General Internal Medicine Flashcards
1
Q
What is the most appropriate next step in the management of a patient with a 15% pretest probability of PE and a negative D-dimer test?
A
Consider an alternative diagnosis.
D-Dimer is a highly sensitive diagnostic test for PE. If it is negative in a patient with a low pretest probability consider another diagnosis.
2
Q
What does a negative result from a highly sensitive test tell you about the presence of disease?
A
“SnOUT”
A highly sensitive test with detect virtually all cases of disease if present, if the test result is negative, the disease is likely not present.
3
Q
Treatment:
Hyperlipidemia in a low-risk patient
A
- Dietary, weight loss and exercise recommendations
- Follow up fasting lipid profile (USPSTF suggest 5 years, but ACC/AHA recommend repeat testing based on individual patient’s risk factor profile)
4
Q
What lab values indicate hyperlipidemia for the following labs:
Total cholesterol
LDL
HDL
Fasting TG
A
total cholesterol >200 mg/dL
LDL>130 mg/dL
HDL<40 mg/dL in men; HDL <50 mg/dL in women
fasting TG>/= 150 mg/dL
5
Q
According to the ACC/AHA, what are the four high-risk groups that should receive treatment for hyperlipidemia?
A
- Patients with established atherosclerotic cardiovascular disease (ASCVD)
- Patients with diabetes
- Patients with LDL cholesterol >190 mg/dL
- Patients with ASCVD risk >7.5% using the Pooled Cohort Equations calculator
6
Q
When are triglycerides considered as separate target for hyperlipidemia therapy?
A
TGs are only considered separate targets when their values are very high (i.e. >500 mg/dL).
Fibrates are most effective at lowering triglycerides
7
Q
Management:
Hyperlipidemia refractory to medical therapy
A
Consider secondary causes:
- Hypothyroidism
- Diabetes mellitus
- Nephrotic syndrome
- Obstructive liver disease
8
Q
Treatment:
Obesity
A
- Recommend exercise and low-calorie diet
2. Orlistat
9
Q
Pharmacology:
Orlistat
MA?
F?
Secondary benefits?
Side effects?
A
MA: lipase inhibitor
F: leads to fat malabsorption and weight loss
Secondary benefits: reduced LDL, reduced blood pressure, improved glycemic control
Side effects: flatus, abdominal cramps, fecal incontinence, oily spottage, rare liver injury, vitamin deficiencies (A, D and E).
10
Q
What are the indications for bariatric surgery (i.e. gastric bypass surgery, laparascopic banding) to treat obesity?
A
Class III obesity in a patient unable to maintain weight loss with diet and exercise with or without drug therapy.
Class III obesity=
- BMI >/= 40
- BMI 35-39.9 with obesity-related comorbid conditions (i.e. HTN, impaired glucose tolerance, DM, hyperlipidemia, obstructive sleep apnea)
11
Q
What is Class III Obesity?
A
- BMI >/= 40
- BMI 35-39.9 (Class II obesity) with obesity-related comorbid conditions (i.e. HTN, impaired glucose tolerance, DM, hyperlipidemia, obstructive sleep apnea, severe joint disease)
12
Q
Treatment:
Depression + Obesity
A
Bupropion
13
Q
What is the most successful and safest long-term weight loss strategy in obese and overweight patients?
A
Reduction in daily dietary caloric intake
14
Q
How long can a patient remain on phentermine as adjunctive treatment for obesity?
A
12 weeks
15
Q
Diagnosis:
- Macrocytic anemia (MCV >100)
- Thrombocytopenia (platelets <150K)
- Mild neutropenia
- Inappropriately low reticulocyte count
…in a patient with a past surgical history of Roux-en-Y gastric bypass
A
Vitamin B12 deficiency
16
Q
What is the diagnostic test of choice to diagnose a vertebral compression fracture?
A
Plain radiography
i.e. lumbar spine radiography
17
Q
What is the initial imaging study of choice for suspected ankylosing spondylitis?
A
Anterior-posterior plain radiography of the pelvis providing a view of the sacroiliac joints and hips
18
Q
Treatment:
Acute low back pain
A
- Analgesics–> mitigate symptoms
2. Mobilization as tolerated –> maintain function
19
Q
When is lumbar spine MRI useful in evaluating acute lumbosacral back pain?
A
- Rapidly progressing neurologic symptoms
- Evidence of cord compression
- Evidence of cauda equina syndrome
- Suspicion for malignancy
- Suspicion for infection
20
Q
When should you suspect pertussis in an adult patient complaining of cough?
A
- Cough >/= 2 weeks
- Associated with:
A. Paroxysms of coughing
B. Inspiratory Whoop
C. Posttussive emesis
21
Q
Treatment:
Pertussis
A
Macrolide antibiotic (i.e. azithromycin, clarithromycin, erythromycin)
22
Q
Treatment:
Upper Airway Cough Syndrome
A
- Diphenhydramine (1st generation antihistamine)
- Pseudoephedrine (decongestant)
Treat for 2-3 weeks. IF this fails consider GERD and treat with PPI.
Treatment of GERD can be added to treatment of UACS, because chronic cough usually has multiple etiologies.
23
Q
What is the most common cause of chronic cough?
A
Upper airway cough syndrome (UACS)
24
Q
Diagnosis:
Symptoms:
- Cough
- Nasal discharge
- Sensation of postnatal drip
- Frequent throat clearing
Physical Examination:
- Cobblestoning of the posterior pharyngeal mucosa
- Mucoid or mucopurulent secretions at the nasopharynx or oropharynx
A
Upper airway cough syndrome (UACS)
25
Management:
Cough in a patient taking an ACE inhibitor
1. Smoking cessation
2. Discontinuation of ACE inhibitor
Wait 4 weeks before doing any additional evaluation for the cough.
*Rarely, it takes 3 months for cough to abate after discontinuing ACEi*
**Ensure patient has a normal chest radiograph.**
26
Differential Diagnosis:
Chronic cough (>8 weeks duration)
1. Asthma
2. COPD
3. Upper airway cough syndrome (UACS)
4. GERD
5. Pneumonia
6. ACEi induced cough
27
How long is the empiric PPI therapy for a patient with GERD?
8-12 weeks
28
Treatment:
Cough-variant asthma
Bronchodilator (albuterol)
*It may take 6-8 weeks for symptomatic benefit to occur.*
29
What diagnostic test is necessary to evaluate patients with hemoptysis?
Chest radiography
*Even is chest radiography is normal, patients at high risk for lung cancer should be referred for chest CT and fiberoptic bronchoscopy.*
30
List the risk factors for malignancy in a patient with hemoptysis.
1. Male sex
2. Age older than 40
3. Smoking history of more than 40 pack years
4. Symptoms lasting >1 week
*These patients should be referred for chest CT and fiberoptic bronchoscopy.*
31
Treatment:
Mild influenza in a healthy person
Symptomatic treatment
32
When is treatment of influenza with either oseltamivir or zanamivir indicated?
1. Hospitalized patients with the flu
2. Patients with severe, complicated or progressive illness
3. High risk for influenza complications (cardiovascular disease, active cancer, chronic kidney disease, chronic liver disease, hemoglobinopathies, immunocompromised, neurologic diseases that impair handing or respiratory secretions)
33
What is the preferred time window to treat influenza with oseltamivir or zanamivir?
Within the first 2 days of symptoms
F: (1) to reduce duration of illness and (2) decrease the risk of serious complications
34
Treatment:
Tobacco addiction in a patient with psychiatric disease
Nicotine replacement therapy
35
What are the contraindications for bupropion therapy for smoking cessation?
Contraindicated in patients with:
1. Seizure disorders
2. Monoamine oxidase inhibitors
3. Eating disorders
4. Serious psychiatric disease (may cause personality changes, vivid dreams, suicidal ideation)
36
What are the contraindications for varenicline therapy for smoking cessation?
Contraindicated in patients with:
1. Kidney impairment
2. Dialysis
3. Cardiovascular disorders
4. Serious psychiatric disease (may cause personality changes, vivid dreams, suicidal ideation)
37
What is the best medication for treating tobacco addiction and preventing smoking cessation-related weight gain?
Bupropion
38
What are two second-line therapies for smoking cessation?
1. Clonidine
| 2. Nortriptyline
39
Select the best therapy for smoking cessation:
1. Counseling
2. Anti-smoking medication
Both
Smoking cessation is achieved more effectively with a combination of counseling and anti-smoking medication use than with either intervention alone.
40
What are the five A's of smoking cessation counseling?
1. Ask about smoking
2. Advise smokers to quit
3. Assess the level of interest in quitting
4. Assist by offering resources or medications
5. Arrange for follow up
41
Management:
Newly diagnosed depression
1. Perform PHQ9 to establish baseline
2. Begin antidepressant
3. Follow up at 2 and 4 weeks to assess adherence, adverse drug reactions, suicide risk
4. Follow up at 6-8 weeks to asses response to therapy using PHQ-9
- Complete responders (now normal PHQ-9???) remain on medications for 4-9 months
- Partial responders (50% or greater decrease in PHQ-9 symptoms) and nonresponders: (1) increase dosage (2) switch to new drug (3) add psychotherapy (4) add second drug for dual therapy if patient has failed monotherapy twice
42
Treatment:
suicidal patient
Suicidal patients who have a suicidal plan should be hospitalized if they:
1. Have poor social support,
2. Are intoxicated,
3. Are actively delusional or
4. Likely to be noncompliant with medication
43
When is electroconvulsive therapy (ECT) indicated in treatment for depression?
ECT is considered for depressed patients with:
1. Psychotic features
2. Suicidal thoughts
3. No response to antidepressants
4. Unable to tolerate antidepressants
*ECT should be managed by a psychiatrist.*
44
When should you consider a possible diagnosis of bipolar disorder in a young, depressed adult?
If the patient experienced hypomanic symptoms in childhood.
*Mania: (1) distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week (2) inflated self-esteem or grandiosity (3) decreased need for sleep (4) distractibility (5) increased goal-directed behavior (6) excessive involvement in pleasurable activities with a high potential for consequences (purchasing sprees, sexual indiscretions)
45
Symptoms:
Major depressive disorder
1. Depressed mood nearly every day for at least 2 weeks
2. Loss of all interest and pleasure
3. Appetite disturbance
4. Weight disturbance
5. Activity level distrubance
6. Fatigue or loss of energy
7. Self-reproach or inappropriate guilt
8. Poor concentration or indecisiveness
9. Morbid thoughts or death or suicide
46
Symptoms:
Dysthymia
1. Depressed mood or anhedonia at least 50% of the time for 2 at least 2 years
2. >/=2 vegetative or psychological symptoms and functional impairment
(??? look up more on this)
47
Treatment:
Situational adjustment reaction
Typically resolves with resolution of the acute stressor WITHOUT medication.
48
What are the different questionnaires or test available to screen for alcohol substance abuse?
1. Alcohol Use Disorders Identification Test (AUDIT): 10 questions
2. AUDIT-C: 3 questions version; more SN than AUDIT, but less SP
3. CAGE questionnaire: >/= 2 positive answers; 77%-95% SN; 79%-97% SP
4. TWEAK test: designed to detect low levels of alcohol use in pregnant women
49
USPSTF recommendations:
Alcohol abuse screening
Screen and counsel all adults for alcohol use and abuse.
Identify the:
1. Quantity and frequency of drinking
2. Adverse consequences
3. Patterns of use
50
USPSTF recommendations:
Bladder cancer screening
Recommended AGAINST
51
USPSTF recommendations:
Ovarian cancer screening
Recommended AGAINST
52
USPSTF recommendations:
Pancreatic cancer screening
Recommended AGAINST
53
USPSTF recommendations:
Skin cancer screening
Insufficient evidence to recommend for or against.
Fair-skinned persons age 10-24 years old should be counseled about reducing their exposure to ultraviolet radiation to the reduce the risk of skin cancer.
54
Treatment:
Opioid addiction
1. Buprenorphine + Naloxone
| 2. Methadone
55
Why is buprenorphine preferred over metahadone for treatment of opioid addiction?
1. Buprenorphine is a partial opioid agonist and thus reduces withdrawal symptoms.
2. When used with naloxone there is less potential for abuse and respiratory depression in overdose.
56
How do you prevent seizures in acute alcohol withdrawal syndrome?
Benzodiazepines (Lorazepam)
*Patients with a history of seizures should receive a prophylactic benzodiazepine on a fixed schedule even if they are asymptomatic during the acute alcohol withdrawal period.*
**Long-acting benzodiazepines such as (chlordiazepoxide or diazepam) may be more effective in preventing seizures but are associated with excess sedate in older adults and patients with liver failure.**
57
Signs/Symptoms:
Acute alcohol withdrawal syndrome
1. Hypertension
2. Tachycardia
3. Sweating
4. Agitation
5. Tremulousness
6. Cognitive changes
58
Treatment:
Cocaine-induced chest pain
1. Calcium channel blockers (i.e. diltiazem)
| 2. Benzodiazepine (i.e. lorazepam)
59
Diagnosis:
FSH: WNL
TSH: WNL
Prolactin: WNL
Progesterone challenge testt: no bleeding
Hypothalamic amenorrhea
*Suspect low-estrogen state.)*
60
Management:
Hypothalamic amenorrhea confirmed with negative progesterone challange
obtain MRI to rule out pituitary adenoma.
61
Treatment:
Vaginal dryness and discomfort in a postmenopausal woman
Mild to moderate symptoms: vaginal moisturizers and lubricants
Severe symptoms: vaginal estrogen
62
What are the adverse outcomes associated with oral estrogen therapy?
Increased rates of:
1. Coronary heart disease
2. Stroke
3. Venous thromboembolism
4. Invasive breast cancer
63
Work up:
Secondary amenorrhea
1. beta hCG --> rule out pregnancy
2. FSH, TSH prolactin levels (To check for ovarian failure, thyroid disease and hyperprolactinemia)
3. Progesterone challenge
64
Define secondary amenorrhea.
The absence of menses for 3 or more consecutive months in a previously menstruating woman
65
What is the most commone cause of secondary amenorrhea?
Polycystic ovary syndrome
66
What is the most common cause of hypogonadotropic hypogonadism?
Hyperproactinemia
67
What lab values would indicate hypogonadotropic hypogonadism:
FSH
Estrogen
FSH: low
Estrogen: low
68
What FSH level is suggestive of ovarian failure?
FSH >20 mU/mL
69
What are the diagnostic criteria for polycystic ovary syndrome?
1. Ovulatory dysfunction
2. Laboratory or clinical evidence of androgen excess
3. Polycystic ovaries on ultrasonography
70
Treatment:
Heavy menstrual bleeding
Oral medroxyprogesterone for 10-21 days
71
How do you evaluate secondary amenorrhea if FSH, TSH and prolactin levels are within normal limits?
Progestin withdrawal challenge
72
How does a progestin withdrawal challenge help i the diagnosis of secondary amenorrhea?
Menstrual flow on progestin withdrawal indicates normal estrogen production and a patent outflow tract.
This limits the diagnosis to chronic anovulation with estrogen present (i.e. PCOS).
73
Management:
Abnormal uterine bleeding in a postmenopausal woman
Endometrial biopsy to rule out endometrial cancer or hyperplasia
74
What is the most likely cause of arrhythmia in an elderly adult?
Cardiac diseases (i.e. arrhythmia)
Bradycardias: sinus node dysfunction, atrioventricular dysfunction
Tachyarrhythmias: supraventricular, ventricular
75
What is the most common type of syncope?
Neurocardiogenic syncope
76
Diagnosis:
1. Palpitations
2. Nausea
3. Blurred vision
4. Warmth
5. Diaphoresis
6. Lightheadness
10 seconds before passing out
EKG normal
Neurocardiogeic syncope
77
When is a Tilt table test indicated in the work up o f syncope?
1. recurrent syncope in the absence of known heart disease
2. To discriminate neurocardiogenic syncope from orthostatic syncope
3. To evaluate frequent syncope in a patient with psychiatric disease
4. recurrent syncope in patients with known cardiac disease, but syncope not related to heart disease
5. high risk occupations requiring documentation
6. to differentiate cause of syncope from neurologic or psychiatric etiologies
78
When are implantable loop recorders indicated in the workup of an arrhythmia?
If previous shorter-duration monitoring is not diagnostic.
79
What change in blood pressure indicates orthostatic hypotension?
SBP decrease of at least 20mmHg or DBP decrease of at least 10 mmHg within 3 minutes of standing
80
What is the most suggestive clinical feature of pathologic lymphadenopathy?
Age
>40= 20x more likely to have pathologic lymphadenopathy
81
Benign or malignant:
Cervical lymphadenopathy
Soft
Tender to touch
Freely moveable in association with fever
Benign
82
What diagnostic study would you use to diagnose and upper GI cause of involuntary weight loss in an elderly patient?
Upper endoscopy
83
What is the initial management for involuntary weight loss?
Age and sex appropriate cancer screening
84
USPSTF Recommendation:
Breast cancer screening
Women 50-74 years old every 2 years
85
Why should diphenhydramine be avoiding in older patients?
It is highly anti-cholinergic and increases the risk of:
1. confusion
2. dry mouth
3. constipation
4. urinary retention
86
What is the initial management of an elderly patient with a fall?
Medication review and discontinuation of any nonessential medications.
87
Treatment:
Functional urinary incontinence
Prompted voiding
88
Treatment:
Elderly patient with:
1. Leg muscle weakness
2. Slow gait
3. Recent fall
Vitamin D
89
Treatment:
Terminal dyspnea with pleural effusion identified on chest radiograph
Therapeutic thoracentesis
90
Treatment:
Delirium associated with terminal disease
Low-dose antipsychotic (i.e. Haloperidol)
91
Treatment:
Terminal dyspnea in a patient with cardiopulmonary disease or malignancy
Opioids
*Opioids are effective in reducing dyspnea in patients with underlying cardiopulmonary disease and malginancy.*
92
Management:
Opthalmic herpes zoster
1. This is a medial emergency! Urgent referral to an ophthalmologist is required.
2. Administer an antiviral
