General Internal Medicine Flashcards
Define first-order kinetics.
In first-order kinetics the rate of drug clearance is dependent on (and proportional to) the drug concentration. That is, the rate of drug clearance increases linearly as the plasma concentration of the drug increases. This occurs when the available enzyme sites far exceed the substrate molecule.
How many half-lives does it take to eliminate a drug from the system?
A drug will be 97% eliminated from the body at 5 half-lives.
What does TMP/SMX do to the INR in patients on warfarin?
TMP/SMX markedly raises the INR within the first few days of therapy.
You have invented a test that is 90% sensitive and 95% specific for screening of breast cancer. If you tested 100 women with known breast cancer, how many would the test say have breast cancer (true positives)?
With 90% sensitivity, testing 100 woman with breast cancer would yield 90 positive tests.
Which of the following take into account disease prevalence: sensitivity, specificity, PPV, NPV?
Prevalence of disease affects the predictive value (both PPV and NPV) of a test.
Define positive and negative likelihood ratios in terms of sensitivity and specificity.
\+LR = sensitivity/(1-specificity). -LR = (1-sensitivity)/specificity
You read a study that shows a new treatment for lung cancer improves survival by 60% and the p value for the study is .2. With these results would you recommend this treatment based on statistical significance?
No, the p value of 0.2 means that this result is not statistically significant.
What is the cutoff p value that is considered statistically significant?
A result is statistically significant if the p value is <0.05.
A study shows a newer treatment for lung cancer improves survival by 5% and the 95% confidence interval for the study is 1.6 to 4.9. Assuming treatments have the same side effects, would it be worthwhile to consider this new treatment?
Yes, it would be worthwhile to consider this treatment since the 95% confidence interval does not cross 1.
Be able to calculate the NNT.
NNT = 1/ARR
What are the risk factors for osteoporosis?
Risk factors for osteoporosis include age, personal history of fragility fracture, weight < 127 lbs or BMI < 21, alcohol intake, early menopause, glucocorticoid use, cigarette smoking, and malabsorption.
How do you screen for osteoporosis?
DXA is the preferred method for screening for osteoporosis.
How are the Z-score and T-score used in the evaluation of osteoporosis?
Osteoporosis and osteopenia are defined by the T-score which is the comparison to young, healthy bone.
What are the common recommendations for all patients with osteoporosis?
Common recommendations for all patients with osteoporosis include: dietary calcium intake of 1200-1500mg/d, vitamin D 600-800 IU daily, fall prevention, tobacco avoidance, regular weight-bearing exercise, and avoidance of excess alcohol.
Which patients should be treated with drug therapy for osteoporosis?
Drug therapy should be considered in postmenopausal women and men > 50 years of age with hip or vertebral fracture, T-score between -1.0 and -2.5 with prior fracture, T-score < -2.5, T-score between -1.0 and -2.5 with secondary causes associated with high fracture risk (ie. steroid use), or T-score between -1.o and -2.5 with 10 year risk of hip fracture > 3% or 10 year risk of major osteoporosis related fracture > 20% based on FRAX model.
For how long can teriparatide be used? Why?
Teriparatide can be used for only 2 years because of increased risk of osteosarcoma.
A patient on alendronate presents with difficulty swallowing. What is the likely etiology?
A patient on alendronate who develops difficulty swallowing should be suspected to have pill-induced esophagitis/ulcer.
What is the most serious consequence of osteoporosis?
Fractures are the most serious complication of osteoporosis. Mortality for proximal femoral fracture is about 20% in the first year.
How do you diagnose “frailty”?
Make a diagnosis of frailty if >3 of the following are present: unintentional weight loss >10 pounds/year, decreased hand strength, exhaustion due to lack of endurance, walking slowly, or reduced activity.
What assessments should be done periodically in elderly patients?
Elderly patients should have interval functional evaluation including ADLs, IADLs, cognition, hearing, vision, gait and balance, nutrition, and driving ability.
What are the major features of delirium, using the Confusion Assessment Method?
The major features of delirium in the Confusion Assessment Method are acute onset and fluctuating course, inattention, disorganized thinking,
What are the criteria that diagnose malnutrition?
Malnutrition is defined as any of the following: unintended weight loss >10 pounds in 6 months, BMI < 22, albumin < 3.8 g/dl, cholesterol < 160, any vitamin deficiency.
Which factors associated with aging, predispose patients to imbalance and falls?
The elderly have a stiffer, less agile gait with decreased position reflexes that predispose to falls. They also have impaired baroreceptors and frequently suffer from orthostatic hypotension.
What are the risk factors for falls in the elderly?
There are many risk factors for falls in the elderly. These include age, female gender, past history of falls, rugs and dim lighting, poor vision, orthostatic hypotension, unsteady gait, cognitive impairment, musculoskeletal disease, cardiovascular disease, peripheral neuropathy, and psychotropic drug use.
How does immobilization affect serum calcium levels?
Immobilization increases calcium levels.
What factors are associated with development of decubitus ulcers?
Moist environments, neurological impairment, and malnutrition are major risk factors for decubitus ulcers.
What is the role of wet-to-dry dressings in decubitus ulcer treatment?
Wet-to-dry dressings are not recommended for ulcer treatment as they also remove/damage friable new tissue.
What should you do for an elderly woman who is on chronic low-dose benzodiazepines for “nerves”?
Elderly patients on benzodiazepines should be slowly weaned off these medicines over 3-6 months after first switching to a water-soluble form such as oxazepam.
What is the average age of menopause?
The average age of menopause is 51 years.
What is “andropause”?
Male symptoms of low testosterone with low free testosterone is termed “andropause”.
What is the typical presentation of Paget disease?
Paget disease affects 1% of people > 40 in the U.S. It is typically discovered by elevated alkaline phosphatase in an asymptomatic person.
What complications are geriatric patients specifically at risk for developing as they are being treated for diabetes?
Elderly patients are particularly at risk for hypoglycemia when treated for diabetes.
Metformin should not be given to patients with estimated GFR below what calculation?
Metformin should not be used if GFR is < 60 cc/min regardless of age.
What is apathetic hyperthyroidism?
Apathetic hyperthyroidism presents with apathy, fatigue, anorexia/weight loss, and tachycardia.
What are the main features of delirium? Precipitating factors?
The main features of delirium are abnormal attention span, disorganized thinking, and altered consciousness. Common precipitating factors include drugs, poor nutritional status, and acute illness.
How is delirium different from “sundowning”?
Sundowning is a disturbance of behavior that occurs predictably in the evening. It is not associated with a precipitating illness.
What is the recommended initial therapy for elderly patients with delirium? What are some options for drug therapy, and what are their associated risks?
Initial treatment of delirium is supportive with focus on diagnosis and treatment of the underlying cause. Medication treatment options include haloperidol (QT prolongation and parkinsonism). Risperidone, olanzapine, and quetiapine have fewer side effects but are associated with increased mortality with long-term use.
How is dementia different from delirium?
Patients with dementia have a progressive deterioration in cognitive function but without altered consciousness as seen in patients with delirium.
What are the 3 most common causes of dementia in the U.S.?
The 3 most common causes of dementia in the U.S. are Alzheimer disease (80%), multi-infarct dementia, and dementia with Lewy bodies.
When do patients derive the greatest benefit from Alzheimer treatment?
The benefit of treating Alzheimer disease is greatest early in the disease process.
What are the common symptoms of geriatric depression? What are the common side effects of medications for depression?
Dysphoria, psychomotor slowing, anorexia, weight loss, and multiple aches and pains are the most common symptoms of depression in the elderly. Common side effects of antidepressants include GI complaints, tremor, and sexual dysfunction.
Name some medicines typically linked to insomnia in the elderly.
Medications linked to insomnia in the elderly include beta-blockers, beta-agonists, and corticosteroids.
What is the role of benzodiazepines in treatment of insomnia?
Benzodiazepines can help insomnia by reducing time to fall asleep, reducing awakenings, and increasing duration of sleep. However, they have many negative effects including addiction, memory loss, drowsiness, dizziness, and impaired coordination.
What dangerous side effects are sometimes seen with both benzodiazepine and non-benzodiazepine sleep agents?
Benzodiazepines should be avoided in the elderly due to confusion, wandering, imbalance, and daytime grogginess.
What is the common condition associated with restless leg syndrome?
Restless leg syndrome is commonly associated with iron deficiency, dialysis, diabetic peripheral neuropathy, Parkinson disease, and pregnancy.
What type is dizziness is caused by deficits in visual, hearing, neurologic, and orthopedic functioning? What can help these symptoms?
Disequilibrium is a multifactorial problem caused by deficits in vision, hearing, neurologic, and orthopedic functioning. Treat this by targeting each deficit and use of assistive devices like walkers and canes.
Which maneuver helps identify benign paroxysmal positional vertigo?
BPPV is diagnosed with the Dix-Hallpike maneuver.
What are the GOLD recommendations for diagnosis of asthma in the elderly?
In the elderly, the GOLD recommendations use an FEV1/FVC <89% lower limit of normal for age to diagnose asthma, rather than using a 70% cutoff. A response to bronchodilator should be >200 cc increase in FEV1 and >12% predicted post-bronchodilator.
Is urinary incontinence considered a normal consequence of aging?
Urinary incontinence is not a normal consequence of aging.
What are the 4 types of incontinence?
The 4 types of incontinence are stress, urge, mixed, and incomplete bladder emptying (“overflow”) incontinence.
What is the best treatment for urge incontinence?
Bladder training is more effective than the more commonly prescribed antimuscarinic medications.
What is the best treatment for stress urinary incontinence?
Behavioral therapy, especially Kegel exercises, is the best initial treatment for stress urinary incontinence.
What is a common cause for incomplete bladder emptying in males?
Incomplete bladder emptying in males is usually due to BPH.
What is the role of bladder catheterization in the treatment of geriatric incontinence?
Incontinence is NEVER an indication for long-term bladder catheterization.
Name a scenario in which a physician can ethically have a sexual relationship with a patient.
It is absolutely unethical for a physician to have a sexual relationship with a current patient.
You see a colleague drinking shots in a bar shortly before his 12-hour shift in the emergency department. Are you obligated to inform anyone?
A physician is obligated to report this to the colleague’s supervisor or the medical board.
What is the difference between an advance directive and a living will?
A living will is a specific form of advance directive which outlines what the patient would want done in specific situations.
About 6 months ago, a man with terminal cancer decided to invoke a living will that states he refuses all life support in case of cardiopulmonary arrest. Today, he presents to the emergency department in severe distress and says he wants everything done, including intubation. His family does not want anything done; you have the signed living will at the bedside. What should you do?
You should follow the patient’s current wishes as he is capacitated to make this decision. The desires of his family and the patient’s previous living will should not be followed given the patient’s current decision.
What is the difference between hospice and palliative care?
Palliative care focuses on symptom management. Patients in palliative care may continue to receive aggressive treatments. Hospice is a subset of palliative care which is focused solely on provision of comfort care.
Describe the causes of pain and adjuvant medications that can be used for each type of pain.
Causes of pain include neuropathic pain, nociceptive pain (somatic pain and visceral pain), and non-physical pain. Adjuvant medicines for neuropathic pain include antidepressants, anticonvulsants (gabapentin, pregabalin, valproic acid, and carbamazepine. Steroids and NSAIDs may help if there is irritation around a nerve. Bone pain may respond to steroids, NSAIDs, bisphosphonates, and external beam radiation.
What opioids should be avoided in renal failure?
Avoid codeine and morphine if GFR < 30. Use caution with hydrocodone and oxycodone. Fentanyl and methadone are the safest in renal failure.
