ABIM 2015 - General IM Flashcards
The degree to which the investigator’s conclusions are supported by a research study is called the study’s?
INTERNAL Validity
The generalizability of an investigator’s conclusions beyond the internal confines of the research study is called the study’s?
EXTERNAL Validity
In therms of what specifically is the error for a given study shown?
Confidence Interval (CI) - usually 95%
What does it mean when there is a “wide” Confidence Interval?
It means that the research study has less certainty and precission
What causes a research study’s Confidence Interval to be less precise or less certain (“wide”)?
Small sample size
The probability of detecting the difference between two groups when a difference exists is affected by a small sample size and is called?
Power of a study
Non-random errors that occur in a research study are called what?
Bias (can occur in selection of patients, measurement and analysis)
What type of bias exists when patients chosen for a study group have characteristics that can affect the results of a study?
Selection Bias
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?
Confounder (MALE)
How can confounders be minimized in research studies?
By using a randomized study design
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?
EXPERIMENTAL Study
What is the objective of an EXPERIMENTAL Study?
To prove that the “new” therapy is “non-inferior” to existing therapies (but is cheaper, more convenient to take, etc.)
True differences between studied subjects can be masked if the sample size is too small, what is this called?
Low-power
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?
Generalizability (External Validity)
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?
Quasi-Experimental Study
What are studies called when instead of randomizing individual patients, entire GROUPS of patients are randomized?
Cluster-Randomized Study
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?
Observational Study
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?
Confounding error and Bias
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?
Observational Study
What types of studies are COHORT and CASE-CONTROL?
Observational Studies
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?
Cohort Study
Which type of Cohort study, prospective or retrospective, minimizes a certain type of bias?
Prospective Cohort Studies (minimize “recall” bias - inaccurate recall of past events)
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)?
CASE (disease)-Control Study
What study design is best for studying RARE diseases or those that occur many years after specific exposures?
CASE (disease)-Control Study
Being EXCLUSIVELY a RETROSPECTIVE study, Case-Control Study, much like retrospective Cohort Studies are susceptible to what type of bias?
Recall Bias (those patients WITH disease may be more likely to remember previous exposure than those without disease)
Which Observational Study design assesses BOTH for exposure and disease at the SAME TIME POINT rather than prospectively or retrospectively?
Cross-Sectional Study
This Observational Study is merely a REPORT of clinical outcomes in a group of patients?
Case Series (group of patients rather than a “case report” involving only one patient)
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?
Control Group
This type of study compares outcomes in AGGREGATE, of TWO different POPULATIONS (countries, socioeconomic groups)?
Epidemiological Study
What is the ECOLOGICAL FALLACY, a specific study error of Epidemiological Study?
Erroneously ASSUMING that population-level associations imply individual-level associations
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?
Systematic Reviews
The Systematic Review Study that QUANTITATIVELY combines data (not qualitatively) is known as what?
A Meta-Analysis
What is the strength of systematic reviews?
Their ability to combine the data of MANY small studies thus minimizing the impact of RANDOM ERROR
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)?
Meta-Analysis
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?
Comparative Effectiveness Research
This error occurs when SYSTEMATIC differences between groups affect the outcome of a study?
Bias
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?
Experimental Study: Randomized Controlled Trial (RCT)
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?
Experimental Study: Cluster-Randomized Trial
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?
Experimental Study: Quasi-Experimental Study
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?
Observational Study: Cohort Study
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?
Observational Study: Case-Control Study
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?
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
The NUMBER of patients NEEDED to receive TREATMENT for ONE additional patient to be expected to benefit from the intervention?
Number Needed to Treat (NNT) - the lower this number, the better
How are Number Needed to Treat (NNT) and the Absolute Risk Reduction (ARR) related?
NNT=1/ARR
The NUMBER of patients NEEDED to receive TREATMENT to expect ONE of them to be HARMED from the intervention?
Number Needed to Harm (NNH)
How are Number Needed to Harm (NNH) and the Absolute Risk Increase (ARI - same as ARR) related?
NNH=1/ARI
Defining the risk of an exposure or treatment in ABSOLUTE terms (ARI) and calculating the NNT/NNH does what?
Provides the BEST way to understand the MAGNITUDE of DIFFERENCE in the sample (effect size)
What statistical value allows one to asses how likely ANY DIFFERENCE seen in a study is due to chance alone?
The P value
What does a P value of LESS than 0.05 (P
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
When does a study produce HIGHLY Statistically Significant Results (P
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)
The ability of a test to DETECT a disease IF it is PRESENT is called?
SENSITIVITY (does not vary with the prevalence of disease)
The ability of a test to EXCLUDE a disease IF the disease is NOT PRESENT is called?
SPECIFICITY (does not vary with the prevalence of disease)
In a given population, 80% of the people HAVE a disease, what is that disease’s PREVALENCE?
80%
What statistical tests are AFFECTED by the PREVALENCE of a disease when taking into account a given test’s specificity and sensitivity?
Positive Predictive Value (PPV) and Negative Predictive Value (NPV)
The PROBABILITY that subjects with a POSITIVE screening test result truly DO HAVE the disease is called what?
Positive Predictive Value (PPV)
The PROBABILITY that subjects with a NEGATIVE screening test truly DON’T have the disease.
Negative Predictive Value (NPV)
(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?
Positive Likelihood Ration (LR+)
(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?
Negative Likelihood Ratio (LR-)
Sensitivity/(1-Specificity)=?
Positive Likelihood Ratio (LR+), where the scale is 0-1
(1-Specificity)/Sensitivity=?
Negative Likelihood Ratio (LR-), where the scale is 0-1
LR >1?
An INCREASED likelihood that the condition IS PRESENT
LR
A DECREASED likelihood that the condition IS PRESENT
LR=1?
The test result does NOT change the probability of the test at all (i.e. useless test)
How do pre-test odds and post-test odds relate to the Likelihood Ratio?
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)
Pre-test probability/(1-Pre-test probability)=?
Pre-test odds
What is VALUE in healthcare defined by?
OUTCOMES achieved (rather than procedures performed or services rendered)
(TP+FN)/(TP+FP+FN+TN)=?
PREVALENCE (number of patients in the population who HAVE the disease)
TP/(TP+FN)=?
SENSITIVITY (Patients WITH the disease who have a POSITIVE test)
TN/(FP+TN)=?
SPECIFICITY (Patients WITHOUT the disease who have a NEGATIVE test)
TP/(TP+FP)=?
POSITIVE PREDICTIVE VALUE (PPV) - number of patients who have tested POSITIVE who actually HAVE the disease (INCREASES with INCREASING PREVALENCE)
TN/(TN+FN)=?
NEGATIVE PREDICTIVE VALUE (NPV) - number of patients who have tested NEGATIVE who actually DO NOT HAVE the disease (INCREASES with DECREASING PREVALENCE)
SENSITIVITY/(1-SPECIFICITY)=?
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
(1-SENSITIVITY)/SPECIFICITY=?
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
The odds that a patient HAS the disease BEFORE the test is performed?
PRE-TEST ODDS
The odds that a patient HAS the disease AFTER the test is performed?
POST-TEST ODDS
Number of patients WITH the disease BEFORE the test is performed?
PRE-TEST PROBABILITY
Number of patients WITH the disease AFTER the test is performed?
POST-TEST PROBABILITY
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?
Screening Tests
What type of STUDY is the BEST for determining the EFFECTIVENESS of screening tests in reducing morbidity and mortality?
Experimental Study: Randomized Controlled Trial (RCT)
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?
Lead-Time Bias
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?
Length-Time Bias
Identification of cancers that are NOT destined to progress thereby INFLATING “survival” statistics
Overdiagnosis
Whom should be SCREENED for Depression, EtOH misuse, Obesity and HTN?
ALL Adults
What patients WITHOUT increased cardiovascular risk should be SCREENED for Lipid Disorders?
ALL Men ≥35
What patients WITH increased cardiovascular risk should be SCREENED for Lipid Disorders?
ALL Women ≥45
ALL ADULTS with a sustained BP ≥135/80 mm Hg should be SCREENED for?
Diabetes Mellitus Type II
What patients should be SCREENED for Osteoporosis?
ALL Women ≥65 OR younger women with fracture risk greater than that of a 65 yo white woman without additional risk factors
What patients should be SCREENED for AAA?
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)
What patients should be SCREENED for HIV?
All PREGNANT women and ALL those at an increased risk
What patients should be SCREENED for Hep B?
ALL Women at their FIRST prenatal visit
What patients should be SCREENED for Chlamydia infection?
ALL Women ≤24 who are SEXUALLY ACTIVE OR ALL women ≥24 who are at an increased risk (multiple partners)
What patients should be SCREENED for Gonorrhea?
ALL women ≥24 who are at an increased risk (multiple partners)
What patients should be SCREENED for Asymptomatic Bacteriuria?
ALL PREGNANT women at 12-16 weeks gestation OR at their FIRST prenatal visit (whichever comes first)
What patients should be SCREENED for Syphilis?
ALL PREGNANT women and ALL patients at an increased risk (multiple sexual partners)
What Women should be SCREENED for Breast Cancer and WHEN and how FREQUENTLY?
ALL Women 50-75 yo EVERY 2 YEARS (starting at the age of 40 should be individualized for risk)
What Women should be SCREENED (PAP-Smear) for Cervical Cancer?
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
If a woman has NOT had a HIGH-RISK PAP-Smear and undergoes Hysterectomy, when do you SCREEN for Cervical Cancer?
You Don’t
What patients do you SCREEN for Colon Cancer?
ALL ALDULTS 50-75 yo (routine screening)
Are PERIODIC Health Examinations (“yearly physical”) recommended?
NO
How OFTEN should an adult with a BP of
Every 2 years
How OFTEN should an adult with a SBP of 120-139 mm Hg and DBP of 80-89 mm Hg be SCREENED for HTN?
YEARLY
What is the MOST IMPORTANT risk factor for the development of BREAST CANCER in women?
Age
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?
An INHERITED Syndrome
Which GENETIC mutation has the HIGHER risk for developing BREAST CANCER by the age of 70, BRCA-1 or BRCA-2?
BRCA-1 (65% vs. 45% with BRCA-2)
If concern exists for an inherited syndrome in a patient, what should be done besides counseling?
Referral to a GENETICIST
What should Post-Menopausal women with a ≥1.66 risk of developing breast cancer in the next 5 years be offered?
A 5-YEAR course of either tamoXIFEN or raloXIFENe
What should be recommended to a woman s/p PAP-Smear with “unsatisfactory” cytology?
Immediately REPEAT the test
What should be recommended to a woman s/p PAP-Smear with “ATYPICAL squamous cells of undetermined significance”?
Either of these is acceptable:
- COLPOSCOPY referral
- Obtain HPV DNA test and refer for COLPOSCOPY if POSITIVE
- REPEAT PAP-Smear in 6-12 months
What should be recommended to a woman s/p PAP-Smear with ANYTHING other than “ATYPICAL squamous cells of undetermined significance” OR unsatisfactory” cytology?
COLPOSCOPY referral
Should a patient who presents with benign prostatic hyperplasia (BPH) symptoms prompt screening for prostate cancer?
NO (no screening method is recommended by the USPSTF)
A patient’s recall of ONLY which two (2) vaccines should be considered “valid”?
Influenza and Pneumococcus (for ALL other vaccines, either re-vaccinate according to age or obtain serology)
Which are the four (4) LIVE Attenuated Vaccines?
MMR, Influenza (intranasal only), Herpes Zoster, Varicella (not for immunocompromised and pregnant patients)
ALL Adults should be Vaccinated with what four (4) vaccines?
Influenza, Tdap (Tetanus, diphtheria, pertussis), Varicella, MMR
Who should receive the Herpes Zoster vaccine?
ALL adults ≥60 yo
Who should receive the Pneumococcal vaccine?
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)
Who should receive the HPV vaccine?
ALL men and women 11-26 yo
Who should receive the Meningococcal vaccine?
Adolescents, persons living in dorms, military and those with HIV or asplenia
Who should receive the HAV vaccine?
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
Who should receive the HBV vaccine?
ALL children, Health Care workers and persons with chronic liver disease
What VACCINE should ALL pts with HIV get?
Meningococcal Vaccine
What VACCINES should Health Care Workers get?
HBV, MMR (second dose), Varicella (if born before 1980)
Which HIV patients CAN receive Live Attenuated Vaccines (MMR, Varicella, Herpes Zoster and Intranasal-Influenza)?
Those with CD4 counts ≥200
In whom are INACTIVATED vaccines contraindicated?
Those with ALLERGIES to the vaccines
What needs to be done if a patient received two of the three required shots needed to complete a vaccination?
Resume where that patient left off and give the THIRD shot
A patient with a SERIOUS ACUTE disease wants to be vaccinated, what do you do?
DO NOT VACCINATE until illness resolves (ok to vaccinate if mild to moderate illness -URI, even with fever)
What should be done if MULTIPLE vaccines are given at the same time?
Give at different SITES
What is the process by which we require a NEW influenza vaccine yearly?
Antigenic DRIFT
In whom is it ok to give the LIVE Attenuated Influenza vaccine?
ALL patients 2-49 yo WITHOUT medical conditions that make them susceptible to Influenza or its complications
What patients CANNOT use EITHER LIVE Attenuated NOR INACTIVATED Influenza vaccines?
Those who developed Guillain-Barre after Influenza infection and those with severe EGG allergies (anaphylaxis)
What are the components of the Influenza vaccine?
Influenza A & B as well as H1N1
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?
ONE (1) MONTH (counsel for possible birth defects if before)
Which patients should be RE-VACCINATED with the pneumococcal vaccine EVERY 5 YEARS?
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
What patients should receive the Meningococcal vaccine every 5 years?
Those with ASPLENIA and Complement deficiencies
When should a patient consult a physician before starting an exercise program?
Cardiovascular disease or HTN, musculoskeletal disorder or symptoms of chest pain and dizziness when exercising in the past
What is smoking considered?
A disease (not a habit)
What is the LEADING cause of ILLNESS and DEATH in the US?
Smoking
What are the two effective medical interventions for smoking cessation?
- Bupropion + Nicotine Replacement
2. Varenicline + Nicotine Replacement (superior)
Can patients on MAOI’s, those with eating disorders or seizures be on BUPROPION?
NO
16 oz beer, 5 oz wine, 1.5 oz (one shot) of spirits?
A STANDARD Alcoholic beverage
40% of Malpractice payments in 2003 were for what?
Diagnostic Errors
When should a patient’s medication reconciliation take place during their hospital stay?
THROUGHOUT and at DISCHARGE with PRINTED LIST
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?
Availability Heuristic
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?
Anchoring Heuristic
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?
Representativeness Heuristic
Does a diagnosis of DEMENTIA or MENTAL ILLNESS mean that a patient is incapable of making health care decisions?
NO!!
What should be done if a patient or proxy wants to have FUTILE treatments administered?
Request ETHICAL and LEGAL consultations
WHEN is the only time where it is ETHICALLY permissible to give a terminally-ill patient a treatment that may HASTEN their DEATH?
ONLY when the PRIMARY INTENT is THERAPEUTIC
Is the ACTIVE administration of a drug with INTENT to cause DEATH legal?
ABSOLUTELY NOT (regardless of consent)
Whom can a physician disclose information to regarding a patient?
Staff involved in patient’s care and other persons specifically designated by the patient ONLY
In which two (2) situations can patient confidentiality be broken?
- Communicable diseases
2. Pt is a risk of harm to themselves or others
What are the three (3) key components of ERROR disclosure? (certainly can and should obtain legal counsel advice prior to error disclosure)
- Provide the FACTS
- Express REGRET
- Formal APOLOGY
Should GIFTS or other ITEMS of material value be accepted by physicians by pharmaceuticals, medical device vendors or biotech companies?
NO
Should educational presentations controlled by industry be given?
NO
When should a physician accept a drug sample?
For patients who lack financial access to medications
A service which addresses PAIN, SUFFERING and QUALITY of LIFE across ALL stages of treatment and DOES NOT exclude life-prolonging treatment and rehabilitation?
Palliative Care
When should HOSPICE care be offered?
When a patient reaches the final weeks or months of life, when harm from life-prolonging therapies exceed benefit and when therapies are discontinued
How should CANCER-related pain be initially treated?
With NSAIDS, OPIOIDS and RADIATION therapy
Which long-acting opioid has been reported to cause arrhythmia and QT-prolongation?
Methadone (requires baseline, 30-day and regular follow-up ECG)
Why should meperidine (demerol) be avoided as an analgesic?
Seizures, confusion and mood alterations (especially in kidney disease)
Can opioids CAUSE pain?
YES, rarely “opioid-induced hyperalgesia” where increased dosages exacerbate pain
What bowel regimen should ANY patient starting an OPIOID analgesic agent?
Stool SOFTENER + LAXATIVE
Since fatigue caused by cancer and chemo/radiation therapy agents CANNOT be relieved by rest, what should be recommended?
Energy conservation, Biofeedback and Exercise program
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?
FENTANYL
What are the two most powerful analgesic agents used?
FENTANYL and Hydromorphone
What two (2) agents are used in cancer-related dyspnea?
Opioids and Benzodiazepines
What disease are ß-agonists, morphine, pulmonary rehabilitation and oxygen used in, for the purpose of dyspnea symptom relief?
COPD
What is considered “chronic” nausea?
Nausea ≥1 week
What are Metoclopramide, Ondasetron, Dronabinol and Dexamethasone used for in cancer patients?
Anti-emetics
What two (2) medications can increase appetite in cancer patients?
Megestrol and Corticosteroids
What are the preferred antidepressants for use in end-of life patients?
TCAs and SSRIs
How is delirium treated in end-of-life patient however can exacerbate delirium in pts with dementia?
Sedatives such as Haloperidol and Benzodiazepines
Does morphine cause respiratory depression in patients who are in pain?
NO
What is considered “Complicated Grief” in family members who have lost a loved one?
Grief >6 months
What would you ask a patient during a visit if you wanted to uncover possibly uncomfortable issues which the patient would benefit from discussing?
Ask if they had “OTHER” concers
What should be considered in a patient who presents with multiple symptoms in different parts of the body?
Depression, Anxiety, Somatization
A patient presenting with complaints of PAIN should be screened for?
Depression, Anxiety and Substance Abuse
PRIOR to starting pain therapy for a patient who c/o pain, what BARRIERS must be excluded?
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
Treatment of neuropathic pain such as burning, shooting or stabbing is best treated with what agents?
Gabapentin, pregabalin, TCA’s, SNRIs, (DULOXETINE, venlafaxine) TRAMADOL, opioids and carbamazepine
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?
TCA’s (amitriptyline, imipramine, nortriptyline, doxepin, clomipramine), MILNACIPRAN (specifically for fibromyalgia)
Treatment of inflammatory pains such as from joints in RA is best done with what agents?
NSAIDS, DMARDS, TCA’s
Treatment of mechanical/compressive pain such as BACK pain, NECK pain, MUSCULOSKELETAL pain is best done with?
NSAIDS, acetaminophen, TCA’s, SNRI’s (duloxetine-Cymbalta)
What is the goal of treatment of patients with Chronic Non-Cancer Pain (CNCP)?
Improvement of function and quality of life (exercise, rehabilitation, cognitive-behavioral therapy, pharmacological therapy and massage - low back pain, fibromyalgia, knee osteoarthritis)
What other disease state tends to coexist in patients with chronic pain?
Depression - must be treated (if major depression - by psychiatrist)
These two herbals have been shown to be effective for the treatment of HA and back pain as glucosamine, chondroitin and others have NOT?
Feverfew (HA) and Willow bark (back pain)
Which OPIOID medication has been shown to be efficacious in moderate-to-severe CHRONIC pain and has SSRI properties as well?
TRAMADOL (therefore caution when using together with SSRIs as it can cause SEROTONIN SYNDROME)
Use of these analgesic agents is contraindicated in patients with current PUD, chronic KIDNEY disease (CKD) or HF?
NSAIDs
If an NSAID must be used in a patient with cardiovascular risk, which should it be?
Naproxen
What is the ideal pharmacologic combination therapy for a patient with POST-herpetic neuralgia and diabetic neuropathy pain?
Nortriptyline + Gabapentin
In what patients do you want to consider OPIOID analgesia?
Those with MODERATE-to-SEVERE pain who did not respond well to non-opioid analgesia) acetaminophen, NSAIDS, TCAs
Are opioids beneficial in patients with inflammatory or mechanical/compression pain (spinal)?
NO
What is considered “acute” cough?
Cough
In acute bronchitis, how long can cough last for and what is the time-frame for resolution of bronchitis?
5 days; 3-8 weeks
How do you test for Bordetella pertusis and how do you treat?
Nasopharyngeal aspirate/swab; treat with macrolides (erythromycin)
Should a non-elderly, immunocompetent patient with an uncomplicated URI or Bronchitis be treated with an antibiotic?
NO
How soon after starting therapy with an ACE-I do 15% of patients develop a cough?
1-week
What should be done in a patient (15%) who started ACE-I therapy and developed a cough?
STOP the ACE-I, don’t start a different ACE-I (will resolve in
What is the best and closest alternative to an ACE-I if the ACE-I must be discontinued due to COUGH, etc.?
ARB
What meds are best used for supportive treatment for patients with acute cough (common cold, etc.)?
Antihistamines (-“adine” -“amine” -“azine”), decongestants, ipratropium bromide, cromolyn and naproxen
What types of antihistamines are generally weak and not effective?
Non-sedating ones
When should ß2-agonists (-“terol”) be used to treat cough?
ONLY when WHEEZING is present
What is considered “subacute” cough and what is this generally due to?
3-8 weeks, usually POST-INFECTIOUS
What is considered “chronic” cough and what generally causes this?
Cough >8 weeks, usually by Upper Airway Cough Syndrome (post-nasal drip), asthma and GERD
Best initial diagnostic test for chronic cough is?
CXR
What is considered empiric therapy for Upper Respiratory Cough Syndrome (post-nasal drip) which causes chronic cough (>8 weeks)?
Antihistamines + decongestants
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?
Asthma (because bronchoprovocation testing can have false-positive results)
What two agents can be used for patients in whom disease-specific cough therapy fails?
Codeine or Dextromethorphan (centrally acting)
How is the approach of cough treatment different for Immunocompromised patients?
Definitive work-up is indicated as well as EMPIRIC antibiotics during diagnostic period
What are the two most common causes of HEMOPTYSIS and what amount is considered LIFE-threatening?
Infection (bronchitis, bronchiectasis, PNA, tuberculosis, Goodpasture syndrome, Granulomatosis with polyangiitis - Wegener granulomatosis) and Malignancy; >200 mL/day
What should be done for a patient with hemoptysis?
CXR and if needed, chest CT or Bronchoscopy
How long must FATIGUE persist for to be diagnosed as CHRONIC FATIGUE SYNDROME?
> 6 months (with memory impairment, sore throat, tender lymph nodes, muscle/joint pain, HA, unrefreshing sleep and post-exertional malaise)
Can patients with substance abuse, eating disorders, underlying psychiatric disorders or severe obesity (BMI ≥45) be diagnosed with Chronic Fatigue Syndrome?
NO!! (if they have fatigue ≥6 months it is “idiopathic chronic fatigue”
Post-viral infection (Parvovirus B19), childhood trauma or pre-existing psychiatric disorders are all thought to be associated with?
Chronic Fatigue Syndrome (CFS)
Is routine laboratory testing for symptoms of dizziness helpful?
NO!!
Vascular disease/stroke, mass lesions of the brainstem/cerebellum, MS, migraines and seizures all have this SYMPTOM in common which causes dizziness?
VERTIGO
Aminoglycosidetoxicity with Tobramycin, Neomycin, Gentamicin can all cause what neurological symptom?
VERTIGO
What maneuver can DISTINGUISH between Central and Peripheral vertigo?
Dix-Hallpike maneuver (POSITIVE for BPV if BRIEF nystagmus is present WITHOUT latency, otherwise likely central etiology)
The TRIAD of Vertigo + UNILATERAL low-frequency hearing loss + Tinnitus is seen in what condition?
MENIERE disease
What maneuver can be used to TREAT BPV (benign positional vertigo)?
Epley maneuver (used because MEDS are typically NOT effective for BPV)
What are the three (3) medication types used to treat SYMPTOMS of Vestibular Neuronitis (vestibular neuritis/labyrinthitis) which is caused by viral infection?
Antihistamines, Benzodiazepines, Phenothiazines (-“azine” - used as antiemetic)
How long does vertigo last in BPV?
SECONDS
How long does vertigo last in Meniere disease, TIA, Migraines?
MINUTES
How long does vertigo last in Vestibular neuronitis/labyrinthitis, stroke, MS?
DAYS (if longer , likely psychogenic - i.e. bullshit)
Dix-Hallpike maneuver demonstrates immediate nystagmus (without latency) that lasts ≥1 MINUTE?
CENTRAL disease (not BPV)
Can BPV present with vertical nystagmus?
No, NEVER (if it’s vertical, it’s central)
What is a side effect of treatment of VERTIGO that is NOT a result of BPV?
Sedation
Caffeine and Salt restriction together with Diuretic therapy are used in the treatment of VERTIGO in which associated condition?
Meniere disease
Are neurological symptoms present in VERTIGO due to Vestibular Neuronitis or BPV?
NO! (only in Meniere diease or other central causes - bleed)
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?
MRI with angiography
Dysequilibrium is caused by what generally?
Defective sensory input (vision, vestibular), impaired propioception or motor function, generalized weakness
ALL patients undergoing evaluation for DIZZINESS should be tested for what?
Orthostatic Hypotension and undergo a thorough CARDIAC and NEUROLOGIC examination (routine labs NOT helpful)
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?
Overnight Polysomnography
What is the BEST therapy for BOTH primary and secondary INSOMNIA?
Cognitive Behavioral Therapy (can use in combination with meds initially)
What are the PREFERRED meds to use for INSOMNIA initially and in combination with Cognitive Behavioral Therapy?
SHORT-ACTING Non-benzodiazepine GABA-receptor agonists (zolpidem, ezopiclone and zaleplon) and Melatonin-receptor agonists
Which two (2) antidepressants can be used to treat INSOMNIA when it is caused by depression?
Trazodone & Mirtazapine
Which SHORT-ACTING benzodiazepine GABA-receptor agonists ARE used for INSOMNIA?
Estazolam, Temazepam, Triazolam
Transient loss of CONSCIOUSNESS with loss of POSTURAL TONE and SPONTANEOUS recovery resulting from GLOBAL CEREBRAL HYPOPERFUSION (arrhythmias, etc.), usually
Syncope
What is the most common cause of NEUROCARDIOGENIC syncope?
Vasovagal reaction
What should be the FIRST diagnostic test done in patients being evaluated for SYNCOPE?
ECG (rule out obvious arrhythmias and other conduction defects)
Leg-crossing, hand-grip, squatting and muscle tensing are abortive maneuvers for what condition?
Neurocardiogenic Syncope
How should patients with Carotid Sinus Hypersensitivity induce syncope be treated?
With placement of PERMANENT dual-chamber pacemaker
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?
Orthostatic Hypotension
Patients presenting with Exertional or Supine syncope, palpitations prior to syncope or abnormal ECG findings require what?
Hospital admission
In the outpatient setting, what are the most common causes of chest pain?
Musculoskeletal (40%) and GERD (19%)
Pain with RADIATION to arms or shoulder indicates what?
High-likelihood of CARDIAC chest pain (MI)
When chest pain is relived with nitroglycerin, does it indicate an MI?
NO (no association - can treat symptoms of GERD as well)
What must ALWAYS be considered in a patient with SEVERE THORACIC PAIN?
An acute AORTIC condition (dissection)
What type of chest pain do patients with PE, pneumothorax, pleuritis, PNA and pulmonary HTN experience?
Pleuritic chest pain WITH DYSPNEA
Pleuritic chest pain with dyspnea with cough/wheezing, hemoptysis, tachypnea and tachycardia indicate?
PE
What is a NEGATIVE D-dimer useful for?
RULES OUT PE
Hyperresonance to percussion on the back suggests?
Pneumothorax
Hypotension and Tracheal deviation?
Tension Pneumothorax - EMERGENCY
Chest pain accompanied by EXERTIONAL DYSPNEA and Fatigue with elevated JVP, parasternal heave, Widely Split S2 and Loud P2 is suspected to be?
Pulmonary HTN
Wide Split of S2 & Loud P2?
Pulmonary HTN
Is imaging helpful for Musculoskeletal chest pain? How do you treat?
NO!!; NSAIDS
What is considered ELEVATED Central Venous Pressure?
> 8 mm Hg (cardiac disease or pulmonary HTN)
What are the three most common causes of UNILATERAL LE edema?
DVT, Cellulitis, Malignancy
What is the BEST treatment for Chronic Venous Insufficiency (stasis edema) or Lymphedema?
Sodium restriction, Leg elevation, Compression stockings (NOT DIURETICS)
At what age do most spondyloarthropathies (low back pain) present?
At what age do most cancers and compression fractures that cause symptomatic low back pain present?
> 50 yo
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?
Disk HERNIATION
Increased pain when walking and relief when sitting (“pseudoclaudication”) in a patient older than 65, is usually?
Lumbar SPINAL STENOSIS
Pt presents with NON-SPECIFIC low back pain without symptoms or signs of systemic illness should get what other diagnostic testing?
NONE!!
What INITIAL diagnostic test is recommended for persistent low back pain (>1-2 months) or suggestive of malignancy or fracture?
Plain X-rays
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?
MRI or CT myelography
Most low back pain responds well to therapy EXCEPT?
SCIATICA
Exercise therapy and physical therapy works better for low back pain when in the course of symptoms?
> 4 weeks
What are the PREFERRED meds for treating low back pain?
Acetaminophen (no more than 4 g/day) and NSAIDs or COX-2 inhibitors
When should Opioids and TRAMADOL be used to treat low back pain?
ONLY when acetaminophen, NSAIDs and COX-2 inhibitors are found to be inadequate
What can patients with radiculopathy (disk herniation) and low back pain be treated acutely with?
Epidural corticosteroid injection
Pts with disk herniation with PERSISTENT radiculopathy, those with PAINFUL SPINAL STENOSIS and those with CAUDA EQUINA syndrome (emergency) should be treated how?
Surgery
Pain of the neck that is BURNING in character and radiates down the ARM is usually what type of pain?
NEUROGENIC
HA with Visual changes and SHOULDER and HIP GIRDLE pain suggests what diagnosis?
Polymyalgia Rheumatica
If systemic illness is suspected in a patient with low back pain or neck pain, what blood work would be appropriate?
CBC, ESR, CRP
Since MOST patients with neck neck pain recover with conservative therapy, in which patients would you consider an X-ray?
Those >50 yo
Irritation and infection of what organ can cause shoulder pain?
Lungs and Diaphragm (PNA, apical lung MASSES, diaphragmatic irritation); also GB
Shoulder pain on ACTIVE but not PASSIVE motion of the shoulder suggests what etiology location?
Extraarticular
Shoulder pain with BOTH ACTIVE and PASSIVE motion of the shoulder suggests what etiology location?
Intraarticular
Pain with shoulder ABDUCTION (raise arms up) between 60 and 120 degrees suggests? Beyond 120 degrees?
Rotator Cuff Impingement; AC-Joint pathology
Which is the most commonly-affected tendon in ROTATOR CUFF TENDINITIS?
Supraspinatus
If Rotator Cuff Impingement is not treated, what can occur?
Full-thickness tear of the rotator cuff
Pain over the lateral deltoid muscle with abduction and with internal rotation of the arm suggests?
Rotator Cuff injury
Weakness and loss of function with Rotator Cuff injury suggest?
Rotator Cuff Tear
What is the preferred imaging modality for Rotator Cuff TEAR?
MRI
How do you treat FULL thickness tears of the Rotator Cuff?
Surgery
This disease of the Shoulder is associated with DM, Parkinson Disease, Hypothyroidism, Stroke, previous Trauma or idiopathic?
Adhesive Capsulitis (Frozen Shoulder)
Drop-Arm test where examiner a slow lowering of the arm to the waist but if not supported, drops is caused be?
Rotator Cuff Tear
Pts do not want to lie down on the affected shoulder, BOTH active and passive range of motion is limited, this is seen in?
Adhesive Capsulitis (Frozen Shoulder)
Pain on shoulder ABDuction above 120 degrees or ADDuction?
Acromio-Clavicular Joint Degeneration (AC-joint)
What is the recommended progression of treatment for shoulder injuries (rotator cuff, ac-joint, etc. - unless fully torn)?
Physical therapy–>NSAIDs–>Corticosteroid Injection–>Surgery
Elbow pain can be referred from these three (3) structures which must also be examined?
Neck, Shoulder and Wrist
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?
LATERAL Epicondylitis (tennis elbow)
An overuse in jury with pain in the MEDIAL ELBOW due to OVERUSE of WRIST flexor muscles usually seen in golfers?
MEDIAL Epicondylitis (Golfer’s elbow)
PAINFUL swelling of the posterior elbow WITHOUT limitation of range of motion from repetitive TRAUMA, Inflammation (RA, gout) or Infection?
Olecranon Bursitis
When a bursa is PAINFUL, INFLAMED or FEVER is present, what should be done?
Aspiration, to evaluate for GRAM stain, culture (septic bursitis) and crystal analysis - gout
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?
Cubital Tunnel Syndrome (entrapment of the ULNAR nerve at the elbow
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?
X-rays, to r/o fracture
What is considered as the diagnostic STANDARD for Carpal Tunnel Syndrome?
Nerve Conduction studies (if diagnosis is uncertain)
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?
Surgical release
Which two bones in the WRIST most commonly sustain FRACTURES when falling on an outstretched hand?
Scaphoid and Distal Radius
What must be done for WRIST fractures?
Immediate surgical repair to avoid avascular necrosis
What WRIST bone commonly gets fractured from repetitive trauma such as with swinging a golf club or baseball bat?
Hamate fracture
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?
De Quervain tenosynovitis
How is De Quervain tenosynovitis treated?
Ice application with splinting to prevent movement, corticosteroid injections or surgery
Involvement of the FIRST Carpal (WRIST) Metacarpal (HAND) joint as well the Distal InterPhalangeal (DIP) and Proximal InterPhalangeal (PIP) joints is seen in?
OSTEOarthritis (OA)
Involvement of the Proximal InterPhalangeal, Metacarpal Phalangeal and Carpal Metacarpal joints is seen in?
Rheumatoid Arthritis (RA)
Arthritis involving the DISTAL InterPhalangeal joint is?
OSTEOarthritis
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?
Hip
What must be done for ALL patients who present with ACUTE Hip pain?
X-rays to r/o fracture
What should be done in a patient who presents with ACUTE Hip pain and X-rays are negative but suspicion for fracture is high?
MRI (avascular necrosis, infection, tumor)
What is ANTERIOR (groin) Hip pain with CHRONIC, SLOW onset which worsens with activity most often caused by?
Osteoarthritis of the Hip (early morning stiffness that improves with activity)
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?
ANTERIOR Hip (groin)
ACUTE Hip pain is usually caused by?
Trauma, Necrosis (steroids and alcohol), septic arthritis or synovitis
When examination of the Hip is normal without pain elicited with normal range of motion, what is the likely diagnosis of Hip pain?
Inguinal hernia, lower abdominal pathology or L1 disk disease
Pt with known GAIT abnormalities presents with LATERAL Hip pain and reports that he cannot lie on the affected side?
TROCHANTERIC BURSITIS
Pt resents with an OVAL-shaped area of NUMBNESS, BURNING and TINGLING in the DISTAL LATERAL thigh?
MERALGIA PARESTHEICA vs L4-L5 Disk disease
Posterior Hip Pain (Gluteal pain) sometimes seen with paresthesias and back pain?
Sacroiliitis or Lumbosacral Disk disease
When Sciatica and pain in the Buttock is present WITHOUT evidence of Lumbosacral disk disease, it is caused by?
Entrapment of the Sciatic nerve by the Piriformis muscle - Piriformis Syndrome
Sciatic nerve pain WITHOUT evidence of Lumbosacral Disk disease?
Piriformis Syndrome (entrapment of the sciatic nerve by the piriformis muscle)
What is the most common cause of Anterior Hip AND KNEE pains?
OSTEOarthritis
What is the cause of knee pain when there are MULTIPLE joints involved with systemic symptoms?
Rheumatoid Arthritis
When the skin OVERLYING a JOINT (Knee, elbow, etc) is SWOLLEN with ACUTE pain AND ERYTHEMATOUS, warm, what should be done and why?
ASPIRATION (arthrocentesis) to evaluate for BOTH SEPTIC and Crystalline disorders
Anterior and Posterior DRAWER tests assess what?
Integrity of the ANTERIOR and POSTERIOR CRUCIATE Ligaments
VARUS (adduction) and VALGUS (abduction) stress tests assess what?
Integrity of the LATERAL (varus-adduction) and MEDIAL (valgus-abduction) COLLATERAL ligaments
What is the BEST test for assessing the integrity of the MEDIAL and LATERAL MENISCI?
The Medial-Lateral GRIND test (detect grinding)
For LIGAMENT or MENISCAL injuries AFTER fracture is r/o by X-rays, what is the BEST diagnostic test?
MRI
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?
Osteoarthritis of the Knee
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?
Anterior Cruciate Ligament tear (ACL)
Sudden twisting motions of the knee with swelling and with the patient ABLE TO BEAR WEIGHT can result in?
Meniscal tears
Anterior KNEE pain that is worsened when SITTING and WALKING UP and DOWN STAIRS?
Patello-femoral pain syndrome (overuse injury - runners)
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?
Patello-femoral pain syndrome; NO other test (no x-rays needed)
Besides reduced activity and icing, NSAIDS for pain control, what is a VERY important part of treating Patello-Femoral Pain Syndrome?
REHAB
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?
PES ANSERINE BURSITIS
How is Pes Anserine Bursitis treated?
Avoid squatting or stretching the joint or direct trauma, place PILLOW between legs when sleeping, avoid crossing legs, APPLY ICE
Do NSAIDs help Pes Anserine Bursitis?
No, no penetration, treat with ICE
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?
Prepatellar Bursitis - inflammation of the bursa above the patella and just under the skin (treated by avoiding kneeling and rest)
Pain in the LATERAL part of the knee just above lateral epicondyle with walking up and down steps seen in runners and cyclists?
Iliotibial Band Syndrome (friction between the iliotibial band and lateral (tibial) epicondyle
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?
Iliotibial Band Syndrome (treat with rest, NSAIDS)
Why can BURSITIS not be treated with NSAIDS?
Because there is NO penetration of drug
Posterior knee pain with a sense of fullness in the popliteal area with palpable fullness?
Popliteal (Baker) Cyst
How is a Popliteal (Baker) Cyst treated?
Underlying condition (if an effusion from knee joint) or by aspiration/surgery
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?
ANTERIOR TALOFIBULAR ligaent
What is the recommended treatment of ANKLE SPRAINS Grades I & II (no complete tear) besides ice, rest with compression and elevation and NSAIDS?
Rehabilitation, weight bearing exercises and proprioceptive training (want to AVOID joint instability)
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?
Plantar Fasciitis
How is plantar fasciitis treated?
Stretching Exercises and Analgesics, Injected Corticosteroids
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?
Improper stepping, improper footwear, pes planus (flat footed)/pes cavus (high arch)
A history of fluoroquinolone or corticosteroid use can cause what particular tendon injury?
Achilles Tendinitis
How is Achilles Tendinitis treated?
Avoidance of aggravating activities and NSAIDs
Pt pushes off against a heavy load with his feet and hears a “pop” sound followed by severe pain above his heel?
Achilles Tendon Rupture (SURGERY!! if complete rupture)
How can you diagnose an Achilles Tendon rupture if diagnosis is in question?
Ultrasound
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?
Tarsal Tunnel Syndrome (caused by fragment from previous fractures or scar tissue)
How is Tarsal Tunnel Syndrome treated that is very different than the treatment of Carpal Tunnel Syndrome?
NSAIDs, Orthotics and Modification of Footwear
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?
- Morton’s Neuroma
- Caused by entrapment of one of the common digital nerves
- Avoidance of wearing high heels and corticosteroid shots (NSAIDs do not help)
What set of RULES is very useful at ruling out fractures and determining when imaging is needed for the FOOT?
Ottawa Ankle and Foot rules
At what ages and how frequently should SCREENING for Dyslipidemia begin for men and for women?
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
Reducing the LDL by 1% reduces Coronary Heart Disease risk by?
1%
What effect does a high TRIGLYCERIDE level have on HDL and how does worsen the metabolic syndrome?
Lowers the HDL, causes INCREASED insulin resistance
What is considered “LOW” HDL cholesterol?
What are considered “Optimal” TRIGLYCERIDE and TOTAL Cholesterol levels?
Besides therapeutic LIFESTYLE changes, at what LDL levels should DRUG therapy be initiated?
Low-Risk pt ≥190 mg/dL; Moderate-Risk pt ≥130-160 mg/dL; High-Risk pt ≥130 mg/dL
Above what TRIGLYCERIDE level is DRUG therapy recommended?
≥500 mg/dL
After initiating Therapeutic LIFESTYLE changes ALONE for a patient with dyslipidemia, when is it appropriate to begin DRUG therapy?
If changes (diet, exercise, fiber) not at optimal levels after 3 MONTHS
What is significant about STATIN therapy for patients with established Coronary Heart Disease?
Mortality reduction by 20%-30% AND decreased CRP levels
Doubling of a STATIN dose decreases LDL by what?
6%
How do Cyclosporine, Fibrates, Protease Inhibitors and Amiodarone afftect STATINS?
Increase their levels with increased risk of MYOPATHY
What STATINS are SAFER in patients treated with MULTIPLE medications?
ROSUVAstatin, PRAVAstatin and FLUVAstatin
What laboratories should be checked BEFORE initiating STATIN therapy and how frequently thereafter?
Serum CK and LFTs; ONLY if symptomatic, no routine checks
What medications can be used as monotherapy for only a “modest” LDL reduction?
Bile Acid Sequestrants, Ezetimibe (18% LDL reduction)
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?
STATINS + Bile Acid Sequestrants + Nicotinic Acid (Vitamin B3 or “Niacin”)
Can STATINS be used in PREGNANCY?
NO!!!
What is the MOST effective agent for INCREASING HDL?
Nicotinic Acid (Niacin or “Vitamin B3”)
What can be used as an ALTERNATIVE to Fibrates or Nicotinic Acid (Niacin) for significant TRUGLYCERIDE reduction?
Omega-3 fatty acids
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?
FENOFIBRATE
What is considered “ACCEPTABLE” elevation of LFTs with statin therapy, because these will eventually normalize and are asymptomatic?
What should be done after ANY adverse effect (myositis, rhabdomyolysis, myalgia, LFT elevation >3 x normal, hepatotoxicity - added elevation of bilirubin >2 x normal)?
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
In a patient with HYPERTRIGLYCERIDEMIA but NO elevated LDL, what should be the FIRST choice of medication?
Nicotinic Acid (“niacin” or Vitamin B3); fibrates are secondary BECAUSE they can raise LDL levels
What are Omega-3 fatty acids and what are they good for?
“Fish Oils” excellent for SIGNIFICANT triglyceride reduction
A waist circumference >40 (M), >35 (W), Triglyceride levels of ≥150 mg/dL, HDL
Metabolic Syndrome (obesity, dyslipidemia, insulin resistance, HTN)
Patients with an intermediate or high Framingham Risk Score for 10-year mortality should be started on what?
81 mg Aspirin if no contraindications exist
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?
Because they WORSEN glucose tolerance; ACE-Is and ARBs (improve glycemic control)
What is the recommended LDL level for SECONDARY risk prevention (already had one) of TIA or stroke?
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?
M≥45-79 NOT FOR WOMEN (≥55 ONLY if at increased risk)
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?
W≥55-79
What BMI constitutes OBESITY?
≥30
The risk of what three (3) cancers is associated with OBESITY?
BREAST, COLON, ENDOMETRIAL
What waist circumference constitutes OBESITY?
M≥40; W≥35
What do ALL of the following meds have in common: Clozapine, Olanzapine, Quetiapine, Risperidone, Sulfonylureas, Thiazolidinediones, Insulin, Amitriptyline, Paroxetine, Valproic Acid, Carbamazepine, ß-blockers?
They ALL cause WEIGHT GAIN
ADA recommends SCREENING for DM in patients above which BMI AND have other risk factors?
≥25 (family history)
Which are the ADJUNCTIVE therapy drugs used for weight loss?
ORLISTAT (interferes with fat absorption), [PHENTERMINE (phentermine/topiramate - arrhythmogenic), diethylpropion, lorcaserin] - suppress appetite “anorectic”
What is the only WEIGHT LOSS medication approved for LONG-TERM use?
ORLISTAT
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)?
Bariatric Surgery
Pt s/p Roux-en-Y eats a sugary, fatty meal and has severe diarrhea?
Dumping Syndrome
Methylmalonic Acid AND Homocysteine levels are BOTH elevated in?
Vitamin B12 defficiency
If Methylmalonic Acid is NORMAL and ONLY Homocysteine level is increased?
Folate defficiency
What are the four (4) most commonly modifiable risk factors for ED?
Obesity, Smoking, Alcohol use, Drugs
Sudden loss of the ability to achieve an erection suggests?
Psychogenic condition (in absence of s/p prostatectomy or trauma)
What is Peyronie disease?
A disease associated with ED - penile curvature and pain
Pt’s on NITRATES, Protease Inhibitors, Ketoconazole or Erythromycin should not take what medication type?
Phosphodiesterase Inhibitors (sildenafil, etc.)
What medications besides topical anesthetic creams can be used to treat premature ejaculation by causing anorgasmia?
SSRIs
What is the BEST way to measure possible ANDROGEN deficiency in men?
Measuring MORNING total testosterone level
Excessive exercise, corticosteroid use, marijuana use and opioids affect this component of men’s sexual health?
Decrease Testosterone levels
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?
Testosterone
What should be done FIRST for a pt presenting with symptoms of ANDROGEN deficiency and low testosterone levels BEFORE initiating testosterone therapy?
CONFIRMATORY TESTING!!
Symptoms of Nocturia, urinary frequency and urgency are caused by?
Overactive bladder (detrusor muscle hyperactivity)
Decreased urinary stream, incomplete bladder emptying and incontinence are caused by?
Blader Outlet Obstruction (BPH)
What two rudimentary tests should be done when evaluating BPH?
Digital Rectal Examination AND Urinalysis (r/o infection)
What medications are used to treat an overactive bladder?
Anticholinergics (Oxybutynin, Tolterodine)
In what patients with BOTH overactive bladder and BPH causing Bladder Outlet Obstruction are Anticholinergics (oxybutynin and tolterodine) contraindicated?
Those with a residual volume ≥250 ml
What is the BEST COMBINATION of medications to successfully treat BPH that causes Bladder Outlet Obstruction?
5-alpha blockers (relax smooth muscle in prostate and urinary bladder neck) AND 5-alpha reductase inhibitors (to shrink the prostate)
What are the 5-alpha blockers?
“-osin” (terazOSIN, tamsulOSIN, doxazOSIN)
Bladder stones, kidney failure with hydronephrosis, recurrent retention with/without UTIs in a patient with BPH on medications are indications for?
Surgical intervention
Acute testicular/scrotal pain is usually due to?
Testicular torsion or Epidydimitis
What is Orchitis and what causes it?
Inflammation of the testicle, caused by MUMPS or from a UTI or epidydimitis
In most patients with testicular torsion, this physical exam finding is ABSENT?
Cremasteric reflex (stroking upper, inner thigh observing a rise in the ipsilateral testicle)
ACUTE testicular pain with fever and elevated white count, with dysuria and can occur with prostatitis?
Infectious Epididymitis (Chlamydia, Gonorrhea, E.coli, Pseudomonas)
Recent sexual activity, bicycle riding, heavy exertion with testicular pain?
Epidydimitis
What medications are used to treat INFECTIOUS epididymitis (Chlamydia, Gonorrhea, E.coli, Pseudomonas)?
CEFtriaxone + Fluoroquinolone
What is NON-INFECTIOUS epidymitis caused by?
Urine REFLUX into epididymis (NSAIDS, NO antibiotics)
What MUST be done when evaluating scrotal/testicular pain?
Obtain a URINANALYSIS
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?
Ultrasound
Which hydrocele types require surgical intervention?
Communicating ones that are painful
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?
Epididymal cyst; Spermatocele
Scrotal mass in the LEFT (90%) testicle with a “dull ache” that increases in size when standing and decreases when supine?
Varicocele
What is the LEADING cause of INFERTILITY (low sperm count) in men?
Varicoceles
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?
Prostatitis
How is prostatitis treated?
Fluoroquinolones or TMP-SMX
What are the 5-alpha reductase inhibitors used in combination with 5-alpha blockers for the treatment of BPH with Bladder Outlet Obstruction?
FinASTERIDE, DutASTERIDE
Chronic prostatitis WITHOUT bacterial infection but WITH chronic pelvic pain with or without leukocytes in semen or urine is?
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
How is Chronic Prostatitis/Chronic Pelvic Pain Syndrome treated?
NSAIDS, ONE, SINGLE COURSE of antibiotics, 5-alpha blockers
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?
INDIRECT Inguinal Hernia
When do hernias require surgical repair?
When symptomatic or EMERGENTLY when strangulated
What is the MOST common female sexual disorder?
Hypoactive Sexual Desire Disorder (lack of sexual thoughts, desire or receptiveness to sexual activity)
Spontaneous sexual interest (Sexual DRIVE) is controlled by what?
BIOLOGIC, neuroendocrine functions
What two hormones in WOMEN is essential for a normal sex drive?
Testosterone (decline with age), Estradiol (declines after menopause)
How are sexual aversion disorders (aversion to any genital contact, feelings of revulsion, panic) treated pharmacologically besides therapy?
SSRIs
For most sexual disorders in women (desire, orgasmic, arousal and pain) what is the most effective component of treatment?
Cognitive - Behavioral Therapy
What is used for POSTmenopausal women for the treatment of inadequate vaginal lubrication?
Systemic or Local Estrogen therapy
What is used in PREmenopausal women for the treatment of inadequate vaginal lubrication?
Vaginal Moisturizers
Inadequate lubrication, vaginismus, vulvodynia, interstitial cystitis, pelvic adhesions, infections, endometriosis or pelvic venous congestion can all cause?
Dyspareunia (painful intercourse)
What is the best treatment for vaginal atrophy?
Low-Dose ESTROGEN tablets or RING (estrogen cream is LEAST preferred)
What is the best treatment for inadequate vaginal lubrication?
Systemic Estrogen
How is vaginismus (vaginal spasm usually due to anticipation of pain) treated?
Cognitive - Behavioral Therapy
Milky vs Bloody nipple discharge suggests what?
Benign etiology rather than malignant
What is NECESSARY in the evaluation of a PALPABLE BREAST MASS regardless of the features on exam?
Imaging/Tissue sampling
What is the best IMAGING modality for evaluation of a PALPABLE breast mass in a woman ≤35 or PREGNANT?
Ultrasound (NOT MAMMOGRAPHY) - can differentiate between cystic and solid lesions
What should be done if drainage of a breast cyst is non-bloody and disappears completely? If bloody?
Likely benign cyst; Send to cytology
A solid lesion in the breast with uniform borders and uniform internal echoes is most likely what?
A fibroadenoma (only remove surgically if patient wants to)
What breast tumor can have both BENIGN and MALIGNANT variants?
Phyllodes tumor
If a breast nodule is found on mammogram to be IRREGULAR with MICRO-CALCIFICATIONS and SPICULATIONS what should be done?
BIOPSY - likely malignant
What should be done if a breast nodule is suspicious for malignancy but is UNDETECTED on US or Mammogram (10%-20%)?
CORE NEEDLE BIOPSY
When is a Fine Needle Aspiration done for a breast nodule?
When it is Cystic (US)
When is an EXCISIONAL biopsy done for a breast nodule?
When a CORE Needle Biopsy is non-diagnostic
What should be done in ALL women who present with breast pain and why?
Thorough physical exam, because malignancy also can present with pain
Reproducible breast pain that is unilateral, localized and is described as BURNING is typically what?
Chest Wall Inflammation
How should Cyclical Mastalgia (painful breasts during menstrual cycle) be treated if the symptoms interfere with quality of life?
DANAZOL (menorrhagia and weight gain) or TAMOXIFEN
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?
COMBINATION (estrogen-progesterone) Oral Contraceptives (USE Progesterone ONLY pills)
Barbiturates (-“barbital”), carbamazepine, anti-seizure meds, rifampin, antiretroviral and some antibiotics affect the liver CYP3A enzymes affecting oral contraceptive pills how?
REDUCE EFFICACY
How long AFTER discontinuation of a medication that reduces effectiveness of an oral contraceptive pill should a woman wait before having UNPROTECTED sex again?
4 WEEKS
What component of COMBINATION Oral Contraceptive Pills increases the RISK of THROMBOSIS, BREAST CANCER, LIVER CANCER, CERVICAL CANCER and MI/STROKE?
ESTROGEN
Estrogen reduces the RISK of only what two (2) cancers?
Endometrial and Ovarian
Of the COMBINATION contraceptives, which has the LOWEST estrogen amount?
Vaginal RING
Of ALL contraceptive methods, which three (3) have the HIGHEST failure rates?
Cervical CAP, Diaphragm, Sponge
How long are the intrauterine devices COPPER and LEVONORGESTREL effective for?
Copper - 10 years; Levonorgestrel - 5 years
Which is the ONLY contraceptive agent that improves endometriosis?
DEPOT (IM/SQ) medroxyprogesterone acetate
How long after the discontinuation of a DEPOT contraceptive method can contraceptive-induced infertility continue?
2 years
What are the four (4) methods of EMERGENCY contraception available?
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)
Which of the EMERGENCY contraceptive methods is the BEST and easiest to implement?
Levonorgestrel-ONLY single dose regimen
Immunity to which two DISEASES should be PROVIDED to ALL women considering PREGNANCY at least 4 WEEKS before conception?
VARICELLA and RUBELLA (both LIVE vaccines) also Pertussis and Tetanus
What supplementation is recommended in ALL women of reproductive age?
FOLIC ACID
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?
DO NOT USE IN REGNANCY
How long must a woman experience amenorrhea before she can be formally diagnosed with MENOPAUSE?
12 MONTHS (average age of 51)
What happens to FSH and Estradiol in Menopause?
FSH is HIGH (>40), Estradiol is LOW (
Sudden onset of intense warmth that starts in the FACE or CHEST and spreads throughout the body with sweating and palpitations?
Hot Flush (perimenopause) - when these occur at night, they are called “night sweats” (resolve in a few years)
Thyroid disease, Elevated Prolactin levels and Pregnancy can mimic this preimenopausal symptom?
Hot Flush
In which cases is Systemic Hormonal Therapy (17 ß-estradiol) prescribed for women?
Peri/Post menopausal with moderate to severe vasomotor symptoms (Hot Flushes, palpitations, sweating, etc.)
Which Systemic Hormonal Therapy preparation causes LESS thrombosis, breast pain and uterine bleeding?
TRANS-DERMAL 17 ß-estradiol as compared to the ORAL formulation
In women who have an INTACT UTERUS (i.e. no HYSTERECTOMY), what MUST be given WITH systemic hormonal therapy to avoid UTERINE CANCER?
PROGESTERONE
Pregnancy, unexplained vaginal bleeding, thrombosis, CAD, Stroke, Breast/Endometrial Cancer, Hyperlipidemia, Immobilization or MI are ABSOLUTE CONTRAINDICATIONS to what therapy?
Systemic HORMONAL therapy
What is the time limit for Systemic Hormonal Therapy?
5 years
What is the AGE LIMIT for use of HORMONAL Therapy in women?
60 yo (high risk of CHD if older)
When in the PERImenopausal period is Systemic Hormonal Therapy at GREATEST RISK for causing BREAST CANCER?
In the EARLY period
What are the alternative (to hormonal) medications used for women with VASOMOTOR Symptoms (Hot Flushes, palpitations, sweating, etc.) in the perimenopausal period?
SSRIs, SNRIs, Gabapentin and Clonidine
What is POLY/OLIGO MenoRRHEA?
Poly- menstrual bleeding MORE than every 24 days; Oligo- menstrual bleeding LESS than every 35 days
What is METRorrhagia?
IRREGULAR menstrual bleeding
What is MENORRHAGIA?
REGULAR menstrual bleeding that is HEAVY in flow
What is MENOMETRORRHAGIA?
IRREGULAR menstrual bleeding that is HEAVY in flow
What is Dysfunctional Uterine Bleeding?
ANOVULATORY bleeding (non-cyclical) that has no identified MEDICAL or ANATOMIC cause
Whys is ANOVULATORY menstrual bleeding erratic and non-cyclical?
Because it is ESTROGEN-mediated WITHOUT the stabilizing effects of progesterone
In POST-Menopausal women (no menses ≥1 year) ANY vaginal bleeding is considered ABNORMAL and what should be done?
Evaluation for ENDOMETRIAL Cancer
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?
- Pelvic Exam
- Pregnancy test
- Evaluate for COAGULATION disorder
What MUST be done for women ≥35 who have PROLONGED ANOVULATION and why?
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
For women who desire pregnancy but have anovulatory bleeding, what can be used to stabilize the bleeding?
Progesterone
For women who do not desire pregnancy but have anovulatory bleeding, what can be used to stabilize the bleeding?
Oral Contraceptive Pills
How is SEVERE anovulatory bleeding treated?
GnRH (gonadotropin releasing hormone) or HIGH-DOSE IV ESTROGEN
For women who CANNOT be treated with HORMONAL therapy for anovulatory bleeding, what can be used for treatment?
NSAIDs and Danazol (this can also be used for breast pain)
What is DYSMENORRHEA and what is it caused by?
Painful menstrual cycle (90% - normal, no pathology); (10% - fibroids, endometriosis)
In the absence of pelvic pathology, what is DYSMENORRHEA treated with?
NSAIDs, Combined Oral Contraceptive pills
Pelvic pain that is cyclic (with menses) and non-cyclic and is of at least 6 MONTHS duration is often caused by?
Endometriosis or IBS (worsen during menstrual cycle)
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?
Laparoscopy; NSAIDs
How is endometriosis treated aside from surgery (laparoscopy)?
Oral Contraceptive Pills, GnRH agonists (Leuprorelin, -“relin”)
Pelvic pain (dull, worsened with prolonged standing) caused by pelvic varices and diagnosed by US is treated how?
Medroxyprogesterone acetate (DEPOT contraceptive method)
How is pelvic pain from interstitial cystitis treated?
TCA’s, Pentosan Polysulfate Sodium (PPS)
What is GnRH helpful with in women?
Treats pain in Chronic Pelvic Pain, Endometriosis, IBS
What are the two (2) MOST COMMON causes of VAGINITIS?
Trichomoniasis and Candidiasis
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)?
Gardnerella vaginalis, Ureplasma, Mycoplasma, Bacteroides
What VAGINITIS doe douching, lack of condom use and multiple new sexual partners place a woman at risk for?
Bacterial Vaginosis, Complicated pregnancy, HIGH risk for acquiring HIV, Gonorrhea, Chlamydia and genital Herpes (HSV-2)
Adding 10% Potassium Hydroxide to vaginal secretions produces a fishy smell (whiff test) and CLUE cells, what’s the diagnosis?
Bacterial Vaginosis (BV)
Should you culture vaginal discharge for Gardnerella Vaginalis?
NO (low specificity)
What is the BEST treatment for Bacterial Vaginosis (BV)?
METRONIDAZOLE oral/cream for 7 days - SAFE in Pregnancy (alternative is clindamycin but NOT safe in Pregnancy)
What VAGINITIS dos being promiscuous, using IVDA, being a prostitute place a woman at risk for?
Trichomonas Vaginalis (STI) - malodorous yellow-green discharge
Malodorous yellow-green vaginal discharge in a prostitute using IVDA?
Trichomoniasis (STI)
Vulvar itching, burning and post-coital bleeding with a yellow-green malodorous vaginal discharge, motile bacteria, in a prostitute using IVDA?
Trichomoniasis (STI)
Gray vaginal discharge with a fishy smell with CLUE cells and “whiff” test in a woman who douches?
Bacterial Vaginosis: Gardnerella vaginalis (metronidazole cream or clindamycin if NOT pregnant)
How is Trichomonas Vaginalis (STI) treated?
ORAL Metrodinazole (pregnancy safe) - single dose or 7-days if persistent - PARTNERS need treatment as well
Treatment in women with antibiotics or corticosteroids places them at risk for which Vaginitis type?
Candidiasis
How MUST vaginal candidiasis be DIAGNOSED, EVEN if it is OBVIOUS?
Demonstration of yeasts, hyphae or pseudohyphae on MICROSCOPY or Gram Stain or culture
In what women can vaginal candidiasis be a COMPLICATED (severely symptomatic) infection?
Pregnant, Immunosuppressed, Diabetic
- How do you treat UNCOMPLICATED vaginal candidiasis? 2. COMPLICATED 3. Candida species other than albicans?
- TOPICAL imidazole cream OR oral Fluconazole x 1 dose
- TOPICAL imidazole cream OR oral Fluconazole x 2 doses 3 DAYS apart
- Intravaginal BORIC ACID
What is Conjunctivitis usually caused by?
ADENOVIRUS (recent URI or contact with person with conjunctivitis)
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?
Conjunctivitis
How LONG is VIRAL (most common) conjunctivitis contagious for?
2 WEEKS AFTER the SECOND eye becomes involved
What should FOOD handlers and HEALTH CARE PROVIDERS be advised of if they have CONJUNCTIVITIS?
NOT TO RETURN TO WORK until CLEAR watery eye DISCHARGE stops
How is VIRAL conjunctivitis treated?
Supportive ONLY, no meds
What bacteria are responsible for BACTERIAL Conjunctivitis?
Staph. aureus (most common), Step. pneumoniae, Haemophilus influenzae AND N. Gonorrhea
What is the MAIN difference in presentation between VIRAL and BACTERIAL Conjunctivitis?
Bacterial conjunctivitis has a STICKY, CRUSTY mucopurulent discharge WORSE when waking in the morning and dried
RAPID onset conjunctivitis in a sexually active pt WITH COPIOUS purulent discharge and PAIN with POSSIBLE corneal PERFORATION is caused by?
N. gonorrhea
How is N. gonorrhea conjunctivitis treated?
ORAL antibiotics for BOTH gonorrhea AND chlamydia
When MUST a bacterial conjunctivitis be initially CULTURED and Gram stained PRIOR to treatment?
When Gonorrheal, Immunocompromised or Contact Lenses
How do you treat Bacterial conjunctivitis when NOT gonorrhea?
Broad Spectrum antibiotic EYE DROPS
What is done for CHRONIC (>4 weeks) conjunctivitis?
Referral to Ophthalmologist
Painless bleeding in the eye from trauma, valsalva maneuver, cough, blood thinners, endocarditis is called what?
SUBconjunctival Hematoma
Abrasions of this structure cause tearing, foreign-body sensation in the eye, photophobia, pain?
Cornea - the structure that contact lenses rest on (thin conjunctival layer in between)
How is the CORNEA of the eye best examined?
With FLUORESCEIN dye, under a WOOD/Slit lamp
How long do MOST corneal abrasions heal?
24-48 hours
Bacterial infections, contact lenses, HSV or trauma can cause this type of corneal injury?
Corneal ULCER
How would you manage a corneal ulcer (P. aeruginosa - gentamicin/fluoroquinolones)?
Ophthalmology consult (for antibiotics and scraping for culture)
What is the SCLERA of the EYE?
The white part
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?
EPIscleritis
When the sclera (not conjunctiva) is wide-spread red with SEVERE dull pain, what condition is it?
Scleritis
When can SCLERITIS cause VISUAL LOSS?
When it is deeper (POSTERIOR scleritis)
What type of SCLERITIS is most common which does NOT have visual loss?
ANTERIOR Scleritis
What is seen in 50% of patients with SCLERITIS?
Underlying SYSTEMIC disease (RA, infection - TB or Syphilis)
How is scleritis treated?
By ophthalmologist (if anterior - NSAIDS; if posterior - systemic corticosteroids or TNF-alpha inhibitors)
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?
ANTERIOR Uveitis
Which SCLERITIS and UVEITIS can cause visual changes (blurry, loss)?
POSTERIOR scleritis and uveitis
Swelling of the EYE Lid, caused by Staph aureus (most common) but also with seborrheic dermatitis and rosacea?
Blepharitis
How is BLEPHARITIS treated when NOT associated with Rosacea?
Warm compress + TOPICAL antibiotic
How is BLEPHARITIS treated when associated with Rosacea?
ORAL Tetracyclines (-“cycline”)
What do CORNEAL abrasions, SCLERITIS and UVEITIS ALL REQUIRE?
Ophthalmologist evaluation
What is the LEADING cause of age-related visual loss?
Macular degeneration
What is the most common of the two (2) types of macular degeneration?
DRY (atrophic) - 85%
Drusen (deposits of extracellular material) in the macula with loss of central vision is called what?
DRY (atrophic) Macular Degeneration - most common type (85%)
UNILATERAL neovascularization of the macula with suspected bleeding and scar formation is called what?
WET (neovascular) Macular Degeneration - aggressive
AGE, Smoking, Cardiovascular Disease and Family History are all causes of this visual loss condition?
Macular Degeneration
Why should smokers avoid ß-carotene?
Increases risk of LUNG Cancer
How is DRY (drusen deposits) Macular Degeneration treated?
STOP smoking, Antioxidants - Vitamin C, Vitamin E, ß-carotene in NONsmokers ONLY and Zinc)
What is the PREFERRED method of treatment of WET (neovascular) Macular Degeneration in the ABSENCE of FOVEOLAR involvement?
Vascular Endothelial Growth Factor inhibitors (VGEF - inhibitors)
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?
PRIMARY OPEN Angle Glaucoma
How is PRIMARY OPEN Angle Glaucoma BEST treated?
Timolol (ß-blocker), Epi, Brimonidine (alpha-blocker), Pilocarpine (parasympathomimetic), Acetazolamide, Mannitol, Latanoprost (prostaglandin)
Is surgery or laser therapy recommended for Glaucoma?
NO!
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?
ACUTE Angle Closure Glaucoma
What is the BEST treatment for ACUTE Angle Closure Glaucoma?
Urgent Ophthalmologist referral
What is the Cup and Disc of the eye?
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
What is a normal Cup-to-Disc ratio in the eye and what is considered an increased ratio?
Normal is 0.3; Increased is >0.3 (in glaucoma - ≥0.5)
Opacity of the LENS caused by DM, Smoking, UV-B light, Corticosteroid use, old age is called?
Cataract
When should cataract SURGERY (the ONLY treatment for cataracts) be done?
When symptoms interfere with daily living
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?
KeratoCONJUNCTIVITIS sicca (dry eye)
What diseases can cause inflammation of the lacrimal gland?
Sjogren syndrome, RA
What is eye LID inflammation treated with BESIDES warm compresses?
Oral Tetracyclines (-“cycline”) - as in Blepharitis (lid inflammation) when associated with Rosacea
How do you treat keratoCONJUNCTIVITIS sicca (dry eye)?
Warm compresses and artificial tears
UNILATERAL floaters, squiggly lines, flashes of light in a MYOPIC patient, with a sudden peripheral visual defect appearing like a black curtain?
Retinal Detachment
What is the most common type of retinal detachment?
POSTERIOR (due to vitreous traction)
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?
CENTRAL Retinal Vein Occlusion (Thrombus)
What MUST be done for CENTRAL Retinal Vein Occlusion OR CENTRAL Retinal Artery Occlusion?
Urgent Ophthalmological evaluation
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?
CENTRAL Retinal Artery Occlusion (thrombus)
Central retinal vein or artery occlusions, Temporal Arteritis, Retinal Detachment and Optic Neuritis ALL have this in common?
ACUTE visual loss - URGENT Ophthalmologic evaluation
When do ORBITAL fractures require URGENT Ophthalmological evaluation?
When there is EITHER Visual LOSS, GLOBE PENETRATION or Impairment of Extraocular Muscles
Usually a post-operative infection complication, inflammation of the AQUEOUS and VITREOUS (gel-like) humors associated with Endocarditis?
Endophthalmitis - URGENT Ophthalmologic evaluation - need intra-vitreal antibiotics
Trauma to eye GLOBE or LID?
Urgent Ophthalmologic evaluation
A pt with a SINUS or DENTAL infection presents with MARKED ocular and eyelid erythema, swelling, pain and fever?
Orbital Cellulitis (EMERGENCY - needs ophtho eval and aggressive antibiotics)
How can you distinguish (since they look similar) between ORBITAL Cellulitis (deep, EMERGENCY) and PRE-SEPTAL or PERIORBITAL Cellulitis?
CT-scan for depth and evaluation of extraocular muscles and pupillary reflexes
PAIN with eye MOVEMENT, BLURRED vision, VISUAL FIELD deficits and change in COLOR PERCEPTION?
Optic NEURITIS (Need Ophtho eval and BRAIN MRI) usually self-limitied
Optic NEURITIS may be a sign of what? How is it treated?
MS; IV steroids!
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?
Conductive Hearing Loss
Problems with the perception and transmission of sound vibrations involving the COCHLEA or ACOUSTIC NERVE?
Sensorineural Hearing Loss
When can the Weber and Rinne tests be utilized to differentiate between Conductive vs. Sensorineural Hearing Loss?
ONLY when the hearing loss is UNILATERAL
Instead of the Weber-Rinne tests, what test should ALL patients who report hearing loss have?
AUDIOMETRY
Progressive, UNILATERAL onset of SENSORINEURAL hearing loss, what can this be?
Acoustic Neuroma - MRI (also affects facial nerve)
Viral infections, Bacterial meningitis, Lyme disease, Migraines, Meniere disease, Head injuries and Drug reactions can all cause what type of hearing loss?
SUDDEN Sensorineural Hearing Loss
What is the treatment of Tinnitus?
Neurocognitive Interventions (behavioral therapy)
Sensorineural hearing loss, tinnitus and vertigo?
Meniere Disease
Hearing loss caused by Chemotherapy or Loop Diuretics?
IRREVERSIBLE
Hearing loss caused by Aminoglycosides, NSAIDs, Aspirin and anti-Malarials?
Reversible Hearing Loss
Ear pain for 24-48 hours following a URI +/- fever with bulging, cloudiness, erythema or immobility of the tympanic membrane?
Otitis Media
What ear infection can result in Meningitis, Mastoiditis, Perforated tympanic membrane with resulting hearing loss?
Otitis Media
How is Otitis Media treated?
Analgesia with anti-inflammatory agent (steroid drops) and if antibiotics are started (Amoxicillin or Amoxicillin-Clavulanate OR Macrolide (erythromycin) if PCN allergic)
What is the cause of ACUTE Otitis Externa?
P. aeruginosa or Staph. aureus (rarely fungi)
What causes CHRONIC Otitis Externa (>3 months)?
Fungi, Alleries, Systemic Dermatitis
When can Otitis Externa become life threatening?
When it involves the Temporal/Mastoid bones
Allergic contact dermatitis, from earrings, cosmetics, soaps shampoos, or hearing aids can cause what ear pathology?
CHRONIC Otitis Externa
White cotton-like strands with/without white or black fungal balls seen in the external ear suggest?
Fugnal Otitis Externa with Candida or Aspergillus
How is Otitis Externa treated?
CLEAR the canal of as much debris as possible, then If Mild - acetic acid solution (works for fungal also), If Moderate - topical fluoroquinolones
How is Fungal Otitis Externa treated?
Topical acetic acid or Topical 1% Clotrimazole
Purulent rhinorrhea with pus in the nasal cavity suggest?
Sinusitis
When should imaging be done in patients with sinusitis?
If Immunocompromised (fungal, pseudomonal)
How is sinusitis treated?
Antihistamines, intranasal corticosteroids, topical decongestants
Why should topical decongestants for sinusitis be used only for a few days?
Because they can cause Rebound Rhinitis (rhinitis medicamentosa)
What sinusitis patients are treated with Antibiotics?
Those with 3-4 days of SEVERE symptoms - Fever, purulent drainage, facial pain or those who don’t resolve spontaneously after 10 days
What are the two (2) BEST choices for antibiotic treatment of sinusitis (3-4 days of severe symptoms, purulent discharge and facial pain)?
Amoxicillin-Clavulanate or Doxycycline
When should you test for specific IgE allergens in a pt with allergic rhinitis?
If allergen immunotherapy is being considered OR if patient is considering significant, costly lifestyle changes due to their symptoms
What is the FIRST line therapy for allergic rhinitis?
Intranasal corticosteroids +/- oral antihistamines if needed
Odors, spicy foods, changes in temperature that cause rhinitis in the ABSENCE of an allergic trigger is?
Non-allergic Rhinitis (vasomotor)
How is Non-allergic rhinitis treated?
Same as allergic rhinitis with intranasal corticosteroids, antihistamines and anticholinergic meds
How should PHARYNGITIS be diagnosed and WHEN should it be treated with more than symptomatic therapy?
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)
A patient that presents with PHARYNGITIS with FEVER, ABSENCE of cough, TONSILLAR Exudates and TENDER anterior CERVICAL LYMPHADENOPATHY likely has?
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)
What is the preferred medication for the treatment of GROUP-A STREP Pharyngitis? If PCN allergic?
10-day ORAL Penicillin-G OR IM Penicillin-G x 1; Erythromycin or Azithromycin
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?
GROUP-C and GROUP-G STREP
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?
LEMIERRE Syndrome; IV Vancomycin + Ceftriaxone for 2-4 weeks
Fusobacterium Necrophorum (anaerobic Gram neg. rod) is found in?
Lemierre Syndrome (pharyngitis with thrombosis of internal jugular vein)
In which patients with RECURRENT Epistaxis should radiologic imaging be obtained?
Those who smoke (to rule out malignancy)
Patients with POSTERIOR epistaxis (elderly), require what type of treatment?
Posterior Nasal PACKING by OTORHINOLARYNGOLOGIST
When MUST antibiotics be prescribed for epistaxis?
WHEN NASAL PACKING IS IN PLACE
What is the treatment for MOST ANTERIOR epistaxis?
Compression for 15 minutes
What three (3) medications are typically associated with Gingival Hyperplasia?
Phenytoin, Cyclosporine and Nifedipine
What disease has PERIODONTAL disease (caused by xerostomia or gingival hyperplasia) been associated with?
Coronary Heart Disease
What is the most common ORAL malignancy, particularly in smokers?
Squamous Cell Carcinoma
What is the best method of prevention of Periodontal Disease (gums, teeth, jaw bone)?
Oral Hygiene (brushing, flossing) and prevention of CAD
Where is the MOST common location of HALITOSIS (90%)?
MOUTH
Patients with Vitamin B12 deficiency, Iron deficiency and Celiac disease have what type of tongue?
Atrophic, bright red, smooth, tender and no visible taste buds
Patchy areas of atrophy of tongue papillae with erythematous patches with white borders on the tongue?
Geographic Tongue (benign, no treatment)
Jaw pain, HA, clicking/grinding/grating/crepitus when chewing?
Temporo-Mandibular Joint Disorder
How is OSTEOARTHRITIS of the TMJ diagnosed?
CT/MRI
Jaw relaxation, heat, therapeutic exercises, cognitive behavioral therapy, NSAIDs, TCA’s, injected corticosteroids are all treatment for?
TMJ Disorders
When does the treatment of an abscess BESIDES surgical drainage require ANTIBIOTICS as well?
If cellulitis or DM are present OR if patient is immunocompromised
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?
MAJOR DEPRESSION (score ≥10 with each factor scored from 0-3 out of 27 total points possible)
If symptoms of depression are there but t does not qualify for MAJOR depression, what else can it be?
Minor depression
What is the requirement for MINOR depression to be diagnosed as Dysthymia?
It MUST be going on for AT LEAST 2 YEARS (≥2 years)
When should you treat a patient with BEREAVEMENT-caused DEPRESSION?
If symptoms of MAJOR Depression occur ≥2 months after the loss
When does post-partum depression usually occur?
WITHIN 6 months post delivery
What patients with DEPRESSION require PSYCHIATRIC evaluation?
Those with SUICIDAL/HOMICIDAL thoughts, BIPOLAR disorder, PSYCHOTIC symptoms or symptoms REFRACTORY to at least 2 medications
If FIRST depression episode, how much longer do you treat AFTER remission?
4-9 MONTHS
In patient with RECURRENT depression, how long do you treat after remission?
Life-Long
BEST antidepressants for DEPRESSION without pain?
SSRIs (citalopram, paroxetine, sertraline)
BEST antidepressants for DEPRESSION with PAIN?
SNRIs (venlafaxine, duloxetine, milnacipran)
What is a side effect of SSRIs & SNRIs that patients switch to BUPROPION for?
Sexual side-effects
The presence of what condition makes BUPROPION contraindicated?
Seizure disorder (lowers threshold)
What is the ONLY non-oral (transdermal) antidepressant med?
SELEGILINE (MAOI)
Potentially FATAL mental status changes, neuromuscular hyperactivity, and autonomic instability in a patient taking SSRIs, SNRIs or MAOIs?
SEROTONIN Syndrome
Any contraindications to using ANY antidepressants while breastfeeding? Pregnancy?
NO; Pregnancy Category C (use caution)
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?
Generalized Anxiety Disorder
What two (2) MENTAL disorders have SOMATOFORM symptoms causing HIGH utilization of HEALTH CARE resources (er visits, PCP visits, etc.)?
Generalized Anxiety Disorder and Panic Disorder
What PHOBIA is PANIC DISORDER associated with ?
AGORAPHOBIA
What meds are used for the treatment of Generalized Anxiety Disorder and Panic Disorder?
SSRIs, SNRIs and BUSPIRONE (alternative)
What three (3) actual medical disorders mimic Panic Disorder?
Cardiac Disease, Pheochromocytoma, Thyroid Disease
Patients whom have had Traumatic Brain Injury (soldiers, etc.) are at a much higher risk for what mental health disorder?
Post-Traumatic Stress Disorder (PTSD)
What medications are used in conjunction with Cognitive Behavioral Therapy to treat Post Traumatic Stress Disorder?
SSRIs OR TCAs
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?
SSRIs
What is the BEST treatment for Obsessive-Compulsive Disorder?
Cognitive Behavioral Therapy with EXPOSURE and RESPONSE PREVENTION (if severe, can use SSRIs or Clomipramine)
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?
Intermittent Explosive Disorder (IED)
How is Intermittent Explosive Disorder treated?
Cognitive Behavioral Therapy + Mood Stabilizers (carbamazepine or Lithium or Phenytoin)
What is the leading cause of SUICIDE?
BIPOLAR Disorder
How is bipolar disorder treated?
By Psychiatrist with MOOD stabilizers (Lithium, Valproate, Carbamazepine, Lamotrigine) + Olanzepine or Quetiapine or Aripirazole
What can occur if BIPOLAR disorder is MISS-Diagnosed as depression (because no manic episodes were revealed) and a pt is treated with SSRIs?
A MANIC episode can be triggered!
The presence of MEDICALLY UNEXPLAINED symptoms is called?
Somatization
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”?
YEARS
What is “Undifferentiated Somatoform Disorder”?
Just one Medically Unexplained SYMPTOM needed (unlike in somatization disorder where multiple symptoms are required) and for at least 6 months (not one year)
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?
CONVERSION Disorder (a faking disorder)
A patient that misinterprets NORMAL bodily sensations as serious illness is classified as what?
Hypochondriac
A patient preoccupied with either a REAL but minor or IMAGINED physical finding is classified as having what?
Body Dysmorphic Disorder
Should testing be ordered to reassure a patient?
NO!!!
When a patient ‘FAKES” a symptom, what is the difference between “MALINGERING” and “FACTITIOUS”?
MALINGERING (a faking disorder): there is secondary gain (avoidance of work, money, etc.) FACTITIOUS (a faking disorder): wanting to remain in the “sick role”
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?
SOMATOFORM Disorders
A history of childhood anxiety or OCD predisposes a pt to this eating disorder that presents with Amenorrhea, VERY low body weight (BMI
Anorexia Nervosa
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?
Bulimia Nervosa
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?
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
How is the treatment of Anorexia DIFFERENT than that for BULIMIA?
Anorexia: Psychotherapy + nutritional support
Bulimia: Cognitive Behavioral Therapy + SSRIs (Fluoxetine, Sertraline, Topiramate)
DISORGANIZED thoughts, RAPID shift in topics, CONFUSED speech ≥1 month, GENETICS play the biggest role, can be sudden onset or slow?
SCHIZOPHRENIA
What is SCHIZOPHRENIA best treated with ?
Atypical antipsychotics (olanzepine, clozapine) or Haldol, chlorpromazine
22% of patients diagnosed with schizophrenia have what?
Other psychiatric illness and NOT schizophrenia
Besides amphetamine and methylphenidate (stimulants) what else can ADHD be treated with ?
ATOMOXETINE (SNRI) or Bupropion + TCAs
What should be done periodically in adults with ADHD as they age?
Reassess need for medication therapy as the disorder improves with age
What is the MAIN DIFFERENCE between diagnosis of Autism and Asperger disorder?
Patients with Asperger disorder DO NOT have DELAYS in LANGUAGE or COGNITIVE development and therefore are diagnosed when they are OLDER
Unstable moods, behavior and unstable relationships?
BORDERLINE personality disorder
Perversive psychological dependence on other people with need to be taken care of and intense fear of abandonment?
DEPENDENT Personality disorder
Long pattern of attention seeking behavior and extreme emotionality, behave sexually seductive and need to be the center of attention?
HISTRIONIC Personality disorder
Disregard for other people’s rights, are arrogant and lack empathy for the suffering of others?
ANTISOCIAL Personality disorder
What should a physician do if a COMPLETE lack of trust develops between themselves and their patient or a therapeutic relationship is not possible?
Refer the patient to ANOTHER provider
Bathing, dressing, toileting, feeding?
Activities of Daily Living (ADLs)
Shopping for food, taking your own medications, handling finances?
INSTRUMENTAL Activities of Daily Living (IADLs)
In elderly individuals, INCREASED GAIT SPEED was associated with what?
Increased SURVIVAL
Supplementation of what for 6 months has resulted in a 14% relative risk reduction for falls in the ELDERLY?
Vitamin D
Does Mild Cognitive Impairment (MCI) progress?
YES, to DEMENTIA at the rate of 12%/year
What Mini Mental State Examination score diagnoses Mild Cognitive Impairment?
24-25/30 (scores
What is the BEST treatment for Mild Cognitive Impairment and Dementia?
Cognitive Rehabilitation performed by a neuropsychologist
What type of cognitive difficulty can elderly patients with depression have?
PSEUDOdementia (improves with treatment of the depression)
Although not without RISK (GI bleed, SIADH), these antidepressants work well in elderly patients?
SSRIs
If an elderly patient has depression associated with weight LOSS and INSOMNIA, what is the preferred agent instead of SSRIs?
Mirtazapine
HIGH-Frequency hearing loss (associated with localization and hearing the spoken voice) is a common occurrence in whom?
Elderly patients (presbycusis)
What diagnostic methods should be used to diagnose presbycusis in elderly patients?
Questionnaire or Whisper test
Somatic and vegetative symptoms are seen in the elderly more so than dysphoria (unhappiness) if they have this condition?
Depression
Insulin, Warfarin, Anti-platelet meds and Oral Hypoglycemic agents resulted in >60% of emergency hospitalizations for adverse drug effects in whom?
The elderly
Loss of urine with effort, coughing, sneezing, caused by sphincter incompetence?
STRESS Incontinence
Loss of urine with effort, coughing, sneezing, caused by sphincter incompetence?
STRESS Incontinence
When is a POST-VOID residual urine volume determination required in a patient with incontinence?
When there is a STRONG suspicion of NEUROLOGIC disease or BLADDER OUTLET OBSTRUCTION
When is a POST-VOID residual urine volume determination required in a patient with incontinence?
When there is a STRONG suspicion of NEUROLOGIC disease or BLADDER OUTLET OBSTRUCTION
What is the FIRST LINE therapy for STRESS and URGE incontinence?
Kegel exercises and Bladder training (void regularly regardless of urge, increase interval between voiding)
What medication works well for URGE INCONTINENCE?
Anticholinergic (Oxybutynin, Tolterodine)
Can a patient with Urge Incontinence with Angle Closure Glaucoma use Anticholinergics?
NO!!!
In women, what medical device and surgery are BEST for STRESS INCONTINENCE when medications fail?
Pessaries (medical device that must be fitted professionally); Sling Procedure (surgery)
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?
BOTOX Injection into the detrusor muscle (lasts 6 months)
How are STAGE I Pressure Ulcers treated?
Transparent film
How are STAGE II Pressure Ulcers treated?
Occlusive Dressing to keep wound MOIST and CLEAN
How are STAGE III and IV Pressure Ulcers treated?
DEBRIDEMENT with WOUND Infection treatment
What should be done for ALL STAGE III & IV Pressure Ulcers that do not heal?
Imaging to rule out OSTEOMYELITIS
What is the ONLY purpose of a WOUND-VAC (negative pressure device) for a patient with a PRESSURE Ulcer Wound?
Comfort ONLY (no effect on healing)
PRIOR to a medical PROCEDURE, how early should a PRE-procedural visit be made with a PCP for proper preoperative management without delaying surgery?
3-4 weeks
What patients require PERIOPERATIVE cardiac evaluation for the prevention of MYOCARDIAL Infarction?
Those patients whom are at the HIGHEST RISK for his complication
What INDEX is used for risk stratification of patients at risk for PERIOPERATIVE MI?
Revised Cardiac Risk Index (RCRI)
If a patient needs an EMERGENCY surgery but may be of VERY high risk of MI, should PERIOPERATIVE testing be done?
NO!! (do the surgery!) THEN manage post-operative complications
If a patient has a HIGH risk for PERIOPERATIVE MI, should ELECTIVE/MINOR surgeries be done?
NO!! delay until condition is treated
What patients do not require PERIOPERATIVE testing for risk of MI?
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
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?
- Exercise STRESS Testing (can predict functional capacity)
2. DOBUTAMINE STRESS ECHO
In what patients with CAD is CORONARY REVASCULARIZATION SURGERY (CABG) recommended prior to elective NON-cardiac surgeries?
Those with a LEFT MAIN lesion or with ≥3 vessel disease
If a patient is ALREADY on a ß-blocker pre-operatively, what should they do?
CONTINUE it
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?
ß-blockers (and continued INDEFINITELY)
What patients with Heart Failure (HF) should have their surgeries DEFERRED if possible?
Those with DECOMPENSATED HF
Should Clopidogrel be stopped prior to any surgery?
NO, for all except when a cardiac stent has been recently placed
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?
Aspirin
If a patient is NOT on this medicine, it should ALWAYS be started prior to a planned CABG?
Aspirin
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?
CONTINUED
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?
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)
What types of surgeries are Intrathoracic, Intraperitoneal and Supra-inguinal vascular?
HIGH-Risk surgeries
Ischemic heard disease, HF, DM, Kidney disease, CVA, High-Risk surgery?
Components of the Revised Cardiac Risk Index (RCRI - 1 point each)
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?
ß-blocker
What are the two types of HIGHEST-Risk Surgeries for patients with PULMONARY Disease?
Thoracic and Abdominal surgeries
What patients should be tested with SPIROMETRY (FEV1/FVC) prior to surgery?
ONLY those with UNEXPLAINED Dyspnea (otherwise NO benefit)
What should be done for patients with poorly-controlled ASTHMA or COPD prior to surgery?
SYSTEMIC corticosteroids and INHALED bronchodilators
When should SMOKING be STOPPED prior to SURGERY?
8 WEEKS
What measures should be taken post-op to PREVENT atelectasis and pulmonary complications?
PAIN management and INCENTIVE Spirometry
How should OSA patients be monitored post-operatively?
Monitored closely with possible CPAP or BiPAP (continuous or bilevel Positive Airway Pressure)
What pulmonary disease should be SCREENED for BEFORE surgery?
Obstructive Sleep Apnea (OSA)
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?
PULMONARY
In patients with a low risk for VTE (venous thromboembolism), what post-operative prophylaxis is recommended?
EARLY AMBULATION
What can be done for patients whom are at a HIGH bleeding risk post-op (neurosurgery) for VTE prophylaxis?
Pneumatic Compression Devices alone
What post-op VTE prophylaxis should be given to patients who are not LOW risk NOR high-BLEEDING risk post-op (neurosurgery)?
LMWH or SQ Unfractionated Heparin or Warfarin
How soon POST-OP should patients be given VTE prophylaxis and when should it be discontinued?
STARTED 12-HOURS post-op and given until DISCHARGE
How long BEYOND discharge should patients s/p ORTHOPEDIC surgery, abdominal/GYN surgeries for MALIGNANCY, or PREVIOUS VTE receive VTE prophylaxis for?
AT LEAST 5 WEEKS
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?
Removable IVC filter
What should patients who are ON WARFARIN, undergoing CATARACT surgeries, DENTAL procedures or BIOPSY from NON-MAJOR organs do?
CONTINUE WARFARIN with target INR 1.3-1.5
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?
4-5 days
What should patients with INTERMEDIATE-to-HIGH risk of VTE do for prophylaxis prior to SURGERY?
Bridged with LMWH or IV Unfractionated Heparin
When is BRIDGING with LMWH or Unfractionated Heparin typically started for INTERMEDIATE-to-HIGH risk patients on WARFARIN who are planning to have SURGERY?
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
When is BRIDGING of WARFARIN with LMWH/UFH stopped?
When the INR is THERAPEUTIC
Older than 40, Hip or Knee surgery, major trauma or spinal cord injury?
High-Risk for VTE
What should patients undergoing surgeries with LOW risk for bleeding do with ASPIRIN and CLOPIDOGREL?
CONTINUE them
Pt s/p recent MI or cardiac STENT (BARE METAL) placement should do what with ASPIRIN and CLOPIDOGREL?
CONTINUE for AT LEAST 6 WEEKS from event
Pt s/p cardiac STENT (DRUG ELUTING) placement should do what with ASPIRIN and CLOPIDOGREL?
CONTINUE for AT LEAST 1 YEAR
WHICH is the ONLY anti-platelet medication that is to be STARTED or CONTINUED prior to a CABG surgery?
ASPIRIN
When are ASPIRIN and CLOPIDOGREL stopped prior to SURGERIES and when are they restarted?
ASPIRIN: 7-10 days BEFORE, restarted after 24 hours
CLOPIDOGREL: 4-5 days BEFORE, restarted after 24 hours
CBC and coagulation studies should be done for which patients prior to surgery?
HIGH-RISK for significant bleeding, HEPATIC dysfunction, Ashkenazi Jews (factor XI deficiency)
How high should a patient’s PLATELET count be PRIOR to surgery?
≥50,000 µL/L (give platelets if lower or desmopressin, 1-HOUR before surgery)
What should be done PRE-OP for a patient with Immune Thrombocytopenic Purpura (ITP)?
Corticosteroids, IVIG or Rho(D) immune globulin
What should be done PRE-OP for a patient with Thrombotic Thrombocytopenic Purpura (TTP)?
PLASMAPHARESIS
When should patients with ANEMIA of Kidney disease be given ERYTHROPOIETIN PRE-OP?
ONLY if LARGE blood losses are expected AND TRANSFUSION is CONTRAINDICATED
What should be done for patients with PRE-OP Hb
TRANSFUSE
What should ALL patients with SICKLE CELL DISEASE do prior to SURGERY and why?
Consult HEMATOLOGIST because of RISK of Sickle Cell CRISIS
What should be measured in ALL patients with DM PRE-OP?
HbA1c and Kidney function (BUN/Cr)
What should be done in POORLY-controlled DM patients prior to ELECTIVE surgery?
Delay surgery until fasting glucose ≤220 mg/dL
What should be done with ORAL DM medications and INSULIN prior to surgery?
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)
What should ALL THYROID disease patients have checked PRIOR to surgery?
TSH
A-fib, Respiratory Failure and Thrombocytopenia are all complications that can develop POST-OP in a patient with what disease?
HYPERthyroidism (pt MUST be made EUTHYROID before)
If a patient with HYERthyroidism cannot have surgery DELAYED and not time to make them euthyroid, what can be given PRE-OP?
ß-blocker, corticosteroids, Iodine
When should patients with HYPOthyroidism have their elective surgeries delayed?
ONLY if SEVERE disease
Patients taking HOW MUCH daily STEROIDS for HOW LONG, must take their usual daily dose PRIOR to surgery?
≥10 mg for ≥3 WEEKS (stress dose steroids may be required - 25 mg for minor surgery, 150 mg for major)
In what patients taking ACE-I or ARBs should have these medications HELD on their surgery day and why?
Pts with Chronic Kidney Disease (CKD) because they can develop INTRA-OP HYPOTENSION
What should be given ITRA-OP to patients with Chronic Kidney Disease (CKD) and what meds should be avoided post-op?
IVF’s to avoid dehydration; NSAIDs (nephrotoxic)
Patients with Chronic Kidney Disease (CKD) and UREMIA are at risk for what PERI-operatively?
Platelet Dysfunction and bleeding (schedule dialysis to coincide with surgery)
What should be done PRE-OP for patients with NEWLY diagnosed LIVER disease?
DEFER elective surgery to evaluate and POSTPONE elective surgery in patients with ACUTE Hepatitis of ANY cause
Should elective procedures be delayed in patients with CHRONIC liver disease WITHOUT cirrhosis?
NO!
What does the Child-Pugh classification (A, B, C) suggest for patients with liver disease?
Class A - 10% mortality risk after GENERAL Surgery
Class B - 30% mortality risk after GENERAL Surgery
Class C - 80% mortality risk after GENERAL Surgery
What pharmacologic agents should be given PRE-OP in patients with Cirrhosis and coagulopathy?
Vitamin K, FFP (or cryoprecipitate/factor VIIa)
When should a TIPS procedure be done as a RISK reducing measure PRE-OP in a patient with ASCITES planned for surgery?
If diuretic control of ascites is poor/refractory and if pt has esophageal varices prior to MAJOR Surgery
What should a patient with advanced liver disease be monitored post-operatively for?
HYPOglycemia (impaired gluconeogenesis)
What can pts with MS typically experience post-op?
An acute exacerbation
