General Internal Medicine

Question 1

LR determines pre-test to post-test probability change

LRs of 2, 5, and 10 correspond to an increase in disease probability of 15%, 30%, and 45%, respectively.

Answer 1

So if pretest = 45%, LR = 10, post test = 45+45 = 90

Question 2

NNT = 1/ (RF - Ri)

NNH =

Answer 2

1/ (Absolute change in risk)

1/ (Risk Increase) –> similar formula

Question 3

Diabetes Screening Guidelines

American Diabetes Association (ADA) recommends that screening be performed in patients of any age with overweight or obesity and one or more risk factors for diabetes (Table 8). The ADA also recommends screening all adults beginning at age ____ years, regardless of risk factors, and repeating screening at 3-year intervals

Answer 3

45

Question 4

USPSTF recommends lipid screening for adults aged ___ to 75 years for the purposes of calculating 10-year risk for atherosclerotic cardiovascular disease (ASCVD)

Answer 4

40

The ASCVD calculator only starts at age 40

Question 5

HTN Screening

Answer 5

The American Heart Association/American College of Cardiology recommend evaluating patients with a normal blood pressure (<120/<80 mm Hg) annually and patients with elevated blood pressure (120-129/<80 mm Hg) whose 10-year estimated ASCVD risk is less than 10% every 3 to 6 months.

Question 6

BMI Screening dults with a BMI of ____ or higher should be offered or referred for intensive behavioral interventions, according to the USPSTF.

Answer 6

30

Question 7

FRAX cutoff to consider bisphosphonate therapy: ___ for hip fracture ___ for any fracture

Answer 7

3%, 20%

Question 8

Mammogram screening age _____

Answer 8

50-75 , Age 40+ is discussion with patient and matter of choice, but much higher false positive rate

Dense breast does not necessitate MRI/US breast, its based on whether there is increased risk (1st degree relative)

Question 9

Cervical cancer screening

recommends screening women aged 21 to 65 years every 3 years with cytology (Pap test). In women aged 30 to 65 years who want to lengthen the screening interval, high-risk human papillomavirus (HPV) testing (preferred) or cytology combined with high-risk HPV testing can be performed every 5 years

Answer 9

From 21 - 30, q3year annual screening regardless of having HPV co-test

When to stop Pap: 2 consecutive negative co-testing (10 years)

Question 10

Live attenuated influenza vaccine is contraindicated in patients with HIV infection regardless of CD4 count (T/F)

Answer 10

True

Common live attenuated vaccines: MMR, Rotavirus, Pox virus, Yellow Fever,Chickenpox (there are 2 versions, life and conjugate x2)

Question 11

Pregnant women should receive one dose of the Tdap vaccine between 27 weeks’ and 36 weeks’ gestation with every pregnancy, regardless of when the Td or Tdap vaccine was last administered. (T/F)

Answer 11

True

TdAP you usually receive as a series of 3 as a child:

Adults who have received fewer than three doses of the primary series should complete the series with the Td or Tdap vaccine, while ensuring at least one dose of the Tdap vaccine.

Question 12

When to give PPSV 23 (Now PCV 20) before age 65 :

Answer 12

chronic heart, liver, or lung disease; diabetes mellitus; cochlear implants; cerebrospinal fluid leak; alcoholism; or cigarette smoking.

Pre 65: PCV 13 –> PPSV 23

Question 13

HPV vaccine age

Answer 13

Patients should be administered the vaccine series at age 11 or 12 years or between the ages of 13 and 26 years

Do not give to pregnant patients

Question 14

MMR Vaccine

Answer 14

Pregnant women who lack immunity should be vaccinated at the time of delivery before leaving the hospital or at the time of pregnancy termination, not during pregnancy because live attenuated

Health care workers: Consider second dose MMR (2 dose series) given risk if no immunity documented

Question 15

Meningitis Vaccine

Answer 15

MenACWY is recommended in adolescents aged 11 to 18 years. If vaccinated at age 11 to 12 years (preferred), a booster dose is administered at age 16; if the initial dose was administered at age 13 to 15, a booster dose is administered at 16 to 18 years.

*If the first dose is administered after age 16, a booster dose is not required

MenB is with shared decision making

Question 16

Aspirin for prevention:

Answer 16

The USPSTF recommends low-dose aspirin for the primary prevention of ASCVD and colorectal cancer in adults aged 50 to 59 years with a 10-year ASCVD risk of 10%

Question 17

Treatment of depression on home hospice____

Answer 17

Methylphenidate

Question 18

Current literature does not support the routine use of antimuscarinic drugs in the treatment of death rattle (T/F)

Answer 18

True

Question 19

Labrinthitis vs Menier’s

Answer 19

Labyrinthitis is characterized by sudden-onset, severe, persistent peripheral vertigo accompanied by hearing loss; it is most often preceded by a viral infection affecting both branches of the vestibulocochlear nerve (cranial nerve VIII)

Meniere disease presents with recurrent, spontaneous, and brief episodes of vertigo, tinnitus, and hearing loss. Nystagmus may be present. Symptoms resolve completely between episodes. In patients with Meniere disease, episodes of vertigo typically last hours, whereas this patient has experienced unremitting symptoms for the past 2 days.

Episodic Nature

Vestibular neuronitis is a peripheral vestibular condition caused by inflammation of the vestibular branch of the vestibulocochlear nerve, leading to vertiginous symptoms and nystagmus. It is most often preceded by a viral infection. Symptoms are sustained, ranging from days to weeks; however, auditory symptoms are not present

Question 20

treatments of choice for persistent postural-perceptual dizziness are vestibular and balance rehabilitation therapy and medical therapy_____

Answer 20

SSRI

Hint is preceding trauma, or known syndrome such as BPPV

Question 21

First-line therapy for insomnia is _____

Answer 21

CBT, you do not need to go directly to sleep study unless there was some pre-risk

Question 22

Symptoms of ________ include paresthesias and pain that typically worsen with activities that involve continued use of the arm or hand, especially those that include elevation of the arm; first-line therapy includes improving posture and strengthening the shoulder girdle muscles.

Answer 22

Neurogenic thoracic outlet syndrome

Question 23

_______is characterized by posterior elbow swelling and tenderness with normal elbow range of motion; swelling and pain on elbow extension suggest elbow joint effusion and an alternate cause.

Answer 23

Olecranon bursitis

Question 24

Popliteal cysts should always be aspirated ____

Answer 24

False, only with symptoms

In pre-patellar bursitis, you are always aspirating (in front of knee)

Question 25

Common cause of mid foot pain migrating superiorly

Answer 25

Tarsal Tunnel Syndrome

Question 26

Patients with triglyceride levels of _______or more without an identifiable cause should be evaluated for familial hypertriglyceridemia.

Answer 26

500, those with LDL>250 should also be evaluated for familiar syndromes

Question 27

Start statin regardless if LDL>____

Answer 27

190 (high intensity statin)

Question 28

Lipid guidelies

For primary prevention of atherosclerotic cardiovascular disease (ASCVD), the American Heart Association and American College of Cardiology recommend (1) high-intensity statin therapy for an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher, (2) moderate-intensity statin therapy in patients aged 40 to 75 years with diabetes mellitus, (3) moderate-intensity statin therapy for patients aged 40 to 75 years with risk-enhancing factors and 10-year ASCVD risk of 7.5% to less than 20%, and (4) high-intensity statin therapy for patients with 10-year ASCVD risk of 20% or higher.

Answer 28

Diabetes = mod intensity statin

Question 29

PSC9/Ezetimibe use

Answer 29

Ezetimibe, and possibly proprotein convertase subtilisin/kexin type 9 inhibitors, should be considered in combination with statins in very high-risk patients with atherosclerotic cardiovascular disease and patients with an initial LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher who do not achieve adequate LDL cholesterol reduction with statin therapy.

Question 30

General Bariatric surgery indications

Answer 30

Bariatric surgery should be reserved for patients with a BMI of 40 or greater or for those with a BMI of 35 or greater who have obesity-associated comorbid conditions.

Question 31

Test for low T______

Answer 31

AM Testosterone, when not in acute illness

Question 32

Treatment for concomitant ED and BPH______

Answer 32

Tadalafil

Unlike α-blockers, which work relatively quickly, 5α-reductase inhibitors take approximately 6 months to improve symptoms. Side effects include erectile and ejaculatory dysfunction and decreased libido, will also reduce PSA by default

Question 33

A positive Prehn sign (relief of pain with scrotal elevation) suggests a diagnosis of ______

Answer 33

epididymitis

An absent cremasteric reflex suggests testicular torsion. A patient with testicular torsion would have acutely worsening and severe hemiscrotal pain, hemiscrotum elevation, abdominal pain, nausea, and vomiting.

Question 34

Acute prostatitis in older man treatment_______

Answer 34

Bactrim, in younger: Ceftrioxone/Doxy

Both chronic/acute forms treated for 6 weeks

Question 35

A trial of________is the most appropriate treatment for this patient with chronic pelvic pain syndrome (CPPS). CPPS is characterized by chronic pelvic pain and intermittent voiding symptoms without evidence of infection.

Answer 35

Pregabalin; in select cases can also be treated with Abx, tamsulosin

Question 36

Surgical repair is recommended for most _____hernias given the high incidence of complications.

Answer 36

Femoral

Question 37

For women younger than 30 years with a low-risk breast mass, and palpated breast mass, __________ is usually the only imaging required.

Answer 37

ultrasonography

For evaluation of palpable breast abnormalities in women aged 40 years or older, mammography, followed in most cases by ultrasonography, is recommended. : biopsy BIRADS 4-5

Question 38

_____ is often related to hormonal changes that occur with ovulation, resulting in diffuse premenstrual breast pain that resolves with the menstrual cycle;

Answer 38

Cyclic mastalgia, Tx: conservative , severe = Danazol

Question 39

Contraindications to combination pills include breast cancer, venous thromboembolism, uncontrolled hypertension, liver disease, and migraine with aura. _________

Answer 39

Women who smoke more than 15 cigarettes per day and are older than 35 years should not use estrogen-containing preparations because of the increased risk for thrombotic disorders.

Can consider progesterone only pill

Question 40

Anti hypertensive to be avoided during pregnancy no matter what______

Answer 40

ACE/ARB

Question 41

______ is an option for women with moderate to severe vasomotor symptoms of menopause who are younger than 60 years and within 10 years of menopause onset, provided they are at low risk for breast cancer, coronary heart disease, stroke, and thromboembolic disease.

Answer 41

Hormone therapy: combines estrogen/progesterone pill

Question 42

________ may be helpful for patients with moderate chronic pelvic pain without a clearly identified cause.

Answer 42

NSAIDS

Question 43

___________, are available for premenopausal women with sexual interest/arousal disorder.

Answer 43

Two FDA-approved drugs, flibanserin and bremelanotide, are available for premenopausal women with sexual interest/arousal disorder. Flibanserin is taken daily whereas bremelanotide is a subcutaneous injection taken before anticipated sexual activity. However, both agents are only marginally effective compared with placebo and are commonly associated with side effects and significant drug-drug interactions. Low-dose testosterone treatment (off-label) increases sexual function scores, but side effects must be discussed. Phosphodiesterase inhibitors, such as sildenafil, have shown inconsistent results in women.

Use conservative measures first such as CBT, counselling, sexual health

Question 44

Clue cells, KOH whiff test, fishy discharge white or grey, suggestive of _______

yellow grey discharge, strawberry cervix, negative KOH suggestive of ______

Answer 44

BV (Treated with Mtronidazole)

Trichomoniasis (Also treated with metronidazole), you also have to treat the sexual partner, and screen for other STD

Vulvo-vaginal candida can be treated with topical clotrimazole or oral fluconazole

Question 45

Treatment of bacterial conjunctivitis______

Answer 45

Topical bactrim

Question 46

Hallmark symptom of keratitis_____

Answer 46

Foreign body sensation, ocular emergency

Question 47

Treatment of corneal abrasion____

Answer 47

Topical NSAIDS

Question 48

Increased cup: disk ratio, gradual painless peripheral vision loss___________

Answer 48

Open angle glaucoma

Question 49

_________severe eye pain, headache, nausea, and blurred vision or halos around lights. Examination may demonstrate severe conjunctive hyperemia, corneal edema, a mid-dilated (4-6 mm) nonreactive pupil, and severe elevation in IOP.

Answer 49

Angle closure glaucoma, sudden blockage of aqueous humor blockage

Question 50

Biggest behavior to prevent macular degeneration______

Answer 50

Smoking cessation

Question 51

hallmarks of _______ are acute vision loss, eye pain with movement, color perception change, and afferent pupillary defect

Answer 51

Optic neuritis

Tx: High dose steroids, associated with mysthenia gravis

Question 52

Painless vision loss, retinal palor with cherry red spot at the fovea______

Answer 52

Retinal artery occlusion

Question 53

_________ is characterized by optic disc swelling, dilated and tortuous veins, as well as flame-shaped retinal hemorrhages (white arrow) and cotton-wool spots (yellow arrow) (“blood and thunder”), with painless vision loss

Answer 53

Central retinal vein occlusion

Question 54

Patients should be evaluated urgently by an otolaryngologist when tinnitus is associated with sudden hearing loss, otorrhea, vestibular dysfunction, focal neurologic deficits, or pulsatile tinnitus (particularly if tinnitus is sudden in onset, which may suggest a vascular cause).

Question 55

Imaging is needed to diagnose chronic sinusitis____(T/F)

Answer 55

True, treatment with steroids and antibiotics

Question 56

_________ is chronic rhinitis resulting from the inappropriate long-term use of topical nasal decongestants. Treatment consists of cessation of the decongestant and intranasal glucocorticoids when needed.

Answer 56

Rhinitis medicamentosa

Question 57

Pharyngitis

Patients with fewer than three of the four Centor criteria (fever by history, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough) do not need to be tested or treated for group A Streptococcus. These patients should be treated conservatively with symptom control (such as analgesics [NSAIDs or acetaminophen], lozenges or topical sprays, and increased environmental humidity). Patients with three or more Centor criteria should be tested by using a rapid antigen detection test.

Throat culture should be considered in patients who are at high risk for complications (immunocompromised state) in the setting of high clinical suspicion but negative results on rapid antigen detection testing.

Question 58

Worse SSRI for pregnancy_____

Answer 58

Paroxetine (Class D drug)

Question 59

Treatment of social anxiety disorder____________

Answer 59

Both CBT and pharmacotherapy with SSRIs and SNRIs are effective for treatment of social anxiety disorder.

Question 60

Treatment of OCD_______________

Answer 60

CBT is first-line treatment for OCD. CBT is more effective than pharmacotherapy alone, but SSRIs may be beneficial as adjunct therapy in patients with severe symptoms or inadequate response to CBT. For patients treated with medication, the American Psychiatric Association recommends continued treatment for at least 1 to 2 years.

Question 61

Eating disorder treatments_______

Answer 61

Psychotherapy and monitored dietary intake are the mainstays of treatment for anorexia nervosa; antidepressant therapy has not proved effective.
Cognitive behavioral therapy is the most effective intervention for bulimia nervosa and binge eating disorder; antidepressant therapy and topiramate may also be beneficial.

Question 62

_______ requires that the patient be able to participate in 3 hours of therapy at least 5 days per week; in patients who cannot tolerate this level of therapy, subacute rehabilitation is appropriate.

Answer 62

Acute rehabilitation

Question 63

Prompted voiding is a treatment for ________

Answer 63

Functional incontinence

Question 64

Treatment for Urge incontinence___________

Treatment of Overflow incontinence_________

Answer 64

oxybutynin (anti-muscarinic, squeeze), Mirabegron –> botox

Tamsulosin, Finasteride

*In most cases some kind of mix, therefore tamsulosin seen everywhere

Question 65

Elective noncardiac surgery should be delayed 14 days after balloon angioplasty, 30 days after bare metal stent implantation, and optimally _____ after drug-eluting stent placement.

Answer 65

6-12 months, patient would be on DAPT

In patients taking dual antiplatelet therapy, if the risk of surgical delay exceeds the risk for stent thrombosis, discontinuation of the P2Y12 inhibitor can be considered after a minimum of 30 days in the case of bare metal stent placement or 3 months after drug-eluting stent placement.

Question 66

Medications to stop before surgery_____

Answer 66

NSAID, Hyoscamine, TNF inhibitors, supplements

DM2: Oral and injectable noninsulin medications should be withheld 12 to 72 hours before surgery, replaced with supplemental insulin, and resumed at hospital discharge or when the patient has resumed a full diet.

Question 67

Post orthopedic surgery requires ____ days of post op anticoag prophylaxis

Answer 67

35

The minimum recommended duration of pharmacologic venous thromboembolism prophylaxis in patients undergoing orthopedic surgery is 10 to 14 days; however, in patients without increased bleeding risk, extended-duration postoperative prophylaxis (up to 35 days) is preferred.

Question 68

Stop apixaban ____ days before surgery

Answer 68

3 days

Warfarin needs to be stopped 5 days before

Question 69

According to recent AHA/ACC and ACCP guidelines, preoperative bridging is not recommended in patients with atrial fibrillation taking warfarin without a mechanical valve or high risk for thromboembolism. Examples of high-risk conditions for thromboembolism include ischemic stroke, transient ischemic attack, or systemic embolism within the past 3 months.

Answer 69

Bridging is not necessary in patients with a bileaflet mechanical aortic valve and no other risk factors for thrombosis

Mitral valve needs bridging

Question 70

In most patients receiving long-term aspirin monotherapy for both primary and secondary prevention of cardiovascular events (in the absence of a coronary stent), aspirin should be discontinued at least 5 days before surgery and restarted postoperatively once bleeding risk has decreased. This recommendation is based on the POISE-2 trial, which found that continued perioperative aspirin resulted in increased bleeding without a decrease in cardiac events.

*Contrary to current practice