Transcript General Medicine Board Review

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A 51yo woman with chronic low back pain is evaluated for a
2-week history of moderate low back pain radiating down
her right leg to her right foot following a paroxysm of
sneezing. She has no leg weakness or numbness. She is on
no meds, and her medical history is only significant for a
hysterectomy.
On physical examination, temp is 36.9. Her lumbar paraspinal
muscles are tender to palpation. Straight leg test is positive
on the right. Her perineal sensation and rectal sphincter tone
are intact. She has difficulty extending her right great toe
against resistance, but LE strength, sensation and reflexes are
otherwise normal. Xray of the spine shows some lower lumbar
degenerative changes, but no disc narrowing or vertebral
collapse.
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Which of the following is the most appropriate initial
management of this patient?
(a) Referral to orthopedics
(b) Bed rest for 7 days
(c) MRI of lumbar spine
(d) NSAIDs
(e) Back exercises
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Acute sciatica with L5-S1 nerve root involvement
NSAIDs have been shown to provide short-term symptomatic
relief for patients with acute low back pain with or without
sciatica
Possible benefit with spinal manipulation, physical therapy,
and muscle relaxants
Surgery should only be considered if symptoms persist more
than 6 weeks or progressive neurologic deficits develop
Bed rest for 2-3 days may be appropriate for severe pain, but
longer can make symptoms worse
MRI is not indicated this early in the course of her low back
pain
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People who get MRIs are more likely to undergo surgery unnecessarily
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A 67 yo man undergoes urgent evaluation for a 2-month
history of low back pain radiating down his right leg that has
worsened over the past 3 days, causing him difficulty with
walking due to leg weakness. He has also been unable to
urinate for the past 24 hours. His medical history is notable for
COPD, diabetes mellitus, prostate cancer, and
hyperlipidemia. Medications include bronchodilator inhalers,
insulin, leuprolide, simvstatin, and aspirin.
On physical examination, he is in obvious discomfort. The
temperature is normal, HR 88, BP 148/72. He has severe lower
lumbar tenderness to palpation, with no bony abnormalities.
Lower extremity strength is 4/5 bilaterally, and straight leg
raise is positive on the right. On rectal exam, there is
decreased rectal sphincter tone and diminished sensation
over the perineal region and buttocks. His prostate is
asymmetric and hard.
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Which of the following is the most appropriate
diagnostic imaging evaluation for this patient?
(a) CT of lumbar spine
(b) MRI of lumbar spine
(c) Radiography of lumbar spine
(d) PET scan
(e) Radionuclide bone scan
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Cauda equina syndrome
Urinary retention
› Saddle anesthesia
› Radiculopathy
› All resulting from epidural spinal cord compression caused by metastatic
prostate cancer
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MRI =noninvasive definitive imaging study to confirm spinal
cord compression
CT does not visualize the spinal cord and epidural space as
well
PET, Xray, and bone scan do not have the necessary
anatomic clarity to diagnose spinal cord compression
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Defined as pain < 6 weeks in duration
Differential Diagnosis
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Mechanical
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Musculoligamentous injuries/DJD
Herniated disks
Spinal stenosis
Compression fractures
Nonmechanical
 Infections
 Neoplasia
 Inflammatory arthritis
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Visceral
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Pelvic organ dysfunction
Renal disease
Vascular disease
GI disease
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History and physical
Radiographic imaging
› Should be reserved for pts with red flags or those for whom
conservative management has failed
› Radiography (AP and lateral)
› CT or MRI for herniated disks and spinal stenosis
 Should be used only when nonurgent surgery is being
considered
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A 42 yo woman is evaluated for occasional episodes of
severe vertigo with nausea, vomiting, tinnitus, and a feeling of
ear fullness. Her first episode occurred 3 years ago, and since
then, she has had approx 6 episodes, each of which may last
from a few hours to 1 or 2 days. Meclizine and diazepam
taken at the onset of symptoms provide partial relief, but she
often must resort to bed rest during these episodes, missing 12 days of work. She has a family history of migraine
headache, although the patient doesn’t experience
headache or visual symptoms with her episodes of dizziness.
Physical examination, including vital signs, is normal. An
audiogram discloses a bilateral low-frequency sensorineural
hearing loss. MRI of the head is normal.
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Which of the following is the most likely diagnosis in
this patient?
(a) Acephalic migraine
(b) Meniere’s disease
(c) Acoustic neuroma
(d) Benign positional vertigo
(e) Vestibular neuritis
Meniere’s disease is the most common cause of recurrent
disabling attacks of vertigo
 Common findings
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Tinnitus
Fluctation hearing loss
Severe vertigo
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Acute-Meclizine, benzos, antiemetics
Prophylactic-Diuretics and low-salt diet
Usually occurs in 4th to 6th decade of life
Episodes last for several hours and include vomiting and
cochlear symptoms
Can lead to progressive sensorineural hearing loss, usually low
frequency in nature
Diagnosis is established clinically via H and P
Audiogram can identify the bilateral low frequency hearing loss
Treatment
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Pathophys seems to involve increased endolymphatic fluid volume
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Benign positional vertigo
Brief (5-15 sec) episodes of vertigo triggered by changes in head position
› Usually not associated with vomiting
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Vestibular neuritis
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Single episode of disabling vertigo that resolves in a few days to a week
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Rarely chronic or episodic
No association with hearing loss
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Labyrinthitis
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Acute episode of dizziness associated with unilateral hearing loss
Rare causes
Cerebrovascular disease
› Brain tumors
› Multiple sclerosis
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A 40 yo woman is evaluated during a 6 month follow up visit
for episodes of abnormal uterine bleeding. Prior to these
abnormal bleeding episodes, she had heavy 5-day menstrual
periods, with dysmenorrhea for the first 3 days of
menstruation. Exam findings from 6 months ago included a
normal pelvic exam, negative transvaginal ultrasound, and
negative Pap smear. She also had a normal CBC and TSH.
Since that evaluation she has had three episodes of bleeding
between periods, with the last occurring one month ago.
Which of the following is the most appropriate next step in the
management of this patient?
(a)
(b)
(c)
(d)
Placement of a progesterone IUD
Uterine artery embolization
Endometrial biopsy
Repeated transvaginal ultrasound
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Endometrial biopsy is the gold standard for diagnosis of
abnormal uterine bleeding
Not all endometrial abnormalities can be detected on
ultrasound
Possible causes for her bleeding include endometrial polyps,
endometrial hyperplasia, or endometrial cancer
If biopsy is nondiagnostic, hysteroscopy may be indicated
Uterine artery embolization is used for fibroids
An IUD can help with bleeding but should not be placed until
the endometrium has been assessed
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Infrequent menses
Excessive flow
Prolonged duration of menses
Intermenstrual bleeding
Postmenopausal bleeding
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Evaluation should always include:
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H and P
Pelvic exam
Pap smear
Pregnancy test if premenopausal
Other testing should be considered based on age and other
medical history
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GC, chlamydia, CBC, TSH, glucose, coags, prolactin level
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An assessment of the endometrial lining is necessary in all
women older than 35 to r/o endometrial hyperplasia or
cancer
Transvaginal U/S okay for younger patients
Biopsy in older patients
Sonohysterography or hysteroscopy are other options
Treatment (if normal labs and endometrial assessment)
Ovulatory bleeding: high dose estrogens followed by regular OCPs, or
levonorgestrel IUD
› Anovulatory bleeding: OCPs or cyclic progestins to maintain regular
cycles
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Treatment options for fibroids
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Uterine artery embolization
Myomectomy
Hysterectomy
Refer to gynecology at any point
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A 20 yo college wrestler is evaluated for a painful lesion on his
upper back. He first noted a small painful area 7 days ago,
and the lesion enlarged and became more red and painful
during the next several days. The patient states that other
members of his wrestling team have developed similar lesions.
His history is otherwise negative. Exam of the upper back
reveals a 1x1cm red, raised pustule that is tender to
palpation, with a 4x4 cm area of surrounding erythema. The
remainder of the exam, including vital signs, is normal. The
lesion is incised and drained. A culture is sent to the lab.
Which of the following is the most appropriate empiric
treatment pending culture results?
(a)
(b)
(c)
(d)
Levofloxacin
Doxycycline
Dicloxacillin
Cephalexin
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MRSA abscess/cellulitis
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Doxycycline is the most appropriate answer of these choices.
Very common especially in athletes, military, children,
prisoners, MSM, homeless, IV drug users
Levofloxacin and cephalexin do not cover for MRSA
Other treatment options include bactrim, minocycline, and
clindamycin
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Cellulitis
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Infection of the dermis and subcutaneous tissues, marked by warmth,
erythema, and advancing borders
Commonly occurs at breaks in the skin including tinea infections, trauma,
ulcerations, or wounds
Most common organisms are MRSA and Beta hemolytic Streptococci
Rx for 14 days with doxy, bactrim, or clindamycin
Prevent recurrence by treating tinea infections
Folliculitis
A superficial or deep infection or inflammation limited to the hair follicles
Superficial vs . Deep
Risk factors: S. aureus nasal carriage, recent Rx with antibiotics or steroids,
hot tub or whirlpool use
› Superficial usually resolves spontaneously
› Furuncle=deep follicultis usually caused by S. aureus
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 Rx with warm compresses and oral Abx
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Impetigo
A superficial vesiculopustular infection that usually occurs on the face
and exposed extremities
› Groups of vesicles or pustules with oozing or adherent yellow crust
› Group A Strep or S. aureus
› Rx with topical vs oral Abx
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A 27 yo woman has a 1-day history of dysuria, left flank pain,
and fever. The patient is sexually active. She had one
episode of cystitis 3 months ago that was treated successfully
with bactrim. Urine cultures were not obtained at that time.
On physical exam, the patient appears uncomfortable but
not acutely ill. Temp 38.5, HR 100, RR 18, BP 120/78. She has
pain on percussion of the left flank. WBC count is 20,000 with
80% segmented neutrophils and 5% bands. U/A shows 100
WBC/hpf and positive LE.
Which of the following is the most appropriate empiric
therapy for this patient?
(a)
(b)
(c)
(d)
(e)
Oral bactrim
IV bactrim
Oral augmentin
Oral levofloxacin
IV levofloxacin
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Pyelonephritis
Rx with oral levofloxacin x 7-14 days
PO Abx used for compliant patients who can tolerate PO
meds
IV Abx used for pts who have nausea/vomiting
Don’t use bactrim in this case because of increasing
resistance
Other possible options include 3rd gen cephalosporins,
extended-spectrum penicillins, aminoglycosides,
monobactams, and carbapenems
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Uncomplicated
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Healthy, nonpregnant woman
No systemic symptoms (fevers, chills, N/V)
Can treat with 3 days of fluoroquinolone , bactrim, or nitrofurantoin
Urine Cx not always required
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UTI associated with a condition that increases the risk of therapy failure
Complicated
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Anatomic abnormality of GU tract
Pregnancy
Men
Elderly
Diabetes mellitus
Nosocomial
Systemic symptoms
Should be treated with fluoroquinolones as treatment failure with bactrim due to
resistance can cause significant morbidity in these cases
Length of treatment 7-14 days
Recurrent
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Sexual hygiene, decreased estrogen leads to increased colonization in
postmenopausal women
Rx with daily low dose prophylaxis, post coital prophylaxis, or patient-initiated
antimicrobial treatment
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A 70 yo woman undergoes preoperative evaluation before
cataract surgery and excision of a 0.75cm basal cell
carcinoma on the right lateral thigh. Her history includes
CAD, with no angina since she has been adhering to her
current medical regimen, and nonvalvular atrial fibrillation for
which she takes chronic anticoagulation therapy. She has
not had a stroke of TIA. Her functional capacity is good.
Which of the following is the best management approach to
anticoagulation for these procedures?
(a) Continue warfarin at usual dose and target INR for both procedures
(b) Reduce warfarin dose to achieve a lower target INR of 1.3 to 1.5
(c) Stop the warfarin and perform surgery when the INR is normal for both
procedures
(d) Stop warfarin and use therapeutic enoxaparin until 12 hours before
surgery
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Perioperative anticoagulation management varies with the
reason for anticoagulation and the planned surgery
This pt is low risk for thromboembolism and is undergoing low
risk surgery
Bridging with heparin is only indicated in patients who are at
high risk for thromboembolism off warfarin
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Surgery with moderate to high risk of bleeding
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Low risk for clot (atrial fib w/o stroke or w/CHADS2 =0)
 Stop warfarin 4d preop; monitor INR to near normal
 Use VTE prophylaxis (low dose UFH or LMWH) pre and post op
 Restart warfarin when hemostasis achieved
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Intermediate risk (CHADS2=1-2)
 Stop warfarin 4d preop; monitor INR fall
 UFH or LMWH (low or high dose) 2 days preop and postop
 Restart warfarin when hemostasis achieved
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High risk (VTE<3mos, arterial TE 4-6 wk, mechanical MV, ball/cage
mechanical valve, CHADS2>/=3)
 Stop warfarin 4d preop; monitor INR fall
 2d preop start therapeutic SQ dose of UFH or LMWH
 When admitted, change to therapeutic heparin drip or SQ UFH/LMWH
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D/c IV heparin 5 hours preop; SQ heparin 12-24 hrs preop
 Restart full dose heparin postop; restart warfarin when hemostasis achieved
 Continue heparin drip/therapeutic SQ heparin until INR at target
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Surgery with low risk of bleeding (e.g. gynecology or less
invasive orthopedic procedures)
Continue, but lower dose of warfarin 4-5 days preop
› Perform surgery when INR of 1.3-1.5 is achieved
› Return to usual warfarin dose when hemostasis adequate
› VTE prophylaxis with UFH/LMWH as indicated
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Superficial Dermatologic Procedures/Cataract Surgery
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Continue usual warfarin dose
Dental Procedures
Continue usual warfarin dose
› Give tranexamic acid or epsilon aminocaproic acid mouthwash for local
hemostasis
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An 87 year old wheelchair-bound woman is evaluated during
a routine examination. She is accompanied by her son. The
patient lives in a residential living setting in her own
apartment and has recently become socially isolated, no
longer visiting with friends, eating in the common dining
room, or finding enjoyment from watching television. Her
medical history includes hypertension, CAD, and
osteoporosis. Her meds include HCTZ, metoprolol, calcium
carbonate, aspirin, and alendronate.
On PE, she appears well-groomed and has a friendly
demeanor. HR 70, BP 125/75, BMI 18.3. She is oriented to
person, place, and time and is able to ambulate with
assistance. Neuro exam is significant only for a resting tremor
in the right hand. CBC, chemistries, and TSH are normal.
Results of the Five Item Geriatric Depression Screen are 1/5.
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Which of the following is the most appropriate management
option in addressing the current symptoms?
(a) Assess hearing and vision
(b) Discontinue HCTZ
(c) Initiate sertraline
(d) Schedule neuropsychological testing
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Hearing and vision loss are a common reason for social
isolation in the elderly.
Functional assessment of the elderly serves to address
unrecognized problems to improve quality of life.
Several scales exist to assess this
Katz Index of ADLs
› Barthel Index
› Lawton and Brody Instrumental ADL scale
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Vision screening
Hearing tests
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Whispered voice test, Hearing Handicap Inventory for the Elderly, audioscope
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Three item recall test, animal naming test, clock-completion test
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Are you generally satisfied with your life?
Do you feel bored?
Do you feel helpless?
Do you prefer to stay home instead of go out?
Do you feel worthless?
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If takes longer than 10 seconds, pt has significant chance of having difficulty with
ADLs in the next year
MMSE
Five-Item Geriatric Depression Scale
Review of prescription drugs
Rapid gain test (walk 10ft, turn, walk back)
Fall risk assessment
Incontinence screening
Weight loss/nutrition screening
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Falls occur in 30-40% of older adults each year
Risk factors
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Age, female sex, h/o falls, cognitive impairment, motor weakness, balance difficulty,
psychotropic medication use, arthritis
Age related changes in vision/hearing/vestibular system and CV system also
predispose to falls
Fall risk assessment
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Get up and Go test
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Patient rises from a chair, walks 10ft, turns around, walks back to the chair, and sits
down
If this takes longer than 20 seconds, patient is at risk for falls.
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Orthostatic evaluation
Carotid sinus hypersensitivity assessment
Review of environmental factors
Vision/hearing screening
Lower extremity sensory function testing
Medication review
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Muscle strengthening/balance retraining
Home hazard modification
Withdrawal of psychotropic meds
Vit D supplementation
Cardiac pacing when indicated
Interventions
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A 67 yo woman is evaluated because she is worried that her
memory is not what it used to be. She has trouble
remembering where she places her keys and purse and
sometimes has difficulty remembering where she parked her
car on shopping trips. She is otherwise well and fully
independent in her ADLs. She denies depression or
anhedonia and plays a round of golf each week. Her
medical history includes HTN and hypothryoidism well
controlled with HCTZ, lisinopril, and levothyroxine. She takes
no herbal supplements, and her other medications are ASA,
calcium, and vitamin D. On PE, her MMSE score is 28/30. The
exam is otherwise unremarkable. Recent lab tests including
TSH, CBC, MVC, LFT’s, and chemistries were all normal.
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Which of the following is the most appropriate management
option for this patient?
(a) Donepezil
(b) Depression screening
(c) MRI of the head
(d) RPR, serum folate, and B12 measurement
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Benign memory loss of aging
Always check for reversible causes
Depression
› Hypercalcemia
› B12/folate deficiency
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B12 deficiency doesn’t always have hematologic
abnormalities
Benign memory loss does not have cognitive impairment on
objective tests
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Areas of localized damage to the skin and underlying tissue
caused by pressure, shear, or friction
Usually occur over bony prominences
Usually in the elderly, immobile, and those with neuro deficits
Incontinence and poor nutritional status also contribute
Stage I
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Stage 2
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Superficial wound, with partial thickness skin loss involving the epidermis or
dermis
Stage 3
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Intact skin, but has evidence of pressure changes including changes in
temperature, consistency, or sensation
Full thickness skin loss extending into the subcutaneous tissues
Stage 4
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Extensive destruction, including to the muscle, bone, or supporting structures
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Prevention
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Change position every 2 hours
Use pillows/foam padding to reduce pressure
Healthy diet
Daily exercise regimen/range of motion exercises
Skin should be kept clean and dry
Treatment
Relieve the pressure, wound debridement, treat infection, maintain a
moist wound environment
› Irrigate with normal saline
› Dressings that keep the surrounding intact skin dry while maintaining
moisture in the ulcer bed and controlling the exudate without dessicating
the ulcer bed
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MKSAP 14
 Up to Date 2009
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