General internal medicine 2 Flashcards
To do before starting statin
Check alanine aminotransferase level
Physical exam suggesting epididymitis
Positive Prehn sign (relief of pain with scrotal elevation)
First and second line for chronic low back pain
1st line = nonpharmacologic treatment (acupuncture, CBT, exercise, yoga)
*even if radicular symptoms present
*tylenol is not effective for back pain
2nd line = NSAIDs in lowest effective dose
Management of in-flight emergency
- Connect to ground-based physician (not flight diversion)
Treatment of premature ejaculation
Combination of SSRI + phosphodiesterase-5 inhibitor
- other options = topical anesthetic/lidocaine (reduces tactile stimulation and prolongs time to ejaculation), clomipramine
Treatment of menopausal symptoms
COMBINED estrogen + progesterone (unopposed estrogen exposure would increase risk for endometrial hyperplasia and malignancy so can only give estrogen alone if woman had hysterectomy and would be preferred)
Other criteria for treating vasomotor symptoms of menopause
Must be younger than 60 and within 10 years of menopause onset
Duration of postoperative pharmacologic VTE prophylaxis for major orthopedic surgeries (hip and knee)
35 days (assuming not increased bleeding risk + no preoperative bleeding) (thrombotic risk continues for quite a while)
Mattress type that is best evidenced for pressure ulcer prevention
Advanced static mattress
Treatment of epididymitis
- younger = CTX + doxy (need to treat for both chlamydia and gonorrhea)
- older AND those who have anal sex = CTX + quinolone (e coli, pseudomonas more common thus treatment)
Supportive care for epididymitis
Scrotal support, ice, NSAIDs
Other clinical features that are not present with strep throat
conjunctivitis, nasal congestion, rhinorrhea
Number of Centor criteria that warrant workup
3 or more
Centor criteria
- Fever by history
- Tonsillar exudates
- Tender anterior cervical LAD
- Absence of cough
Treatment of bacterial conjunctivitis
Trimethoprim-polymyxin B ophthalmic drops
Other clinical feature of bacterial conjunctivitis
Thin mucopurulent discharge
MMR vaccination for adults
- all adults undocumented adults need at least one dose
- healthcare workers, international travelers, postsecondary students need a second dose at least 28 days after the first dose
People who need hep A vaccine
- travelers to endemic area
- men who have sex with men
- chronic liver disease
- HIV
- IVDU
Patients who require perioperative bridging
AF w/ mechanical valves
Next step in evaluation of tinnitus + hearing loss
MRI (rule out acoustic neuroma)
Caveat about FOBT for CRC
Requires dietary restriction to reduce false-positive results
Management of impaired physician colleague
Directly approach him or her
Management of LDL greater than 190
High-intensity statin
AAA screening indication
65 to 75 ever smokers
Definition of ever smoker
More than 100 cigarettes in their lifetime
Med to discontinue in patients following bariatric surgery
NSAIDS (increased internal bleeding risk)
Treatment of cancer related pain (lytic lesions) in CKD
Hydromorphone
Caveat about fentanyl patches
Can only be used in opioid-tolerant patients not opioid naive
Caveats about tramadol
- don’t use for cancer pain (poor analgesic)
- don’t use in CKD (accumulation of active metabolites)
- has potential for significant drug interactions
weber test + interpretation
- tuning fork placed on top of the head
- if defective ear hears tuning fork louder, the finding indicates a conductive hearing loss in the defective ear (localizes to affected ear)
Rinne test interpretation
IF conductive hearing loss present – patient is not able to hear the tuning fork after it is moved from mastoid to pinna (bone conduction better than air conduction)
IF sensorineural hearing loss - patient will hear tuning fork by air conduction after they can no longer hear it through bone conduction (Air conduction better than bone conduction)
Congenital adrenal hyperplasia
group of autosomal recessive disorders characterized by impaired cortisol synthesis.[1][2] It results from the deficiency of one of the five enzymes required for the synthesis of cortisol in the adrenal cortex.[3] Most of these disorders involve excessive or deficient production of hormones
17 alpha hydroxylase deficiency clinical features
Mike in the driveway and driveway is covered in colorful tacs/17. He has a thong on and has no dick/xy: pseudohermaphroditism (ambiguous genitalia, undescended testes due to decreased sex hormones). Abby’s naked and completely flat chested/xx: females are born with normal genitalia, but lack secondary sexual development (OPPOSITE of 11-beta-hydroxylase). He has a BP cuff around his neck/hypertension. Garage is filled to the ceiling with small bananas/hypokalemia. He’s ramming a baseball bat up his vagina/primary ammenorhea. She/he’s completely bald and flat chested/lack of secondary sexual development, including breast buds or pubic hair.
21-hydroxylase deficiency presentation
Abby wrapped up in a net/21. She’s super hairy and has really bad acne and a huge clit/with delayed presentation (non-classic form) females present with xx virilization (so 46,xx karyotype but virilized) leads to enlarged clitoris/ambigouous genitalia (patient may have a scrotal sac and enlarged phallus and normal-sized ovaries) and partially fused labioscrotal folds. Baby next to her with a huge clit/In severe form, female infants present at birth with ambigous genitalia. Huge baby on left wall with thick pubes and armhair on top of a salt mound + three dicks (precocious puberty code/In classic, non-salt-wasting form, affected male infants present at ages 2-4 with early virilization + increased linear growth + salt-wasting or precocious puberty. She has a metal pole for an IV bag next to her and she’s sitting on top of a small salt mound/hypotension. Ceiling is covered in colorful tacs/without functioning 21-hydroxylase, precursor molecule 17-hydroxyprogesteron accumulates. Huge banana alongside the wall + group of higschool runners running around the room/21-hydroxylase deficiency results in the inability to synthesize aldosterone, resulting in salt wasting (causing hypotension), leading to hyponatremia and hyperkalemia.
NMS clinical features
- fevers + rigidity + autonomic dysfunction
NMS vs serotonin syndrome
- NMS = lead pipe rigidity
- Serotonin syndrome = clonus + hyperreflexia
Criteria for diagnosis of depression
5 of 7 of below over a 2 week period: - sleep (too much or too little) - Depressed mood or loss of interest - Guilt or worthlessness - decreased Concentration - Psychomotor Agitation or slowing ALSO: - weight changes - recurrent thoughts of death or suicide
adjustment disorder vs depression
Adjustment disorder = clear precipitant + doesn’t meet 5 out of 9 criteria
Paroxetine SE to know
pregnancy category D
Mirtazepine SE’s to know
- sedation
- weight gain
Duration of SSRI treatment
1st episode = 6-12 weeks
2nd episode = 2x interval from previous episode
3 episodes or suicide attempt = lifelong
First line meds for obesity treatment after failed lifestyle modifications
- Orlistat
- lorcaserin
Bupropion contraindications
- uncontrolled HTN
- epilepsy
- opiate use
lorcaserin contraindications
- caution with multiple serotonin active meds (serotonin agonist)
phentermine, topiramate for weight loss contraindications
- pregnancy, MAOI’s, hyperthyroid
bariatric surgery indications
- BMI over 40
- BMI over 35 with comorbidities
Gastric banding SE’s
- nausea, vomiting
- ulcers
- obstruction
Sleeve gastrectomy SE’s
- stenosis
- bleeding
Gastric bypass SE’s
- stenosis
- cholelithiasis
- dumping syndrome
- SIBO
- micronutrient deficiencies
Presentation of biceps tendinopathy
- pain in anterior shoulder + radiation distally over biceps muscle
Biceps tendinopathy initial treatment
- conservative measures, then NSAIDS
Glenohumeral OA presentation
- hx of chronic wear and tear or trauma + anterior or deep shoulder pain
Lung cancer screening indication
50 to 80 years old + at least 20 pack-year smoking history + either current smokers or have quit within the past 15 years)
Treatment of genitourinary syndrome of menopause
Initial therapy with moisturizers and lubricants
IF persistent symptoms –> vaginal estrogen
Treatment of PCOS – infertility and amenorrhea treatment
- First line = weight loss
- If infertility –> weight loss (which can restore ovulation), second line: letrozole or clomiphene?
- IF amenorrhea Or hirsutism –> OCP’s –> (suppressing pituitary LH secretion and decreasing ovarian androgen production)
Other treatment for oligomenorrhea in PCOS
clomiphene
Ophtho presentation of ankylosing spondylitis
His eyes are blood red + intensely scarred of lights/eye feature = anterior uveitis, presenting with pain + blurred vision + photophobia + conjunctival erythema.
Cardiac complications of Ankylosing spondylitis
Big red aorta above him + big wide golden ring stuck in it + Ben glennon pushing his wheelchair/cardio complication = ascending aortitis, leading to dilation of the aortic ring + aortic insufficency + aortic regurgitation.
Lumbar spinal stenosis clinical features
- neurogenic claudication (pain worse when walking, standing and relieved with sitting or lying). Often symptomatic only when active.
- also sensory loss, weakness in legs
Trichomonas presentation
Picture a green mona + smelling terribly + itching herself + on fire/presentation = yellow-green discharge + foul smelling + itching and burning.
Trichomonas treatment
Metro running around perimeter of yard/treat both partners with metronidazole.
Visceral leishmaniasis presentation
Anna with leash around her neck. She’s sweating profusely + riding a hippo + has a huge pan on top of her head/presentation = spiking fevers + hepatosplenomegaly + pancytopenia.
Treatment of leishmaniasis
Will Ferrell is in his old school car + huge bottle of pepsi with candy spilling out stuck into back/treat with amphotericin B or sodium sibogluconate.
Indication for testosterone replacement therapy
- clinically significant androgen deficiency (low libido, ED, loss of body hair, gynecomastia, testicular atrophy AND unequivocally low morning T (less than 200 typically) that is REPEATED
Contraindications to testosterone replacement therapy
- breast or prostate cancer
- polycythemia
- severe lower UTI symptoms
- untreated OSA
Prostatitis treatment
Acute = Bactrim or fluoroquinolone Chronic = fluorquinolones
Chronic prostatitis clinical features
- Persistent or recurrent LUTS
- Prostatic tenderness
Antibiotic treatment duration for chronic prostatitis
4-6 weeks
Diagnosis of IgG4 related disorders
biopsy showing IgG4-positie plasma cells
Treatment of IgG4-related disease
steroids or other immunomodulators
Other clinical features of IgG4-related disease
- pancreatitis
- sclerosis cholangitis
- bilateral salivary and or lacrimal gland enlargement
epididymitis clinical features
- acute scrotal pain (POSTERIOR aspect of scrotum)
- exquisite testicular tenderness
- intact cremasteric reflex
- may or may not have urinary symptoms
epididymitis treatment
- testicular elevation + NSAIDS + antibiotics
clinical features of CVID
- recurrent infections (rhino sinusitis, pneumonia, conjunctivitis)
- chronic lung disease
- often comorbid autoimmune disorders and GI disorders
- granulomatous disease in lymphoid or solid organs
- increased risk of malignancy
- poor response to vaccinations
lab features of CVID
- extremely low IgG
- low IgA and or IgM
treatment and monitoring of CVID
- IVIG
- age appropriate cancer screening
- monitoring for lymphoma
Wegener’s clinical features
- pulmonary + renal disease + oronasal ulcers + persistent rhinorrhea
Myeloperoxidase deficiency clinical features
- recurrent candida infections
primary ciliary dyskinesia clinical features
nasal polyposis + otitis + recurrent respiratory infections + situs inverses + infertility
Clinical features of varicocele
- soft scrotal mass that decreases in supine position and increases with standing
- subfertility (increased scrotal temperature)
- testicular atrophy
varicocele management
- scrotal support and NSAIDS
IF young with testicular atrophy – gonadal vein ligation
Management of patient with anaphylaxis from hymenoptera sting
- refer to immunology for immunotherapy (venom immunotherapy reduces risk of recurrent anaphylaxis)
- epi pen
Management of refractory scrotal pain
scrotal US (epididymitis, testicular torsion are frequently misdiagnosed clinically)
risk factors for osteoporosis in men
- *androgen deprivation therapy (can decrease bone mineral density within 6-9 months of starting drug)
- chronic steroids
- low-trauma fractures
- hyperthyroidism
- smoking, drinking
first and second line of carpal tunnel
First step = nocturnal wrist splinting unless motor weakness or atrophy of thenar eminence or axonal injury then surgery
Refractory = steroid joint injections
Management of hirsutism refractory to OCPs in PCOS
spironolactone (only after 6 months of OCPs)
Hereditary hemorrhagic telangiectasia clinical features
- spontaneous epistaxis + mucocutaneous telangiectasia + GI bleeding + AVM’s
Tuberous sclerosis clinical features
- hypo pigmented macules (ash leaf spots)
- angiofibromas on face
- seizures
- shagreen patches in lower trunk
- brown fibrous plaque on the face
Peutz-Jeghers presentation
- GI polyps
- flat blue-gray-to-brown spots resembling freckles on lis, perioral region, hands, feet, buccal mucosa
management of urge incontinence
- behavioral therapy (pelvic muscle exercises, bladder training, smoking cessation, weight loss, dietary changes)
- voiding diary
Second line for urge incontinence
Antimuscarinics (anticholinergics), beta-3 agonists
Presentation of stress urinary incontinence
- Leakage of urine with Valsalva (Coughing, sneezing)
- Positive cough stress test
- due to decreased urethral sphincter tone and urethral hypermobility
presentation of urge incontinence
- overwhelming urge to urinate
cause + presentation of overflow incontinence
- incomplete emptying and persistent involuntary dribbling
* due to impaired detrusor contractility and bladder outlet obstruction
BPH vs urge incontinence
- BPH causes obstructive voiding symptoms (decreased stream, nocturia)
- urge incontinence is caused by detrusor hyperactivity leading to involuntary urine leakage + sudden urge to void
- urge incontinence can happen in BPH patients
Management of neuropsychological symptoms in alzheimers (agitation, aggression, paranoia, hallucinations)
behavioral and environmental therapy (structured routines, music therapy, etc)
Orlistat SE’s
- fat malabsorption (flatus, fecal incontinence, abdominal distention)
- calcium oxalate stones (fat malabsorption can increase intestinal calcium binding, leading to decreased available calcium to bind oxalate)
Orlistat mechanism
inhibits pancreatic lipase to alter fat digestion and decrease fat absorption
Management of fat malabsorption SE’s from orlistat
low fat diet
*patient should also be on daily MVI
Main SE’s of GLP-1 agonists
- nausea
- acute pancreatitis
- AKI
