General Internal Medicine Flashcards
1
Q
Define first-order kinetics.
A
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.
2
Q
How many half-lives does it take to eliminate a drug from the system?
A
A drug will be 97% eliminated from the body at 5 half-lives.
3
Q
What does TMP/SMX do to the INR in patients on warfarin?
A
TMP/SMX markedly raises the INR within the first few days of therapy.
4
Q
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)?
A
With 90% sensitivity, testing 100 woman with breast cancer would yield 90 positive tests.
5
Q
Which of the following take into account disease prevalence: sensitivity, specificity, PPV, NPV?
A
Prevalence of disease affects the predictive value (both PPV and NPV) of a test.
6
Q
Define positive and negative likelihood ratios in terms of sensitivity and specificity.
A
\+LR = sensitivity/(1-specificity). -LR = (1-sensitivity)/specificity
7
Q
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?
A
No, the p value of 0.2 means that this result is not statistically significant.
8
Q
What is the cutoff p value that is considered statistically significant?
A
A result is statistically significant if the p value is <0.05.
9
Q
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?
A
Yes, it would be worthwhile to consider this treatment since the 95% confidence interval does not cross 1.
10
Q
Be able to calculate the NNT.
A
NNT = 1/ARR
11
Q
What are the risk factors for osteoporosis?
A
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.
12
Q
How do you screen for osteoporosis?
A
DXA is the preferred method for screening for osteoporosis.
13
Q
How are the Z-score and T-score used in the evaluation of osteoporosis?
A
Osteoporosis and osteopenia are defined by the T-score which is the comparison to young, healthy bone.
14
Q
What are the common recommendations for all patients with osteoporosis?
A
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.
15
Q
Which patients should be treated with drug therapy for osteoporosis?
A
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.
16
Q
For how long can teriparatide be used? Why?
A
Teriparatide can be used for only 2 years because of increased risk of osteosarcoma.
17
Q
A patient on alendronate presents with difficulty swallowing. What is the likely etiology?
A
A patient on alendronate who develops difficulty swallowing should be suspected to have pill-induced esophagitis/ulcer.
18
Q
What is the most serious consequence of osteoporosis?
A
Fractures are the most serious complication of osteoporosis. Mortality for proximal femoral fracture is about 20% in the first year.
19
Q
How do you diagnose “frailty”?
A
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.
20
Q
What assessments should be done periodically in elderly patients?
A
Elderly patients should have interval functional evaluation including ADLs, IADLs, cognition, hearing, vision, gait and balance, nutrition, and driving ability.
21
Q
What are the major features of delirium, using the Confusion Assessment Method?
A
The major features of delirium in the Confusion Assessment Method are acute onset and fluctuating course, inattention, disorganized thinking,
22
Q
What are the criteria that diagnose malnutrition?
A
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.
23
Q
Which factors associated with aging, predispose patients to imbalance and falls?
A
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.
24
Q
What are the risk factors for falls in the elderly?
A
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.
25
How does immobilization affect serum calcium levels?
Immobilization increases calcium levels.
26
What factors are associated with development of decubitus ulcers?
Moist environments, neurological impairment, and malnutrition are major risk factors for decubitus ulcers.
27
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.
28
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.
29
What is the average age of menopause?
The average age of menopause is 51 years.
30
What is “andropause”?
Male symptoms of low testosterone with low free testosterone is termed “andropause”.
31
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.
32
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.
33
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.
34
What is apathetic hyperthyroidism?
Apathetic hyperthyroidism presents with apathy, fatigue, anorexia/weight loss, and tachycardia.
35
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.
36
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.
37
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.
38
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.
39
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.
40
When do patients derive the greatest benefit from Alzheimer treatment?
The benefit of treating Alzheimer disease is greatest early in the disease process.
41
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.
42
Name some medicines typically linked to insomnia in the elderly.
Medications linked to insomnia in the elderly include beta-blockers, beta-agonists, and corticosteroids.
43
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.
44
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.
45
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.
46
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.
47
Which maneuver helps identify benign paroxysmal positional vertigo?
BPPV is diagnosed with the Dix-Hallpike maneuver.
48
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.
49
Is urinary incontinence considered a normal consequence of aging?
Urinary incontinence is not a normal consequence of aging.
50
What are the 4 types of incontinence?
The 4 types of incontinence are stress, urge, mixed, and incomplete bladder emptying (“overflow”) incontinence.
51
What is the best treatment for urge incontinence?
Bladder training is more effective than the more commonly prescribed antimuscarinic medications.
52
What is the best treatment for stress urinary incontinence?
Behavioral therapy, especially Kegel exercises, is the best initial treatment for stress urinary incontinence.
53
What is a common cause for incomplete bladder emptying in males?
Incomplete bladder emptying in males is usually due to BPH.
54
What is the role of bladder catheterization in the treatment of geriatric incontinence?
Incontinence is NEVER an indication for long-term bladder catheterization.
55
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.
56
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.
57
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.
58
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.
59
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.
60
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.
61
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.
62
Describe the steps in terminal extubation.
Prior to extubation counsel families on what to expect. Remove all monitors and restraints. Stop life-sustaining treatments. Premedicate patient with an opioid and benzodiazepine, and dose further with bolus doses. Manage secretions.
63
What are the differences among process measurement, outcome measurement, and balancing measurement?
Process measures are what we do. Outcome measures are the results of what we do. Balancing measures are the unintended consequences of our changes in one or more parts of the system.
64
Name the 4 elements of the PDSA cycle.
Plan, Do, Study, Act.
65
Is FMEA used before or after an adverse outcome occurs?
FMEA is used before an adverse outcome to analysis the potential effects of system failures.
66
Define a sentinel event.
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
67
What do six sigma projects attempt to accomplish?
Six sigma projects attempt to reduce variation to increase quality by making a process more predictable and effective.
68
What is the goal of lean management?
The goal of lean management is to enhance customer value by eliminating waste.
69
What is a just culture?
Just culture eliminates punishment for an unintentional human error and instead focuses on redesigning process flaws to improve patient safety.
70
Why do hospitals use HCAHPS?
Hospitals use HCAHPS because they are tied to hospital reimbursement and publicly reported.
71
Know the 5 step process used in determining if a patient requires a pre-op cardiac evaluation.
Step 1: Does the patient need emergent surgery?
Step 2: Does the patient have an active cardiac condition?
Step 3: Is the patient undergoing low-risk surgery?
Step 4: Does the patient have good functional capacity? If so, proceed with medium to high-risk non-cardiac surgery.
Step 5: If the patient has 3 or more clinical risk factors consider starting a beta-blocker preoperatively.
72
What is a simple, easy method to assess functional capacity?
Use METS to assess functional capacity. Think of 4 METs as being able to walk 4 city blocks at 3-4 mph or up 2 flights of stairs.
73
Which patients are started on beta-blockers before surgery?
Patients with 3 or more clinical risk factors should be considered for preoperative beta-blockers. These clinical risk factors include 1. history of ischemic heart disease, 2. heart failure history, 3. history of cerebrovascular disease, 4. diabetes requiring insulin, 5. renal insufficiency (creatinine > 2 mg/dl).
74
Know the preoperative screening labs and who gets them.
Hematocrit is recommended for those >65 years of age and all surgeries that may result in major blood loss. Electrolytes should be checked only if there is a clinical reason to expect abnormal results. Creatinine should be checked in those > 50yo, major vascular surgery, hypotension is likely, and nephrotoxic drugs will be used.
75
Who needs endocarditis prophylaxis?
Endocarditis prophylaxis is indicated for those with artificial heart valves, previous endocarditis, congenital heart defects, and heart transplant patients who develop valvulopathy.
76
What is the BP cutoff for treatment in the perioperative period?
Patients with BP not exceeding 170/110 can proceed with elective surgery. In the perioperative period control BP exceeding 180/110 with hydralazine, labetalol, or nicardipine.
77
How do you treat postoperative atrial fibrillation?
In postoperative atrial fibrillation use beta-blockers, calcium channel blockers, or amiodarone to control heart rate to a goal HR < 110. If patient cannot tolerate the arrhythmia consider cardioversion. If arrhythmia last greater than 24-48 hours consider anticoagulation based on CHADS2 score.
78
What is the preferred postoperative method for DVT prophylaxis?
In general, LMWH is preferred over other agents for postoperative DVT prophylaxis unless CrCl is < 30 ml/min.
79
Know diabetic perioperative management. How do you manage insulin?
Patients on a continuous insulin pump can continue their basal insulin. Short-acting insulin should not be taken the morning of surgery. Reduce long-acting insulin by 25-50%. Hold oral diabetic medications on the morning of surgery.
80
What is thyroid storm?
Thyroid storm is a medical emergency with 10-30% mortality which can be precipitated by surgery. It presents with fever, tachycardia, heart failure, CNS and GI dysfunction.
81
Who should receive stress-dose steroids?
Patients on prednisone > 20 mg/day for > 3 weeks should receive stress dose steroids starting 12-24 hours prior to surgery.
82
Know how to manage postoperative delirium.
Treatment of postoperative delirium should be directed at treating the underlying cause. Antipsychotics can be used to control behavioral symptoms. Benzodiazepines should only be used if delirium is related to alcohol withdrawal.
83
What patient education topics should you review and counsel patients about periodically?
Patients should periodically be counseled on tobacco, alcohol, firearms, substance abuse, physical activity, and obesity.
84
What are the screening indications for patients at risk for AAA? Do they apply to women?
A man over 65 with any history of tobacco use should be screened once for AAA. There is no recommendation to screen women for AAA.
85
Should you do a PSA screening in a 75-year old man?
PSA screening is controversial. However, there is no evidence for benefit in men over the age of 70.
86
When should Pap smears be initiated?
Pap smears should be initiated at age 21.
87
What are the USPSTF indications for lung cancer screening?
Low dose chest CT is indicated for patients 55-79 years of age who are current smokers or have quit in the past 15 years who have at least a 30 pack-year history.
88
What external forces contribute to pressure ulcers in immobilized patients?
External forces that contribute to pressure ulcers in immobilized patients include friction, moisture, and shearing forces.
89
What is the difference between airborne and droplet precautions?
Droplets are large particle aerosols which do not remain in the air and are blocked by a standard surgical mask. Airborne precautions are needed for infections with small particles that remain suspended in air. These require an N-95 mask or powered air purifying respirator (PAPR). These include TB, measles, SARS, varicella infection, or herpes zoster (if disseminated or in the immunocompromised).
90
List 5 ACO “never events”.
“Never events” are events that do occur, but they should never occur if the patient is receiving competent healthcare. These include foreign body retained after surgery, stage 3 and 4 pressure ulcers, catheter-associated UTI, patient suicide, and wrong site surgery.
91
What is the goal of the accountable care organization?
The goal of an ACO is to provide high-quality, coordinated care to CMS patients while avoiding duplication of medical services and serious hospitalization medical errors.
92
What are the procedures and tests that you should consider for general management of an obtunded patient?
Empiric management of the obtunded patient is guided by history, physical exam, and vital signs. First, you should assess ABCs. further management includes IV D50 if glucose is low, thiamine 100mg IM or IV, ABG, basic chemistries, urine and serum tox screen. Measure salicylate and acetaminophen levels. CXR and supplemental oxygen as needed. Naloxone IV if opioid overdose suspected.
93
Activated charcoal is not used for which overdoses?
Activated charcoal is not effective is overdose is with the heavy metals lithium and iron.
94
Which acid-base disorder is classically found when a patient presents with ASA overdose?
ASA overdose typically presents with HAGMA and respiratory alkalosis.
95
Which drug is used to treat acetaminophen overdose?
N-acetyl cysteine is used to treat acetaminophen overdose.
96
What are the findings in anticholinergic overdose?
Those with anticholinergic overdose are “red as a beet, dry as a bone, hot as a hare, mad as a hatter, and full as a flask”.
97
Which ECG finding correlates most closely with the degree of intoxication with a tricyclic antidepressant?
QRS prolongation is most closely correlated with the degree of tricyclic intoxication.
98
For tricyclic overdose, where should you keep the serum pH?
Alkalinization to serum pH 7.5-7.55 helps prevent the cardiac arrhythmias associated with tricyclic overdose.
99
A 30-year old man presents with acute MI. Which illicit drug should be ruled out as the cause?
Cocaine should be ruled out as a cause of MI in a young patient.
100
Methanol causes which neurologic deficit?
Visual impairment, from blurred vision to blindness, is associated with methanol ingestion.
101
Does ethylene glycol cause an increased osmolal gap, anion gap, or both?
Ethylene glycol causes an increased anion gap and osmolal gap.
102
Know carbon monoxide poisoning.
Think of carbon monoxide poisoning in someone who presents with altered mentation, especially during the winter. Poisoning can cause long-term to permanent CNS impairment. Treat with 100% oxygen or hyperbaric oxygen.
103
What are the 3 drugs used to treat cyanide poisoning?
Step 1: Hold amyl nitrate under patient’s nose for 30 seconds.
Step 2: Administer 3% sodium nitrate IV.
Step 3: Administer sodium thiosulfate IV.
104
How do you check for ongoing inorganic lead exposure? What about an exposure 2 years ago? 10 years ago?
For ongoing inorganic lead exposure check whole blood lead level. After exposure, RBC protoporphyrin levels and zinc protoporphyrin levels remains elevated for months. To evaluate exposure from years before, measure urine lead 24 hours after giving 1g of EDTA.
105
What is the treatment of organophosphate poisoning?
The treatment for organophosphate poisoning is IV/IM pralidoxime.
106
What are the pupillary findings in heroin withdrawal?
Patients with heroin withdrawal have dilated pupils.
107
What is the difference between alcohol withdrawal hallucinosis and DTs?
Patients with alcohol withdrawal hallucinosis have normal sensorium but start to develop auditory or visual hallucinations. With DTs the patient develops delirium.
108
Which medication can precipitate seizures in patients with DTs?
Haloperidol can precipitate seizures in a patient with DTs.
109
What is the difference between open-angle and angle-closure glaucoma? Which is a medical emergency?
In open-angle glaucoma there is no closure of the inlet of the trabecular network. Angle-closure glaucoma is a medical emergency.
110
What is the treatment for open-angle glaucoma? Angle-closure glaucoma?
Open-angle glaucoma is treated with topical prostaglandins (1st line) or topical beta-blockers. Angle-closure glaucoma is treated by laser iridotomy.
111
Describe the findings with retinal detachment.
Retinal detachment presents with flashes or streaks of light or a “shade pulled down” or “curtain waving” in a portion of the visual field. On exam, a portion of the retina may appear raised or folded.
112
What is the treatment for retinal detachment?
Retinal detachment is treated with surgical repair or vitrectomy.
113
How do retinal artery occlusion and retinal vein thrombosis differ?
Both retinal artery occlusion and retinal vein thrombosis cause acute, painless vision loss. In retinal artery occlusion, there is a cherry red fovea. In retinal vein thrombosis the fundus has a “blood and thunder” appearance of multiple hemorrhages.
114
What is the most common cause of acquired legal blindness in the U.S.?
The most common cause of acquired legal blindness in the U.S. is macular degeneration.
115
Optic neuritis can signal the development of what neurologic disorder?
Optic neuritis can signal the development of multiple sclerosis.
116
What is vitreous hemorrhage?
Vitreous hemorrhage causes sudden, painless vision loss. It is caused by either vitreous detachment tearing a retinal vessel or as a result of the fragile blood vessels in diabetics with neovascularization.
117
Know the eye movements controlled by the 3rd, 4th, and 6th cranial nerves, and the symptoms of their associated dysfunctions.
Most eye movements are controlled by the 3rd cranial nerve. The 6th CN innervates the lateral rectus muscle, and with paralysis the eye cannot move laterally. The 4th CN innervates the superior oblique muscle, and with paralysis the eye is deviated upward and head tilts toward the univolved side (Bielschowsky sign).
118
What virus is usually responsible for conjunctivitis?
Adenovirus is the virus most commonly responsible for viral conjunctivitis.
119
A contact lens wearer presents with severe keratitis and says she uses tap water frequently for lens care. Which organism should you consider?
Acanthamoeba should be suspected in a contact lens wearer who develops severe keratitis.
120
What is the best way to diagnose an acoustic neuroma?
MRI is the diagnostic test of choice for acoustic neuroma.
121
A Rinne test is done. The patient can hear the tuning fork more loudly when it is on the bone. What does this mean?
A Rinne test revealing louder hearing when tuning fork is placed on bone is consistent with conductive hearing loss.
122
A Weber test is done on the same patient. He can hear sounds more loudly on the left side. What does this mean?
The combination of better hearing when tuning fork is placed on bone with Weber lateralizing to the left ear suggests left sided conductive hearing loss.
123
A young woman presents with weight loss and lack of menses for 6 months. What diagnosis should you consider?
Anorexia nervosa should be considered in a young woman with weight loss and lack of menses for 6 months.
124
How does anorexia nervosa differ from bulimia?
Anorexia patients are generally more than 15% below ideal body weight whereas bulimic patients are rarely under 85% of ideal weight.
125
Describe the clinical features of neuroleptic malignant syndrome.
Neuroleptic malignant syndrome presents with autonomic instability, extrapyramidal symptoms, and fevers.
126
What is the risk of disease in each child of a parent affected with an autosomal dominant disease?
Each child of a parent with an autosomal dominant disease has a 50% risk of having the disease.
127
What chance does the daughter of a male with an X-linked disease have of being a carrier?
The daughter of a male with an X-linked disease has a 100% chance of being a carrier.
128
Define the Philadelphia chromosome.
The Philadelphia chromosome is the first chromosomal abnormality found to be associated with malignancy (CML). It is a translocation of 9:22 which causes the c-ABL protooncogene to be moved from chromosome 9 to 22.
129
How does prostatic hyperplasia affect PSA levels?
PSA levels increase as the prostate increases in size.
130
What is the initial treatment for BPH? Which medications are commonly used for treatment?
The initial treatment of BPH is behavioral therapy with reduced intake of caffeine and alcohol, reduced fluid intake before bed, and attempting to urinate twice to completely empty bladder. After these, alpha-blockers are used for rapid symptomatic treatment. Then 5-alpha-reductase inhibitors can be given to try to decrease the size of the prostate over time.
131
What is the most common cause of neurogenic ED?
The most common cause of neurogenic ED is diabetes.
132
If an exam presents a young male with ED who is on no medications, what is the most likely etiology?
ED in a young man who is on no medicines is most likely psychogenic.
133
What is the mechanism of action of sildenafil?
Sildenafil inhibits phosphodiesterase-5 leading to increased cGMP levels and vasodilation.
134
How do you differentiate acute scrotal pain caused by epididymitis from that caused by testicular torsion?
Acute testicular torsion causes sudden onset scrotal pain often accompanied by nausea and vomiting. There is often a lack of cremasteric reflex.
135
Know the common drugs to avoid in pregnancy.
Drugs to avoid in pregnancy include ACEIs, ARBs, nitroprusside, quinolones, doxycycline, metronidazole (in 1st trimester), aminoglycosides, radioactive iodine, methimazole, most antihistamines, warfarin, most antidepressants (can use fluoxetine, citalopram, and bupropion), TZDs, opioids, ASA, NSAIDs.
136
Are ACE inhibitors safe in pregnancy?
ACE-Is are not safe in pregnancy.
137
During which trimester is metronidazole contraindicated?
Metronidazole is contraindicated in the 1st trimester.
138
A pregnant woman has a DVT. Which commonly used anticoagulant is contraindicated?
Warfarin is contraindicated in pregnancy.
139
Is an S3 gallop normal in pregnancy?
An S3 is considered a normal finding in pregnancy.
140
Is electrical cardioversion possible during pregnancy?
Electrical cardioversion can be performed during pregnancy.
141
What do you have to rule out in a pregnant patient who presents with new onset atrial fibrillation and pulmonary edema?
In a pregnant patient presenting with atrial fibrillation and pulmonary edema you need to rule out both mitral stenosis and secundum ASD.
142
How is peripartum cardiomyopathy treated?
Peripartum cardiomyopathy is treated similarly to other forms of heart failure. Women with persistently decreased LV EF should be counseled not to get pregnant again.
143
Should asymptomatic bacteriuria in a pregnant woman be treated?
Asymptomatic bacteriuria should be treated in pregnancy due to high risk of progression to pyelonephritis.
144
What is the maternal to fetal transmission rate of HIV without ART? With ART?
Without treatment, the maternal-to-fetal transmission risk for HIV is 30%. With ART this drops to < 1% with a 3 drug regimen.
145
Know the difference between preeclampsia and eclampsia.
Preeclampsia is pregnancy-induced hypertension which presents in the 3rd trimester and resolves with delivery. Eclampsia is defined as grand mal seizures in a woman with preeclampsia or gestational HTN.
146
How do you make a diagnosis of preeclampsia?
Preeclampsia is defined as SBP > 140 or DBP > 90 AND proteinuria > 300 mg in 24 hours in a pregnant woman > 20 weeks gestation.
147
What are the symptoms that may occur with preeclampsia?
Symptoms of preeclampsia may be mild (headache, vision changes) or severe (seizures, low platelets, stroke or intracranial hemorrhage, pulmonary edema, hepatic and/or renal failure, and placental abruption).
148
What is HELLP syndrome?
HELLP is a severe form of preeclampsia with hemolysis, thrombocytopenia and elevated lilver enzymes.
149
What is the treatment of postpartum thyroiditis?
In postpartum thyroiditis, use propranolol for significant hyperthyroid symptoms and thyroid replacement for hypothyroid symptoms or TSH > 10.
150
A pregnant woman has Graves disease. What can you do to treat her?
A pregnant woman with Graves disease should be treated with PTU and propranolol. Surgery can be considered in pregnant Graves disease patients with significant local compressive symptoms.
151
What is gestational diabetes, and how is it treated?
Gestational diabetes occurs in pregnant woman who cannot overcome the insulin resistant state of pregnancy. It is treated with insulin if diet and exercise do not provide adequate control.
152
What is a common mineral deficiency in pregnant women who have not had prenatal care?
Iron deficiency is common in pregnant women who receive no prenatal care.
153
True or false? DUB usually does not require any workup.
False, DUB is a diagnosis of exclusion. Its many causes include hypothyroidism, liver disease, renal disease, coagulopathies, pregnancy complications, anatomic lesions, and drugs.
