Step Up-Ambulatory Medicine Flashcards
1
Q
What are the two most common causes of hypertension?
A
1) Essential HTN (95%) 2) OCPs are the most common secondary cause of HTN. Other secondary causes include renovascular disease, endocrine disorders, medications, coarctation and OSA.
2
Q
Why are patients with HTN at increased risk of CAD, PVD and CVA?
A
HTN accelerates atherosclerosis
3
Q
4 non-modifiable risk factors for HTN
A
1) Age > 60 2) Male 3) African-American 4) FHx
4
Q
3 modifiable risk factors for HTN
A
1) Obesity 2) Sodium intake 3) Alcohol intake > 2 oz.
5
Q
Complications of uncontrolled HTN
A
1) Cardiovascular: MI, CHF due to LVH, PVD, aortic dissection 2) Retinopathy: AV nicking, cotton wool spots, scotomata, hemorrhages, exudates and papilledema 3) CNS: hemorrhage, TIA, CVA and lacunar stroke 4) Renal: nephrosclerosis (atherosclerosis of afferent AND efferent arterioles), decreased GFR and ESRD
6
Q
Diabetic & renal disease definition of HTN
A
> 130/80
7
Q
A patient comes in for a BP check, how long should you wait if they just drank coffee or had a cigarette?
A
30 minutes
8
Q
A patient comes to clinic and has blood pressure elevations on two separate visits over a span > 4 weeks. You diagnose him with HTN and assess for target organ damage. What labs do you want to order at this time?
A
1) UA (proteinuria) 2) BMP (K, BUN, Cr) 3) FBG (r/o DM) 4) Lipid panel (minimize atherosclerosis) 5) ECG (check for LVH)
9
Q
When will most newly diagnosed patients with HTN get 2-drug tx from the start?
A
Stage II (> 160/100)
10
Q
What lifestyle modifications have the most profound effect on dropping BP?
A
DASH diet (8-14), q10kg wt. loss (5-20), 30 min exercise q5-6x/week (4-9), Na
11
Q
Best anti-HTN med for AAs? What if they have DM?
A
AAs = HCTZ. AA + DM = ACE-I is 1st line in all patients with DM due to its renal protective effect
12
Q
Lifestyle modification necessary for HCTZ to work?
A
Na restriction, otherwise hypokalemia will be exacerbated
13
Q
Best anti-HTN med for old men with BPH?
A
Alpha-blockers
14
Q
Meds usually tried in patients with HTN refractory to 1st and 2nd line therapy?
A
Vasodilators (hydralazine and minoxidil) in combination w/beta-blockers and diuretics
15
Q
Anti-HTN medications contraindicated in pregnancy?
A
ACE-I, ARBs, CCBs and thiazides. Beta-blockers and hydralazine are safe.
16
Q
Which anti-HTN is the best 1st line medication?
A
Unless there is a compelling reason HCTZ, dihydropyridine (CCB), ACE-I and ARBs are all commonly used as initial monotherapy.
17
Q
ACCOMPLISH trial findings regarding effectiveness of combination therapy
A
Benazepril + amlodipine was more effective than and ACE-I or CCB alone.
18
Q
A patient presents with HTN non-responsive to lifestyle modifications and 6 weeks of HCTZ. What is your next step?
A
Change to a different type of monotherapy before adding on a second medication.
19
Q
Who gets screening lipid testing?
A
All adults > 20 yrs q5 years
20
Q
What are the causes of primary dyslipidemia syndromes? How are they treated?
A
I) Exogenous HLD = chylomicrons, tx’d w/diet modification. IIa) Familial hypercholesterolemia = LDL, tx’d w/statins, niacin, cholestyramine. IIb) Combined hyperlipoproteinemia = LDL + VLDL, tx’d w/statins, niacin, gemfibrozil. III) Familial dysbetalipoproteinemia = IDL, tx’d w/gemfibrozil, niacin. IV) Endogenous HLD = VLDL, tx’d w/niacin, gemfibrozil, statins. V) Familial hypertriglyceridemia = VLDL + chylomicrons tx’d w/niacin, gemfibrozil
21
Q
Causes of secondary dyslipidemia?
A
Endocrine (hypothyroidism, DM, Cushing’s), Renal (nephrotic syndrome), ESLD, Meds (propranolol, HCTZ, estrogen, prednisone) and Pregnancy.
22
Q
Foods that will elevate LDL
A
Saturated fatty acids and cholesterol
23
Q
Foods that will elevate triglycerides (VLDL)?
A
High calorie diets and alcohol
24
Q
At what age do cholesterol levels stop increasing?
A
65
25
When do both genders have equal risk for HLD?
After menopause
26
How is LDL measured?
Total cholesterol - HDL - TG/5
27
LDL levels associated with significant increase in CAD risk
160
28
Total cholesterol levels associated with significant increase in CAD risk?
160-200, \> 240 is really bad
29
Why is HDL so good?
Every 10mg/dL increase = 50% decrease CAD risk. HDL 60 subtracts 1 point from risk.
30
Risk associated with total cholesterol to HDL ratio
31
A patient with DM presents with an LDL of 120, what is your next move?
Old guidelines say all DM patients with LDL \> 100 should be on a statin. They should be on a statin if LDL \> 70 if they have DM + CAD.
32
Labs to get routinely if you put your patient on a statin or fibrate?
LFTs, these can cause transaminase elevations. Statin should be discontinued in the setting of elevated transaminases. Note that patients on statins can also get benign CK elevations
33
Risk of hypertriglyceridemia
Associated w/CAD and pancreatitis
34
Labs to order when diagnosing someone who came back with a non-fasting elevation in their total cholesterol and drop in HDL?
Full fasting lipid panel (TChol, HDL, TGs, calculated LDL), TSH (hypothyroidism), LFTs (ESLD), BUN/Cr/UA (nephrotic) and HbA1c (DM).
35
Statins listed most to least potent
Simvastatin/Atorvastatin \> Lavastatin/Pravastatin \> Fluvastatin
36
What are the LDL goals in patients with CHD or CHD risk equivalents (PVD, AAA, DM, CAD), no CHD w/\>2 risk factors, no CHD w/2 risk factors and no CHD w/
\*
37
What are the CHD risk equivalents that make a patient have a target LDL
DM, PVD, CAD, AAA
38
What is the most effective lifestyle change you can ask patients to make in order to lower their LDL?
Reduce saturated fat intake, this lowers LDL more than decreased cholesterol intake does. Diet should be
39
How does exercise help patients with lipidemia?
It increases HDL
40
How does prescribing a statin to a patient affect their relative cardiovascular risk?
Drops it by 20-30% regardless of baseline LDL
41
Why are statins so effective?
They reduce LDL AND act as an antioxidant in the endothelial lining of coronary arteries
42
What levels on the lipid panel are affected by statins? Niacin? Cholestyramine? Gemfibrozil?
Statin: LDL (most potent drug). Niacin: TG, LDL and HDL (most potent drug for TG & HDL). Cholestyramine: LDL, TG. Gemfibrozil: VLDL, TG, HDL.
43
Medications that can be considered for elevated TGs?
Fibrates, nicotinic acid and fish oil. Statins should be given because they are cardioprotective.
44
Lipid lowering agent contraindicated in diabetics
Niacin, it may worsen glycemic control
45
Lipid lowering agent with possible side effects of gynecomastia, gallstones, weight gain and myopathy.
Gemfibrozil
46
What are the defining characteristics of a tension headache?
Worsens throughout the day, precipitated by anxiety/depression/stress, “band-like” pain around entire head, radiates to neck/upper back w/muscle tightness.
47
Treatment of tension headaches
Stress reduction, anxiety/depression eval. NSAIDs, Tylenol, ASA are 1st line. Migraine medications can be 2nd line.
48
What are the defining characteristics of a cluster headache?
More common in men, episodic HA may last 2-3 mo. and remit for years, chronic HA may last 1-2 years. Deep, searing, stabbing unilateral pain behind the eye. Pts may become suicidal. Lacrimation, flushing, nasal discharge. Typically occur a few hours after going to bed and last 30-90 min, awakes from sleep. Worse w/alcohol.
49
Treatment of cluster headaches
Acute: sumatriptan + O2. Prophy: verapamil is 1st line and works very well. May also use ergotamine, methysergide, Li and prednisone.
50
What are the defining characteristics of a migraine w/aura?
Bilateral homonymous scotoma, scintillating scotoma, flashing lights, hemiparesis and/or dysphagia
51
What are the defining characteristics of a menstrual migrain
2 days b/f menses or on the last day of menses due to estrogen withdrawal.
52
Definition of status migrainosus
\> 72 hours w/o spontaneous resolution
53
What are the defining characteristics of the migraine without aura (common migraine)?
F \> M. +FHx. Triggers (stress, anxiety, poor sleep, chocolate, cheese, alcohol, tobacco, OCPs, weather change). Prodrome: CNS excitation or inhibition. Progresses to severe, unilateral, throbbing HA that lasts for 4-72 hours. Worse w/cough, activity or bending over. Associated N/V, photophobia, phonophobia, sensitivity to smell.
54
Postulated pathogenesis behind migraines
5-HT depletion
55
A patient presents with a severe, unilateral throbbing headache for the past 10 hours. It is non-responsive to DHE or sumatriptan and he claims to get these headaches often. What is the most likely cause?
Rebound analgesic HA occur every 1-2 days (unlike migraines which occur 1-2x/month) and do not respond to drugs. If he did not have a long hx of these you would consider a more serious etiology
56
Treatment of an acute migraine attack?
1st line: NSAIDs, Tylenol. 2nd line: dihydroergotamine (DHE, a 5-HT1 agonist) or sumatriptan (more selective 5-HT1 agonist).
57
When is dihydroergotamine contraindicated?
Pregnancy, CAD, TIAs, PVD and sepsis
58
When is sumatriptan contraindicated?
Use \> 1-2x/week, pregnancy, CAD, uncontrolled HTN, basilar aa migraine, hemiplegic migraine and use of MAOI, SSRI or Li.
59
Migraine prophylaxis
Used in patients with weekly HA interfering with activities that do not resolve by avoiding triggers. 1st line: amitriptyline, propranolol (most effective). 2nd line: verapamil, valproic acid and methysergide.
60
Treatment of menstrual migraines
NSAIDs are 1st line. Estrogen supplementation can be added.
61
What defines a chronic cough and when should further work up begin? What are the most common causes of chronic cough in adults?
\> 3 weeks. Failure to resolve in a month should result in further work up. Common causes are smoking, PND, GERD, asthma.
62
When is ordering a CXR appropriate in a patient with cough?
Chronic cough, suspected pulmonary etiology, hemoptysis or long-term smokers w/suspect COPD or lung cancer
63
When is bronchoscopy appropriate in a patient with cough?
No dx after CXR, CBC or PFTs. Suspected tumor, web/ring or foreign body.
64
Tx for post-nasal drip
1st gen. antihistamine/decongestant. +/- abx if sinusitis is present. +/- non-sedating long-acting antihistamine like loratadine if allergic rhinitis
65
When to use non-specific antitussives? What are they?
Unknown cause, ineffective specific tx or cough serves no purpose. Codeine, dextromethorphan and Benzonatate capsules
66
When to get labs and rads in a patient with acute bronchitis?
CXR and CBC is pneumonia is suspected +/- ABGs. If you only suspect acute bronchitis, labs/rads are not indicated.
67
Tx of acute bronchitis
Supportive
68
Viruses that are common perpetrators in the common cold (acute rhinosinusitis)?
1) Rhinovirus (50%, 100 different serotypes. Others include parainfluenza, adenovirus, coronavirus, coxsackie and RSV
69
Features concerning for secondary bacterial sinusitis or pneumonia in patients with acute rhinosinusitis?
Fever in an adult
70
Tx for acute rhinosinusitis
Hydration to loosen up secretions, analgesics (ASA, ibuprofen, acetaminophen), anti-tussive, decongestant nasal spray for
71
Common causes of acute sinusitis?
Follows URI/common cold or causes it to persist beyond 8-10 days, polyps, deviated septum or foreign body
72
Common bacteria that cause bacterial sinusitis
S. pneumo, non-typeable H. flu, anaerobes
73
Sinuses most commonly affected in bacterial sinusitis
Maxillary
74
Features of chronic sinusitis
At least 2-3 months of nasal congestion, PND usually w/o HA, pain or fevers and hx of multiple sinus infections.
75
A patient presents with 6 mo of nasal congestion and PND w/a PMHx significant for multiple sinus infxns. How should you treat this patient?
Broad-spectrum penicillinase resistant abx to cover S. aureus and possible GNRs. Refer to ENT.
76
Complication of ethmoid sinusitis
Orbital cellulitis
77
Complications possible in all types of sinusitis
Mucocele, polyps, osteomyelitis, cavernous sinus thrombosis, epidural abscess, subdural empyema, meningitis and brain abscesses
78
A patient presents with a cold for 8-10 days with painful sinuses and nasal congestion. Physical exam reveals purulent drainage from the left turbinates and impaired maxillary sinus transillumination. How do you treat this patient?
This patient has acute sinusitis. Tx with saline nasal spray to help with drainage, pseudoephedrine or oxymetazoline for decongestion for
79
Common bugs involved in laryngitis?
Mostly viral, M. cat and H. flu can also be involved
80
Tx of laryngitis
Self-limiting, rest voice to avoid formation of vocal cord nodules
81
Most common cause of pharyngitis?
Viruses (adeno, para, rhino, EBV and HSV). GABHS is only a concern for tx due to possibility of rheumatic fever, not the pharyngitis.
82
Other bacterial causes of pharyngitis
Chlamydia, mycoplasma, gonococci, c. diphtheriae and candida (if immunosuppressed)
83
DDx in a patient w/sore throat
Viral infxn, tonsillitis, strep throat and mono
84
50:50 pharyngitis rule
Only 50% of patients w/exudates have strep and only 50% of patients w/strep have exudates
85
Work up in a patient w/strep throat
CENTOR criteria, +/- rapid strep swab. If rapid strep swab is positive treat, if negative culture. +/- mono spot blood test
86
Tx of strep throat
10 days PCN or erythromycin
87
Tx of mono
Rest, tylenol/ibuprofen avoid contact sports
88
Tx of viral pharyngitis
Symptomatic (acetaminophen, ibuprofen, salt water gargle, humidifier, throat lozenges)
89
A patient presents with heartburn, bloating and epigastric discomfort. What are the most common causes of her condition?
She has dyspepsia. 90% of patients who present with dyspepsia have PUD, GERD, gastritis or non ulcer dyspepsia. Other less common causes include hepatobiliary disease, malignancy, pancreatic disease, esophageal spasm, hiatal hernia, lactose intolerance, malabsorption, DM w/gastroparesis and IBS.
90
Dx of nonulcer dyspepsia
Dyspepsia for at least 4 weeks and no other dx after endoscopy
91
Indications for endoscopy in patients presenting w/dyspepsia
Red flags (wt loss, anemia, dysphagia, hematemesis), new onset dyspepsia if \> 45 years, recurrent vomiting, no response to empiric therapy
92
Tx of dyspepsia in a pt w/negative H. pylori testing
Avoid alcohol, caffeine, tobacco, avoid eating before sleep and raise the head of the bed. Add H2 blocker, PPI or sucralfate. Endoscopy if medical therapy fails.
93
Types of testing used for H. pylori
Gold standard = endoscopy w/biopsy. Convenience = urease breath test (95% sen and spec), documents active infection. Serology = lower specificity b/c ab presence does not = active infection, abs can remain elevated for months to years after eradication, 90% sensitive.
94
Things to look out for in H. pylori testing that may cause false negative results
PPIs, bismuth, many abx and upper GI bleed
95
Tx of dyspepsia in a pt w/positive urea breath test
Triple tx: PPI, amox, clarithromycin 10-14 days. Quad tx for retreatment: PPI, bismuth and 2 abx.
96
A 40 year old woman presents with retrosternal chest pain associated with meals that is worse when lying down. She has associated regurgitation occasionally and salivary hyper secretion (water brash). What is the DDx for her condition?
She has GERD which can be secondary to decreased esophageal motility, gastric outlet obstruction, hiatal hernia, decreased LES tone (idiopathic or alcohol, tobacco, chocolate, fatty foods and coffee).
97
How is GERD diagnosed?
Gold standard = 24-hour pH monitoring is most sensitive and specific. Endoscopy w/biopsy if heartburn is refractory to tx or +red flags. Upper GI barium contrast study if suspicious for strictures/ulcerations. Esophageal manometry if suspected motility disorder
98
Barrett’s esophagus
10% of patients w/chronic reflux (\> 5 years) develop metaplasia of the distal esophagus from squamous epithelium to columnar epithelium that carries an increased risk for adenocarcinoma
99
Screening and tx for Barrett's
Endoscopy w/biopsy if GERD sx \> 5 years in duration. If +Barrett’s metaplasia but -dysplasia then screening endoscopy q3 years. Tx = chronic PPI
100
Cytologic findings that can diagnose recurrent pneumonia due to aspiration in GERD patients
Lipid-laden macrophages
101
Key physical exam findings in patients w/GERD
Pitting of dental enamel, night time cough, metallic taste in mouth
102
Tx of GERD
Phase I: lifestyle changes w/antacids after meals and before bed. Phase II: add an H2 blocker. Phase III: switch H2 blocker to PPI if no resolution or pt has erosive esophagitis. Phase IV: add metoclopramide (DA antagonist) or bethanechol (cholinergic agonist) for motility. Phase V: Combo therapy (H2 + promotility, PPI + promotility, +/- increased dose of H2 or PPI). Phase VI: Nissen fundoplication if intractable disease, respiratory problems or esophageal injury.
103
Tx for a patient w/chronic GERD and new onset dysphagia
They likely have peptic strictures and will need dilation
104
Definition of acute vs chronic diarrhea
4 weeks
105
Most common bugs involved in acute diarrhea
Rotovirus and norovirus.
106
Most common bugs involved in severe acute diarrhea
Bacteria (typically diarrhea is accompanied by fever and blood): Shigella, enterohemorrhagic E. coli, enterotoxic E. coli (no fever/blood), Salmonella, Campylobacter, C. perfingens (no fever/blood), staph aureus food poisoning (no fever/blood), C. difficile. Protozoa: Giardia, Entamoeba, Cryptosporidium.
107
Common bugs involved in acute diarrhea in the immunocompromised
MAI, Cryptosporidium, Cyclospora, CMV
108
Aside from infection what are common causes of acute diarrhea?
Antibiotics: esp. clinda, amp and cephalosporins. Meds: laxatives, prokinetics (cisapride), antacids, digitalis, cochicine, alcohol, Mg, chemo. Malabsorption. Ischemic bowl. Tumors.
109
Common causes of chronic diarrhea
1) IBS. Others include IBD, meds, infection, colon cancer, diverticulitis, malabsorption, post surgical (vagotomy, gastrectomy), endocrine (hyperthyroid, Addison’s, DM, gastrinoma, VIPoma), fecal impaction and laxative abuse.
110
Indications for lab work up in patients with diarrhea? What labs?
Usually none is required unless diarrhea is chronic, pt is severely ill, there is blood in the stool, peritonitis, immunodeficient or volume depleted. Labs: CBC, stool sample for fecal leukocytes, stool culture for C. difficile/shigella/salmonella/campylobacter if +leukocytes, O&P x 3 if suspect parasite +/- giardia ELISA, stool for C. difficile toxin assay.
111
Why do bacterial stool cultures kind of suck?
Fecal leukocytes are only positive if the infection is due to campylobacter, salmonella, shigella, EIEC or C. difficile. There are no + fecal leukocytes w/staph, c. perfringens or viruses and consequently due to the algorithm no culture will be done for these patients. Additionally, if you do a culture, there is a low sensitivity.
112
Most common electrolyte abnormality in patients with diarrhea
Metabolic acidosis + hypokalemia
113
4 reasons to admit a patient w/acute diarrhea
Unable to tolerate PO, bloody diarrhea, toxic appearing, volume deplete
114
Treating acute diarrhea
Rehydrate + correct electrolytes, NPO trial, 5-day course of cipro for patients w/moderate to severe sx (high fever, bloody stools, +cx, traveler’s diarrhea), give PO metronidazole or vanc if C. difficile. Only giver loperamide if diarrhea is mild to moderate w/no fever or blood.
115
A patient presents to the clinic with diarrhea for the past 48 hours, myalgia, malaise, nausea and vomiting. He has family members w/similar sx. Physical exam reveals a low-grade fever. Labs show no fecal leukocytes. What is the most likely diagnosis?
Acute viral gastroenteritis (norwalk or rotavirus)
116
A patient presents to the clinic with a 48 hours hx of diarrhea, abdominal pain, nausea and vomiting. He admits to eating raw eggs. On physical exam he has a fever. Labs are +for fecal leukocytes. What is the most likely dx and how do you treat?
Salmonella. No tx necessary unless suspect typhoid fever, then tx w/cipro (also tx if immunocompromised).
117
A patient presents to the clinic with 48 hour hx of diarrhea, tenesmus and abdominal pain. On physical exam he has a fever. Labs are + for fecal leukocytes. How will you likely treat this patient?
Bactrim, he likely has shigella which commonly presents w/tenesmus
118
A patient presents with a 6 hour hx of abdominal pain, diarrhea, nausea and vomiting. He has no fever and stool leukocytes are negative. He admits to eating potato salad 6 hours ago. How do you treat this guy?
He likely has staph food poisoning, supportive tx is appropriate.
119
A patient presnets with 48 hour hx of HA that just recently was followed by diarrhea and abdominal pain. He admits to blood in his stool. He has a fever and + stool leukocytes. How do you treat him?
He likely has been infected by campylobacter and needs erythromycin.
120
A patient presents with a 12 hour hx of crampy abdominal pain and diarrhea. He ate chinese food prior to onset of sx. He does not have a fever and negative stool leukocytes. What is causing his sx?
C. perfringens
121
A patient presents with watery diarrhea, nausea and abdominal pain for 48 hours. He just returned from Mexico. He does not have a fever and stool leukocytes are negative. What is causing his sx?
Enterotoxic E. coli
122
A patient presents with 24 hours of bloody diarrhea and is very toxic appearing. He has a fever and admits to eating undercooked meat at a barbecue. Stool leukocytes are positive. What are major complications associated with his infection?
He likely has been infected by E. coli O157:H7 which is typically self-limited, but can be complicated by hemolytic uremic syndrome and thrombotic thrombocytopenic purpura.
123
A patient presents with 5 days of watery, foul-smelling diarrhea and bloating. He recently went hiking and does not have a fever and has negative stool leukocytes. How do you treat him?
He likely has giardiasis. Tx w/metronidazole.
124
A patient presents with rice water stools, abdominal pain and vomiting. He has a low-grade fever and negative stool leukocytes. What is likely causing his condition?
Vibrio cholera
125
What are common causes of constipation?
Lack of dietary fiber, meds (anticholinergics, antidepressants, narcotics, Fe, CCB, Al, Ca and laxative abuse), IBS, obstruction (cancer, stricture, hemorrhoids, fissures), ileus, endocrine (hypothyroidism, hypercalcemia, hypokalemia, uremia, dehydration), neuromuscular (Parkinson’s, MS, scleroderma, CNS tumor, DM) and congenital disorders (Hirschprung’s).
126
Work up in patients w/constipation
If lifestyle modification fails or + red flags, consider TSH, serum Ca, CBC, electrolytes, abdominal films, flex sig and rectal exam depending on level of suspicion. Consider radiopaque marker transit study or anorectal motility study if above work up fails.
127
Conservative management of constipation
Increase fiber, exercise and fluids. Fleet enema for temporary relief.
128
Criteria necessary to diagnose IBS?
Sx present for \> 3 months w/no other likely etiology: 1) Diarrhea, constipation or alternating diarrhea/constipation 2) Crampy abdominal pain relieved by defectation 3) Bloating or abdominal distention.
129
Common findings associated w/IBS
Depression, anxiety, stress and somatization. Note that psych sx typically precede GI sx. Lab tests are normal and no lesions are found on sigmoidoscopy.
130
Things to think of before diagnosing someone w/IBS
Obstruction, IBD, lactose intolerance, chronic infection, malignancy. Hence you should get a KUB, CBC, renal panel, FOBT, stool O&P x 3, ESR and flex sig depending on suspicion for more organic causes.
131
Tx of IBS
Symptomatic: diarrhea = diphenoxylate or loperamide. constipation = colace, psyllium or cisapride. Lifestyle: avoid dairy and caffeine. Medical: tegaserod maleate (zelnorm) is a 5-HT agonist useful in women w/IBS.
132
DDx in a patient who presents w/nausea and vomiting
Head to toe: increased ICP, migraines, vestibular neuritis, eating disorders, meds, hyperthyroidism, esophageal dysmotility, GERD, PUD, gastric outlet obstruction, gastroparesis, strictures, volvulus, ileus, bacterial overgrowth, fistula, gastroenteritis, cholecystitis, cholangitis, appendicitis, pancreatitis, DKA, Addison’s, uremia, hypercalcemia, hypokalemia, pyelonephritis
133
Complications of severe or prolonged vomiting
Dehydration, metabolic alkalosis, hypokalemia, dental caries, aspiration, Mallory-Weis tears, Boerhaave’s syndrome
134
First step in management in a patient presenting w/nausea and vomiting
1/2 NS + K, treat underlying cause. +/- prochlorperazine (compazine), promethazine (phenergan), clear liquid diet and NG.
135
A pregnant truck driver w/PMHx significant for constipation, obesity and portal HTN presents w/occult rectal bleeding. What is your next step?
She likely has hemorrhoids, but you can’t stop at this dx until you rule out other causes like perforated diverticula, colon cancer, ischemic colitis etc.
136
Conservative tx for hemorrhoids
Fitz baths, ice, bed rest, stool softeners, high fiber/fluids, topical steroids
137
Surgical tx for hemorrhoids
Band ligation for internal hemorrhoids or hemorrhoidectomy if refractory, severe prolapse, strangulation, large anal tags or fissures.
138
3 most common causes of low back pain?
Musculoligamentous strain, DDD, facet arthritis
139
Definition of acute, subacute and chronic LBP?
12 weeks
140
When is L-spine imaging indicated in patients w/LBP before the 4-6 week mark?
Severe radicular leg pain, leg weakness, bladder dysfunction, saddle anesthesia, suspect infection (these all get MRI). Radiographs for osteoporosis, chronic steroid use, hx of malignancy, B-symptoms, recent trauma and IV drug abuse. MRI is only indicated if conservative tx for 3 months fails.
141
Differentiating spinal stenosis from disc herniation
Disk herniation = pain w/forward flexion. cough/sneezing and straight leg test. Spinal stenosis = pain w/back extension, standing, walking.
142
Why is spinal surgery controversial for many types of back pain?
Many people without any back pain have imaging findings of DDD, spondylolisthesis.
143
Common findings in patients with spondylolithesis
L4-5 or L5-S1 slippage, associated spinal stenosis and neurogenic claudication
144
A patient presents to the clinic after lifting a heavy box with radiating left leg pain worse with forward flexion and coughing. He has a + straight leg test on both sides. How do you treat him?
Disc herniation can be managed w/anti-inflammatory meds, physical therapy and epidural steroid injections. Surgery is only needed in about 10% of cases.
145
Strongest predictors of pain and disability in patients with LBP?
MRI doesn’t correlate, psychosocial factors matter more
146
A patient presents with left leg pain and cramping that progresses to numbness and tingling with walking that is relieved by sitting and forward flexion. How do you treat him?
Spinal stenosis can be treated with epidural steroid injections. If these fail surgery is very effective.
147
An 88 year old woman presents with point tenderness at the center of the spine that radiates across the back and around the trunk. She has no radiation to her legs. She has been on chronic prednisone for rheumatoid arthritis. She does not recollect any trauma. How do you treat her?
She likely has osteoporosis from old age and chronic steroid use resulting in vertebral compression fraction. You can treat with bracing and analgesics for 6-8 weeks to try to prevent severe kyphosis (esp if fx was in thoracic spine). Other options for more severe fxs include kyphoplasty/vertebroplasty which have questionable efficacy.
148
Most common spinal tumor
Metastatic carcinoma from breast, lung, prostate, kidney and thyroid
149
Patients at risk for discitis or osteomyelitis of the spine
IV drug users, dialysis and pts w/indwelling catheters
150
Infection in the spine that requires rapid surgical decompression
Epidural abscesses
151
Other organ systems that may cause back pain sx
Aortic aneurisms/dissection, prostatitis, nephrolithiasis, endometriosis, ectopic pregnancy and PID
152
When is the straight leg test +
Radiating leg pain w/elevation to 30-60 degrees
153
What motor deficit on physical exam signifies L2 motor weakness? L3? L4? L5? S1?
L2 = hip flexion, L3 = knee extension, L4 = ankle dorsiflexion, L5 = great toe dorsiflexion, S1 = plantar flexion
154
A patient presents with musculotendinous low back pain and attempted management with NSAIDs, Tylenol and gradual return to activities for 4-6 weeks. He has had modest improvement but is not back to his normal self. What is your next step?
A course of physical therapy for core strengthening and aerobic conditioning, possibly some imaging.
155
When do you start considering surgery for chronic LBP?
Failure of conservative measures after 1 year. Note that response to surgery will be better for nerve root decompression than fusion for DJD
156
Advice you’d give about activity in a patient with LBP
Avoid inactivity. In the 1st week walk 20 min TID and rest in between
157
What is the chronic LBP equivalent in the c-spine?
Chronic axial neck pain
158
When is surgery a good option for patients w/neck pain
When there are associated radicular sx
159
Most common cause of acute neck pain? Tx?
Cervical strain. PT if sx last \> 2-4 weeks
160
DDx for a patient presenting with cervical radiculopathy?
Spondylosis, herniated disc, shoulder impingement, cubital/carpal tunnel syndrome, thoracic outlet syndrome, HZV and Pancoast tumor.
161
How is cervical radiculopathy diagnosed?
MRI after 6 week trial of conservative therapy
162
A patient presents to the clinic complaining of unsteadiness while walking, clumsy hands and muscle weakness in his legs. He admits to 2 episodes of incontinence in the last week. How do you work up this patient?
He is showing symptoms of cervical myelopathy likely due to cervical stenosis. He needs an MRI to confirm the stenosis and urgent spinal cord decompression to avoid permanent paralysis and incontinence.
163
A 79 year old man presents with gait unsteadiness. He admits to relying on his walker and cane more than before. What is your next step?
MRI. Elderly patients often attribute these changes to old age, however, it can be a result of cervical stenosis and surgery can correct the problem.
164
What are the different types of arthritis?
OA, AI (RA, SLE, IBD, seroneg. spondyloarthropaties), Crystal, Infxn, Trauma, Charcot joint, Heme (sickle cell, hemophilia), Deposition (Wilson’s, hemochromatosis) and peds conditions (SCFE, Legg-Calve-Perthes, congenital hip dysplasia)
165
A patient presents with anterior knee pain worse when climbing stairs. How do you treat him?
Patellofemoral pain is treated w/PT strengthening of hamstrings and quadriceps
166
When is surgery best for a patient with a meniscal tear?
If no OA is present
167
A patient presents with a history of knee pain and new onset acute pain, catching, popping and locking of the knee. How do you treat him?
He has osteochondritis dissecans which occurs when an area of necrotic bone and overlying cartilage breaks off and becomes a free body in the joint. It is best treated by arthroscopic removal of the free body.
168
Common cause of a Baker’s cyst?
Meniscal tear
169
A patient presents with anterior knee pain at the inferior pole of the patella. He is a marathon runner and has never had this pain before. How do you manage his pain?
He likely has patellar tendinitis and needs quad/hami strengthening and stretching exercises.
170
Plica syndrome
Patients have pain along the medial patella and a feeling of snapping over the knee when walking +/- effusions intermittently. MRI and PE findings are unreliable. Tx w/PT, anti-inflammatory drugs and steroid injections. If this fails you can arthroscopically release plica
171
When is it appropriate to image a knee?
Hx of trauma, suspect degeneration = rads. Suspect lig. or meniscal tear = MRI.
172
How do you grade ankle sprains?
Grade 1 = partial ATFL rupture. Grade 2 = complete ATFL and partial CFL. Grade 3 = complete ATFL/CFL
173
When do you NOT have to get ankle radiographs in a patient with an acutely sprained ankle?
Able to walk 4 steps after injury and at time of evaluation. No bony tenderness over distal 6cm of either malleolus
174
Management of ankle sprains
RICE during acute injury, then pain-free ROM exercises, perennial tendon strengthening, proprioceptive training and gradual return to weight bearing. If recurrent may consider surgery to correct ankle instability (even single grade 3 sprains don’t typically need surgery).
175
Most common cause of shoulder pain?
Supraspinatous tendinitis, i.e. impingement syndrome due to impingement of supraspinatous tendon between greater tuberosity of humerus and acromion.
176
When to get an MRI in a patient with impingement syndrome?
Weakness w/shoulder abduction is suspicious for a tear. Pain alone is more suspicious for tendinitis and does not warrant MRI.
177
Management of impingement syndrome
1) PT 2) Subacromial steroid injections 3) Acromioplasty
178
Management of lateral and medial epicondylitis?
Splint the forearm and wrist to limit supination/pronation and give extensor/flexor tendons a rest. This can be followed by strengthening/stretching exercises and typically leads to resolution. If PT fails, consider injections or surgery (rarely needed).
179
Management of De Quervain’s tenosynovitis?
Thumb spica splint + NSAIDs +/- local corticosteroid injections. If this fails surgery can be done.
180
Tendons affected in De Quervain’s tenosynovitis?
APL, EPB
181
Where does hip OA pain present? What hip pain is not OA?
OA hip pain = groin pain. Lateral hip or buttock pain is not due to OA
182
Tx of trochanteric bursitis
NSAIDs, corticosteroid injections if sx persist
183
What other conditions are associated with carpal tunnel syndrome?
Hypothyroidism, DM, pregnancy
184
Definitive dx of carpal tunnel syndrome
EMG (cannot r/o carpal tunnel even if Phalen’s and Tinnel’s are negative)
185
What is responsible for the pain felt in patients with osteoarthritis?
Cartilage has no innervation and patients don’t feel its destruction. Once it is gone, patients feel the bone on bone movements because bone is innervated by sensory fibers.
186
Features of OA
Relieved w/rest, worse w/activity. Stiff in morning or after inactivity. Limited ROM. Bony crepitus.
187
Radiographic characteristics of OA
Standing LE radiographs show joint space narrowing, osteophytes, subchondral cysts and sclerosis. Note that there is no conisistent correlation between symptoms and x-ray findings
188
Bouchard’s nodes
Boney overgrowth at PIP joints
189
Heberden’s nodes
Bony overgrowth at DIP joints
190
Which hand should the cane be held in if a patient has left knee OA?
Right hand
191
Ideal exercise for OA
Swimming
192
1st line drug for OA
Acetaminophen
193
Where did the COX-2 inhibitors go?
Celexicob is still around, all the rest got removed from the market due to increased risk of cardiovascular disease (despite a decrease in gastritis/PUD)
194
How often might a patient expect to get a revision if they get a knee replacement?
Every 15-20 years
195
OTC products for OA with no meaningful benefit in high quality RCTs
Clucosamine and chondroitin sulfate
196
Definition of osteoporosis?
T-scores are used in all post-menopausal/peri-menopausl women and men \> 50. Osteoporosis is defined as 1. Z-scores are used in all other patients.
197
Mechanism of osteoporosis
Failure of adequate bone deposition by age 30 w/bone resorption rate that exceeds deposition rate later in life
198
Who gets osteoporosis
Postmenopausal women and elderly men
199
Type I primary osteoporosis
Excess loss of trabecular bone. Presents in postmenopausal women (51-75) as Colles and vertebral compression fx (multiple thoracic vertebral compression fx -\> progressive kyphosis, decreased ROM)
200
Type II primary osteoporosis
Equal loss of trabecular AND cortical bone. Presents in elderly over age 70 as femoral neck, proximal humerus and pelvic fx
201
Secondary osteoporosis
Cause other than aging to include Cushing’s, chronic steroid use, immobilization, hyperhyroidism, chronic heparin use, hypogonadism in men, body wt
202
Risk factors for osteoporosis
Estrogen depletion (menopause, female athlete triad), vit D/Ca deficiency, female, FHx, Asians, Europeans, immobility, male hypogonadism w/low testosterone, hyperthyroidism, smoking, alcohol abuse and medications (steroids, heparin).
203
Maintainstay of prevention/treatment of osteoporosis
Vit D (800 IU) and Ca (1200mg) per day supplementation, weight-bearing exercise 30 min 3x/week, smoking cessation and alcohol reduction.
204
What did the PROOF trial show
Calcitonin is effective in the treatment of osteoporosis by decreasing risk of vertebral fx by 40% w/slight increases in lumbar vertebrae density. It has no effect on the hip.
205
Pts w/highest morbidity/mortality due to osteoporosis
Those that get hip fx
206
How is osteoporosis diagnosed
Gold standard = DEXA scan of femoral neck and l-spine. Done in all women over 65, postmenopausal women
207
How often should women over 65 get a DEXA scan if the scan is normal?
q3-5 years
208
Who gets pharmacologic therapy for osteoporosis?
Postmenopausal women w/osteoporosis, fragility fx and high risk postmenopausal women w/osteopenia
209
1st line tx for osteoporosis
Bisphosphonates (alendronate/risedronate): inhibit bone resorption by binding hydroxyapatite and decreasing osteoclast activity.
210
Next step if you patient cannot tolerate oral bisphosphonates due to reflux, esophageal irritation or ulceration?
IV bisphosphonates (zoledronic acid)
211
Who get recombinant PTH for osteoporosis
Pts w/severe osteoporosis who cannot tolerate bisphosphonates or continue to fracture despite being on them for 1 year.
212
Duration of tx of rPTH for patients with osteoporosis
2 years. Stop at this time due to concerns for osteosarcoma
213
Medication used short-term in elderly females with vertebral compression fractures
Calcitonin nasal spray
214
Risks of using raloxifene for osteoporosis
Increased risk of breast CA, CVA, VTE and CAD
215
Most common cause of vision loss in people \> 65
Age-Related Macular Degeneration (ARMD). The biggest risk factor for this condition is advanced age. Other risks include females, Caucasian, smoking, HTN and FHx.
216
2 types of ARMD
Wet (exudative): sudden visual loss due to leakage of serous fluid and blood from neovascularization under the retina. Dry (non-exudative): yellow-white deposits (drusen) for under the pigment epithelium and cause atrophy and degeneration of the central retina.
217
Symptoms described in ARMD
Central vision loss, burry, distorted vision +/- scotoma
218
Tx for ARMD
Intra-ocular VEGF inhibitor (Ranibizumab) injections for wet. OTC vitamins for dry.
219
Most common cause of non-reversible blindness in African Americans
Glaucoma
220
Pathogenesis of glaucoma
Increased intra-ocular pressure leads to ischemia, loss of ganglion cells and cupping of the optic cup (atrophy of the disc)
221
2 types of glaucoma
1) Open angle: impaired outflow of aqueous humor from the eye, silent disease initially. Consequently paintings have a painless, insidious increased in IOP and peripheral visual field loss 2) Closed angle: rapid increase in intra-ocular pressure due to occlusion of the narrow angle and obstruction of outflow of aqueous humor (emergency). Consequently patients have a red, painful eye with sudden decrease in visual fields, halos, N/V, HA and dilated, non-reactive pupil on the involved side.
222
Common misdiagnosis in patients with acute angle glaucoma
Acute surgical abdomen due to abdominal pain, nausea and vomiting
223
Risk factors for glaucoma
Age \> 50, AA race, FHx, Hx of eye trauma and steroids.
224
Dx glaucoma
Tonometry to measure IOP, opthalmoscopy to assess optic nerve, gonioscopy to visualize anterior chamber and visual field testing.
225
Tx glaucoma
Open angle: topical beta-blocker, alpha-agonist, CAI and or prostaglandin analogue +/- laser/surgical therapy for refractory cases. Closed angle: emergent pilocarpine drops, IV CAI (acetazolamide) and oral glycerin w/laser or surgical iridectomy
226
A 70 year old patient presents with steady loss of vision over the past 20 years and glare that makes it difficult to drive at night time. Her eye is shown below. How do you treat her?
Cataracts are present in 50% of people over the age of 75 and are the cause of her condition. Note the opacifications in the lens. Surgery is definitive w/great results.
227
Risk factors for cataracts
Old age, cigarette smoking, glucocorticoids, UV exposure, radiation, trauma, DM, Wilson’s, Down’s syndrome
228
Most common cause of red eye. How is it diagnosed and treated?
Viral conjunctivitis. Adnovirus is the most common organism and patients typically present w/hx of URI, hyperemia in one eye that recently spread to the other w/watering. Physical exam may reveal a pre auricular LN. Tx w/cold compress, strict hand washing and topical abx if suspect bacterial superinfection.
229
What is “second sight"
People with cataracts become increasingly near-sighted due to increased refractive power of the lens caused by the cataract. This may result in no need for reading glasses later in life.
230
A patient presents with a single red eye with blotchy redness in the conjunctiva. He is a weight lifter with high blood pressure and a history of Hemophilia. How do you treat hime?
He has subconjunctival hemorrhage and all of the risk factors to include Valsalva, HTN and coagulopathy. This condition is self-limiting.
231
A patient presents with mildly injected eyes bilateral and complains that it feels like something is inside her eye. What are possible causes of her condition? How do you treat her?
Keratoconjunctivitis sicca (dry eye) can be caused by medications (esp. antihistamines and anticholinergics), autoimmune disease (esp. Sjogren’s) and CN V or VII lesions. Tx w/artifical tears during the day and lubricating ointment at night.
232
A patient presents with inflammation of his right eyelid. Examination reveals red and swollen eyelid margins that have crusting that sticks to the lashes. How do you treat this patient?
He has blepharitis. Treat w/lid scrubs, warm compress and topical erythromycin for severe cases.
233
A patient presents with redness, irritation, dull aches and watery discharge from both eyes. Her sclera are blotchy with areas of redness over the blood vessels on the sclera beneath the conjunctiva. How do you treat this patient?
She has episcleritis. This is usually self-limited and can be managed by NSAIDs, but you should still refer to optho due to concerns about autoimmune processes and connective tissue disease.
234
A 35 year old woman presents with deep 8/10 eye pain bilaterally. On physical exam there is ocular redness and pain on palpation of the eyeball. She admits to some decreased vision. How do you treat this patient?
She has scleritis. Refer to optho for topical and possible systemic corticosteroids due to concerns about systemic immunologic disease like RA.
235
A 40 year old woman presents with a red right eye, blurry vision, eye pain, photophobia and constricted pupil only in the right eye. PE shows inflammation of the iris and ciliary body. How do you treat this patient?
She has acute anterior uveitis (iridocyclitis). This condition is associated with connective tissue diseases like sarcoidosis, ankylosing spondylitis, Reiter’s syndrome and IBD. She needs a referral to optho.
236
A patient presents with right eye redness and watering with irritation and photophobia. She has a dendritic ulcer on the cornea seen with fluorescein. How do you treat this patient?
She has HSV-1 keratitis with the classic ulcer that can cause irreversible vision loss if untreated. She will need an optho referral and anti-viral eye drops +/- oral acyclovir for refractory cases.
237
A patient presents with red itchy eyes, bilateral eyelid edema, tearing and nasal congestion. What is the most likely cause of his symptoms? How do you treat him?
Allergic conjunctivitis. Treat with cold compresses, topical antihistamines/mast cell stabilizers. May also use topical NSAIDs and systemic antihistamines.
238
Complication associated with viral conjunctivitis
Membranous conjunctivitis that requires topical steroids and stripping of membranes
239
A patient presents with rapid onset irritation, hyperemia and irritation in his right eye. He has associated mucopurulen exudate and crusting. How do you treat this patient?
This is most likely bacterial conjunctivitis due to S. pneumoniae. He needs to be counseled to have strict personal hygiene due to the contagious nature of conjunctivitis. He also gets empiric topic abx (erythromycin, ciprofloxacin or sulfacetamide) +/- conjunctival cultures depending on severity and need for tailoring of abx.
240
Most common cause of blindness worldwide
Chlamydia trachomatis A, B and C. Due to chronic scarring.
241
Conjunctivitis from STDs. How is it treated?
Likely due to Chlamydia trachomatis D-K or gonorrhea. Can be caused in adults by genital-hand-eye contact or vertically transmitted to kids during birth. If gonococcal conjunctivitis is suspected, txw/1 time dose of 1g ceftriaxone IM AND topical therapy. If chlamydial conjunctivitis tx w/po tetracycline, doxycycline or erythromycin for 2 weeks and tx partner for STDs.
242
A 24 year old male presents with rapid onset of eye redness, swelling, pain and copious purulent exudate over the last 3 hours. What is the next best step?
Immediate optho referral for hyperacute bacterial conjunctivitis due to N. gonorrhoeae. Treatment consists of 1x dose ceftriaxone 1g IM + topical therapy.
243
Risk factors for OSA
Neck obesity, enlarged tonsils, uvula, soft palate, nasal polyps, pharyngeal muscle hypertrophy, deviated septum, FHx, alcohol/sedatives, hypothyroidism and overbite w/small chin
244
Complications associated with OSA
Daytime sleepiness, personality changes, decreased intellectual function, decreased libido, systemic (due to sympathetic tone) AND pulmonary HTN, cor pulmonale (due to hypoxemia), arrhythmias, morning HA and polycythemia
245
Tx of OSA
Mild-moderate (20 apneic episodes w/desats): CPAP, uvulopalatopharyngoplasty, tracheostomy if life-threatening and refractory
246
What causes narcolepsy?
Inherited disorder resulting in REM sleep dysregulation that results in sleep attacks during the day, cataplexy (loss of muscle tone) w/emotion, sleep paralysis when waking up and hypnagogic hallucinations (vivid) while awake
247
Major problem to address in a patient with newly diagnosed narcolepsy
Driving and MVA prevention
248
Tx of narcolepsy
Methylphenidate and planned naps during the day
249
Causes of chronic secondary insomnia?
Psychiatric conditions: depression, anxiety, PTSD, bipolar mania, schizophrenia and OCD. Meds: alcohol, prolonged sedative use, caffeine, beta-blockers, amphetamines, decongestants, SSRI and nicotine. Medical: COPD, ESRD, CHF, chronic pain, fibromyalgia.
250
Definition of chronic primary insomnia?
Dx of exclusion: difficulty initiating/maintaining sleep OR non restorative sleep that lasts \> 1month in absence of other more likely cause OR excess worry and preocupation about not falling asleep
251
Tx for insomnia
1) Treat underlying cause 2) Psych eval 3) Smallest possible does of sedative hypnotic for no longer than 2-3 weeks. Patients can develop tolerance and withdrawal rebound insomnia with chronic use.
252
Normal BMI
18.5 - 24.9
253
1st line agent for obesity
Orlistat. Pancreatic and gastric lipase inhibitor that does not hydrolyze fat and inhibits resorption of fat.
254
Who can get bariatric surgery
Patients who have earnestly tried more conservative methods w/BMI \>40 or BMI \> 35 w/other comorbidities (DM, OSA, HTN, HLD).
255
Causes of conductive hearing loss?
Cerumen impaction, otitis externa, exostoses (repetitive exposure to cole water), perfed TM, middle ear effusion (OME or allergies), otosclerosis (AD condition where stapes fuses to oval window), neoplasms and congenital malformations.
256
Causes of sensorineural hearing loss?
Presbycusis (gradual, symmetric, most common cause of hearing loss in elderly), chronic noise \> 85dB, cochlear/labyrinth infxn, meds (ahminoglycosides, furosemide, ethacrynic acid, cisplatin, quinidine), injury, TORCH infxn, Ménière’s and intracranial pathology (acoustic neuroma, meningitis, auditory nerve neuritis, MS, syphilis, meningioma)
257
Pathology behind presbycusis
Degeneration of sensory cells and nerve fibers at the base of the cochlea results in a gradual, symmetric hearing loss at high frequency 1st, then progresses to low frequency
258
Pathology behind noise-induced hearing loss?
Damage to the hair cells in the organ of Corti
259
How can chronic aspirin use affect hearing
Reversible tinnitus
260
Presentation in patients with Ménière’s?
Fluctuating unilateral SNHL that also presents with pressure/fullness in the ear, tinnitus and vertigo
261
Tx of Meniere's
Dietary salt restriction and meclizine (antiemetic antihistamine). Hearing loss is progressive
262
Frequencies lost in conductive hearing loss
Low-frequency, no problem hearing louder noises
263
Frequencies los in SNHL
High-frequency, associated problems hearing loud noises, deciphering words and tinnitus.
264
Essential component in diagnosis of hearing loss
Audiogram
265
Tx of cerumen impaction
1) Several days of softening with carbide peroxide (Debrox) or triethanolamine (Cerumenex) 2) Irrigation
266
Rinne and Weber for conductive hearing loss
Abnormal Rinne (BC \> AC). Weber: sound lateralizes to affected side.
267
Rinne and Weber for SNHL
Normal Rinne (AC \> BC). Weber: sound lateralizes to good ear
268
What type of hearing loss will be better with a cochlear implant?
SNHL. It stimulates CN VIII
269
4 types of incontinence
Stress, urge, overflow, functional
270
Most common cause of incontinence in elderly
Urge
271
Most common cause of incontinence in women
Stress
272
Common causes of male incontinence
BPH and neurologic disease (MS, Parkinson’s, stroke, spinal cord injury)
273
Meds that can cause incontinence
Diuretics, anticholinergics and adrenergics cause retention, beta-blockers diminish sphincter tone, CCBs/narcotics increase detrusor activity
274
A 65 year old woman presents complaining of urinary urgency, loss of large volumes of urine and small postvoid residual. She also admits to nocturnal wetting. How do you treat her?
She most likely has urge incontinence due to detrusor instability. 1st diagnose w/urodynamic study. Tx with bladder-training, oxybutynin (anticholinergic) and imipramine (TCA).
275
A 70 year old woman presents with involuntary loss of urine in spurts with coughing, laughing, sneezing and exercise. She notes a small post-void residual volume. How do you treat her?
She most likely has stress incontinence due to pelvic floor weakness leading to hyper mobility of the bladder neck. The Proximal urethra then descends below the pelvic floor so increased intraabdominal pressure exceeds the strength of the sphincter. 1st rule out infxn w/UA. Tx w/Kegel exercises, +/- estrogen replacement, pessary or urethropexy.
276
A 50 year old male with a 25 year hx of DM II presents with nocturnal wetting, frequent loss of small amounts of urine and a large postvoid residual \> 100mL. How do you treat this patient?
He most likely has overflow incontinence due to impaired detrusor contractility, urinary retention and over distention. Urine leaks when bladder pressure exceeds urethral resistance. Other causes include lower motor neuron disease, anticholinergics, alpha-agonists, spinal anesthesia, BPH, urethral strictures and severe constipation with fecal impaction. Treat with 1) intermittent self-catheterization and cethanechol (cholinergic) to increase contractility and/or alpha-blocker (treason, doxazosin) to decrease sphincter resistance.
277
Common type of incontinence seen in patients w/spinal cord injury, MS, DM, tabes doornails, disc herniation and spinal cord compression.
Reflex incontinence, characterized by a patient who cannot sense the need to urinate.
278
How should you work up all cases of incontinence
1st r/o UTI w/UA and culture. Then record postvoid residual (normal
279
A patient presents with fatigue and relatively few other sx. What is your initial lab workup?
CBC (r/o anemia, infection, malignancy), TSH (r/o hypothyroidism), fasting glc or HbA1c (r/o new DM), CMP (r/o Addison’s, hyperparathyroidism, renal failure), UA (r/o renal failure, UTI), LFT (r/o liver failure) and STDs (HIV, RPR, GC, CT, hep B)
280
Meds that can cause fatigue
clonidine, methyldopa, amitriptyline, doxepin, trazodone, hypnotics, beta-blockers, anti-histamines
281
What is chronic fatigue syndrome?
New onset fatigue not alleviated by rest or due to exertion. 4+ of following: diminished short term memory/concentration, muscle pain, sore throat, tender LNs, unrefreshing sleep, non-inflammatory joint pain, HA or \> 24 hrs post-exertional malaise. Often comorbid w/depression.
282
Tx of chronic fatigue syndrome
CBT w/exercise, antidepressants prn, NSAIDs for HA/arthralgias
283
Risk factors for erectile dysfunction?
Atherosclerosis, antihypertensive meds, sickle cell, hx of pelvic surgery/trauma, alcohol abuse, hypogonadism, hypothyroidism, congenital penile curvature
284
Next step if a patient has erectile dysfunction, loss of libido and hypogonadism
Serum testosterone, prolactin and TSH/fT4
285
How can you determine if erectile dysfunction is likely psychogenic or organic in nature?
If erections occur at night it is likely psychogenic
286
How can you test to see if vasculature is sufficient enough to cause erection?
Intracavernosal injection of vasoactive substances, duplex u/s and arteriography
287
Tx of erectile dysfunction
PDE inhibitor (sildenafil citrate) 30-60 before intercourse (CI in pts taking nitrates for chest pain), self-administered injections of intracavernosal vasoactive agents, vacuum constriction rings around base of penis to increase venous trapping of blood, psych referral, testosterone replacement if + hypogonadism, penile implant is a last resort.
288
CAGE questions for alcoholism
Cut down? Annoyed? Guilty? Eye-opener?. May follow-up with more extensive MAST questionnaire (25 questions)
289
Benefits of alcohol
Increases HDL (however also increases TGs)
290
Lab findings in chronic alcoholics
Macrocytic anemia (microcytic if +GI bleed), AST \> ALT elevation, increased GGT, increased TGs, hyperuricemia, hypocalcemia, thiamine deficiency and decreased testosterone
291
Malignancies associated w/alcohol use
Esophageal, oral, hepatic and pulmonary
292
A patient presents to the ED with tachycardia, confusion, sweating, anxiety, hallucinations and an elevated BP. He tells you this started because he is quitting alcohol and has his last drink 2-4 days ago. How do you treat him?
5% of alcohol withdrawals present w/delirium tremens which has a mortality rate of 20%. He is presenting with symptoms of DT and needs benzos and a high calorie, high carbohydrate diet w/multivitamins to replace thiamine, folate and magnesium.
293
Best tx for alcoholism
AA meetings. You can also have them on short-term prophylactic disulfiram (SOB, flushing, palpitations, tachycardia, HA, N/V for 90 min. after taking a drink). Naltrexone can be used to lessen cravings. Benzos can be used for withdrawal sx. Correct any fluid, vitamin or electrolyte imbalances.
294
Malignancies associated w/tobacco use
Pulmonary, oral, esophageal, laryngeal, pharyngeal, bladder, cervical and pancreatic
295
Treatment available for smoking cessation
1) Behavioral modification is crucial for long term. Patch or gum for withdrawal (quit rates are higher w/this combo, good because there are no peak/trough nicotine levels). 2) Varenicline (partial alpha-4-beta-2 nAChR partial agonist)
296
Instructions for smokers that want help quitting with the patch
Wear for 16 hours and take off for sleep to avoid HA. Start w/strong 21mg patch for 1 month. Taper to lower 14 and 7 mg patch over 4-6 weeks. Don’t smoke w/patch on due to increased risk of MI.
297
Instructions for smokers that want help quitting with the gum
Use it continuously for 2-4 months. No success typically means not frequent enough use.
298
What drug can be taken in combination with nicotine gum and patch to help smoking cessation?
Bupropion. Note risk of lowering seizure threshold and side effects of dry mouth, insomnia and HA.
299
HTN screening recs
All adults \> 18 q2 years if
300
HLD screening recs
Healthy adult males \> 35 q5 years. Females at risk for CHD \> 45.
301
CRC screening recs
Asymptomatic adults 50-75 w/1) FOBT yearly 2) flex sig q5 years w/FOBT q3 years or colo q10 years (best test). If patient has polyps or hx of CRC repeat colo at 3 years and repeat q5 years. If FHx of CRC or polyps in 1st degree colo at age 40 or 10 years younger than when the youngest case in the family had CRC, repeat q3-5 years. If FAP, do genetic testing at age 10 and consider colectomy if +. If not +, colo q1-2 years starting at puberty. If HNPCC, genetic test at 21, if + colo q2 years until 40, then q1 years thereafter.
302
Breast CA screening recs
Biennial screening for women age 50-74.
303
Cervical CA screening recs
Women age 21-65 w/pap smear q3 years. Screening interval can go to q5 years at from age 30-65 if HPV co-testing is done.
304
Chlamydia screening recs
All women age 24 and under and older non-pregnant women at risk
305
Gonorrhea screening recs
Men and women under age 25 and all adults at increased risk
306
Depression screening recs
All adults at every possible visit
307
Aspirin recs
Men 45-79 and women 55-79 to prevent CVD
308
Osteoporosis screening recs
Women \> 65 and younger women whose fracture risk (FRAX) is equal to or greater than a 65 year old white woman
309
AAA screening recs
Smoker men 65-75 once w/ultrasound
310
Hep C screening recs
One time if born between 1945-1965
311
DM II screening recs
Asymptomatic adults with sustained BP \> 135/80
