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Medicine > Step Up-Ambulatory Medicine > Flashcards

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.

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2
Q

Why are patients with HTN at increased risk of CAD, PVD and CVA?

A

HTN accelerates atherosclerosis

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3
Q

4 non-modifiable risk factors for HTN

A

1) Age > 60 2) Male 3) African-American 4) FHx

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4
Q

3 modifiable risk factors for HTN

A

1) Obesity 2) Sodium intake 3) Alcohol intake > 2 oz.

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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

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6
Q

Diabetic & renal disease definition of HTN

A

> 130/80

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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

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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)

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9
Q

When will most newly diagnosed patients with HTN get 2-drug tx from the start?

A

Stage II (> 160/100)

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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

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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

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12
Q

Lifestyle modification necessary for HCTZ to work?

A

Na restriction, otherwise hypokalemia will be exacerbated

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13
Q

Best anti-HTN med for old men with BPH?

A

Alpha-blockers

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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

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15
Q

Anti-HTN medications contraindicated in pregnancy?

A

ACE-I, ARBs, CCBs and thiazides. Beta-blockers and hydralazine are safe.

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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.

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17
Q

ACCOMPLISH trial findings regarding effectiveness of combination therapy

A

Benazepril + amlodipine was more effective than and ACE-I or CCB alone.

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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.

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19
Q

Who gets screening lipid testing?

A

All adults > 20 yrs q5 years

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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

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21
Q

Causes of secondary dyslipidemia?

A

Endocrine (hypothyroidism, DM, Cushing’s), Renal (nephrotic syndrome), ESLD, Meds (propranolol, HCTZ, estrogen, prednisone) and Pregnancy.

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22
Q

Foods that will elevate LDL

A

Saturated fatty acids and cholesterol

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23
Q

Foods that will elevate triglycerides (VLDL)?

A

High calorie diets and alcohol

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24
Q

At what age do cholesterol levels stop increasing?

A

65

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25
Q

When do both genders have equal risk for HLD?

A

After menopause

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26
Q

How is LDL measured?

A

Total cholesterol - HDL - TG/5

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27
Q

LDL levels associated with significant increase in CAD risk

A

160

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28
Q

Total cholesterol levels associated with significant increase in CAD risk?

A

160-200, > 240 is really bad

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29
Q

Why is HDL so good?

A

Every 10mg/dL increase = 50% decrease CAD risk. HDL 60 subtracts 1 point from risk.

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30
Q

Risk associated with total cholesterol to HDL ratio

A
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31
Q

A patient with DM presents with an LDL of 120, what is your next move?

A

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.

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32
Q

Labs to get routinely if you put your patient on a statin or fibrate?

A

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

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33
Q

Risk of hypertriglyceridemia

A

Associated w/CAD and pancreatitis

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34
Q

Labs to order when diagnosing someone who came back with a non-fasting elevation in their total cholesterol and drop in HDL?

A

Full fasting lipid panel (TChol, HDL, TGs, calculated LDL), TSH (hypothyroidism), LFTs (ESLD), BUN/Cr/UA (nephrotic) and HbA1c (DM).

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35
Q

Statins listed most to least potent

A

Simvastatin/Atorvastatin > Lavastatin/Pravastatin > Fluvastatin

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36
Q

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/

A

*

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37
Q

What are the CHD risk equivalents that make a patient have a target LDL

A

DM, PVD, CAD, AAA

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38
Q

What is the most effective lifestyle change you can ask patients to make in order to lower their LDL?

A

Reduce saturated fat intake, this lowers LDL more than decreased cholesterol intake does. Diet should be

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39
Q

How does exercise help patients with lipidemia?

A

It increases HDL

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40
Q

How does prescribing a statin to a patient affect their relative cardiovascular risk?

A

Drops it by 20-30% regardless of baseline LDL

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41
Q

Why are statins so effective?

A

They reduce LDL AND act as an antioxidant in the endothelial lining of coronary arteries

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42
Q

What levels on the lipid panel are affected by statins? Niacin? Cholestyramine? Gemfibrozil?

A

Statin: LDL (most potent drug). Niacin: TG, LDL and HDL (most potent drug for TG & HDL). Cholestyramine: LDL, TG. Gemfibrozil: VLDL, TG, HDL.

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43
Q

Medications that can be considered for elevated TGs?

A

Fibrates, nicotinic acid and fish oil. Statins should be given because they are cardioprotective.

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44
Q

Lipid lowering agent contraindicated in diabetics

A

Niacin, it may worsen glycemic control

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45
Q

Lipid lowering agent with possible side effects of gynecomastia, gallstones, weight gain and myopathy.

A

Gemfibrozil

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46
Q

What are the defining characteristics of a tension headache?

A

Worsens throughout the day, precipitated by anxiety/depression/stress, “band-like” pain around entire head, radiates to neck/upper back w/muscle tightness.

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47
Q

Treatment of tension headaches

A

Stress reduction, anxiety/depression eval. NSAIDs, Tylenol, ASA are 1st line. Migraine medications can be 2nd line.

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48
Q

What are the defining characteristics of a cluster headache?

A

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.

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49
Q

Treatment of cluster headaches

A

Acute: sumatriptan + O2. Prophy: verapamil is 1st line and works very well. May also use ergotamine, methysergide, Li and prednisone.

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50
Q

What are the defining characteristics of a migraine w/aura?

A

Bilateral homonymous scotoma, scintillating scotoma, flashing lights, hemiparesis and/or dysphagia

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51
Q

What are the defining characteristics of a menstrual migrain

A

2 days b/f menses or on the last day of menses due to estrogen withdrawal.

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52
Q

Definition of status migrainosus

A

> 72 hours w/o spontaneous resolution

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53
Q

What are the defining characteristics of the migraine without aura (common migraine)?

A

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.

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54
Q

Postulated pathogenesis behind migraines

A

5-HT depletion

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55
Q

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?

A

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

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56
Q

Treatment of an acute migraine attack?

A

1st line: NSAIDs, Tylenol. 2nd line: dihydroergotamine (DHE, a 5-HT1 agonist) or sumatriptan (more selective 5-HT1 agonist).

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57
Q

When is dihydroergotamine contraindicated?

A

Pregnancy, CAD, TIAs, PVD and sepsis

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58
Q

When is sumatriptan contraindicated?

A

Use > 1-2x/week, pregnancy, CAD, uncontrolled HTN, basilar aa migraine, hemiplegic migraine and use of MAOI, SSRI or Li.

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59
Q

Migraine prophylaxis

A

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.

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60
Q

Treatment of menstrual migraines

A

NSAIDs are 1st line. Estrogen supplementation can be added.

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61
Q

What defines a chronic cough and when should further work up begin? What are the most common causes of chronic cough in adults?

A

> 3 weeks. Failure to resolve in a month should result in further work up. Common causes are smoking, PND, GERD, asthma.

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62
Q

When is ordering a CXR appropriate in a patient with cough?

A

Chronic cough, suspected pulmonary etiology, hemoptysis or long-term smokers w/suspect COPD or lung cancer

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63
Q

When is bronchoscopy appropriate in a patient with cough?

A

No dx after CXR, CBC or PFTs. Suspected tumor, web/ring or foreign body.

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64
Q

Tx for post-nasal drip

A

1st gen. antihistamine/decongestant. +/- abx if sinusitis is present. +/- non-sedating long-acting antihistamine like loratadine if allergic rhinitis

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65
Q

When to use non-specific antitussives? What are they?

A

Unknown cause, ineffective specific tx or cough serves no purpose. Codeine, dextromethorphan and Benzonatate capsules

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66
Q

When to get labs and rads in a patient with acute bronchitis?

A

CXR and CBC is pneumonia is suspected +/- ABGs. If you only suspect acute bronchitis, labs/rads are not indicated.

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67
Q

Tx of acute bronchitis

A

Supportive

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68
Q

Viruses that are common perpetrators in the common cold (acute rhinosinusitis)?

A

1) Rhinovirus (50%, 100 different serotypes. Others include parainfluenza, adenovirus, coronavirus, coxsackie and RSV

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69
Q

Features concerning for secondary bacterial sinusitis or pneumonia in patients with acute rhinosinusitis?

A

Fever in an adult

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70
Q

Tx for acute rhinosinusitis

A

Hydration to loosen up secretions, analgesics (ASA, ibuprofen, acetaminophen), anti-tussive, decongestant nasal spray for

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71
Q

Common causes of acute sinusitis?

A

Follows URI/common cold or causes it to persist beyond 8-10 days, polyps, deviated septum or foreign body

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72
Q

Common bacteria that cause bacterial sinusitis

A

S. pneumo, non-typeable H. flu, anaerobes

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73
Q

Sinuses most commonly affected in bacterial sinusitis

A

Maxillary

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74
Q

Features of chronic sinusitis

A

At least 2-3 months of nasal congestion, PND usually w/o HA, pain or fevers and hx of multiple sinus infections.

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75
Q

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?

A

Broad-spectrum penicillinase resistant abx to cover S. aureus and possible GNRs. Refer to ENT.

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76
Q

Complication of ethmoid sinusitis

A

Orbital cellulitis

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77
Q

Complications possible in all types of sinusitis

A

Mucocele, polyps, osteomyelitis, cavernous sinus thrombosis, epidural abscess, subdural empyema, meningitis and brain abscesses

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78
Q

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?

A

This patient has acute sinusitis. Tx with saline nasal spray to help with drainage, pseudoephedrine or oxymetazoline for decongestion for

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79
Q

Common bugs involved in laryngitis?

A

Mostly viral, M. cat and H. flu can also be involved

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80
Q

Tx of laryngitis

A

Self-limiting, rest voice to avoid formation of vocal cord nodules

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81
Q

Most common cause of pharyngitis?

A

Viruses (adeno, para, rhino, EBV and HSV). GABHS is only a concern for tx due to possibility of rheumatic fever, not the pharyngitis.

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82
Q

Other bacterial causes of pharyngitis

A

Chlamydia, mycoplasma, gonococci, c. diphtheriae and candida (if immunosuppressed)

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83
Q

DDx in a patient w/sore throat

A

Viral infxn, tonsillitis, strep throat and mono

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84
Q

50:50 pharyngitis rule

A

Only 50% of patients w/exudates have strep and only 50% of patients w/strep have exudates

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85
Q

Work up in a patient w/strep throat

A

CENTOR criteria, +/- rapid strep swab. If rapid strep swab is positive treat, if negative culture. +/- mono spot blood test

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86
Q

Tx of strep throat

A

10 days PCN or erythromycin

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87
Q

Tx of mono

A

Rest, tylenol/ibuprofen avoid contact sports

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88
Q

Tx of viral pharyngitis

A

Symptomatic (acetaminophen, ibuprofen, salt water gargle, humidifier, throat lozenges)

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89
Q

A patient presents with heartburn, bloating and epigastric discomfort. What are the most common causes of her condition?

A

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.

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90
Q

Dx of nonulcer dyspepsia

A

Dyspepsia for at least 4 weeks and no other dx after endoscopy

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91
Q

Indications for endoscopy in patients presenting w/dyspepsia

A

Red flags (wt loss, anemia, dysphagia, hematemesis), new onset dyspepsia if > 45 years, recurrent vomiting, no response to empiric therapy

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92
Q

Tx of dyspepsia in a pt w/negative H. pylori testing

A

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.

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93
Q

Types of testing used for H. pylori

A

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.

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94
Q

Things to look out for in H. pylori testing that may cause false negative results

A

PPIs, bismuth, many abx and upper GI bleed

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95
Q

Tx of dyspepsia in a pt w/positive urea breath test

A

Triple tx: PPI, amox, clarithromycin 10-14 days. Quad tx for retreatment: PPI, bismuth and 2 abx.

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96
Q

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?

A

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).

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97
Q

How is GERD diagnosed?

A

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

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98
Q

Barrett’s esophagus

A

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

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99
Q

Screening and tx for Barrett’s

A

Endoscopy w/biopsy if GERD sx > 5 years in duration. If +Barrett’s metaplasia but -dysplasia then screening endoscopy q3 years. Tx = chronic PPI

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100
Q

Cytologic findings that can diagnose recurrent pneumonia due to aspiration in GERD patients

A

Lipid-laden macrophages

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101
Q

Key physical exam findings in patients w/GERD

A

Pitting of dental enamel, night time cough, metallic taste in mouth

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102
Q

Tx of GERD

A

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.

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103
Q

Tx for a patient w/chronic GERD and new onset dysphagia

A

They likely have peptic strictures and will need dilation

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104
Q

Definition of acute vs chronic diarrhea

A

4 weeks

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105
Q

Most common bugs involved in acute diarrhea

A

Rotovirus and norovirus.

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106
Q

Most common bugs involved in severe acute diarrhea

A

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.

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107
Q

Common bugs involved in acute diarrhea in the immunocompromised

A

MAI, Cryptosporidium, Cyclospora, CMV

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108
Q

Aside from infection what are common causes of acute diarrhea?

A

Antibiotics: esp. clinda, amp and cephalosporins. Meds: laxatives, prokinetics (cisapride), antacids, digitalis, cochicine, alcohol, Mg, chemo. Malabsorption. Ischemic bowl. Tumors.

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109
Q

Common causes of chronic diarrhea

A

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.

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110
Q

Indications for lab work up in patients with diarrhea? What labs?

A

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.

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111
Q

Why do bacterial stool cultures kind of suck?

A

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.

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112
Q

Most common electrolyte abnormality in patients with diarrhea

A

Metabolic acidosis + hypokalemia

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113
Q

4 reasons to admit a patient w/acute diarrhea

A

Unable to tolerate PO, bloody diarrhea, toxic appearing, volume deplete

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114
Q

Treating acute diarrhea

A

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.

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115
Q

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?

A

Acute viral gastroenteritis (norwalk or rotavirus)

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116
Q

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?

A

Salmonella. No tx necessary unless suspect typhoid fever, then tx w/cipro (also tx if immunocompromised).

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117
Q

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?

A

Bactrim, he likely has shigella which commonly presents w/tenesmus

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118
Q

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?

A

He likely has staph food poisoning, supportive tx is appropriate.

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119
Q

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?

A

He likely has been infected by campylobacter and needs erythromycin.

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120
Q

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?

A

C. perfringens

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121
Q

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?

A

Enterotoxic E. coli

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122
Q

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?

A

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.

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123
Q

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?

A

He likely has giardiasis. Tx w/metronidazole.

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124
Q

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?

A

Vibrio cholera

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125
Q

What are common causes of constipation?

A

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
Q

Work up in patients w/constipation

A

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
Q

Conservative management of constipation

A

Increase fiber, exercise and fluids. Fleet enema for temporary relief.

128
Q

Criteria necessary to diagnose IBS?

A

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
Q

Common findings associated w/IBS

A

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
Q

Things to think of before diagnosing someone w/IBS

A

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
Q

Tx of IBS

A

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
Q

DDx in a patient who presents w/nausea and vomiting

A

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
Q

Complications of severe or prolonged vomiting

A

Dehydration, metabolic alkalosis, hypokalemia, dental caries, aspiration, Mallory-Weis tears, Boerhaave’s syndrome

134
Q

First step in management in a patient presenting w/nausea and vomiting

A

1/2 NS + K, treat underlying cause. +/- prochlorperazine (compazine), promethazine (phenergan), clear liquid diet and NG.

135
Q

A pregnant truck driver w/PMHx significant for constipation, obesity and portal HTN presents w/occult rectal bleeding. What is your next step?

A

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
Q

Conservative tx for hemorrhoids

A

Fitz baths, ice, bed rest, stool softeners, high fiber/fluids, topical steroids

137
Q

Surgical tx for hemorrhoids

A

Band ligation for internal hemorrhoids or hemorrhoidectomy if refractory, severe prolapse, strangulation, large anal tags or fissures.

138
Q

3 most common causes of low back pain?

A

Musculoligamentous strain, DDD, facet arthritis

139
Q

Definition of acute, subacute and chronic LBP?

A

12 weeks

140
Q

When is L-spine imaging indicated in patients w/LBP before the 4-6 week mark?

A

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
Q

Differentiating spinal stenosis from disc herniation

A

Disk herniation = pain w/forward flexion. cough/sneezing and straight leg test. Spinal stenosis = pain w/back extension, standing, walking.

142
Q

Why is spinal surgery controversial for many types of back pain?

A

Many people without any back pain have imaging findings of DDD, spondylolisthesis.

143
Q

Common findings in patients with spondylolithesis

A

L4-5 or L5-S1 slippage, associated spinal stenosis and neurogenic claudication

144
Q

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?

A

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
Q

Strongest predictors of pain and disability in patients with LBP?

A

MRI doesn’t correlate, psychosocial factors matter more

146
Q

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?

A

Spinal stenosis can be treated with epidural steroid injections. If these fail surgery is very effective.

147
Q

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?

A

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
Q

Most common spinal tumor

A

Metastatic carcinoma from breast, lung, prostate, kidney and thyroid

149
Q

Patients at risk for discitis or osteomyelitis of the spine

A

IV drug users, dialysis and pts w/indwelling catheters

150
Q

Infection in the spine that requires rapid surgical decompression

A

Epidural abscesses

151
Q

Other organ systems that may cause back pain sx

A

Aortic aneurisms/dissection, prostatitis, nephrolithiasis, endometriosis, ectopic pregnancy and PID

152
Q

When is the straight leg test +

A

Radiating leg pain w/elevation to 30-60 degrees

153
Q

What motor deficit on physical exam signifies L2 motor weakness? L3? L4? L5? S1?

A

L2 = hip flexion, L3 = knee extension, L4 = ankle dorsiflexion, L5 = great toe dorsiflexion, S1 = plantar flexion

154
Q

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

A course of physical therapy for core strengthening and aerobic conditioning, possibly some imaging.

155
Q

When do you start considering surgery for chronic LBP?

A

Failure of conservative measures after 1 year. Note that response to surgery will be better for nerve root decompression than fusion for DJD

156
Q

Advice you’d give about activity in a patient with LBP

A

Avoid inactivity. In the 1st week walk 20 min TID and rest in between

157
Q

What is the chronic LBP equivalent in the c-spine?

A

Chronic axial neck pain

158
Q

When is surgery a good option for patients w/neck pain

A

When there are associated radicular sx

159
Q

Most common cause of acute neck pain? Tx?

A

Cervical strain. PT if sx last > 2-4 weeks

160
Q

DDx for a patient presenting with cervical radiculopathy?

A

Spondylosis, herniated disc, shoulder impingement, cubital/carpal tunnel syndrome, thoracic outlet syndrome, HZV and Pancoast tumor.

161
Q

How is cervical radiculopathy diagnosed?

A

MRI after 6 week trial of conservative therapy

162
Q

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?

A

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
Q

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?

A

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
Q

What are the different types of arthritis?

A

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
Q

A patient presents with anterior knee pain worse when climbing stairs. How do you treat him?

A

Patellofemoral pain is treated w/PT strengthening of hamstrings and quadriceps

166
Q

When is surgery best for a patient with a meniscal tear?

A

If no OA is present

167
Q

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?

A

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
Q

Common cause of a Baker’s cyst?

A

Meniscal tear

169
Q

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?

A

He likely has patellar tendinitis and needs quad/hami strengthening and stretching exercises.

170
Q

Plica syndrome

A

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
Q

When is it appropriate to image a knee?

A

Hx of trauma, suspect degeneration = rads. Suspect lig. or meniscal tear = MRI.

172
Q

How do you grade ankle sprains?

A

Grade 1 = partial ATFL rupture. Grade 2 = complete ATFL and partial CFL. Grade 3 = complete ATFL/CFL

173
Q

When do you NOT have to get ankle radiographs in a patient with an acutely sprained ankle?

A

Able to walk 4 steps after injury and at time of evaluation. No bony tenderness over distal 6cm of either malleolus

174
Q

Management of ankle sprains

A

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
Q

Most common cause of shoulder pain?

A

Supraspinatous tendinitis, i.e. impingement syndrome due to impingement of supraspinatous tendon between greater tuberosity of humerus and acromion.

176
Q

When to get an MRI in a patient with impingement syndrome?

A

Weakness w/shoulder abduction is suspicious for a tear. Pain alone is more suspicious for tendinitis and does not warrant MRI.

177
Q

Management of impingement syndrome

A

1) PT 2) Subacromial steroid injections 3) Acromioplasty

178
Q

Management of lateral and medial epicondylitis?

A

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
Q

Management of De Quervain’s tenosynovitis?

A

Thumb spica splint + NSAIDs +/- local corticosteroid injections. If this fails surgery can be done.

180
Q

Tendons affected in De Quervain’s tenosynovitis?

A

APL, EPB

181
Q

Where does hip OA pain present? What hip pain is not OA?

A

OA hip pain = groin pain. Lateral hip or buttock pain is not due to OA

182
Q

Tx of trochanteric bursitis

A

NSAIDs, corticosteroid injections if sx persist

183
Q

What other conditions are associated with carpal tunnel syndrome?

A

Hypothyroidism, DM, pregnancy

184
Q

Definitive dx of carpal tunnel syndrome

A

EMG (cannot r/o carpal tunnel even if Phalen’s and Tinnel’s are negative)

185
Q

What is responsible for the pain felt in patients with osteoarthritis?

A

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
Q

Features of OA

A

Relieved w/rest, worse w/activity. Stiff in morning or after inactivity. Limited ROM. Bony crepitus.

187
Q

Radiographic characteristics of OA

A

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
Q

Bouchard’s nodes

A

Boney overgrowth at PIP joints

189
Q

Heberden’s nodes

A

Bony overgrowth at DIP joints

190
Q

Which hand should the cane be held in if a patient has left knee OA?

A

Right hand

191
Q

Ideal exercise for OA

A

Swimming

192
Q

1st line drug for OA

A

Acetaminophen

193
Q

Where did the COX-2 inhibitors go?

A

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
Q

How often might a patient expect to get a revision if they get a knee replacement?

A

Every 15-20 years

195
Q

OTC products for OA with no meaningful benefit in high quality RCTs

A

Clucosamine and chondroitin sulfate

196
Q

Definition of osteoporosis?

A

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
Q

Mechanism of osteoporosis

A

Failure of adequate bone deposition by age 30 w/bone resorption rate that exceeds deposition rate later in life

198
Q

Who gets osteoporosis

A

Postmenopausal women and elderly men

199
Q

Type I primary osteoporosis

A

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
Q

Type II primary osteoporosis

A

Equal loss of trabecular AND cortical bone. Presents in elderly over age 70 as femoral neck, proximal humerus and pelvic fx

201
Q

Secondary osteoporosis

A

Cause other than aging to include Cushing’s, chronic steroid use, immobilization, hyperhyroidism, chronic heparin use, hypogonadism in men, body wt

202
Q

Risk factors for osteoporosis

A

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
Q

Maintainstay of prevention/treatment of osteoporosis

A

Vit D (800 IU) and Ca (1200mg) per day supplementation, weight-bearing exercise 30 min 3x/week, smoking cessation and alcohol reduction.

204
Q

What did the PROOF trial show

A

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
Q

Pts w/highest morbidity/mortality due to osteoporosis

A

Those that get hip fx

206
Q

How is osteoporosis diagnosed

A

Gold standard = DEXA scan of femoral neck and l-spine. Done in all women over 65, postmenopausal women

207
Q

How often should women over 65 get a DEXA scan if the scan is normal?

A

q3-5 years

208
Q

Who gets pharmacologic therapy for osteoporosis?

A

Postmenopausal women w/osteoporosis, fragility fx and high risk postmenopausal women w/osteopenia

209
Q

1st line tx for osteoporosis

A

Bisphosphonates (alendronate/risedronate): inhibit bone resorption by binding hydroxyapatite and decreasing osteoclast activity.

210
Q

Next step if you patient cannot tolerate oral bisphosphonates due to reflux, esophageal irritation or ulceration?

A

IV bisphosphonates (zoledronic acid)

211
Q

Who get recombinant PTH for osteoporosis

A

Pts w/severe osteoporosis who cannot tolerate bisphosphonates or continue to fracture despite being on them for 1 year.

212
Q

Duration of tx of rPTH for patients with osteoporosis

A

2 years. Stop at this time due to concerns for osteosarcoma

213
Q

Medication used short-term in elderly females with vertebral compression fractures

A

Calcitonin nasal spray

214
Q

Risks of using raloxifene for osteoporosis

A

Increased risk of breast CA, CVA, VTE and CAD

215
Q

Most common cause of vision loss in people > 65

A

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
Q

2 types of ARMD

A

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
Q

Symptoms described in ARMD

A

Central vision loss, burry, distorted vision +/- scotoma

218
Q

Tx for ARMD

A

Intra-ocular VEGF inhibitor (Ranibizumab) injections for wet. OTC vitamins for dry.

219
Q

Most common cause of non-reversible blindness in African Americans

A

Glaucoma

220
Q

Pathogenesis of glaucoma

A

Increased intra-ocular pressure leads to ischemia, loss of ganglion cells and cupping of the optic cup (atrophy of the disc)

221
Q

2 types of glaucoma

A

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
Q

Common misdiagnosis in patients with acute angle glaucoma

A

Acute surgical abdomen due to abdominal pain, nausea and vomiting

223
Q

Risk factors for glaucoma

A

Age > 50, AA race, FHx, Hx of eye trauma and steroids.

224
Q

Dx glaucoma

A

Tonometry to measure IOP, opthalmoscopy to assess optic nerve, gonioscopy to visualize anterior chamber and visual field testing.

225
Q

Tx glaucoma

A

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
Q

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?

A

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
Q

Risk factors for cataracts

A

Old age, cigarette smoking, glucocorticoids, UV exposure, radiation, trauma, DM, Wilson’s, Down’s syndrome

228
Q

Most common cause of red eye. How is it diagnosed and treated?

A

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
Q

What is “second sight”

A

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
Q

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?

A

He has subconjunctival hemorrhage and all of the risk factors to include Valsalva, HTN and coagulopathy. This condition is self-limiting.

231
Q

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?

A

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
Q

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?

A

He has blepharitis. Treat w/lid scrubs, warm compress and topical erythromycin for severe cases.

233
Q

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?

A

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
Q

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?

A

She has scleritis. Refer to optho for topical and possible systemic corticosteroids due to concerns about systemic immunologic disease like RA.

235
Q

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?

A

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
Q

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?

A

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
Q

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?

A

Allergic conjunctivitis. Treat with cold compresses, topical antihistamines/mast cell stabilizers. May also use topical NSAIDs and systemic antihistamines.

238
Q

Complication associated with viral conjunctivitis

A

Membranous conjunctivitis that requires topical steroids and stripping of membranes

239
Q

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?

A

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
Q

Most common cause of blindness worldwide

A

Chlamydia trachomatis A, B and C. Due to chronic scarring.

241
Q

Conjunctivitis from STDs. How is it treated?

A

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
Q

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?

A

Immediate optho referral for hyperacute bacterial conjunctivitis due to N. gonorrhoeae. Treatment consists of 1x dose ceftriaxone 1g IM + topical therapy.

243
Q

Risk factors for OSA

A

Neck obesity, enlarged tonsils, uvula, soft palate, nasal polyps, pharyngeal muscle hypertrophy, deviated septum, FHx, alcohol/sedatives, hypothyroidism and overbite w/small chin

244
Q

Complications associated with OSA

A

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
Q

Tx of OSA

A

Mild-moderate (20 apneic episodes w/desats): CPAP, uvulopalatopharyngoplasty, tracheostomy if life-threatening and refractory

246
Q

What causes narcolepsy?

A

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
Q

Major problem to address in a patient with newly diagnosed narcolepsy

A

Driving and MVA prevention

248
Q

Tx of narcolepsy

A

Methylphenidate and planned naps during the day

249
Q

Causes of chronic secondary insomnia?

A

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
Q

Definition of chronic primary insomnia?

A

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
Q

Tx for insomnia

A

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
Q

Normal BMI

A

18.5 - 24.9

253
Q

1st line agent for obesity

A

Orlistat. Pancreatic and gastric lipase inhibitor that does not hydrolyze fat and inhibits resorption of fat.

254
Q

Who can get bariatric surgery

A

Patients who have earnestly tried more conservative methods w/BMI >40 or BMI > 35 w/other comorbidities (DM, OSA, HTN, HLD).

255
Q

Causes of conductive hearing loss?

A

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
Q

Causes of sensorineural hearing loss?

A

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
Q

Pathology behind presbycusis

A

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
Q

Pathology behind noise-induced hearing loss?

A

Damage to the hair cells in the organ of Corti

259
Q

How can chronic aspirin use affect hearing

A

Reversible tinnitus

260
Q

Presentation in patients with Ménière’s?

A

Fluctuating unilateral SNHL that also presents with pressure/fullness in the ear, tinnitus and vertigo

261
Q

Tx of Meniere’s

A

Dietary salt restriction and meclizine (antiemetic antihistamine). Hearing loss is progressive

262
Q

Frequencies lost in conductive hearing loss

A

Low-frequency, no problem hearing louder noises

263
Q

Frequencies los in SNHL

A

High-frequency, associated problems hearing loud noises, deciphering words and tinnitus.

264
Q

Essential component in diagnosis of hearing loss

A

Audiogram

265
Q

Tx of cerumen impaction

A

1) Several days of softening with carbide peroxide (Debrox) or triethanolamine (Cerumenex) 2) Irrigation

266
Q

Rinne and Weber for conductive hearing loss

A

Abnormal Rinne (BC > AC). Weber: sound lateralizes to affected side.

267
Q

Rinne and Weber for SNHL

A

Normal Rinne (AC > BC). Weber: sound lateralizes to good ear

268
Q

What type of hearing loss will be better with a cochlear implant?

A

SNHL. It stimulates CN VIII

269
Q

4 types of incontinence

A

Stress, urge, overflow, functional

270
Q

Most common cause of incontinence in elderly

A

Urge

271
Q

Most common cause of incontinence in women

A

Stress

272
Q

Common causes of male incontinence

A

BPH and neurologic disease (MS, Parkinson’s, stroke, spinal cord injury)

273
Q

Meds that can cause incontinence

A

Diuretics, anticholinergics and adrenergics cause retention, beta-blockers diminish sphincter tone, CCBs/narcotics increase detrusor activity

274
Q

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?

A

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
Q

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?

A

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
Q

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?

A

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
Q

Common type of incontinence seen in patients w/spinal cord injury, MS, DM, tabes doornails, disc herniation and spinal cord compression.

A

Reflex incontinence, characterized by a patient who cannot sense the need to urinate.

278
Q

How should you work up all cases of incontinence

A

1st r/o UTI w/UA and culture. Then record postvoid residual (normal

279
Q

A patient presents with fatigue and relatively few other sx. What is your initial lab workup?

A

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
Q

Meds that can cause fatigue

A

clonidine, methyldopa, amitriptyline, doxepin, trazodone, hypnotics, beta-blockers, anti-histamines

281
Q

What is chronic fatigue syndrome?

A

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
Q

Tx of chronic fatigue syndrome

A

CBT w/exercise, antidepressants prn, NSAIDs for HA/arthralgias

283
Q

Risk factors for erectile dysfunction?

A

Atherosclerosis, antihypertensive meds, sickle cell, hx of pelvic surgery/trauma, alcohol abuse, hypogonadism, hypothyroidism, congenital penile curvature

284
Q

Next step if a patient has erectile dysfunction, loss of libido and hypogonadism

A

Serum testosterone, prolactin and TSH/fT4

285
Q

How can you determine if erectile dysfunction is likely psychogenic or organic in nature?

A

If erections occur at night it is likely psychogenic

286
Q

How can you test to see if vasculature is sufficient enough to cause erection?

A

Intracavernosal injection of vasoactive substances, duplex u/s and arteriography

287
Q

Tx of erectile dysfunction

A

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
Q

CAGE questions for alcoholism

A

Cut down? Annoyed? Guilty? Eye-opener?. May follow-up with more extensive MAST questionnaire (25 questions)

289
Q

Benefits of alcohol

A

Increases HDL (however also increases TGs)

290
Q

Lab findings in chronic alcoholics

A

Macrocytic anemia (microcytic if +GI bleed), AST > ALT elevation, increased GGT, increased TGs, hyperuricemia, hypocalcemia, thiamine deficiency and decreased testosterone

291
Q

Malignancies associated w/alcohol use

A

Esophageal, oral, hepatic and pulmonary

292
Q

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?

A

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
Q

Best tx for alcoholism

A

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
Q

Malignancies associated w/tobacco use

A

Pulmonary, oral, esophageal, laryngeal, pharyngeal, bladder, cervical and pancreatic

295
Q

Treatment available for smoking cessation

A

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
Q

Instructions for smokers that want help quitting with the patch

A

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
Q

Instructions for smokers that want help quitting with the gum

A

Use it continuously for 2-4 months. No success typically means not frequent enough use.

298
Q

What drug can be taken in combination with nicotine gum and patch to help smoking cessation?

A

Bupropion. Note risk of lowering seizure threshold and side effects of dry mouth, insomnia and HA.

299
Q

HTN screening recs

A

All adults > 18 q2 years if

300
Q

HLD screening recs

A

Healthy adult males > 35 q5 years. Females at risk for CHD > 45.

301
Q

CRC screening recs

A

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
Q

Breast CA screening recs

A

Biennial screening for women age 50-74.

303
Q

Cervical CA screening recs

A

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
Q

Chlamydia screening recs

A

All women age 24 and under and older non-pregnant women at risk

305
Q

Gonorrhea screening recs

A

Men and women under age 25 and all adults at increased risk

306
Q

Depression screening recs

A

All adults at every possible visit

307
Q

Aspirin recs

A

Men 45-79 and women 55-79 to prevent CVD

308
Q

Osteoporosis screening recs

A

Women > 65 and younger women whose fracture risk (FRAX) is equal to or greater than a 65 year old white woman

309
Q

AAA screening recs

A

Smoker men 65-75 once w/ultrasound

310
Q

Hep C screening recs

A

One time if born between 1945-1965

311
Q

DM II screening recs

A

Asymptomatic adults with sustained BP > 135/80

Medicine (3 decks)

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