General internal medicine Flashcards
Approach to breast cancer screening in women aged 40-49
Individualized, shared decision making
Postoperative VTE prophylaxis in patient undergoing major orthopedic surgery (hip, knee)
Continue low molecular weight heparin following hospital discharge for up to 35 days
First line for neuropathic pain syndromes
- SNRI’s (duloxetine)
- Gabapentin
FDA warning about gabapentinoids
May cause respiratory depression in patients with opioid use and COPD
Management of depression at the end of life
methylphenidate
Treatment of bacterial conjunctivitis
Trimethoprim-polymyxin B or erythromycin topical abx
Treatment of eye irritation due to seasonal allergies
olopatadine ophthalmic drops
What does acceptability of number needed to treat depend on?
Risks associated with the condition, cost and side effects of treatment
Treatment of choice for bacterial prostatitis
6 week course of bactrim or cipro (most due to e coli)
Vaccination of a health care worker
- 2nd dose of MMR (increased risk of contracting measles, mumps, and rubella) (if not received in childhood)
- Hep B vaccination
Management of in-flight medical emergency
Connect with ground-based physician (most airlines have 24-hour call centers with a ground-based physician to aid in event of an in-flight emergency)
Management of elderly patient with advise on driving who has multiple risk factors for accidents
Advise patient to stop driving
risk factors for accidents
Cognitive impairment, minor accidents, concerns from family members
Clinical features of systemic exertion intolerance disease (SEID)
Fatigue of at least 6 months duration Postexertional malaise Unrefreshing sleep Cognitive impairment Orthostatic intolerance (symptoms worse when standing up)
First step with suspected cauda equina
STAT MRI
Evaluation of a breast mass
IF younger than 30 + low risk mass –> just US (breast tissue is more dense in younger women which limits utility of mammography)
IF older than 30 –> mammograph + US
What is the definition of a breast mass
Lesion that persists throughout the menstrual cycle and differs from the surrounding breast tissue
Main utility of US in evaluation of breast masses
Ability to differentiate cystic from solid lesions
appearance of breast cyst on exam
Symmetric, round borders, mobile
Next step if US reveals a solid lesion in young woman with breast mass
biopsy
Indications for bariatric surgery
Patient who doesn’t lose weight with lifestyle modifications
BMI of 40 or greater
OR BMI of 35 + obesity-related comorbid conditions
Features of ACE inhibitor induced cough
Dry cough + within 1-2 weeks of starting ACEi
Term for genetic cunsomer testing
Direct-to-consumer (DTC) genetic testing
How most consumer genetic testing works + clinical relevance
- Genotyping Single-nucleotide polymorphisms (SNPs)
- common but low penetrance (therfore most people don’t develop disease and thus contribute little to overall disease risk)
USPSTF recommendation on prostate cancer screening
Age 55-69 – Discuss potential benefits and harms of PSA screening for PC
USPSTF recommendation on aspirin and colorectal cancer
Adults 50-59 with a 10 year ASCVD risk of 10% or higher
Initial evaluation of chronic insomnia
Sleep diary (need to identify adverse environmental factors, inappropriate exposure to screens)
Lab correlated with restless legs syndrome
Low ferritin
Clinical features of optic neuritis
Acute vision loss + eye pain with movement + color perception change + afferent pupillary defect + often woman with MS
Cervical cancer screening
Age 25-65
- HPV/Pap cotest every 5 years or a Pap test every 3 years.
When cervical cancer screening can be discontinued
Age 65 when *patient has had adequate prior negative screening
Initial evaluation of cognitive impairment in the elderly
Abbreviated testing such as –
Mini-Cog
Mini-Mental State Examination (now proprietary though with cost per use)
Montreal Cognitive Assessment
*don’t usually need formal neurocognitive testing beyond these to diagnose cognitive impairment
Cervical sprain clinical features
Aching sensation isolated to neck + decreased ROM + tenderness to palpation
- most common cause of neck pain
Myelopathy definition
Spinal cord injury caused by severe compression
Next step after patient is diagnosed and treated for trichomonas vaginalis infection
- Treat partner (empirically, don’t test) + screen for other STIs (highly correlated with HIV)
- Retest woman after 3 months also
new term for hypochondriasis
illness anxiety disorder
Definition of somatic symptom disorder
One or more somatic symptoms + at least 6 months + significant impact on life + associated with excessive thoughts or feelings related to symptoms
Other drugs and classes of drugs that can cause lower extremity edema
- Vasodilators (minoxidil, hydral, CCB’s, alpha-blockers)
- NSAIDS
- pregabalin (calcium channel blocker)
MDD criteria
5 of 9 symptoms
Physical exam finding that suggests epidydimitis
Positive Prehn sign (relief of pain with scrotal elevation)
Physical exam finding that suggests varicocele
Scrotal mass that increases with standing and decreases while supine
Study used to identify a hydrocele
transillumination study (mass will transilluminate if hydrocele)
pharmacologic treatment of low back pain per boards (once nonpharmacologic options fail)
NSAIDs at lowest possible dose
- little to no evidence that acetaminophen is effective in reducing pain
evaluation of recurrent unilateral epistaxis
Nasal endoscopy (rule out neoplasm)
Preoperative DAPT management for patient who has had STENT placed recently
Hold plavix 5-7 days before surgery (assuming minimum of 30 days if bare metal or 3 months after drug-eluting)
Pneumovax indicatinos
Age 19-64 w/ chronic heart, liver, or lung disease, **DM2, CSF leak, *alcoholic, or cigarette smoking
Zoster indication
All adults 50 or older
PCV13 indications
19-64 w/ immunocompromise, cochlear implants, or history of CSF leaks + all adults 65 or older
difference between bulimia and binging subtype of anorexia nervosa
Patients with anorexia nervosa have a low BMI
Management of cyclic mastalgia
Wear well-fitting bra
How to determine if vertigo is central (ie vertebrobasilar ischemia, infarction, hemorrhage)
- Dix-Hallpike, which produces nystagmus with immediate onset + nystagmus of long duration + nystagmus direction varies depending on direction of patient’s gaze
Knee condition caused by repetitive stress on anterior knee
prepatellar bursitis
Management of prepatellar bursitis
Fluid aspiration w/ gram stain and culture (can also be caused by gout and infection)
how to prevent pressure ulcers
- advanced static mattress (made of specialized sheepskin, foam or gel)
USPSTF recommendation on screening for HIV
One-time of anyone over age 15 + repeat for high-risk people
indication for fibrates
fasting triglyceride level of 500 or higher (to prevent pancreatitis)
workup of suspected overflow incontinence
PVR
Term for continence due to neurogenic bladder + presentation
- (overflow incontinence)
- constant urine leaking and dribbling
common causes of overflow incontinence
*BPH (outflow obstruction)
DM2 (neurogenic bladder)
clinical features of chronic pelvic pain syndrome
chronic pelvic/perineal pain + intermittent voiding symptoms + no evidence of infection
treatment of chronic pelvic pain syndrome
Neuromodulatory meds (pregabalin, gabapentin, nortriptyline)
Management of somatic symptom disorder
CBT
central retinal artery occlusion clinical features
painless
acute loss of vision
APD
*cherry red spot
acute angle-closure glaucoma presentation
severe eye pain + vision loss
New term for pseudotumor cerebri
idiopathic intracranial hypertension
idiopathic intracranial hypertension clinical features
diplopia + headache + bilateral visual symptoms + papilledema
retinal detachment clinical features
- photopsias (flashes of light)
- floaters
- progressive vision compromise that my involve partial visual fields
management of patient with severe refractory dyspnea/end stage COPD who doesn’t want further medical therapy
low dose oral opioids
High ankle sprain exam features
- pain elicited by compressing the leg at mid-calf (squeeze test)
- pain elicited by having patient cross the legs with the lateral malleolus of the injured leg resting on the other knee (Crossed-leg test)
Treatment of vulvovaginal candidiasis
Intravaginal azole
Evaluation of obesity
BP
Fasting blood glucose or A1c
Lipid panel
*TSH not needed, prevalence of endocrine cause of obesity is very low, should be reserved for patients with symptoms of thyroid disease.
Treatment of unexplained chronic cough
Multimodal speech therapy (teaches you how to suppress cough, breathing exercises)
Treatment of medically unexplained symptoms
CBT
Imaging for nonspecific low back pain?
- not indicated
- only indicated if neuro deficits,
Function of APC gene
Tumor suppressor gene
Clinical presentation of patients with APC gene mutations
High penetrance (almost all develop colon cancer with most developing colon cancer before age 40)
Particular NSAID that has been shown to cause regression of colorectal adenomas in FAP
Sulindac
AAA screening guideline
65-75
+ EVER smoker (even if quite greater than 15 years ago)
Osteoporosis screening in men
- INSUFFICIENT evidence per USPSTF
lung cancer screening guidelines
Age 55-80 years + **20 pack year smoking history + have quit within past 15 years
Score for determining patients response to medical treatment
FRAIL
Meralgia paresthetica presentation
Paresthesias on anterolateral thigh
Noncyclic mastalgia clinical features
Focal breast pain but no palpable mass
Umbrella term for trauma, cysts, duct ectasias, mastitis,
Noncyclic mastalgia management
Breast US (despite absence of mass, 1% have cancer at the site of pain)
Rule of thumb for correlation of likelihood ratios to increase in disease probability
LRs of 2,5,10 correspond to 15,30,45 percent increase in probability (add this percentage to pretest)
What is an LR in general?
Indicator of how much the result of a diagnostic test will increase or decrease the pretest probability of a disease
How to prevent post op VTE in pt at high risk for VTE
LMWH + SCDs
Management of radiation induced nausea on cancer patients + why
Zofran (radiation is thought to cause mucosal injury and subsequent serotonin release)
Cause of most pharyngitis
Typically all viral
Approach to pharyngitis/strep testing
Determine CENTOR criteria (fever, tonsillar exudates, tender anterior cervical LAD, absence of cough)
*3 or more = test for strep
other term for neurocardiogenic syncope
neurally mediated syncope
management of urgency urinary incontinence
First line = behavioral therapy (bladder training and scheduled voiding)
second line = anticholinergic agents or mirabegron
Cervical cancer screening in woman vaccinated against HPV
same as typical screening
HPV testing and age
Not indicated in women younger than 30 years (high prevalence of transient HPV in this age group)
varicocele treatment
Ibuprofen and scrotal support
scleritis clinical features
patient with RA
eye pain
pain w/ gentle palpation of the globe
photophobia
NSAIDs and bariatric surgery
Avoid (increased bleeding risk due to anastomoses and staple or suture lines and increased risk for marginal or gastric ulceration)
Antihypertensives safe for pregnancy
Methyldopa
Labetalol
CCB’s
patients with AF who need bridging prior to surgery
Only patients with mechanical valves
Management of recurrent major depression (3 or more episodes or persistent depression)
Long-term maintenance therapy with an SSRI
Management of cervical radiculopathy
Conservative – stretching and strengthening exercises of neck muscles w/ neck exercises (usually resolves within 2-3 months)
*only image if history of malignancy, progressive neuro symptoms, or myelopathy findings
HPV vaccination age range
11-12
13-26
Tdap vaccination indication if unknown
Indicated for all adults aged 19 years and older
Treatment of menopause
IF moderate to severe vasomotor symptoms (hot flashes, night sweats) + at low risk for breast cancer, coronary artery disease, stroke, or VTE –>
Labyrinthitis clinical features
- severe, persistent peripheral vertigo + hearing loss + preceded by a viral infection
Vestibular neuronitis clinical features
- preceded by a viral infection + NO hearing loss (unlike labyrinthitis)
Indications for antibiotics with sinusitis
- symptoms lasting more than 10 days, severe, high fever, purulent nasal discharge for at least 3 consecutive days
Preferred opioid for patients with cancer-related pain and CKD
hydromorphone
IF not opioid naive –> fentanyl patch
When preoperative cardiac stress testing is needed
1) Patients at elevated risk for a major cardiac event
2) Functional capacity can’t be determined
How to manage impairment (cognitive or substance use) in a physician colleague
Directly approach the colleague with concerns of impairment
- Unless patient harm seems likely, in which place you need to refer to state medical board
Management of ED in a patient who experiences nocturnal penile tumescence per boards
Psychotherapy or CBT (most likely situational or mood related)
Sildenafil contraindication
Nitrates
Management of patient with ED and symptomatic androgen deficiency
testosterone supplementation
Clinical features of morton neuroma
- pain between metatarsal heads
- sensation of walking on a pebble
- paresthesias
Plantar fasciitis features
Pain improves with walking
Model used for PDSA cycle
Model for Improvement
Management of functional incontinence in dementia patients
Prompted voiding every 2-3 hours
What is functional incontinence
Patient who can’t reach and use toilet in time (eg demented patients)
Management of abnormal uterine bleeding (without secondary cause) in woman with contraindication to combined OCP
first line = Progestin-containing IUD (levonorgestrel-containing IUD)
second line = endometrial ablation or hysterectomy
Persistent postural perceptual dizziness clinical features
Dizziness or imbalance that worsens with motion or upright positioning or movement of objects in surrounding environment + precipitated by another vestibular process (eg. trauma, BPPV, psych conditions)
Treatment for persistent postural perceptual dizziness
Vestibular therapy
SSRI or SNRI’s
Lead-time bias concept
Early detection of a disease with a screening test leads to an increase in measured survival but not overall survival time (patient is diagnosed earlier during preclinical phase but intervention doesn’t enable patient to live any longer)
selection bias concept
Study participants don’t accurately reflect population being studied
First line therapy for alcohol use disorder
Naltrexone
Step before initiating statin therapy always
CMP (ALT)
When to screen for diabetes
Overweight + one other RF for DM2 (loosely defined)
*IF over age 45 –> everyone
Criteria for BV diagnosis
- Clue cells
- positive whiff test (can be negative
- pH greater than 4.5 (loss of hydrogen-producing lactobacilli and subsequent overgrowth of g vaginalis, mycoplasma)
- thin and homogenous vaginal discharge
BV treatment
Metronidazole or clindamycin
Management of BPH if patient also has ED
Tadalafil
Diagnosis of BPH
Enlarged prostate on rectal exam + LUTS
Perioperative management of aspirin in patient with stent
Continue unless bleeding risk is prohibitively high
Management of high breast density in mammogram
IF no additional breast cancer RF’s –> no additional screening (although breast density is an RF for breast cancer, further imaging with MRI has not been shown to have a survival benefit)
IF additional breast cancer RF’s –> breast MRI in addition to mammogram
What is digital breast tomosynthesis?
Imaging technology that creates a three-dimensional image of the breast. Has been found to have sensitivity equal to or exceeding sensitivity of mammogram in detection of breast cancer in women with dense breasts but there isn’t enough RCTs or long term data to support it.
Management of chronic pain when alternative methods have failed and patient has ESRD
cannabis oil
management of baker cyst
no treatment
Next step after determining peripheral vs central vertigo
MRI brain (rule out stroke) + MRA
Presentation of central vertigo
- usually have concomitant neurologic findings (eg ataxia, nystagmus, dysphagia, dysarthria, diplopia, postural instability, hemiparesis)
Initial step for weight loss
First line = high-intensity behavioral therapy program (regular self monitoring of weight and calorie intake). Must be long term and require monthly contact.
Second line = pharmacologic therapy (phentermine, low dose topamax)
medication used to reverse opioid-induced constipation
Methylnaltrexone
Greater trochanteric pain syndrome (trochanteric bursitis) clinical presentation
Lateral hip pain + radiating down lateral leg to knee + pain over palpation of trochanter
trochanteric bursitis treatment
Activity modification
APAP or NSAIDs
PT
Term for pale dry vaginal mucosa + vaginal pain following menopause + vulvar itching
Genitourinary syndrome of menopause
Vulvar lichen sclerosus clinical features
- white, atrophic patches on skin + patches circumferentially involve vaginal introitus and perianal area (“figure 8” appearance)
First step before prescribing long term opioids for pain
Opioid risk assessment
- IF high risk for opioid overdose –> prescribe naloxone
When to hold NOACs before surgery
2 (low bleeding risk) or 3 (high bleeding risk) days
Pes anserine bursitis location + clinical features
…
Indications for bisphosphonates on chronic steroids
1) ALL men over 50 and postmenopausal women taking 7.5 mg/day or more of pred for anticipated course of 3 months
2) 10-year fracture risk greater than 20% regardless of dose or duration
Treatment duration of SSRI for single episode of major depressive disorder + multiple episodes
6 months following acute response (continuation phase treatment) – then gradually taper and discontinue
IF 2 episodes – 1-3 following remission
Management of UC flare
Systemic steroids + high dose 5-aminosalicylic acid compounds
IF signs of severe systemic toxicity Or toxic megacolon OR peritonitis – empiric abx
