motor function, generalized weakness

Question 230

ALL patients undergoing evaluation for DIZZINESS should be tested for what?

Answer 230

Orthostatic Hypotension and undergo a thorough CARDIAC and NEUROLOGIC examination (routine labs NOT helpful)

Question 231

Patients with INSOMNIA who are refractory to initial therapy, those with strongly SUSPECTED OSA, Restless Leg Syndrome or Periodic Limb Movements of Sleep should be further tested how?

Answer 231

Overnight Polysomnography

Question 232

What is the BEST therapy for BOTH primary and secondary INSOMNIA?

Answer 232

Cognitive Behavioral Therapy (can use in combination with meds initially)

Question 233

What are the PREFERRED meds to use for INSOMNIA initially and in combination with Cognitive Behavioral Therapy?

Answer 233

SHORT-ACTING Non-benzodiazepine GABA-receptor agonists (zolpidem, ezopiclone and zaleplon) and Melatonin-receptor agonists

Question 234

Which two (2) antidepressants can be used to treat INSOMNIA when it is caused by depression?

Answer 234

Trazodone & Mirtazapine

Question 235

Which SHORT-ACTING benzodiazepine GABA-receptor agonists ARE used for INSOMNIA?

Answer 235

Estazolam, Temazepam, Triazolam

Question 236

Transient loss of CONSCIOUSNESS with loss of POSTURAL TONE and SPONTANEOUS recovery resulting from GLOBAL CEREBRAL HYPOPERFUSION (arrhythmias, etc.), usually

Answer 236

Syncope

Question 237

What is the most common cause of NEUROCARDIOGENIC syncope?

Answer 237

Vasovagal reaction

Question 238

What should be the FIRST diagnostic test done in patients being evaluated for SYNCOPE?

Answer 238

ECG (rule out obvious arrhythmias and other conduction defects)

Question 239

Leg-crossing, hand-grip, squatting and muscle tensing are abortive maneuvers for what condition?

Answer 239

Neurocardiogenic Syncope

Question 240

How should patients with Carotid Sinus Hypersensitivity induce syncope be treated?

Answer 240

With placement of PERMANENT dual-chamber pacemaker

Question 241

A drop of 20 mm Hg in SBP OR a drop of 10 mm Hg in DBP when standing from a seated or supine position is?

Answer 241

Orthostatic Hypotension

Question 242

Patients presenting with Exertional or Supine syncope, palpitations prior to syncope or abnormal ECG findings require what?

Answer 242

Hospital admission

Question 243

In the outpatient setting, what are the most common causes of chest pain?

Answer 243

Musculoskeletal (40%) and GERD (19%)

Question 244

Pain with RADIATION to arms or shoulder indicates what?

Answer 244

High-likelihood of CARDIAC chest pain (MI)

Question 245

When chest pain is relived with nitroglycerin, does it indicate an MI?

Answer 245

NO (no association - can treat symptoms of GERD as well)

Question 246

What must ALWAYS be considered in a patient with SEVERE THORACIC PAIN?

Answer 246

An acute AORTIC condition (dissection)

Question 247

What type of chest pain do patients with PE, pneumothorax, pleuritis, PNA and pulmonary HTN experience?

Answer 247

Pleuritic chest pain WITH DYSPNEA

Question 248

Pleuritic chest pain with dyspnea with cough/wheezing, hemoptysis, tachypnea and tachycardia indicate?

Answer 248

PE

Question 249

What is a NEGATIVE D-dimer useful for?

Answer 249

RULES OUT PE

Question 250

Hyperresonance to percussion on the back suggests?

Answer 250

Pneumothorax

Question 251

Hypotension and Tracheal deviation?

Answer 251

Tension Pneumothorax - EMERGENCY

Question 252

Chest pain accompanied by EXERTIONAL DYSPNEA and Fatigue with elevated JVP, parasternal heave, Widely Split S2 and Loud P2 is suspected to be?

Answer 252

Pulmonary HTN

Question 253

Wide Split of S2 & Loud P2?

Answer 253

Pulmonary HTN

Question 254

Is imaging helpful for Musculoskeletal chest pain? How do you treat?

Answer 254

NO!!; NSAIDS

Question 255

What is considered ELEVATED Central Venous Pressure?

Answer 255

> 8 mm Hg (cardiac disease or pulmonary HTN)

Question 256

What are the three most common causes of UNILATERAL LE edema?

Answer 256

DVT, Cellulitis, Malignancy

Question 257

What is the BEST treatment for Chronic Venous Insufficiency (stasis edema) or Lymphedema?

Answer 257

Sodium restriction, Leg elevation, Compression stockings (NOT DIURETICS)

Question 258

At what age do most spondyloarthropathies (low back pain) present?

Question 259

At what age do most cancers and compression fractures that cause symptomatic low back pain present?

Answer 259

> 50 yo

Question 260

Low back pain reproduced with leg elevation and EXTENSION of PAIN BELOW the KNEE, weakness and diminished weakness at the ankles and sensory loss in the feet are all associated with?

Answer 260

Disk HERNIATION

Question 261

Increased pain when walking and relief when sitting (“pseudoclaudication”) in a patient older than 65, is usually?

Answer 261

Lumbar SPINAL STENOSIS

Question 262

Pt presents with NON-SPECIFIC low back pain without symptoms or signs of systemic illness should get what other diagnostic testing?

Answer 262

NONE!!

Question 263

What INITIAL diagnostic test is recommended for persistent low back pain (>1-2 months) or suggestive of malignancy or fracture?

Answer 263

Plain X-rays

Question 264

What is the PREFERRED INITIAL diagnostic testing for low back pain with symptoms of systemic illness (fever, etc.) or rapidly progressing neurological symptoms or for patients considering surgical intervention of herniated disks?

Answer 264

MRI or CT myelography

Question 265

Most low back pain responds well to therapy EXCEPT?

Answer 265

SCIATICA

Question 266

Exercise therapy and physical therapy works better for low back pain when in the course of symptoms?

Answer 266

> 4 weeks

Question 267

What are the PREFERRED meds for treating low back pain?

Answer 267

Acetaminophen (no more than 4 g/day) and NSAIDs or COX-2 inhibitors

Question 268

When should Opioids and TRAMADOL be used to treat low back pain?

Answer 268

ONLY when acetaminophen, NSAIDs and COX-2 inhibitors are found to be inadequate

Question 269

What can patients with radiculopathy (disk herniation) and low back pain be treated acutely with?

Answer 269

Epidural corticosteroid injection

Question 270

Pts with disk herniation with PERSISTENT radiculopathy, those with PAINFUL SPINAL STENOSIS and those with CAUDA EQUINA syndrome (emergency) should be treated how?

Answer 270

Surgery

Question 271

Pain of the neck that is BURNING in character and radiates down the ARM is usually what type of pain?

Answer 271

NEUROGENIC

Question 272

HA with Visual changes and SHOULDER and HIP GIRDLE pain suggests what diagnosis?

Answer 272

Polymyalgia Rheumatica

Question 273

If systemic illness is suspected in a patient with low back pain or neck pain, what blood work would be appropriate?

Answer 273

CBC, ESR, CRP

Question 274

Since MOST patients with neck neck pain recover with conservative therapy, in which patients would you consider an X-ray?

Answer 274

Those >50 yo

Question 275

Irritation and infection of what organ can cause shoulder pain?

Answer 275

Lungs and Diaphragm (PNA, apical lung MASSES, diaphragmatic irritation); also GB

Question 276

Shoulder pain on ACTIVE but not PASSIVE motion of the shoulder suggests what etiology location?

Answer 276

Extraarticular

Question 277

Shoulder pain with BOTH ACTIVE and PASSIVE motion of the shoulder suggests what etiology location?

Answer 277

Intraarticular

Question 278

Pain with shoulder ABDUCTION (raise arms up) between 60 and 120 degrees suggests? Beyond 120 degrees?

Answer 278

Rotator Cuff Impingement; AC-Joint pathology

Question 279

Which is the most commonly-affected tendon in ROTATOR CUFF TENDINITIS?

Answer 279

Supraspinatus

Question 280

If Rotator Cuff Impingement is not treated, what can occur?

Answer 280

Full-thickness tear of the rotator cuff

Question 281

Pain over the lateral deltoid muscle with abduction and with internal rotation of the arm suggests?

Answer 281

Rotator Cuff injury

Question 282

Weakness and loss of function with Rotator Cuff injury suggest?

Answer 282

Rotator Cuff Tear

Question 283

What is the preferred imaging modality for Rotator Cuff TEAR?

Answer 283

MRI

Question 284

How do you treat FULL thickness tears of the Rotator Cuff?

Answer 284

Surgery

Question 285

This disease of the Shoulder is associated with DM, Parkinson Disease, Hypothyroidism, Stroke, previous Trauma or idiopathic?

Answer 285

Adhesive Capsulitis (Frozen Shoulder)

Question 286

Drop-Arm test where examiner a slow lowering of the arm to the waist but if not supported, drops is caused be?

Answer 286

Rotator Cuff Tear

Question 287

Pts do not want to lie down on the affected shoulder, BOTH active and passive range of motion is limited, this is seen in?

Answer 287

Adhesive Capsulitis (Frozen Shoulder)

Question 288

Pain on shoulder ABDuction above 120 degrees or ADDuction?

Answer 288

Acromio-Clavicular Joint Degeneration (AC-joint)

Question 289

What is the recommended progression of treatment for shoulder injuries (rotator cuff, ac-joint, etc. - unless fully torn)?

Answer 289

Physical therapy–>NSAIDs–>Corticosteroid Injection–>Surgery

Question 290

Elbow pain can be referred from these three (3) structures which must also be examined?

Answer 290

Neck, Shoulder and Wrist

Question 291

An overuse in jury with pain in the LATERAL ELBOW with radiation down forearm and to dorsal hand, due to OVERUSE of WRIST extensor muscles usually seen in computer users who use a mouse and tennis players?

Answer 291

LATERAL Epicondylitis (tennis elbow)

Question 292

An overuse in jury with pain in the MEDIAL ELBOW due to OVERUSE of WRIST flexor muscles usually seen in golfers?

Answer 292

MEDIAL Epicondylitis (Golfer’s elbow)

Question 293

PAINFUL swelling of the posterior elbow WITHOUT limitation of range of motion from repetitive TRAUMA, Inflammation (RA, gout) or Infection?

Answer 293

Olecranon Bursitis

Question 294

When a bursa is PAINFUL, INFLAMED or FEVER is present, what should be done?

Answer 294

Aspiration, to evaluate for GRAM stain, culture (septic bursitis) and crystal analysis - gout

Question 295

Pain in the elbow with FLEXION that radiates to the hand with paresthesias and sensory loss of the 4th and 5th fingers is caused by?

Answer 295

Cubital Tunnel Syndrome (entrapment of the ULNAR nerve at the elbow

Question 296

What must be done for ALL patients who present with WRIST or HAND pain WITH BOTH a h/o trauma AND localized tenderness to palpation?

Answer 296

X-rays, to r/o fracture

Question 297

What is considered as the diagnostic STANDARD for Carpal Tunnel Syndrome?

Answer 297

Nerve Conduction studies (if diagnosis is uncertain)

Question 298

Pt with Carpal Tunnel Syndrome with >6 months of persistent symptoms (moderately severe), severe motor impairment and confirmatory nerve conduction studies should be treated how?

Answer 298

Surgical release

Question 299

Which two bones in the WRIST most commonly sustain FRACTURES when falling on an outstretched hand?

Answer 299

Scaphoid and Distal Radius

Question 300

What must be done for WRIST fractures?

Answer 300

Immediate surgical repair to avoid avascular necrosis

Question 301

What WRIST bone commonly gets fractured from repetitive trauma such as with swinging a golf club or baseball bat?

Answer 301

Hamate fracture

Question 302

Inflammation of the abductor pollicis longus and extensor pollicis brevus tendons in the THUMB presenting with PAIN on the RADIAL aspect of the WRIST when the THUMB is used to grasp, is caused by what?

Answer 302

De Quervain tenosynovitis

Question 303

How is De Quervain tenosynovitis treated?

Answer 303

Ice application with splinting to prevent movement, corticosteroid injections or surgery

Question 304

Involvement of the FIRST Carpal (WRIST) Metacarpal (HAND) joint as well the Distal InterPhalangeal (DIP) and Proximal InterPhalangeal (PIP) joints is seen in?

Answer 304

OSTEOarthritis (OA)

Question 305

Involvement of the Proximal InterPhalangeal, Metacarpal Phalangeal and Carpal Metacarpal joints is seen in?

Answer 305

Rheumatoid Arthritis (RA)

Question 306

Arthritis involving the DISTAL InterPhalangeal joint is?

Answer 306

OSTEOarthritis

Question 307

GI, GU and Gynecologic systems as well as referred pain from the BACK and KNEE can cause pain in this musculoskeletal structure and thus MUST be investigated?

Answer 307

Hip

Question 308

What must be done for ALL patients who present with ACUTE Hip pain?

Answer 308

X-rays to r/o fracture

Question 309

What should be done in a patient who presents with ACUTE Hip pain and X-rays are negative but suspicion for fracture is high?

Answer 309

MRI (avascular necrosis, infection, tumor)

Question 310

What is ANTERIOR (groin) Hip pain with CHRONIC, SLOW onset which worsens with activity most often caused by?

Answer 310

Osteoarthritis of the Hip (early morning stiffness that improves with activity)

Question 311

Pain in the Hip with internal rotation of the leg and with rocking the thigh back and forth while pt is supine indicates pain where?

Answer 311

ANTERIOR Hip (groin)

Question 312

ACUTE Hip pain is usually caused by?

Answer 312

Trauma, Necrosis (steroids and alcohol), septic arthritis or synovitis

Question 313

When examination of the Hip is normal without pain elicited with normal range of motion, what is the likely diagnosis of Hip pain?

Answer 313

Inguinal hernia, lower abdominal pathology or L1 disk disease

Question 314

Pt with known GAIT abnormalities presents with LATERAL Hip pain and reports that he cannot lie on the affected side?

Answer 314

TROCHANTERIC BURSITIS

Question 315

Pt resents with an OVAL-shaped area of NUMBNESS, BURNING and TINGLING in the DISTAL LATERAL thigh?

Answer 315

MERALGIA PARESTHEICA vs L4-L5 Disk disease

Question 316

Posterior Hip Pain (Gluteal pain) sometimes seen with paresthesias and back pain?

Answer 316

Sacroiliitis or Lumbosacral Disk disease

Question 317

When Sciatica and pain in the Buttock is present WITHOUT evidence of Lumbosacral disk disease, it is caused by?

Answer 317

Entrapment of the Sciatic nerve by the Piriformis muscle - Piriformis Syndrome

Question 318

Sciatic nerve pain WITHOUT evidence of Lumbosacral Disk disease?

Answer 318

Piriformis Syndrome (entrapment of the sciatic nerve by the piriformis muscle)

Question 319

What is the most common cause of Anterior Hip AND KNEE pains?

Answer 319

OSTEOarthritis

Question 320

What is the cause of knee pain when there are MULTIPLE joints involved with systemic symptoms?

Answer 320

Rheumatoid Arthritis

Question 321

When the skin OVERLYING a JOINT (Knee, elbow, etc) is SWOLLEN with ACUTE pain AND ERYTHEMATOUS, warm, what should be done and why?

Answer 321

ASPIRATION (arthrocentesis) to evaluate for BOTH SEPTIC and Crystalline disorders

Question 322

Anterior and Posterior DRAWER tests assess what?

Answer 322

Integrity of the ANTERIOR and POSTERIOR CRUCIATE Ligaments

Question 323

VARUS (adduction) and VALGUS (abduction) stress tests assess what?

Answer 323

Integrity of the LATERAL (varus-adduction) and MEDIAL (valgus-abduction) COLLATERAL ligaments

Question 324

What is the BEST test for assessing the integrity of the MEDIAL and LATERAL MENISCI?

Answer 324

The Medial-Lateral GRIND test (detect grinding)

Question 325

For LIGAMENT or MENISCAL injuries AFTER fracture is r/o by X-rays, what is the BEST diagnostic test?

Answer 325

MRI

Question 326

Pain in the MEDIAL aspect of the knee that WORSENS with USE and is relieved by REST with possible STIFFNESS in the morning that resolves with activity?

Answer 326

Osteoarthritis of the Knee

Question 327

Injury that typically occurs when the patient PLANTS one foot, then QUICKLY TURNS in the OPPOSITE direction with an audible “POP” and rapid swelling and the patient is NOT ABLE TO COMPLETE THE MOTION?

Answer 327

Anterior Cruciate Ligament tear (ACL)

Question 328

Sudden twisting motions of the knee with swelling and with the patient ABLE TO BEAR WEIGHT can result in?

Answer 328

Meniscal tears

Question 329

Anterior KNEE pain that is worsened when SITTING and WALKING UP and DOWN STAIRS?

Answer 329

Patello-femoral pain syndrome (overuse injury - runners)

Question 330

Applying pressure to the PATELLA with the KNEE EXTENDED and moving it side to side causes pain, what’s the diagnosis and what other test is needed?

Answer 330

Patello-femoral pain syndrome; NO other test (no x-rays needed)

Question 331

Besides reduced activity and icing, NSAIDS for pain control, what is a VERY important part of treating Patello-Femoral Pain Syndrome?

Answer 331

REHAB

Question 332

Overuse or direct trauma with symptoms of tenderness at the tibial tuberosity (just below patella) with swelling at the insertion of the medial hamstring muscles is?

Answer 332

PES ANSERINE BURSITIS

Question 333

How is Pes Anserine Bursitis treated?

Answer 333

Avoid squatting or stretching the joint or direct trauma, place PILLOW between legs when sleeping, avoid crossing legs, APPLY ICE

Question 334

Do NSAIDs help Pes Anserine Bursitis?

Answer 334

No, no penetration, treat with ICE

Question 335

Erythema, swelling and tenderness to palpation near the bottom of the patella in a housemaid who kneels constantly while working with repeated knee trauma is called?

Answer 335

Prepatellar Bursitis - inflammation of the bursa above the patella and just under the skin (treated by avoiding kneeling and rest)

Question 336

Pain in the LATERAL part of the knee just above lateral epicondyle with walking up and down steps seen in runners and cyclists?

Answer 336

Iliotibial Band Syndrome (friction between the iliotibial band and lateral (tibial) epicondyle

Question 337

A cyclist presents with pain just above lateral epicondyle and when supine, with finger pressure over the lateral epicondyle, pt c/o pain while repeatedly flexing and extending the knee?

Answer 337

Iliotibial Band Syndrome (treat with rest, NSAIDS)

Question 338

Why can BURSITIS not be treated with NSAIDS?

Answer 338

Because there is NO penetration of drug

Question 339

Posterior knee pain with a sense of fullness in the popliteal area with palpable fullness?

Answer 339

Popliteal (Baker) Cyst

Question 340

How is a Popliteal (Baker) Cyst treated?

Answer 340

Underlying condition (if an effusion from knee joint) or by aspiration/surgery

Question 341

Pain and swelling of the lateral ANKLE after Inversion of the foot injury (misstepping) and diminished propioception with PAIN, INSTABILITY and STIFFNESS that can persist for years occur due to injury of what ligament?

Answer 341

ANTERIOR TALOFIBULAR ligaent

Question 342

What is the recommended treatment of ANKLE SPRAINS Grades I & II (no complete tear) besides ice, rest with compression and elevation and NSAIDS?

Answer 342

Rehabilitation, weight bearing exercises and proprioceptive training (want to AVOID joint instability)

Question 343

What is the most common cause of HEEL pain that occurs in runners, those who stand for long periods at work or obese individuals, with the first few steps after a period of inactivity that initially IMPROVES with walking but subsequently WORSENS?

Answer 343

Plantar Fasciitis

Question 344

How is plantar fasciitis treated?

Answer 344

Stretching Exercises and Analgesics, Injected Corticosteroids

Question 345

Recurrent trauma to the achilles tendon caused by ABRUPT increase in activity level can cause ACUTE achilles tendinitis whereas CHRONIC achilles tendinitis can be caused by what?

Answer 345

Improper stepping, improper footwear, pes planus (flat footed)/pes cavus (high arch)

Question 346

A history of fluoroquinolone or corticosteroid use can cause what particular tendon injury?

Answer 346

Achilles Tendinitis

Question 347

How is Achilles Tendinitis treated?

Answer 347

Avoidance of aggravating activities and NSAIDs

Question 348

Pt pushes off against a heavy load with his feet and hears a “pop” sound followed by severe pain above his heel?

Answer 348

Achilles Tendon Rupture (SURGERY!! if complete rupture)

Question 349

How can you diagnose an Achilles Tendon rupture if diagnosis is in question?

Answer 349

Ultrasound

Question 350

Pt with remote fractures of the CALCANEUS, MEDIAL MALLEOLUS or TALUS presents with paresthesias in the mid-foot, heel, toes and plantar surface of the foot made worse by prolonged standing and at night is likely due to?

Answer 350

Tarsal Tunnel Syndrome (caused by fragment from previous fractures or scar tissue)

Question 351

How is Tarsal Tunnel Syndrome treated that is very different than the treatment of Carpal Tunnel Syndrome?

Answer 351

NSAIDs, Orthotics and Modification of Footwear

Question 352

A burning pain worsened with standing that occurs BETWEEN the toes usually seen in women who wear high heels is what? What is it caused by? How is it treated?

Answer 352

1. Morton’s Neuroma
2. Caused by entrapment of one of the common digital nerves
3. Avoidance of wearing high heels and corticosteroid shots (NSAIDs do not help)

Question 353

What set of RULES is very useful at ruling out fractures and determining when imaging is needed for the FOOT?

Answer 353

Ottawa Ankle and Foot rules

Question 354

At what ages and how frequently should SCREENING for Dyslipidemia begin for men and for women?

Answer 354

M=35; W=45-if at increased cardiovascular risk (or 20 for both if increased cardiovascular risk) repeating every 5 yrs for low-risk pts

Question 355

Reducing the LDL by 1% reduces Coronary Heart Disease risk by?

Answer 355

1%

Question 356

What effect does a high TRIGLYCERIDE level have on HDL and how does worsen the metabolic syndrome?

Answer 356

Lowers the HDL, causes INCREASED insulin resistance

Question 357

What is considered “LOW” HDL cholesterol?

Question 358

What are considered “Optimal” TRIGLYCERIDE and TOTAL Cholesterol levels?

Question 359

Besides therapeutic LIFESTYLE changes, at what LDL levels should DRUG therapy be initiated?

Answer 359

Low-Risk pt ≥190 mg/dL; Moderate-Risk pt ≥130-160 mg/dL; High-Risk pt ≥130 mg/dL

Question 360

Above what TRIGLYCERIDE level is DRUG therapy recommended?

Answer 360

≥500 mg/dL

Question 361

After initiating Therapeutic LIFESTYLE changes ALONE for a patient with dyslipidemia, when is it appropriate to begin DRUG therapy?

Answer 361

If changes (diet, exercise, fiber) not at optimal levels after 3 MONTHS

Question 362

What is significant about STATIN therapy for patients with established Coronary Heart Disease?

Answer 362

Mortality reduction by 20%-30% AND decreased CRP levels

Question 363

Doubling of a STATIN dose decreases LDL by what?

Answer 363

6%

Question 364

How do Cyclosporine, Fibrates, Protease Inhibitors and Amiodarone afftect STATINS?

Answer 364

Increase their levels with increased risk of MYOPATHY

Question 365

What STATINS are SAFER in patients treated with MULTIPLE medications?

Answer 365

ROSUVAstatin, PRAVAstatin and FLUVAstatin

Question 366

What laboratories should be checked BEFORE initiating STATIN therapy and how frequently thereafter?

Answer 366

Serum CK and LFTs; ONLY if symptomatic, no routine checks

Question 367

What medications can be used as monotherapy for only a “modest” LDL reduction?

Answer 367

Bile Acid Sequestrants, Ezetimibe (18% LDL reduction)

Question 368

What medication COMBINATION works VERY well for additional and SIGNIFICANT LDL reduction and is an especially good choice for patients whom cannot tolerate high doses of statins?

Answer 368

STATINS + Bile Acid Sequestrants + Nicotinic Acid (Vitamin B3 or “Niacin”)

Question 369

Can STATINS be used in PREGNANCY?

Answer 369

NO!!!

Question 370

What is the MOST effective agent for INCREASING HDL?

Answer 370

Nicotinic Acid (Niacin or “Vitamin B3”)

Question 371

What can be used as an ALTERNATIVE to Fibrates or Nicotinic Acid (Niacin) for significant TRUGLYCERIDE reduction?

Answer 371

Omega-3 fatty acids

Question 372

What Fibrate drug is PREFERRED in combination with STATINS for the additional reduction in TRIGLYCERIDES without the RISK of ≥2 x elevated serum concentrations of the statins used?

Answer 372

FENOFIBRATE

Question 373

What is considered “ACCEPTABLE” elevation of LFTs with statin therapy, because these will eventually normalize and are asymptomatic?

Question 374

What should be done after ANY adverse effect (myositis, rhabdomyolysis, myalgia, LFT elevation >3 x normal, hepatotoxicity - added elevation of bilirubin >2 x normal)?

Answer 374

STOP statin, allow levels to normalize, restart at LOWER dose or use a different statin (ROSUVAstatin, PRAVAstatin or FLUVAstatin) or alternative such as bile acid sequestrant, or nicotinic acid

Question 375

In a patient with HYPERTRIGLYCERIDEMIA but NO elevated LDL, what should be the FIRST choice of medication?

Answer 375

Nicotinic Acid (“niacin” or Vitamin B3); fibrates are secondary BECAUSE they can raise LDL levels

Question 376

What are Omega-3 fatty acids and what are they good for?

Answer 376

“Fish Oils” excellent for SIGNIFICANT triglyceride reduction

Question 377

A waist circumference >40 (M), >35 (W), Triglyceride levels of ≥150 mg/dL, HDL

Answer 377

Metabolic Syndrome (obesity, dyslipidemia, insulin resistance, HTN)

Question 378

Patients with an intermediate or high Framingham Risk Score for 10-year mortality should be started on what?

Answer 378

81 mg Aspirin if no contraindications exist

Question 379

Why are ß-blockers and Thiazide diuretics POOR drugs for BP control (≥130/85 mm Hg) in patients with METABOLIC SYNDROME? What meds ARE recommended for these patients?

Answer 379

Because they WORSEN glucose tolerance; ACE-Is and ARBs (improve glycemic control)

Question 380

What is the recommended LDL level for SECONDARY risk prevention (already had one) of TIA or stroke?

Question 381

In which patients is it recommended to start ASPIRIN at 75 mg for PRIMARY prevention of HEART DISEASE IF GI BLEED RISK DOES NOT OUTWEIGH BENEFIT?

Answer 381

M≥45-79 NOT FOR WOMEN (≥55 ONLY if at increased risk)

Question 382

In which patients is it recommended to start ASPIRIN at 75 mg for PRIMARY prevention of STROKE IF GI BLEED RISK DOES NOT OUTWEIGH BENEFIT?

Answer 382

W≥55-79

Question 383

What BMI constitutes OBESITY?

Answer 383

≥30

Question 384

The risk of what three (3) cancers is associated with OBESITY?

Answer 384

BREAST, COLON, ENDOMETRIAL

Question 385

What waist circumference constitutes OBESITY?

Answer 385

M≥40; W≥35

Question 386

What do ALL of the following meds have in common: Clozapine, Olanzapine, Quetiapine, Risperidone, Sulfonylureas, Thiazolidinediones, Insulin, Amitriptyline, Paroxetine, Valproic Acid, Carbamazepine, ß-blockers?

Answer 386

They ALL cause WEIGHT GAIN

Question 387

ADA recommends SCREENING for DM in patients above which BMI AND have other risk factors?

Answer 387

≥25 (family history)

Question 388

Which are the ADJUNCTIVE therapy drugs used for weight loss?

Answer 388

ORLISTAT (interferes with fat absorption), [PHENTERMINE (phentermine/topiramate - arrhythmogenic), diethylpropion, lorcaserin] - suppress appetite “anorectic”

Question 389

What is the only WEIGHT LOSS medication approved for LONG-TERM use?

Answer 389

ORLISTAT

Question 390

What should be done for Obesity Classes I&II (BMI≥35) patients who failed diet, exercise and pharmacologic therapy, especially in those with OBESITY-RELATED Comorbidity (OSA, Joint Disease, DM)?

Answer 390

Bariatric Surgery

Question 391

Pt s/p Roux-en-Y eats a sugary, fatty meal and has severe diarrhea?

Answer 391

Dumping Syndrome

Question 392

Methylmalonic Acid AND Homocysteine levels are BOTH elevated in?

Answer 392

Vitamin B12 defficiency

Question 393

If Methylmalonic Acid is NORMAL and ONLY Homocysteine level is increased?

Answer 393

Folate defficiency

Question 394

What are the four (4) most commonly modifiable risk factors for ED?

Answer 394

Obesity, Smoking, Alcohol use, Drugs

Question 395

Sudden loss of the ability to achieve an erection suggests?

Answer 395

Psychogenic condition (in absence of s/p prostatectomy or trauma)

Question 396

What is Peyronie disease?

Answer 396

A disease associated with ED - penile curvature and pain

Question 397

Pt’s on NITRATES, Protease Inhibitors, Ketoconazole or Erythromycin should not take what medication type?

Answer 397

Phosphodiesterase Inhibitors (sildenafil, etc.)

Question 398

What medications besides topical anesthetic creams can be used to treat premature ejaculation by causing anorgasmia?

Answer 398

SSRIs

Question 399

What is the BEST way to measure possible ANDROGEN deficiency in men?

Answer 399

Measuring MORNING total testosterone level

Question 400

Excessive exercise, corticosteroid use, marijuana use and opioids affect this component of men’s sexual health?

Answer 400

Decrease Testosterone levels

Question 401

Pts with Breast or Prostate cancer, Palpable prostate nodule, PSA ≥4, Hct ≥50, severe OSA, severe urinary tract symptoms and HF should NOT be treated with this sexual health medication?

Answer 401

Testosterone

Question 402

What should be done FIRST for a pt presenting with symptoms of ANDROGEN deficiency and low testosterone levels BEFORE initiating testosterone therapy?

Answer 402

CONFIRMATORY TESTING!!

Question 403

Symptoms of Nocturia, urinary frequency and urgency are caused by?

Answer 403

Overactive bladder (detrusor muscle hyperactivity)

Question 404

Decreased urinary stream, incomplete bladder emptying and incontinence are caused by?

Answer 404

Blader Outlet Obstruction (BPH)

Question 405

What two rudimentary tests should be done when evaluating BPH?

Answer 405

Digital Rectal Examination AND Urinalysis (r/o infection)

Question 406

What medications are used to treat an overactive bladder?

Answer 406

Anticholinergics (Oxybutynin, Tolterodine)

Question 407

In what patients with BOTH overactive bladder and BPH causing Bladder Outlet Obstruction are Anticholinergics (oxybutynin and tolterodine) contraindicated?

Answer 407

Those with a residual volume ≥250 ml

Question 408

What is the BEST COMBINATION of medications to successfully treat BPH that causes Bladder Outlet Obstruction?

Answer 408

5-alpha blockers (relax smooth muscle in prostate and urinary bladder neck) AND 5-alpha reductase inhibitors (to shrink the prostate)

Question 409

What are the 5-alpha blockers?

Answer 409

“-osin” (terazOSIN, tamsulOSIN, doxazOSIN)

Question 410

Bladder stones, kidney failure with hydronephrosis, recurrent retention with/without UTIs in a patient with BPH on medications are indications for?

Answer 410

Surgical intervention

Question 411

Acute testicular/scrotal pain is usually due to?

Answer 411

Testicular torsion or Epidydimitis

Question 412

What is Orchitis and what causes it?

Answer 412

Inflammation of the testicle, caused by MUMPS or from a UTI or epidydimitis

Question 413

In most patients with testicular torsion, this physical exam finding is ABSENT?

Answer 413

Cremasteric reflex (stroking upper, inner thigh observing a rise in the ipsilateral testicle)

Question 414

ACUTE testicular pain with fever and elevated white count, with dysuria and can occur with prostatitis?

Answer 414

Infectious Epididymitis (Chlamydia, Gonorrhea, E.coli, Pseudomonas)

Question 415

Recent sexual activity, bicycle riding, heavy exertion with testicular pain?

Answer 415

Epidydimitis

Question 416

What medications are used to treat INFECTIOUS epididymitis (Chlamydia, Gonorrhea, E.coli, Pseudomonas)?

Answer 416

CEFtriaxone + Fluoroquinolone

Question 417

What is NON-INFECTIOUS epidymitis caused by?

Answer 417

Urine REFLUX into epididymis (NSAIDS, NO antibiotics)

Question 418

What MUST be done when evaluating scrotal/testicular pain?

Answer 418

Obtain a URINANALYSIS

Question 419

What is the modality of choice if transillumination of the scrotum to differentiate between a hydrocele, varicocele, hernia or solid mass is insufficient and doubt exists?

Answer 419

Ultrasound

Question 420

Which hydrocele types require surgical intervention?

Answer 420

Communicating ones that are painful

Question 421

A cyst that is NOT painful and on palpation is located separately from the TESTICLE on the epididymis is called? What if it is ≥2 cm?

Answer 421

Epididymal cyst; Spermatocele

Question 422

Scrotal mass in the LEFT (90%) testicle with a “dull ache” that increases in size when standing and decreases when supine?

Answer 422

Varicocele

Question 423

What is the LEADING cause of INFERTILITY (low sperm count) in men?

Answer 423

Varicoceles

Question 424

The presence of leukocytes in the semen or POST-PROSTATIC MASSAGE urine in a patient with a negative urinalysis for UTI but who presents with pelvic pain and testicular/penal pain and dysuria is caused by?

Answer 424

Prostatitis

Question 425

How is prostatitis treated?

Answer 425

Fluoroquinolones or TMP-SMX

Question 426

What are the 5-alpha reductase inhibitors used in combination with 5-alpha blockers for the treatment of BPH with Bladder Outlet Obstruction?

Answer 426

FinASTERIDE, DutASTERIDE

Question 427

Chronic prostatitis WITHOUT bacterial infection but WITH chronic pelvic pain with or without leukocytes in semen or urine is?

Answer 427

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Question 428

How is Chronic Prostatitis/Chronic Pelvic Pain Syndrome treated?

Answer 428

NSAIDS, ONE, SINGLE COURSE of antibiotics, 5-alpha blockers

Question 429

When abdominal contents protrude through the Internal Inguinal Ring rather than through a weak spot in the fascia, this is known as what type of hernia?

Answer 429

INDIRECT Inguinal Hernia

Question 430

When do hernias require surgical repair?

Answer 430

When symptomatic or EMERGENTLY when strangulated

Question 431

What is the MOST common female sexual disorder?

Answer 431

Hypoactive Sexual Desire Disorder (lack of sexual thoughts, desire or receptiveness to sexual activity)

Question 432

Spontaneous sexual interest (Sexual DRIVE) is controlled by what?

Answer 432

BIOLOGIC, neuroendocrine functions

Question 433

What two hormones in WOMEN is essential for a normal sex drive?

Answer 433

Testosterone (decline with age), Estradiol (declines after menopause)

Question 434

How are sexual aversion disorders (aversion to any genital contact, feelings of revulsion, panic) treated pharmacologically besides therapy?

Answer 434

SSRIs

Question 435

For most sexual disorders in women (desire, orgasmic, arousal and pain) what is the most effective component of treatment?

Answer 435

Cognitive - Behavioral Therapy

Question 436

What is used for POSTmenopausal women for the treatment of inadequate vaginal lubrication?

Answer 436

Systemic or Local Estrogen therapy

Question 437

What is used in PREmenopausal women for the treatment of inadequate vaginal lubrication?

Answer 437

Vaginal Moisturizers

Question 438

Inadequate lubrication, vaginismus, vulvodynia, interstitial cystitis, pelvic adhesions, infections, endometriosis or pelvic venous congestion can all cause?

Answer 438

Dyspareunia (painful intercourse)

Question 439

What is the best treatment for vaginal atrophy?

Answer 439

Low-Dose ESTROGEN tablets or RING (estrogen cream is LEAST preferred)

Question 440

What is the best treatment for inadequate vaginal lubrication?

Answer 440

Systemic Estrogen

Question 441

How is vaginismus (vaginal spasm usually due to anticipation of pain) treated?

Answer 441

Cognitive - Behavioral Therapy

Question 442

Milky vs Bloody nipple discharge suggests what?

Answer 442

Benign etiology rather than malignant

Question 443

What is NECESSARY in the evaluation of a PALPABLE BREAST MASS regardless of the features on exam?

Answer 443

Imaging/Tissue sampling

Question 444

What is the best IMAGING modality for evaluation of a PALPABLE breast mass in a woman ≤35 or PREGNANT?

Answer 444

Ultrasound (NOT MAMMOGRAPHY) - can differentiate between cystic and solid lesions

Question 445

What should be done if drainage of a breast cyst is non-bloody and disappears completely? If bloody?

Answer 445

Likely benign cyst; Send to cytology

Question 446

A solid lesion in the breast with uniform borders and uniform internal echoes is most likely what?

Answer 446

A fibroadenoma (only remove surgically if patient wants to)

Question 447

What breast tumor can have both BENIGN and MALIGNANT variants?

Answer 447

Phyllodes tumor

Question 448

If a breast nodule is found on mammogram to be IRREGULAR with MICRO-CALCIFICATIONS and SPICULATIONS what should be done?

Answer 448

BIOPSY - likely malignant

Question 449

What should be done if a breast nodule is suspicious for malignancy but is UNDETECTED on US or Mammogram (10%-20%)?

Answer 449

CORE NEEDLE BIOPSY

Question 450

When is a Fine Needle Aspiration done for a breast nodule?

Answer 450

When it is Cystic (US)

Question 451

When is an EXCISIONAL biopsy done for a breast nodule?

Answer 451

When a CORE Needle Biopsy is non-diagnostic

Question 452

What should be done in ALL women who present with breast pain and why?

Answer 452

Thorough physical exam, because malignancy also can present with pain

Question 453

Reproducible breast pain that is unilateral, localized and is described as BURNING is typically what?

Answer 453

Chest Wall Inflammation

Question 454

How should Cyclical Mastalgia (painful breasts during menstrual cycle) be treated if the symptoms interfere with quality of life?

Answer 454

DANAZOL (menorrhagia and weight gain) or TAMOXIFEN

Question 455

Women with h/o THROMBOSIS, MIGRAINE with AURA, LIVER DISEASE, BREAST CANCER, UNCONTROLLED HTN and those ≥35 who SMOKE should NOT use what birth control type?

Answer 455

COMBINATION (estrogen-progesterone) Oral Contraceptives (USE Progesterone ONLY pills)

Question 456

Barbiturates (-“barbital”), carbamazepine, anti-seizure meds, rifampin, antiretroviral and some antibiotics affect the liver CYP3A enzymes affecting oral contraceptive pills how?

Answer 456

REDUCE EFFICACY

Question 457

How long AFTER discontinuation of a medication that reduces effectiveness of an oral contraceptive pill should a woman wait before having UNPROTECTED sex again?

Answer 457

4 WEEKS

Question 458

What component of COMBINATION Oral Contraceptive Pills increases the RISK of THROMBOSIS, BREAST CANCER, LIVER CANCER, CERVICAL CANCER and MI/STROKE?

Answer 458

ESTROGEN

Question 459

Estrogen reduces the RISK of only what two (2) cancers?

Answer 459

Endometrial and Ovarian

Question 460

Of the COMBINATION contraceptives, which has the LOWEST estrogen amount?

Answer 460

Vaginal RING

Question 461

Of ALL contraceptive methods, which three (3) have the HIGHEST failure rates?

Answer 461

Cervical CAP, Diaphragm, Sponge

Question 462

How long are the intrauterine devices COPPER and LEVONORGESTREL effective for?

Answer 462

Copper - 10 years; Levonorgestrel - 5 years

Question 463

Which is the ONLY contraceptive agent that improves endometriosis?

Answer 463

DEPOT (IM/SQ) medroxyprogesterone acetate

Question 464

How long after the discontinuation of a DEPOT contraceptive method can contraceptive-induced infertility continue?

Answer 464

2 years

Question 465

What are the four (4) methods of EMERGENCY contraception available?

Answer 465

Taken within 5-7 days: COPPER IUD, Taken within 5 days: Levonorgestrel tablets (single dose or two-dose 12-hours apart), Combined Contraceptive tablets (two high-dose tabs taken TWICE, 12 hours apart) and Progesterone modulators (Mifepristone, Ulipristal)

Question 466

Which of the EMERGENCY contraceptive methods is the BEST and easiest to implement?

Answer 466

Levonorgestrel-ONLY single dose regimen

Question 467

Immunity to which two DISEASES should be PROVIDED to ALL women considering PREGNANCY at least 4 WEEKS before conception?

Answer 467

VARICELLA and RUBELLA (both LIVE vaccines) also Pertussis and Tetanus

Question 468

What supplementation is recommended in ALL women of reproductive age?

Answer 468

FOLIC ACID

Question 469

Hormone derivatives, ACE-I, WARFARIN (first 6 weeks of first trimester and before delivery) Carbamazepine, Fluoxetine, Paroxetine, TMP-SMX, Lithium, Phenytoin, Primidone, STATINS, Tetracycline, Valproic Acid, Retinoids?

Answer 469

DO NOT USE IN REGNANCY

Question 470

How long must a woman experience amenorrhea before she can be formally diagnosed with MENOPAUSE?

Answer 470

12 MONTHS (average age of 51)

Question 471

What happens to FSH and Estradiol in Menopause?

Answer 471

FSH is HIGH (>40), Estradiol is LOW (

Question 472

Sudden onset of intense warmth that starts in the FACE or CHEST and spreads throughout the body with sweating and palpitations?

Answer 472

Hot Flush (perimenopause) - when these occur at night, they are called “night sweats” (resolve in a few years)

Question 473

Thyroid disease, Elevated Prolactin levels and Pregnancy can mimic this preimenopausal symptom?

Answer 473

Hot Flush

Question 474

In which cases is Systemic Hormonal Therapy (17 ß-estradiol) prescribed for women?

Answer 474

Peri/Post menopausal with moderate to severe vasomotor symptoms (Hot Flushes, palpitations, sweating, etc.)

Question 475

Which Systemic Hormonal Therapy preparation causes LESS thrombosis, breast pain and uterine bleeding?

Answer 475

TRANS-DERMAL 17 ß-estradiol as compared to the ORAL formulation

Question 476

In women who have an INTACT UTERUS (i.e. no HYSTERECTOMY), what MUST be given WITH systemic hormonal therapy to avoid UTERINE CANCER?

Answer 476

PROGESTERONE

Question 477

Pregnancy, unexplained vaginal bleeding, thrombosis, CAD, Stroke, Breast/Endometrial Cancer, Hyperlipidemia, Immobilization or MI are ABSOLUTE CONTRAINDICATIONS to what therapy?

Answer 477

Systemic HORMONAL therapy

Question 478

What is the time limit for Systemic Hormonal Therapy?

Answer 478

5 years

Question 479

What is the AGE LIMIT for use of HORMONAL Therapy in women?

Answer 479

60 yo (high risk of CHD if older)

Question 480

When in the PERImenopausal period is Systemic Hormonal Therapy at GREATEST RISK for causing BREAST CANCER?

Answer 480

In the EARLY period

Question 481

What are the alternative (to hormonal) medications used for women with VASOMOTOR Symptoms (Hot Flushes, palpitations, sweating, etc.) in the perimenopausal period?

Answer 481

SSRIs, SNRIs, Gabapentin and Clonidine

Question 482

What is POLY/OLIGO MenoRRHEA?

Answer 482

Poly- menstrual bleeding MORE than every 24 days; Oligo- menstrual bleeding LESS than every 35 days

Question 483

What is METRorrhagia?

Answer 483

IRREGULAR menstrual bleeding

Question 484

What is MENORRHAGIA?

Answer 484

REGULAR menstrual bleeding that is HEAVY in flow

Question 485

What is MENOMETRORRHAGIA?

Answer 485

IRREGULAR menstrual bleeding that is HEAVY in flow

Question 486

What is Dysfunctional Uterine Bleeding?

Answer 486

ANOVULATORY bleeding (non-cyclical) that has no identified MEDICAL or ANATOMIC cause

Question 487

Whys is ANOVULATORY menstrual bleeding erratic and non-cyclical?

Answer 487

Because it is ESTROGEN-mediated WITHOUT the stabilizing effects of progesterone

Question 488

In POST-Menopausal women (no menses ≥1 year) ANY vaginal bleeding is considered ABNORMAL and what should be done?

Answer 488

Evaluation for ENDOMETRIAL Cancer

Question 489

What are three (3) things that MUST be done for a woman of REPRODUCTIVE age that presents with a CHANGE in her menstrual bleeding pattern?

Answer 489

1. Pelvic Exam
2. Pregnancy test
3. Evaluate for COAGULATION disorder

Question 490

What MUST be done for women ≥35 who have PROLONGED ANOVULATION and why?

Answer 490

Pelvic US to assess ENDOMERIAL STRIPE thickness and if the endometrial STRIPE is ≥5 mm, MUST BIOPSY; because exposure to UNOPPOSED ESTROGEN EXPOSURE (no progesterone from lack of ovulation) of the ENDOMETRIUM can cause ENDOMETRIAL cancer

Question 491

For women who desire pregnancy but have anovulatory bleeding, what can be used to stabilize the bleeding?

Answer 491

Progesterone

Question 492

For women who do not desire pregnancy but have anovulatory bleeding, what can be used to stabilize the bleeding?

Answer 492

Oral Contraceptive Pills

Question 493

How is SEVERE anovulatory bleeding treated?

Answer 493

GnRH (gonadotropin releasing hormone) or HIGH-DOSE IV ESTROGEN

Question 494

For women who CANNOT be treated with HORMONAL therapy for anovulatory bleeding, what can be used for treatment?

Answer 494

NSAIDs and Danazol (this can also be used for breast pain)

Question 495

What is DYSMENORRHEA and what is it caused by?

Answer 495

Painful menstrual cycle (90% - normal, no pathology); (10% - fibroids, endometriosis)

Question 496

In the absence of pelvic pathology, what is DYSMENORRHEA treated with?

Answer 496

NSAIDs, Combined Oral Contraceptive pills

Question 497

Pelvic pain that is cyclic (with menses) and non-cyclic and is of at least 6 MONTHS duration is often caused by?

Answer 497

Endometriosis or IBS (worsen during menstrual cycle)

Question 498

A woman presents with c/o non-cyclic pain ≥6 MONTHS duration with no evidence of endometriosis, fibroids or IBS, has no pelvic adhesions or interstitial cystitis (painful bladder syndrome) no h/o physical or sexual abuse, no Pelvic Inflammatory Disease (PID), no difficult obstetric deliveries or Fibromyalgia and her transvaginal US was normal as were her CBC, CMP, U/A, ESR and vaginal swabs. What is the next step in her management? How do you treat?

Answer 498

Laparoscopy; NSAIDs

Question 499

How is endometriosis treated aside from surgery (laparoscopy)?

Answer 499

Oral Contraceptive Pills, GnRH agonists (Leuprorelin, -“relin”)

Question 500

Pelvic pain (dull, worsened with prolonged standing) caused by pelvic varices and diagnosed by US is treated how?

Answer 500

Medroxyprogesterone acetate (DEPOT contraceptive method)

Question 501

How is pelvic pain from interstitial cystitis treated?

Answer 501

TCA’s, Pentosan Polysulfate Sodium (PPS)

Question 502

What is GnRH helpful with in women?

Answer 502

Treats pain in Chronic Pelvic Pain, Endometriosis, IBS

Question 503

What are the two (2) MOST COMMON causes of VAGINITIS?

Answer 503

Trichomoniasis and Candidiasis

Question 504

A woman presents with c/o a thin, white or gray vaginal discharge with a fishy smell and a pH >4.5, what are the possible organisms of her Bacterial Vaginosis (BV)?

Answer 504

Gardnerella vaginalis, Ureplasma, Mycoplasma, Bacteroides

Question 505

What VAGINITIS doe douching, lack of condom use and multiple new sexual partners place a woman at risk for?

Answer 505

Bacterial Vaginosis, Complicated pregnancy, HIGH risk for acquiring HIV, Gonorrhea, Chlamydia and genital Herpes (HSV-2)

Question 506

Adding 10% Potassium Hydroxide to vaginal secretions produces a fishy smell (whiff test) and CLUE cells, what’s the diagnosis?

Answer 506

Bacterial Vaginosis (BV)

Question 507

Should you culture vaginal discharge for Gardnerella Vaginalis?

Answer 507

NO (low specificity)

Question 508

What is the BEST treatment for Bacterial Vaginosis (BV)?

Answer 508

METRONIDAZOLE oral/cream for 7 days - SAFE in Pregnancy (alternative is clindamycin but NOT safe in Pregnancy)

Question 509

What VAGINITIS dos being promiscuous, using IVDA, being a prostitute place a woman at risk for?

Answer 509

Trichomonas Vaginalis (STI) - malodorous yellow-green discharge

Question 510

Malodorous yellow-green vaginal discharge in a prostitute using IVDA?

Answer 510

Trichomoniasis (STI)

Question 511

Vulvar itching, burning and post-coital bleeding with a yellow-green malodorous vaginal discharge, motile bacteria, in a prostitute using IVDA?

Answer 511

Trichomoniasis (STI)

Question 512

Gray vaginal discharge with a fishy smell with CLUE cells and “whiff” test in a woman who douches?

Answer 512

Bacterial Vaginosis: Gardnerella vaginalis (metronidazole cream or clindamycin if NOT pregnant)

Question 513

How is Trichomonas Vaginalis (STI) treated?

Answer 513

ORAL Metrodinazole (pregnancy safe) - single dose or 7-days if persistent - PARTNERS need treatment as well

Question 514

Treatment in women with antibiotics or corticosteroids places them at risk for which Vaginitis type?

Answer 514

Candidiasis

Question 515

How MUST vaginal candidiasis be DIAGNOSED, EVEN if it is OBVIOUS?

Answer 515

Demonstration of yeasts, hyphae or pseudohyphae on MICROSCOPY or Gram Stain or culture

Question 516

In what women can vaginal candidiasis be a COMPLICATED (severely symptomatic) infection?

Answer 516

Pregnant, Immunosuppressed, Diabetic

Question 517

1. How do you treat UNCOMPLICATED vaginal candidiasis? 2. COMPLICATED 3. Candida species other than albicans?

Answer 517

1. TOPICAL imidazole cream OR oral Fluconazole x 1 dose
2. TOPICAL imidazole cream OR oral Fluconazole x 2 doses 3 DAYS apart
3. Intravaginal BORIC ACID

Question 518

What is Conjunctivitis usually caused by?

Answer 518

ADENOVIRUS (recent URI or contact with person with conjunctivitis)

Question 519

Pt presents with UNILATERAL and UNIFORMLY covered red eye, had a recent URI, reported clear watery discharge, itch, mild photophobia and a “gritty” foreign body sensation?

Answer 519

Conjunctivitis

Question 520

How LONG is VIRAL (most common) conjunctivitis contagious for?

Answer 520

2 WEEKS AFTER the SECOND eye becomes involved

Question 521

What should FOOD handlers and HEALTH CARE PROVIDERS be advised of if they have CONJUNCTIVITIS?

Answer 521

NOT TO RETURN TO WORK until CLEAR watery eye DISCHARGE stops

Question 522

How is VIRAL conjunctivitis treated?

Answer 522

Supportive ONLY, no meds

Question 523

What bacteria are responsible for BACTERIAL Conjunctivitis?

Answer 523

Staph. aureus (most common), Step. pneumoniae, Haemophilus influenzae AND N. Gonorrhea

Question 524

What is the MAIN difference in presentation between VIRAL and BACTERIAL Conjunctivitis?

Answer 524

Bacterial conjunctivitis has a STICKY, CRUSTY mucopurulent discharge WORSE when waking in the morning and dried

Question 525

RAPID onset conjunctivitis in a sexually active pt WITH COPIOUS purulent discharge and PAIN with POSSIBLE corneal PERFORATION is caused by?

Answer 525

N. gonorrhea

Question 526

How is N. gonorrhea conjunctivitis treated?

Answer 526

ORAL antibiotics for BOTH gonorrhea AND chlamydia

Question 527

When MUST a bacterial conjunctivitis be initially CULTURED and Gram stained PRIOR to treatment?

Answer 527

When Gonorrheal, Immunocompromised or Contact Lenses

Question 528

How do you treat Bacterial conjunctivitis when NOT gonorrhea?

Answer 528

Broad Spectrum antibiotic EYE DROPS

Question 529

What is done for CHRONIC (>4 weeks) conjunctivitis?

Answer 529

Referral to Ophthalmologist

Question 530

Painless bleeding in the eye from trauma, valsalva maneuver, cough, blood thinners, endocarditis is called what?

Answer 530

SUBconjunctival Hematoma

Question 531

Abrasions of this structure cause tearing, foreign-body sensation in the eye, photophobia, pain?

Answer 531

Cornea - the structure that contact lenses rest on (thin conjunctival layer in between)

Question 532

How is the CORNEA of the eye best examined?

Answer 532

With FLUORESCEIN dye, under a WOOD/Slit lamp

Question 533

How long do MOST corneal abrasions heal?

Answer 533

24-48 hours

Question 534

Bacterial infections, contact lenses, HSV or trauma can cause this type of corneal injury?

Answer 534

Corneal ULCER

Question 535

How would you manage a corneal ulcer (P. aeruginosa - gentamicin/fluoroquinolones)?

Answer 535

Ophthalmology consult (for antibiotics and scraping for culture)

Question 536

What is the SCLERA of the EYE?

Answer 536

The white part

Question 537

What is the BENIGN condition called when the vessels of the membrane that sit atop the sclera and just underneath the conjunctival layer get LOCALLY inflamed, is NOT associated with pain, visual changes or tearing and resolves WITHOUT treatment?

Answer 537

EPIscleritis

Question 538

When the sclera (not conjunctiva) is wide-spread red with SEVERE dull pain, what condition is it?

Answer 538

Scleritis

Question 539

When can SCLERITIS cause VISUAL LOSS?

Answer 539

When it is deeper (POSTERIOR scleritis)

Question 540

What type of SCLERITIS is most common which does NOT have visual loss?

Answer 540

ANTERIOR Scleritis

Question 541

What is seen in 50% of patients with SCLERITIS?

Answer 541

Underlying SYSTEMIC disease (RA, infection - TB or Syphilis)

Question 542

How is scleritis treated?

Answer 542

By ophthalmologist (if anterior - NSAIDS; if posterior - systemic corticosteroids or TNF-alpha inhibitors)

Question 543

Circumferential redness at the JUNCTION of the CORNEA and SCLERA with pain, NORMAL vision and photophobia with anterior chamber “flare cells” on SLIT lamp caused by infection (TB, Syphilis, HSV), trauma or HLA-B27 antigen which requires URGENT ophthalmology consult?

Answer 543

ANTERIOR Uveitis

Question 544

Which SCLERITIS and UVEITIS can cause visual changes (blurry, loss)?

Answer 544

POSTERIOR scleritis and uveitis

Question 545

Swelling of the EYE Lid, caused by Staph aureus (most common) but also with seborrheic dermatitis and rosacea?

Answer 545

Blepharitis

Question 546

How is BLEPHARITIS treated when NOT associated with Rosacea?

Answer 546

Warm compress + TOPICAL antibiotic

Question 547

How is BLEPHARITIS treated when associated with Rosacea?

Answer 547

ORAL Tetracyclines (-“cycline”)

Question 548

What do CORNEAL abrasions, SCLERITIS and UVEITIS ALL REQUIRE?

Answer 548

Ophthalmologist evaluation

Question 549

What is the LEADING cause of age-related visual loss?

Answer 549

Macular degeneration

Question 550

What is the most common of the two (2) types of macular degeneration?

Answer 550

DRY (atrophic) - 85%

Question 551

Drusen (deposits of extracellular material) in the macula with loss of central vision is called what?

Answer 551

DRY (atrophic) Macular Degeneration - most common type (85%)

Question 552

UNILATERAL neovascularization of the macula with suspected bleeding and scar formation is called what?

Answer 552

WET (neovascular) Macular Degeneration - aggressive

Question 553

AGE, Smoking, Cardiovascular Disease and Family History are all causes of this visual loss condition?

Answer 553

Macular Degeneration

Question 554

Why should smokers avoid ß-carotene?

Answer 554

Increases risk of LUNG Cancer

Question 555

How is DRY (drusen deposits) Macular Degeneration treated?

Answer 555

STOP smoking, Antioxidants - Vitamin C, Vitamin E, ß-carotene in NONsmokers ONLY and Zinc)

Question 556

What is the PREFERRED method of treatment of WET (neovascular) Macular Degeneration in the ABSENCE of FOVEOLAR involvement?

Answer 556

Vascular Endothelial Growth Factor inhibitors (VGEF - inhibitors)

Question 557

Increased Intra-Ocular Pressure (IOP) WITHOUT blockage, with PAINLESS, ASYMMETRIC gradual loss of peripheral vision, with an increased CUP:DISC ratio >0.5 with disc hemorrhages, seen more commonly in Blacks and those >40 years old with IRREVERSIBLE visual loss?

Answer 557

PRIMARY OPEN Angle Glaucoma

Question 558

How is PRIMARY OPEN Angle Glaucoma BEST treated?

Answer 558

Timolol (ß-blocker), Epi, Brimonidine (alpha-blocker), Pilocarpine (parasympathomimetic), Acetazolamide, Mannitol, Latanoprost (prostaglandin)

Question 559

Is surgery or laser therapy recommended for Glaucoma?

Answer 559

NO!

Question 560

ACUTE RED eye, SEVERE eye pain, HA, N/V and visual halos with REDUCED visual acuity with a SEMI-dilated, NON-reactive pupil and IOP >50 mm Hg?

Answer 560

ACUTE Angle Closure Glaucoma

Question 561

What is the BEST treatment for ACUTE Angle Closure Glaucoma?

Answer 561

Urgent Ophthalmologist referral

Question 562

What is the Cup and Disc of the eye?

Answer 562

Cup (the hole of a Donut) or where the optic nerve and vessels enter the eye (blind spot); Disc (the Donut) is the surrounding pit around the optic nerve point of entry

Question 563

What is a normal Cup-to-Disc ratio in the eye and what is considered an increased ratio?

Answer 563

Normal is 0.3; Increased is >0.3 (in glaucoma - ≥0.5)

Question 564

Opacity of the LENS caused by DM, Smoking, UV-B light, Corticosteroid use, old age is called?

Answer 564

Cataract

Question 565

When should cataract SURGERY (the ONLY treatment for cataracts) be done?

Answer 565

When symptoms interfere with daily living

Question 566

Decreased tear production or clogged tear duct or increased evaporation of tears (smoke, low humidity, wind) cause what condition that presents with a gritty, dry and burning irritation of the eyes?

Answer 566

KeratoCONJUNCTIVITIS sicca (dry eye)

Question 567

What diseases can cause inflammation of the lacrimal gland?

Answer 567

Sjogren syndrome, RA

Question 568

What is eye LID inflammation treated with BESIDES warm compresses?

Answer 568

Oral Tetracyclines (-“cycline”) - as in Blepharitis (lid inflammation) when associated with Rosacea

Question 569

How do you treat keratoCONJUNCTIVITIS sicca (dry eye)?

Answer 569

Warm compresses and artificial tears

Question 570

UNILATERAL floaters, squiggly lines, flashes of light in a MYOPIC patient, with a sudden peripheral visual defect appearing like a black curtain?

Answer 570

Retinal Detachment

Question 571

What is the most common type of retinal detachment?

Answer 571

POSTERIOR (due to vitreous traction)

Question 572

SUDDEN, unilateral loss of vision with congested and tortuous retinal veins and scattered intra-retinal hemorrhages with cotton wool spots and an AFFERENT Pupillary Defect may be seen?

Answer 572

CENTRAL Retinal Vein Occlusion (Thrombus)

Question 573

What MUST be done for CENTRAL Retinal Vein Occlusion OR CENTRAL Retinal Artery Occlusion?

Answer 573

Urgent Ophthalmological evaluation

Question 574

SUDDEN, painless visual loss in one eye in an elderly pt, with an AFFERENT Pupillary Defect and a PALE retina with a CHERRY-RED fovea?

Answer 574

CENTRAL Retinal Artery Occlusion (thrombus)

Question 575

Central retinal vein or artery occlusions, Temporal Arteritis, Retinal Detachment and Optic Neuritis ALL have this in common?

Answer 575

ACUTE visual loss - URGENT Ophthalmologic evaluation

Question 576

When do ORBITAL fractures require URGENT Ophthalmological evaluation?

Answer 576

When there is EITHER Visual LOSS, GLOBE PENETRATION or Impairment of Extraocular Muscles

Question 577

Usually a post-operative infection complication, inflammation of the AQUEOUS and VITREOUS (gel-like) humors associated with Endocarditis?

Answer 577

Endophthalmitis - URGENT Ophthalmologic evaluation - need intra-vitreal antibiotics

Question 578

Trauma to eye GLOBE or LID?

Answer 578

Urgent Ophthalmologic evaluation

Question 579

A pt with a SINUS or DENTAL infection presents with MARKED ocular and eyelid erythema, swelling, pain and fever?

Answer 579

Orbital Cellulitis (EMERGENCY - needs ophtho eval and aggressive antibiotics)

Question 580

How can you distinguish (since they look similar) between ORBITAL Cellulitis (deep, EMERGENCY) and PRE-SEPTAL or PERIORBITAL Cellulitis?

Answer 580

CT-scan for depth and evaluation of extraocular muscles and pupillary reflexes

Question 581

PAIN with eye MOVEMENT, BLURRED vision, VISUAL FIELD deficits and change in COLOR PERCEPTION?

Answer 581

Optic NEURITIS (Need Ophtho eval and BRAIN MRI) usually self-limitied

Question 582

Optic NEURITIS may be a sign of what? How is it treated?

Answer 582

MS; IV steroids!

Question 583

Mechanical problem preventing transmission of sound vibrations from external sources to the cochlea caused by problems within the ear CANAL, the TYMPANIC MEMBRANE or the OSSICLES of the MIDDLE ear?

Answer 583

Conductive Hearing Loss

Question 584

Problems with the perception and transmission of sound vibrations involving the COCHLEA or ACOUSTIC NERVE?

Answer 584

Sensorineural Hearing Loss

Question 585

When can the Weber and Rinne tests be utilized to differentiate between Conductive vs. Sensorineural Hearing Loss?

Answer 585

ONLY when the hearing loss is UNILATERAL

Question 586

Instead of the Weber-Rinne tests, what test should ALL patients who report hearing loss have?

Answer 586

AUDIOMETRY

Question 587

Progressive, UNILATERAL onset of SENSORINEURAL hearing loss, what can this be?

Answer 587

Acoustic Neuroma - MRI (also affects facial nerve)

Question 588

Viral infections, Bacterial meningitis, Lyme disease, Migraines, Meniere disease, Head injuries and Drug reactions can all cause what type of hearing loss?

Answer 588

SUDDEN Sensorineural Hearing Loss

Question 589

What is the treatment of Tinnitus?

Answer 589

Neurocognitive Interventions (behavioral therapy)

Question 590

Sensorineural hearing loss, tinnitus and vertigo?

Answer 590

Meniere Disease

Question 591

Hearing loss caused by Chemotherapy or Loop Diuretics?

Answer 591

IRREVERSIBLE

Question 592

Hearing loss caused by Aminoglycosides, NSAIDs, Aspirin and anti-Malarials?

Answer 592

Reversible Hearing Loss

Question 593

Ear pain for 24-48 hours following a URI +/- fever with bulging, cloudiness, erythema or immobility of the tympanic membrane?

Answer 593

Otitis Media

Question 594

What ear infection can result in Meningitis, Mastoiditis, Perforated tympanic membrane with resulting hearing loss?

Answer 594

Otitis Media

Question 595

How is Otitis Media treated?

Answer 595

Analgesia with anti-inflammatory agent (steroid drops) and if antibiotics are started (Amoxicillin or Amoxicillin-Clavulanate OR Macrolide (erythromycin) if PCN allergic)

Question 596

What is the cause of ACUTE Otitis Externa?

Answer 596

P. aeruginosa or Staph. aureus (rarely fungi)

Question 597

What causes CHRONIC Otitis Externa (>3 months)?

Answer 597

Fungi, Alleries, Systemic Dermatitis

Question 598

When can Otitis Externa become life threatening?

Answer 598

When it involves the Temporal/Mastoid bones

Question 599

Allergic contact dermatitis, from earrings, cosmetics, soaps shampoos, or hearing aids can cause what ear pathology?

Answer 599

CHRONIC Otitis Externa

Question 600

White cotton-like strands with/without white or black fungal balls seen in the external ear suggest?

Answer 600

Fugnal Otitis Externa with Candida or Aspergillus

Question 601

How is Otitis Externa treated?

Answer 601

CLEAR the canal of as much debris as possible, then If Mild - acetic acid solution (works for fungal also), If Moderate - topical fluoroquinolones

Question 602

How is Fungal Otitis Externa treated?

Answer 602

Topical acetic acid or Topical 1% Clotrimazole

Question 603

Purulent rhinorrhea with pus in the nasal cavity suggest?

Answer 603

Sinusitis

Question 604

When should imaging be done in patients with sinusitis?

Answer 604

If Immunocompromised (fungal, pseudomonal)

Question 605

How is sinusitis treated?

Answer 605

Antihistamines, intranasal corticosteroids, topical decongestants

Question 606

Why should topical decongestants for sinusitis be used only for a few days?

Answer 606

Because they can cause Rebound Rhinitis (rhinitis medicamentosa)

Question 607

What sinusitis patients are treated with Antibiotics?

Answer 607

Those with 3-4 days of SEVERE symptoms - Fever, purulent drainage, facial pain or those who don’t resolve spontaneously after 10 days

Question 608

What are the two (2) BEST choices for antibiotic treatment of sinusitis (3-4 days of severe symptoms, purulent discharge and facial pain)?

Answer 608

Amoxicillin-Clavulanate or Doxycycline

Question 609

When should you test for specific IgE allergens in a pt with allergic rhinitis?

Answer 609

If allergen immunotherapy is being considered OR if patient is considering significant, costly lifestyle changes due to their symptoms

Question 610

What is the FIRST line therapy for allergic rhinitis?

Answer 610

Intranasal corticosteroids +/- oral antihistamines if needed

Question 611

Odors, spicy foods, changes in temperature that cause rhinitis in the ABSENCE of an allergic trigger is?

Answer 611

Non-allergic Rhinitis (vasomotor)

Question 612

How is Non-allergic rhinitis treated?

Answer 612

Same as allergic rhinitis with intranasal corticosteroids, antihistamines and anticholinergic meds

Question 613

How should PHARYNGITIS be diagnosed and WHEN should it be treated with more than symptomatic therapy?

Answer 613

By Rapid GAS antigen OR culture to detect Group-A STREP (rheumatic heart disease); if GROUP-A STREP positive (to prevent possible rheumatic heart disease)

Question 614

A patient that presents with PHARYNGITIS with FEVER, ABSENCE of cough, TONSILLAR Exudates and TENDER anterior CERVICAL LYMPHADENOPATHY likely has?

Answer 614

GROUP-A STREP pharyngitis - needs antibiotic (to prevent possible rheumatic heart disease) ONLY if has ≥1 of the Centor criteria (1. fever, 2. no cough, 3. tonsillar exudates, 4. tender lymphadenopathy)

Question 615

What is the preferred medication for the treatment of GROUP-A STREP Pharyngitis? If PCN allergic?

Answer 615

10-day ORAL Penicillin-G OR IM Penicillin-G x 1; Erythromycin or Azithromycin

Question 616

What two groups of STREP cause similar PHARYNGITIS to GROUP-A STREP but are NOT associated with Rheumatic Heart Disease, but ARE associated with Glomerulonephritis and Reactive Arthritis?

Answer 616

GROUP-C and GROUP-G STREP

Question 617

When ACUTE Pharyngitis causes Septic Thrombosis of the Internal Jugular Vein with persistent fever in spite of antibiotic therapy and neck pain (can see on CT), it is called what, and how is it treated?

Answer 617

LEMIERRE Syndrome; IV Vancomycin + Ceftriaxone for 2-4 weeks

Question 618

Fusobacterium Necrophorum (anaerobic Gram neg. rod) is found in?

Answer 618

Lemierre Syndrome (pharyngitis with thrombosis of internal jugular vein)

Question 619

In which patients with RECURRENT Epistaxis should radiologic imaging be obtained?

Answer 619

Those who smoke (to rule out malignancy)

Question 620

Patients with POSTERIOR epistaxis (elderly), require what type of treatment?

Answer 620

Posterior Nasal PACKING by OTORHINOLARYNGOLOGIST

Question 621

When MUST antibiotics be prescribed for epistaxis?

Answer 621

WHEN NASAL PACKING IS IN PLACE

Question 622

What is the treatment for MOST ANTERIOR epistaxis?

Answer 622

Compression for 15 minutes

Question 623

What three (3) medications are typically associated with Gingival Hyperplasia?

Answer 623

Phenytoin, Cyclosporine and Nifedipine

Question 624

What disease has PERIODONTAL disease (caused by xerostomia or gingival hyperplasia) been associated with?

Answer 624

Coronary Heart Disease

Question 625

What is the most common ORAL malignancy, particularly in smokers?

Answer 625

Squamous Cell Carcinoma

Question 626

What is the best method of prevention of Periodontal Disease (gums, teeth, jaw bone)?

Answer 626

Oral Hygiene (brushing, flossing) and prevention of CAD

Question 627

Where is the MOST common location of HALITOSIS (90%)?

Answer 627

MOUTH

Question 628

Patients with Vitamin B12 deficiency, Iron deficiency and Celiac disease have what type of tongue?

Answer 628

Atrophic, bright red, smooth, tender and no visible taste buds

Question 629

Patchy areas of atrophy of tongue papillae with erythematous patches with white borders on the tongue?

Answer 629

Geographic Tongue (benign, no treatment)

Question 630

Jaw pain, HA, clicking/grinding/grating/crepitus when chewing?

Answer 630

Temporo-Mandibular Joint Disorder

Question 631

How is OSTEOARTHRITIS of the TMJ diagnosed?

Answer 631

CT/MRI

Question 632

Jaw relaxation, heat, therapeutic exercises, cognitive behavioral therapy, NSAIDs, TCA’s, injected corticosteroids are all treatment for?

Answer 632

TMJ Disorders

Question 633

When does the treatment of an abscess BESIDES surgical drainage require ANTIBIOTICS as well?

Answer 633

If cellulitis or DM are present OR if patient is immunocompromised

Question 634

During a 2-WEEK period, if pt experiences EITHER depressed mood or loss of interest or pleasure WITH at LEAST 4 other symptoms (significant CHANGE in weight, sleep changes, psychomotor agitation or retardation nearly every day, fatigue with loss of energy, guilt or worthlessness, can’t think or concentrate, thought of death or suicide) they have?

Answer 634

MAJOR DEPRESSION (score ≥10 with each factor scored from 0-3 out of 27 total points possible)

Question 635

If symptoms of depression are there but t does not qualify for MAJOR depression, what else can it be?

Answer 635

Minor depression

Question 636

What is the requirement for MINOR depression to be diagnosed as Dysthymia?

Answer 636

It MUST be going on for AT LEAST 2 YEARS (≥2 years)

Question 637

When should you treat a patient with BEREAVEMENT-caused DEPRESSION?

Answer 637

If symptoms of MAJOR Depression occur ≥2 months after the loss

Question 638

When does post-partum depression usually occur?

Answer 638

WITHIN 6 months post delivery

Question 639

What patients with DEPRESSION require PSYCHIATRIC evaluation?

Answer 639

Those with SUICIDAL/HOMICIDAL thoughts, BIPOLAR disorder, PSYCHOTIC symptoms or symptoms REFRACTORY to at least 2 medications

Question 640

If FIRST depression episode, how much longer do you treat AFTER remission?

Answer 640

4-9 MONTHS

Question 641

In patient with RECURRENT depression, how long do you treat after remission?

Answer 641

Life-Long

Question 642

BEST antidepressants for DEPRESSION without pain?

Answer 642

SSRIs (citalopram, paroxetine, sertraline)

Question 643

BEST antidepressants for DEPRESSION with PAIN?

Answer 643

SNRIs (venlafaxine, duloxetine, milnacipran)

Question 644

What is a side effect of SSRIs & SNRIs that patients switch to BUPROPION for?

Answer 644

Sexual side-effects

Question 645

The presence of what condition makes BUPROPION contraindicated?

Answer 645

Seizure disorder (lowers threshold)

Question 646

What is the ONLY non-oral (transdermal) antidepressant med?

Answer 646

SELEGILINE (MAOI)

Question 647

Potentially FATAL mental status changes, neuromuscular hyperactivity, and autonomic instability in a patient taking SSRIs, SNRIs or MAOIs?

Answer 647

SEROTONIN Syndrome

Question 648

Any contraindications to using ANY antidepressants while breastfeeding? Pregnancy?

Answer 648

NO; Pregnancy Category C (use caution)

Question 649

A pt presenting with difficulty controlling excessive anxiety (worry about events/activities) on most days for the past 6 MONTHS with symptoms of fatigue, irritability, insomnia, restlessness and difficulty concentrating has?

Answer 649

Generalized Anxiety Disorder

Question 650

What two (2) MENTAL disorders have SOMATOFORM symptoms causing HIGH utilization of HEALTH CARE resources (er visits, PCP visits, etc.)?

Answer 650

Generalized Anxiety Disorder and Panic Disorder

Question 651

What PHOBIA is PANIC DISORDER associated with ?

Answer 651

AGORAPHOBIA

Question 652

What meds are used for the treatment of Generalized Anxiety Disorder and Panic Disorder?

Answer 652

SSRIs, SNRIs and BUSPIRONE (alternative)

Question 653

What three (3) actual medical disorders mimic Panic Disorder?

Answer 653

Cardiac Disease, Pheochromocytoma, Thyroid Disease

Question 654

Patients whom have had Traumatic Brain Injury (soldiers, etc.) are at a much higher risk for what mental health disorder?

Answer 654

Post-Traumatic Stress Disorder (PTSD)

Question 655

What medications are used in conjunction with Cognitive Behavioral Therapy to treat Post Traumatic Stress Disorder?

Answer 655

SSRIs OR TCAs

Question 656

How is FEAR of public speaking, parties, test taking with associated symptoms of blushing, dyspnea, palpitations and emotional distress (Social Anxiety Disorder) treated in combination with Cognitive Behavioral Therapy?

Answer 656

SSRIs

Question 657

What is the BEST treatment for Obsessive-Compulsive Disorder?

Answer 657

Cognitive Behavioral Therapy with EXPOSURE and RESPONSE PREVENTION (if severe, can use SSRIs or Clomipramine)

Question 658

Repeated episodes of AGGRESSIVE, VIOLENT behavior grossly out of proportion to the situation such as ROAD RAGE, SEVERE TEMPER TANTRUMS and DOMESTIC ABUSE followed by remorse or embarrassment?

Answer 658

Intermittent Explosive Disorder (IED)

Question 659

How is Intermittent Explosive Disorder treated?

Answer 659

Cognitive Behavioral Therapy + Mood Stabilizers (carbamazepine or Lithium or Phenytoin)

Question 660

What is the leading cause of SUICIDE?

Answer 660

BIPOLAR Disorder

Question 661

How is bipolar disorder treated?

Answer 661

By Psychiatrist with MOOD stabilizers (Lithium, Valproate, Carbamazepine, Lamotrigine) + Olanzepine or Quetiapine or Aripirazole

Question 662

What can occur if BIPOLAR disorder is MISS-Diagnosed as depression (because no manic episodes were revealed) and a pt is treated with SSRIs?

Answer 662

A MANIC episode can be triggered!

Question 663

The presence of MEDICALLY UNEXPLAINED symptoms is called?

Answer 663

Somatization

Question 664

How long must a patient that developed MULTIPLE Medically Unexplained Symptoms of BEFORE age 30 have had the symptoms before being able to be diagnosed with “SOMATIZATION DISORDER”?

Answer 664

YEARS

Question 665

What is “Undifferentiated Somatoform Disorder”?

Answer 665

Just one Medically Unexplained SYMPTOM needed (unlike in somatization disorder where multiple symptoms are required) and for at least 6 months (not one year)

Question 666

When a patient with “LIMITED” understanding of neurology presents with a SINGLE Medically Unexplained PSEUDOneurologic symptom (hemiparesis would not be possible) what is that called?

Answer 666

CONVERSION Disorder (a faking disorder)

Question 667

A patient that misinterprets NORMAL bodily sensations as serious illness is classified as what?

Answer 667

Hypochondriac

Question 668

A patient preoccupied with either a REAL but minor or IMAGINED physical finding is classified as having what?

Answer 668

Body Dysmorphic Disorder

Question 669

Should testing be ordered to reassure a patient?

Answer 669

NO!!!

Question 670

When a patient ‘FAKES” a symptom, what is the difference between “MALINGERING” and “FACTITIOUS”?

Answer 670

MALINGERING (a faking disorder): there is secondary gain (avoidance of work, money, etc.) FACTITIOUS (a faking disorder): wanting to remain in the “sick role”

Question 671

Frequent office visits with LIMITS (visit time, in-between visit communication - calls, emails, etc.) best treated by Cognitive Behavior Therapy with teaching pt to FUNCTION WITH their SYMPTOMS rather than eliminating them are the strategies of treating what?

Answer 671

SOMATOFORM Disorders

Question 672

A history of childhood anxiety or OCD predisposes a pt to this eating disorder that presents with Amenorrhea, VERY low body weight (BMI

Answer 672

Anorexia Nervosa

Question 673

Dental Carries, Enlarged Salivary glands, Scarring on the DORSUM of the hand from self-induced vomiting (Russel Sign) are all seen in this eating disorder?

Answer 673

Bulimia Nervosa

Question 674

Besides severe electrolyte abnormalities leading to cardiac bradycardia and orthostatic hypotension, amenorrhea and low bone mineral density, what is the MOST worrisome COMPLICATION of anorexia?

Answer 674

RE-FEEDING Syndrome (hypomangesemia, hypophosphatemia, hypokalemia due to edema and large volume shifts when aggressively feeding (oral, enteral, parenteral) severely malnourished patients - can cause death - MUST replete electrolytes

Question 675

How is the treatment of Anorexia DIFFERENT than that for BULIMIA?

Answer 675

Anorexia: Psychotherapy + nutritional support
Bulimia: Cognitive Behavioral Therapy + SSRIs (Fluoxetine, Sertraline, Topiramate)

Question 676

DISORGANIZED thoughts, RAPID shift in topics, CONFUSED speech ≥1 month, GENETICS play the biggest role, can be sudden onset or slow?

Answer 676

SCHIZOPHRENIA

Question 677

What is SCHIZOPHRENIA best treated with ?

Answer 677

Atypical antipsychotics (olanzepine, clozapine) or Haldol, chlorpromazine

Question 678

22% of patients diagnosed with schizophrenia have what?

Answer 678

Other psychiatric illness and NOT schizophrenia

Question 679

Besides amphetamine and methylphenidate (stimulants) what else can ADHD be treated with ?

Answer 679

ATOMOXETINE (SNRI) or Bupropion + TCAs

Question 680

What should be done periodically in adults with ADHD as they age?

Answer 680

Reassess need for medication therapy as the disorder improves with age

Question 681

What is the MAIN DIFFERENCE between diagnosis of Autism and Asperger disorder?

Answer 681

Patients with Asperger disorder DO NOT have DELAYS in LANGUAGE or COGNITIVE development and therefore are diagnosed when they are OLDER

Question 682

Unstable moods, behavior and unstable relationships?

Answer 682

BORDERLINE personality disorder

Question 683

Perversive psychological dependence on other people with need to be taken care of and intense fear of abandonment?

Answer 683

DEPENDENT Personality disorder

Question 684

Long pattern of attention seeking behavior and extreme emotionality, behave sexually seductive and need to be the center of attention?

Answer 684

HISTRIONIC Personality disorder

Question 685

Disregard for other people’s rights, are arrogant and lack empathy for the suffering of others?

Answer 685

ANTISOCIAL Personality disorder

Question 686

What should a physician do if a COMPLETE lack of trust develops between themselves and their patient or a therapeutic relationship is not possible?

Answer 686

Refer the patient to ANOTHER provider

Question 687

Bathing, dressing, toileting, feeding?

Answer 687

Activities of Daily Living (ADLs)

Question 688

Shopping for food, taking your own medications, handling finances?

Answer 688

INSTRUMENTAL Activities of Daily Living (IADLs)

Question 689

In elderly individuals, INCREASED GAIT SPEED was associated with what?

Answer 689

Increased SURVIVAL

Question 690

Supplementation of what for 6 months has resulted in a 14% relative risk reduction for falls in the ELDERLY?

Answer 690

Vitamin D

Question 691

Does Mild Cognitive Impairment (MCI) progress?

Answer 691

YES, to DEMENTIA at the rate of 12%/year

Question 692

What Mini Mental State Examination score diagnoses Mild Cognitive Impairment?

Answer 692

24-25/30 (scores

Question 693

What is the BEST treatment for Mild Cognitive Impairment and Dementia?

Answer 693

Cognitive Rehabilitation performed by a neuropsychologist

Question 694

What type of cognitive difficulty can elderly patients with depression have?

Answer 694

PSEUDOdementia (improves with treatment of the depression)

Question 695

Although not without RISK (GI bleed, SIADH), these antidepressants work well in elderly patients?

Answer 695

SSRIs

Question 696

If an elderly patient has depression associated with weight LOSS and INSOMNIA, what is the preferred agent instead of SSRIs?

Answer 696

Mirtazapine

Question 697

HIGH-Frequency hearing loss (associated with localization and hearing the spoken voice) is a common occurrence in whom?

Answer 697

Elderly patients (presbycusis)

Question 698

What diagnostic methods should be used to diagnose presbycusis in elderly patients?

Answer 698

Questionnaire or Whisper test

Question 699

Somatic and vegetative symptoms are seen in the elderly more so than dysphoria (unhappiness) if they have this condition?

Answer 699

Depression

Question 700

Insulin, Warfarin, Anti-platelet meds and Oral Hypoglycemic agents resulted in >60% of emergency hospitalizations for adverse drug effects in whom?

Answer 700

The elderly

Question 701

Loss of urine with effort, coughing, sneezing, caused by sphincter incompetence?

Answer 701

STRESS Incontinence

Question 702

Loss of urine with effort, coughing, sneezing, caused by sphincter incompetence?

Answer 702

STRESS Incontinence

Question 703

When is a POST-VOID residual urine volume determination required in a patient with incontinence?

Answer 703

When there is a STRONG suspicion of NEUROLOGIC disease or BLADDER OUTLET OBSTRUCTION

Question 704

When is a POST-VOID residual urine volume determination required in a patient with incontinence?

Answer 704

When there is a STRONG suspicion of NEUROLOGIC disease or BLADDER OUTLET OBSTRUCTION

Question 705

What is the FIRST LINE therapy for STRESS and URGE incontinence?

Answer 705

Kegel exercises and Bladder training (void regularly regardless of urge, increase interval between voiding)

Question 706

What medication works well for URGE INCONTINENCE?

Answer 706

Anticholinergic (Oxybutynin, Tolterodine)

Question 707

Can a patient with Urge Incontinence with Angle Closure Glaucoma use Anticholinergics?

Answer 707

NO!!!

Question 708

In women, what medical device and surgery are BEST for STRESS INCONTINENCE when medications fail?

Answer 708

Pessaries (medical device that must be fitted professionally); Sling Procedure (surgery)

Question 709

What is the best NON-pharmacological option for the treatment of URGE INCONTINENCE, especially for patients with Angle Closure Glaucoma who cannot use Anticholinergic drugs?

Answer 709

BOTOX Injection into the detrusor muscle (lasts 6 months)

Question 710

How are STAGE I Pressure Ulcers treated?

Answer 710

Transparent film

Question 711

How are STAGE II Pressure Ulcers treated?

Answer 711

Occlusive Dressing to keep wound MOIST and CLEAN

Question 712

How are STAGE III and IV Pressure Ulcers treated?

Answer 712

DEBRIDEMENT with WOUND Infection treatment

Question 713

What should be done for ALL STAGE III & IV Pressure Ulcers that do not heal?

Answer 713

Imaging to rule out OSTEOMYELITIS

Question 714

What is the ONLY purpose of a WOUND-VAC (negative pressure device) for a patient with a PRESSURE Ulcer Wound?

Answer 714

Comfort ONLY (no effect on healing)

Question 715

PRIOR to a medical PROCEDURE, how early should a PRE-procedural visit be made with a PCP for proper preoperative management without delaying surgery?

Answer 715

3-4 weeks

Question 716

What patients require PERIOPERATIVE cardiac evaluation for the prevention of MYOCARDIAL Infarction?

Answer 716

Those patients whom are at the HIGHEST RISK for his complication

Question 717

What INDEX is used for risk stratification of patients at risk for PERIOPERATIVE MI?

Answer 717

Revised Cardiac Risk Index (RCRI)

Question 718

If a patient needs an EMERGENCY surgery but may be of VERY high risk of MI, should PERIOPERATIVE testing be done?

Answer 718

NO!! (do the surgery!) THEN manage post-operative complications

Question 719

If a patient has a HIGH risk for PERIOPERATIVE MI, should ELECTIVE/MINOR surgeries be done?

Answer 719

NO!! delay until condition is treated

Question 720

What patients do not require PERIOPERATIVE testing for risk of MI?

Answer 720

Those going for LOW-RISK surgery, those with an exercise capacity of >4 METs (Metabolic Equivalents), those with low exercise capacity but no RCRI (Revised Cardiac Risk Index) risk factors

Question 721

What NON-invasive PERIOPERATIVE cardiac testing is PREFERRED for patients with REDUCED exercise tolerance and MULTIPLE cardiac risk factors? If not possible (pt can’t exercise), what is the NEXT BEST ONE?

Answer 721

1. Exercise STRESS Testing (can predict functional capacity)

2. DOBUTAMINE STRESS ECHO

Question 722

In what patients with CAD is CORONARY REVASCULARIZATION SURGERY (CABG) recommended prior to elective NON-cardiac surgeries?

Answer 722

Those with a LEFT MAIN lesion or with ≥3 vessel disease

Question 723

If a patient is ALREADY on a ß-blocker pre-operatively, what should they do?

Answer 723

CONTINUE it

Question 724

In patient who are planned to UNDERGO VASCULAR surgery and have CAD or those planning on undergoing INTERMEDIATE or HIGH-RISK surgery with >1 Revised Cardiac Risk Index (RCRI) factor should take what medicine a few weeks prior to their surgery?

Answer 724

ß-blockers (and continued INDEFINITELY)

Question 725

What patients with Heart Failure (HF) should have their surgeries DEFERRED if possible?

Answer 725

Those with DECOMPENSATED HF

Question 726

Should Clopidogrel be stopped prior to any surgery?

Answer 726

NO, for all except when a cardiac stent has been recently placed

Question 727

Patients with recent MI (up to 6 months), cardiac stent, at High RISK for cardiac events or PRIOR to CABG should NOT have what medicine stopped prior to ANY surgery?

Answer 727

Aspirin

Question 728

If a patient is NOT on this medicine, it should ALWAYS be started prior to a planned CABG?

Answer 728

Aspirin

Question 729

Cardiovascular medicines, statins, inhalers for pulmonary disease, PPIs and H2 blockers, all thyroid meds, stress-dose steroids, Oral Contraceptive Pills, Lithium, antipsychotics, SSRIs and TCAs, anticonvulsants and parkinson meds and Methotrexate should be handled how prior to surgery?

Answer 729

CONTINUED

Question 730

What should be done with these meds: IV Heparin, LMWH, Warfarin, Clopidogrel, Aspirin, Cholestyramine, Oral Hypoglycemic agents, Insulin, Estrogen, MAOIs, Alzheimer meds, Herbals, NSAIDs and COX-2 Inhibitors before surgery?

Answer 730

DISCONTINUED! EXCEPT Clopidogrel if stent requires continuation, Aspirin should be STARTED or continued before CABG and TYPE I DM must have IV insulin given during procedures (prevent DKA)

Question 731

What types of surgeries are Intrathoracic, Intraperitoneal and Supra-inguinal vascular?

Answer 731

HIGH-Risk surgeries

Question 732

Ischemic heard disease, HF, DM, Kidney disease, CVA, High-Risk surgery?

Answer 732

Components of the Revised Cardiac Risk Index (RCRI - 1 point each)

Question 733

Pts with CAD undergoing Vascular surgery OR pts undergoing ANY intermediate or higher surgery and have more than ONE cardiac risk factor should be started on what?

Answer 733

ß-blocker

Question 734

What are the two types of HIGHEST-Risk Surgeries for patients with PULMONARY Disease?

Answer 734

Thoracic and Abdominal surgeries

Question 735

What patients should be tested with SPIROMETRY (FEV1/FVC) prior to surgery?

Answer 735

ONLY those with UNEXPLAINED Dyspnea (otherwise NO benefit)

Question 736

What should be done for patients with poorly-controlled ASTHMA or COPD prior to surgery?

Answer 736

SYSTEMIC corticosteroids and INHALED bronchodilators

Question 737

When should SMOKING be STOPPED prior to SURGERY?

Answer 737

8 WEEKS

Question 738

What measures should be taken post-op to PREVENT atelectasis and pulmonary complications?

Answer 738

PAIN management and INCENTIVE Spirometry

Question 739

How should OSA patients be monitored post-operatively?

Answer 739

Monitored closely with possible CPAP or BiPAP (continuous or bilevel Positive Airway Pressure)

Question 740

What pulmonary disease should be SCREENED for BEFORE surgery?

Answer 740

Obstructive Sleep Apnea (OSA)

Question 741

Low serum ALBUMIN, Kidney Dysfunction, CHF and OLD age besides the obvious (smoking, COPD, poor general health) are MAJOR risk factors for surgeries from what organ perspective?

Answer 741

PULMONARY

Question 742

In patients with a low risk for VTE (venous thromboembolism), what post-operative prophylaxis is recommended?

Answer 742

EARLY AMBULATION

Question 743

What can be done for patients whom are at a HIGH bleeding risk post-op (neurosurgery) for VTE prophylaxis?

Answer 743

Pneumatic Compression Devices alone

Question 744

What post-op VTE prophylaxis should be given to patients who are not LOW risk NOR high-BLEEDING risk post-op (neurosurgery)?

Answer 744

LMWH or SQ Unfractionated Heparin or Warfarin

Question 745

How soon POST-OP should patients be given VTE prophylaxis and when should it be discontinued?

Answer 745

STARTED 12-HOURS post-op and given until DISCHARGE

Question 746

How long BEYOND discharge should patients s/p ORTHOPEDIC surgery, abdominal/GYN surgeries for MALIGNANCY, or PREVIOUS VTE receive VTE prophylaxis for?

Answer 746

AT LEAST 5 WEEKS

Question 747

What VTE prophylaxis should be given to patients whom have HAD VTE 1-3 months BEFORE planned surgical procedure AND anticoagulants are CONTRAINDICATED post-op?

Answer 747

Removable IVC filter

Question 748

What should patients who are ON WARFARIN, undergoing CATARACT surgeries, DENTAL procedures or BIOPSY from NON-MAJOR organs do?

Answer 748

CONTINUE WARFARIN with target INR 1.3-1.5

Question 749

When should patients at LOW risk for VTE (VTE >12 months ago, A-fib CHADS ≤2, no prior CVA) stop WARFARIN prior to surgical procedures?

Answer 749

4-5 days

Question 750

What should patients with INTERMEDIATE-to-HIGH risk of VTE do for prophylaxis prior to SURGERY?

Answer 750

Bridged with LMWH or IV Unfractionated Heparin

Question 751

When is BRIDGING with LMWH or Unfractionated Heparin typically started for INTERMEDIATE-to-HIGH risk patients on WARFARIN who are planning to have SURGERY?

Answer 751

1-2 days AFTER WARFARIN is discontinued and STOPPED 24-HOURS (LMWH) or 4-6 HOURS (UFH) prior to surgery AND RESUMED 12-24 HOURS post-op

Question 752

When is BRIDGING of WARFARIN with LMWH/UFH stopped?

Answer 752

When the INR is THERAPEUTIC

Question 753

Older than 40, Hip or Knee surgery, major trauma or spinal cord injury?

Answer 753

High-Risk for VTE

Question 754

What should patients undergoing surgeries with LOW risk for bleeding do with ASPIRIN and CLOPIDOGREL?

Answer 754

CONTINUE them

Question 755

Pt s/p recent MI or cardiac STENT (BARE METAL) placement should do what with ASPIRIN and CLOPIDOGREL?

Answer 755

CONTINUE for AT LEAST 6 WEEKS from event

Question 756

Pt s/p cardiac STENT (DRUG ELUTING) placement should do what with ASPIRIN and CLOPIDOGREL?

Answer 756

CONTINUE for AT LEAST 1 YEAR

Question 757

WHICH is the ONLY anti-platelet medication that is to be STARTED or CONTINUED prior to a CABG surgery?

Answer 757

ASPIRIN

Question 758

When are ASPIRIN and CLOPIDOGREL stopped prior to SURGERIES and when are they restarted?

Answer 758

ASPIRIN: 7-10 days BEFORE, restarted after 24 hours
CLOPIDOGREL: 4-5 days BEFORE, restarted after 24 hours

Question 759

CBC and coagulation studies should be done for which patients prior to surgery?

Answer 759

HIGH-RISK for significant bleeding, HEPATIC dysfunction, Ashkenazi Jews (factor XI deficiency)

Question 760

How high should a patient’s PLATELET count be PRIOR to surgery?

Answer 760

≥50,000 µL/L (give platelets if lower or desmopressin, 1-HOUR before surgery)

Question 761

What should be done PRE-OP for a patient with Immune Thrombocytopenic Purpura (ITP)?

Answer 761

Corticosteroids, IVIG or Rho(D) immune globulin

Question 762

What should be done PRE-OP for a patient with Thrombotic Thrombocytopenic Purpura (TTP)?

Answer 762

PLASMAPHARESIS

Question 763

When should patients with ANEMIA of Kidney disease be given ERYTHROPOIETIN PRE-OP?

Answer 763

ONLY if LARGE blood losses are expected AND TRANSFUSION is CONTRAINDICATED

Question 764

What should be done for patients with PRE-OP Hb

Answer 764

TRANSFUSE

Question 765

What should ALL patients with SICKLE CELL DISEASE do prior to SURGERY and why?

Answer 765

Consult HEMATOLOGIST because of RISK of Sickle Cell CRISIS

Question 766

What should be measured in ALL patients with DM PRE-OP?

Answer 766

HbA1c and Kidney function (BUN/Cr)

Question 767

What should be done in POORLY-controlled DM patients prior to ELECTIVE surgery?

Answer 767

Delay surgery until fasting glucose ≤220 mg/dL

Question 768

What should be done with ORAL DM medications and INSULIN prior to surgery?

Answer 768

HOLD ALL ORAL DM meds 12 hours BEFORE surgery, HOLD fast-acting insulin, DOSE-Adjust long-acting insulin (give 1/2-2/3 dose 12 hours before)

Question 769

What should ALL THYROID disease patients have checked PRIOR to surgery?

Answer 769

TSH

Question 770

A-fib, Respiratory Failure and Thrombocytopenia are all complications that can develop POST-OP in a patient with what disease?

Answer 770

HYPERthyroidism (pt MUST be made EUTHYROID before)

Question 771

If a patient with HYERthyroidism cannot have surgery DELAYED and not time to make them euthyroid, what can be given PRE-OP?

Answer 771

ß-blocker, corticosteroids, Iodine

Question 772

When should patients with HYPOthyroidism have their elective surgeries delayed?

Answer 772

ONLY if SEVERE disease

Question 773

Patients taking HOW MUCH daily STEROIDS for HOW LONG, must take their usual daily dose PRIOR to surgery?

Answer 773

≥10 mg for ≥3 WEEKS (stress dose steroids may be required - 25 mg for minor surgery, 150 mg for major)

Question 774

In what patients taking ACE-I or ARBs should have these medications HELD on their surgery day and why?

Answer 774

Pts with Chronic Kidney Disease (CKD) because they can develop INTRA-OP HYPOTENSION

Question 775

What should be given ITRA-OP to patients with Chronic Kidney Disease (CKD) and what meds should be avoided post-op?

Answer 775

IVF’s to avoid dehydration; NSAIDs (nephrotoxic)

Question 776

Patients with Chronic Kidney Disease (CKD) and UREMIA are at risk for what PERI-operatively?

Answer 776

Platelet Dysfunction and bleeding (schedule dialysis to coincide with surgery)

Question 777

What should be done PRE-OP for patients with NEWLY diagnosed LIVER disease?

Answer 777

DEFER elective surgery to evaluate and POSTPONE elective surgery in patients with ACUTE Hepatitis of ANY cause

Question 778

Should elective procedures be delayed in patients with CHRONIC liver disease WITHOUT cirrhosis?

Answer 778

NO!

Question 779

What does the Child-Pugh classification (A, B, C) suggest for patients with liver disease?

Answer 779

Class A - 10% mortality risk after GENERAL Surgery
Class B - 30% mortality risk after GENERAL Surgery
Class C - 80% mortality risk after GENERAL Surgery

Question 780

What pharmacologic agents should be given PRE-OP in patients with Cirrhosis and coagulopathy?

Answer 780

Vitamin K, FFP (or cryoprecipitate/factor VIIa)

Question 781

When should a TIPS procedure be done as a RISK reducing measure PRE-OP in a patient with ASCITES planned for surgery?

Answer 781

If diuretic control of ascites is poor/refractory and if pt has esophageal varices prior to MAJOR Surgery

Question 782

What should a patient with advanced liver disease be monitored post-operatively for?

Answer 782

HYPOglycemia (impaired gluconeogenesis)

Question 783

What can pts with MS typically experience post-op?

Answer 783

An acute exacerbation