ITE Board Review: General Internal Medicine – Flashcards

- definition: intentional violent/controlling behavior towards intimate partner - RF: h/o abuse, psych, substance, decr. age, decr. socioeconomics - presentation: somatic symtpoms, vaginal, UTI, STI/ associated with substance abuse, risky sexual behavior, eating disorders, limited access to health care - no gold standard for screening but goals: assist with health, asses for safety, maintain supportive relationship

- definition: neurocardiogenic syncope "faint" prodromal phase N/V/clammy --> withdrawal of sympathetic, increase in parasympathetic/vagal tone, decr. blood pressure, decr. HR - if no surge in vagal tone --> then no decr. in HR --> vasodepressor syncope - provoked: standing, dehydration, preload reduction (diuretics or vasodilators) - risk stratification: no good tool - management: no hospitalization, exception: old people --> risk for face/trauma or secondary cause needs to be ruled out - instruct on abortive/preventative strategies, isometric counter-pressure maneuvers include leg crossing, hand grip, squatting and muscle tensing, no BB

- post-test odds = pretest odds x LR - likelihood ratio: probability WITH disease/ patient withOUT disease

- #1: nasal corticosteroids, decongestion, myringostomy

- Risky/Hazardous - increases the risk of harmful consequences - Harmful - negative effects not not depend (defined by consequences not quantity) - Dependence - desire, impaired control, increased withdrawal/tolerance despite harmful consequences - screening AUDIT/TWEAK (preg) --> assist

- surgery shows no clear benefit - shows in dermatome pattern --> MRI --> surgeon "where to put the knife" - if asymptomatic then --> PT and exercises

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- 23 valent - specific risk factors - if vaccinated before 65, need booster at 65 or 5 years after initial if between 60-64 yo - IMMUNOCOMPETENT: single vaccine with booster - chronic CVD, HTN, chronic lung disease, chronic/URI disease, DM, alcoholism, CSF leak, cochlear implant - IMMUNOCOMPROMISED - 2 doses separated by 54 - HIV, CKD, nephrotic syndrome, malignancy, immunosuppressive meds, multiple myeloma, congenital or acquired deficiency - SPLENIA: 2 doses separated by 5 years - functional asplenia (sickle cell disease, hemoglobinopathies) - anatomic aspenia

- 4 point centor score - 1) fever 2) absence of cough 3) anterior lymphadenopathy 4) tonsillar exudates - 0-1 = low risk --> no additional test - 2-3 = antigen tests or throat culture --> possible abx - 4 = testing --> empiric abx - PCN treatment of choice --> GAS - 10 day oral or 1 day IM PCN G, 10 day erythromycin/azithromycin (macrolide) - Group C and G strep = GN and RA

- 21 yo --> PAP every 3 years - OR - 5 years with HPV DNA for 30-65 - ASCUS 1) colposcopy 2) HPV DNA testing then colposcopy 3) Repeat PAP in 6-12 months

- no gifts

- seasonal allergies/itching - 1) oral antihistamines - 2) topical antihistamines - 3) artificial tears - NO ABX

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- 1) weight loss is most effective - 2) decrease Na intake

- 1) EKG despite low diagnostic yield - 2) echo - 3) telemetry or ambulatory monitoring - 4) pregnancy test - 5) tilt table test: suspected neurocardiogenic, recurrent syncope, arrhythmogenic, incr. RF from CV events where previous test neg - lowest liklihood: head CT scan, carotid doppler U/S, EEG, cardiac enzymes

- varicella, rubella 4 weeks prior to conception - Flu (not intranasal b/c it's live) - pertussis in combo with tetanus and diptheria (tdp, PNA/flu, titers for all rest)

- def: sensorineural hearing loss/attacks for minutes to hours - endolymphatic hydrops - increased hydraulic pressure in the inner ear - cause of increased pressure is unclear? - classic triad: vertigo, unilateral low frequency hearing loss, tinnitus - treatment: antihistamines, benzodiazepines, phenothiazine, vestib rehab - no indication for caffeine, salt, diuretic therapy or steroids - Weber: loudest in affected ear/ Rinne: sensorineural hearing loss is localized to unaffected ear (where it's loudest), conduction loss is in "affected" ear (where it's loudest)

- LMWH "relative contraindication"

- sensitive test --> direct fluorescent antibody, PCR - viral cultures are GOLD standard, takes 2 weeks - Tzanck smear --> cannot distinguish, different herpes (prob should be done at the ID clinic anyway) - treatment not necessary but hastens healing - start treatment at prodrome - topical is NOT best - oral (acyclovir, valacyclovir, famciclovir) or continue oral if recurrent

- "nonallergic" triggers - odors, spices, temperatures - tx: intranasal steroids (DOC), antihistamines, anticholinergics, oral meds are less effective, *nasal saline irrigation may also be helpful

- patient category: incr. sex (STI), incr. percutaneous mucosal transaminitis (healthcare workers), (CKD), long-term facility of development/disabled, incr. morbidity (HIV, chronic disease, DM ages 19-59), travelers, anyone requesting - universal vaccinations of children (0, 2, 6): give Hep B virus immune globulin in newborn w/ vertical transmission - 3 injections: can resume series wherever interrupted, can give vaccine with fever and mild/ mod disease

- transient LOC of postural tone and spontaneous recovery from cerebral hypoperfusion --> global. Less than 1 minute, complete restoration of orientation and function - no risk stratification tool - 1) neurocardiogenic/orthostatic: no hospital, abortive, preventative measure, isometric maneuvers - 2) orthostatic: treat underlying cause, benign - isometric measures, adequate fluid intake, compression stockings, midodrine, hydrocortisone (athletes, pilots, frequent) - 3) carotid sinus hypersensitivity: dual chamber permanent pacer

• no indication before cataract surgery • pregnancy test • OA stability in RA, MR • Cr/GFR in CKD • K in diuretics

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• replace with another antidepressant (same class, different class) • addition of 2nd antidepressant • psychotherapeutic "intervention"

Itching at night, burrows (wavy, threadlike, grayish-white skin elevations capped with small vesicles at the end). "Itchy rash" between fingers, penis, scortum, areolae, nipples Pts with AIDS/institutions → widespread scabies with extensive scaling that may not itch Microscope → mite, feces, eggs using KOH/simple mineral oil. Therapy: treat family/close contacts simultaneously, wash all clothing/linens/towels in hot water and dried heat, topical permethrin and malathion are preferred, oral ivermectin for relapsed scabies (except children, pregnant or lactating women).

Risk Factor: diabetes → patients with central retinal vein occlusion (CRVO) typically report a sudden, unilateral loss of vision. Diagnosis is based on the history of abrupt onset of monocular blindness coupled with classic funduscopic examination findings of congested, tortuous retinal veins; scattered intraretinal hemorrhages; and cotton wool spots in the area of the vein occlusion. An afferent pupillary defect may be seen. Diabetic retinopathy generally develops and progresses slowly and predictably. Chronic hyperglycemia causes edema, hard exudates, and tiny hemorrhages in the retinal layers. Microaneurysms in the vessel wall may result in retinal infarcts (soft exudates or "cotton wool" spots). Retinal screening should start immediately in patients with this type 2 diabetes (because of slow development that can lead to undetected hyperglycemia); approximately 10% of these patients have evidence of diabetic retinopathy at diagnosis. In patients with background retinopathy and poor glycemic control, a rapid improvement in glycemic control can result in a temporary worsening of retinopathy (particularly retinal infarcts). This pattern also is seen in pregnant women with diabetes in whom diabetic retinopathy can appear suddenly and progress rapidly. Therefore, pregnant women with diabetes should be screened for retinopathy during the first trimester and in each trimester thereafter. Reduce risk of retinopathy (or the progression slowed) by excellent glycemic control (hemoglobin A1c value <7.0%), lowering blood pressure, smoking cessation, or use of ACE inhibitors

Number needed to treat (NNT) calculates how many people with a condition require treatment before one person benefits from treatment, NNT = 1/ARR. The number needed to harm (NNH) calculates the number of people with a condition that require treatment before one person experiences harm from the treatment. In this calculation, the denominator is the absolute difference of bad outcomes associated with placebo treatments compared with bad outcomes associated with active treatments.

• Trimethoprim-sulfamethoxazole, nitrofurantoin monohydrate macrocrystals, and fosfomycin are recommended for treating acute uncomplicated cystitis in women. • Antimicrobial prophylaxis may be considered if recurrent urinary tract infections develop in women who have two or more symptomatic infections within 6 months or three or more episodes within 12 months. • Acute pyelonephritis, empiric antimicrobial therapy should be administered after a urine culture is obtained. • Treatment of asymptomatic bacteriuria is recommended only for pregnant women and for men and women undergoing invasive urologic procedures. • Trimethoprim-sulfamethoxazole is the antimicrobial agent of choice for treating acute prostatitis.

Urge incontinence, overactive bladder dysfunction: Daytime frequency, nocturia, bothersome urgency ->Bladder training, anticholinergics (oxybutynin, tolterodine) Stress incontinence:I nvoluntary release of urine secondary to effort or exertion (sneezing, coughing, physical exertion) -> Pelvic floor muscle training for women (Kegel exercises), biofeedback, surgery in recalcitrant cases Overflow incontinence: Nearly constant dribbling of urine, incomplete emptying of bladder, postvoiding residual urine -> Timed urination, intermittent bladder catheterization Functional incontinence: Unable to get to bathroom on time because of mental or physical limitations -> Portable commode, prompted urination, treatment of underlying disorders

Risk Variables: High-risk surgery (emergent major surgery, aortic surgery, major vascular surgery, peripheral vascular surgery, long procedures with large fluid shifts and/or blood loss)... History of ischemic heart disease History of HF History of cerebrovascular disease Insulin treatment Serum creatinine >2.0 mg/dL Patients at low risk (score 0) can undergo any surgery without further risk stratification. Preoperative cardiac risk assessment is not needed for patients at low risk who: • are having minor surgery under local anesthesia (cataract removal) and have no major comorbidities • are <55 years of age, have no pre-existing illnesses, and do not have a cardiac murmur • have had recent (6 months to 1 year) normal coronary imaging studies and no new symptoms • require emergent surgical intervention for life-threatening problems Consider noninvasive testing in patients with ≥3 risk factors or those undergoing vascular surgery (aortic or other major vascular surgery; peripheral vascular surgery) if it will change management. Guidelines vary regarding the necessity of performing preoperative noninvasive testing for patients with intermediate risk of CAD. Because of this, it is unlikely a test question will address this issue.

Patients with trochanteric bursitis report pain when lying on the affected side in the area of greater trochanter. On examination, there is point tenderness to palpation approximately 2.5 cm (1 in) posterior and superior to the greater trochanter. Treatment consists of correction of the underlying etiology, heat, stretching, and corticosteroid injection.

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The goal of therapy is to reduce venous hypertension. Leg compression using knee-high support stockings (20-40 mm Hg of pressure) is recommended whenever possible but should be avoided in those with significant peripheral arterial disease. Leg elevation is encouraged. Diuretics cannot selectively remove edema from the extremities, so their use should be reserved for patients with volume overload. Secondary infection is best treated with oral antibiotics. Allergic contact dermatitis is a potential complication of the use of topical antibiotics, and their use in the treatment of stasis dermatitis should be avoided.

Can be caused by infection, neoplasm, and systemic conditions. Common infectious causes of mucosal lesions include Candida, herpes simplex virus, coxsackievirus, HIV (bacillary angiomatosis, Kaposi sarcoma, hairy leukoplakia), and syphilis. The most common malignancy in the oral cavity is squamous cell carcinoma (particularly in tobacco users); melanoma can also occur. Systemic diseases associated with oral findings include lichen planus, bullous pemphigoid and pemphigus vulgaris, erythema multiforme and Stevens-Johnson syndrome, and Behçet syndrome.

*See above for 34. Do NOT use topical corticosteroids or antibiotics.

The LR is a measurement of the odds of having a disease independent of the disease prevalence. First assess the patient's pretest probability of having a disease before applying the LR of the test/finding to calculate the posttest probability. • Positive LR = (sensitivity) / (1 − specificity); negative LR = (1 − sensitivity) / (specificity). • Positive LR answers the question, "How much more likely is a person to have the disease given a positive test result?" • LRs of 2, 5, and 10 increase the probability of disease by approximately 15%, 30%, and 45%, respectively. • LRs of 0.5, 0.2, and 0.1 decrease the probability of disease by approximately 15%, 30%, and 45%, respectively.

Neurogenic pain is typically burning and often radiates to the shoulder or down the arm. Patients may have dermatomal numbness or muscle weakness in the distribution of a cervical nerve root. Involvement of multiple spinal levels, spasticity, hyperreflexia, gait abnormality, or leg weakness all suggest central spinal cord compression.

5 A/Rs: Advise to quit. Assist patient in identifying the Risks of smoking. Assess willingness to quit. Assist the patient in identifying the Rewards of smoking cessation. Assist in attempt to quit. Discuss with the patient Roadblocks or barriers to attempting cessation. Arrange follow-up. Repeat the motivational intervention at all visits. Nicotine gum, patch, spray, inhaler, lozenges: Increases smoking cessation 1.5 times more than control. Avoid with recent MI, arrhythmia, and unstable angina. Bupropion: Increases smoking cessation rates about 2 times more than control. Avoid with seizure disorder and eating disorder. May be associated with suicidal ideation. Safety in pregnancy is unclear. Varenicline: Increases smoking cessation rates about 3.5 times more than control and almost 2 times more than bupropion. Associated with suicidal ideation and increased risk of cardiovascular events.

The cornerstone of lipid-lowering therapy and rec for all patients with abnormal lipid levels. Reduce saturated fat intake < 7% of total calories (~19 g of sat. fat for 2500 cal-diet), dietary cholesterol < 200 mg/d → reduce LDL cholesterol levels by 9-12%. Combined with exercise → reduced LDL up to 15%. Addition of 2 g/d dietary plant sterols and stanols (fortified margarines and spreads) → decreased LDL by ~10%. Viscous fiber in oatmeal, fruits, legumes can → modest LDL chol reduction.

Waist circumference is measured with a measuring tape placed around the abdomen at the level of the iliac crest. Central adiposity (waist circumference in men >102 cm [40 in]; in women >88 cm [35 in]) is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and heart disease, not only in obese persons, but also in those who are overweight. Overweight 25-29.9 Obese Class I 30-34.9 Class II 35-39.9 Class III ≥40

Median neuropathy (carpal tunnel syndrome): Sensory loss over palmar surface of first three digits and weakness with thumb abduction and opposition Tx: Wrist splints or corticosteroid injections for mild disease; surgical release if severe

Diagnosis: inflammatory, mildly pruritic eruption, possibly related to Herpesvirus 6/7, occurs in spring/fall. Starts as herald patch, a single, raised, bright-red, oval plaque, 2-5 cm in diameter with fine scale and followed by smaller pink papules/plaques with distinct ring of scale at periphery. "Christmas tree" pattern on trunk/chest. Therapy: rash spontaneously resolves in 6-12 weeks. Use oral antihistamines or topical corticosteroids for itching.

Test for HPV infection (alternatively, repeat Pap test at 6 and 12 months and refer for colposcopy if results are grade ASUS or higher).

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Major depression: ≥5 symptoms including either depressed mood or anhedonia for ≥2 weeks Minor depression: 2-4 symptoms for ≥2 weeks Dysthymia: ≥2 symptoms for ≥2 years Screening: rec for all adults, use PHQ2 → > 2 weeks, depressed/hopeless and little interest/pleasure in doing things? Diagnosis: Four categories of depression are relevant to internal medicine: • major depression • minor depression (also known as subthreshold depression) • bipolar disorder • dysthymia Symptom criteria: DSIGECAPS → average of 7 symptoms reported • depressed mood • loss of interest in daily activities • (appetite) weight loss or gain • insomnia or hypersomnia • psychomotor agitation or retardation • fatigue • feelings of worthlessness or guilt • diminished ability to concentrate • recurrent thoughts of death or suicide

Therapy: sertraline is safe for patients with cardiovascular disease bupropion has fewer effects on sexual function and weight gain mirtazapine causes sedation and weight gain (useful for patients with weight loss) venlafaxine can cause nausea and increased blood pressure First episode of depression: Initiate treatment and continue at the dosage required to achieve remission for an additional 4 to 9 months. First recurrence of depression: Increase maintenance treatment to one to two times the interepisode interval (for example, choose 18 to 36 months if the second episode occurs 18 months after the first episode). Three or more recurrences of depression, recurrence within 1 year of successful treatment, or suicide attempt *Watch for serotonin syndrome taking SSRIs

Colorectal cancer screening (average-risk men and women aged ≥50 years) Nonsyndromic Family Hx 1 first-degree relative with CRC: Colonoscopy - Age 40 years or age 10 years before youngest age at CRC diagnosis in the family, whichever is younger -> 5 year

Consider anabolic steroids if PE includes irritability, acne, muscular hypertryophy, testicular atrophy Labs with suppressed LH and FSH levels, variable testosterone levels, otherwise normal pituitary function Serum total test 350 then it's normal. if low → check LH, FSH, prolactin levels increased LH and FSH → primary testicular failure Therapy: testosterone via TD > buccal, IM prep. Stop steroids.

Conservative treatment: reduce fluid intake, stop diuretics/anticholinergics 2 BPH drug classes: a-blockers (terazosin, tamsulosin, doxazosin, alfuzosin, prazosin) > 5-a reductase inhibitors (finasteride, dutasteride). a-blocker + finasteride > either drug alone but associated with increased adverse effects TURP (transurethral resection of prostate) for severe urinary retention/hematuria, recurrent UTI, renal insufficiency due to BPH

If single SSRI not successful → try different SSRI, non-SSRI antidepressant, combination of antidepressants, add lithium, cognitive therapy. INDICATION for nonresponders (if continues to not respond) → increase dose, change, add another med, if no > 50% reduction in score to meds within 6-8 weeks Mimics of depression: • Situational adjustment reaction with depressed mood: depression with a clear precipitant. Usually resolves without medication following resolution of the acute stressor. • Bipolar disorder: one or more manic or mixed manic and depressive episodes, usually accompanied by major depressive disorder. • Seasonal affective disorder: a subtype of major depression, with onset during fall or winter and seasonal remission. Responds to phototherapy and SSRIs. • Grief reaction: transient major depression may be present, but sadness without complete depression is more common. Pervasive and generalized guilt and persistent vegetative signs and symptoms are not consistent with normal grief. Loss of self-esteem is a symptom of depression rather than grief. • Premenstrual dysphoric disorder (PMDD): characterized by the cyclical recurrence of five or more symptoms of depression, anxiety, and emotional lability that have their onset within 1 week before menstruation and resolution within 1 week after menstruation. • Medical conditions: consider substance abuse, hypothyroidism, Cushing syndrome, Parkinson disease, and medications (interferon, β-blockers, corticosteroids). Routine laboratory testing for these conditions is not warranted unless suggested by history and physical examination findings.