General Internal Med

Question 1

HLD Screening

Answer 1

• Start screening in males >35 and females >45
• Screen earlier if risk factors for CAD (20 yo)
• Meas total cholesterol and HDL first; if HDL >35 and total < 200 then repeat in 5 yrs; if abnormal get full lipid panel
• Anyone w/ CAD should get full lipid panel right away

Question 2

Colon Cx Screening Special Circumstances

Answer 2

• FAP - genetic testing at 10 yo; consider colectomy or colonoscopy q 1-2 yrs starting in puberty
• UC - 8 yrs after diagnosis then every yr after that
• HNPCC - genetic testing at 21 yo; colonoscopy q 2 yrs until 40

Question 3

Lung Cx Screening

Answer 3

• annual low dose CT in 30 pack yr smokers aged 55-80

- Can discontinue if quit smoking for 15 yrs

Question 4

DM Screening

Answer 4

-get HbA1c and fasting glucose or 2 hr GTT in overweight adults < 45 or all adults > 45 q 3 yrs

Question 5

AAA Screen

Answer 5

1X US in male smokers 55-65

Question 6

Adult Vaccines (8)

Answer 6

1 - Flu - every yr in season (egg free inactivated vaccines available)

2 - Pneumococcal - PPSV23 in all adults > 65; PCV13 followed by PPSV23 in immune-compromised, asplenia, kidney disease

3 - Tetanus - primary sequence as child; booster q 10 yrs; 1 booster should be Tdap

4 - Zoster - 1x at > 60 regardless of chicken pox status

5 - Hep B - primary series in infants; healthcare workers; MSM; injection drug use; CKD; heterosexual w/ must partners

6 - Hep A - travel; Hep C; MSM
- PEOPLE W/ CHRONIC LIVER DISEASE SHOULD RECEIVE HEP A AND HEP B VACCINES

7 - Meningococcal - asplenia, military, college students

8 - HPV - men and women 9-26 yo; 3 doses

Question 7

Hypertension Eye Findings

Answer 7

arteriovenous nicking (arteriole wall thickening leads to secondary retinal vein discontinuity)

cotton wool spots (infarct of retina nerve fiber layer)

exudates

papilledema

Question 8

Pre-HTN, Hypertensive Crisis, Hypertensive Urgency

Answer 8

• Pre-HTN: 120-139/80-89 - mainly lifestyle modification
• Stage I: 140-159/90-99
• Stage II: >160/100
• Hypertensive Emergency: >180/120
• Hypertensive Urgency: >180/120 + end organ damage

Question 9

Work Up for New HTN Dx

Answer 9

• When diagnosed want to look for signs of end organ damage & signs overall inc CVD risk
• UA (protein), CMP (Cr, K, BUN), fasting glucose, lipid panel, ECG
• If H&P suggests secondary cause then order labs accordingly (renal artery stenosis, pheochromocytoma, hyperthyroid, Cushing, coarctation, OCPs/estrogen, etc)

Question 10

Tx Goals and Med Regimens for HTN

Answer 10

• Goals
  
  • > 60 yo - 150/90
  • All others - 140/90
• First line - Ca channel blocker (dihydro like amlodipine) OR ACE inhibitor/ ARB
• If fails, then can max dose of current med or add the other med
• Blacks - may start w/ thiazide diuretic
• ACE inhibitor if renal disease / DM
• Beta blockers can be added in patients w/ concomitant CHF, CAD or a fib (avoid of pulmonary problems)

Question 11

Common Hypertensive Med Allergies

Answer 11

• Amlodipine - peripheral edema (this is not a reason to stop the drug)
• Beta blockers - AV block, bronchospasm, insomnia, depression
• ACE - bradykinin cough, hyperkalemia, angioedema
• Thiazide - hypokalemia, inc uric acid

Question 12

Drugs that can inc cholesterol

Answer 12

• Thiazides - inc LDL
• Beta blockers and estrogen - inc TGs
• Steroids and HIV protease inhibitors - inc serum lipids

Question 13

4 Groups That Should be Treated for HLD

Answer 13

• 1- Anyone w/ known atherosclerotic CVD
• 2- Anyone w/ LDL > 190
• 3- Diabetics b/n 40-75 yr old w/ LDL b/n 70-189 (use high intensity statin if atherosclerotic risk > 7.5% v. moderate intensity if atherosclerotic risk > <7.5%)
• 4- Anyone b/n 40-75 yo w/ LDL b/n 80-189 + atherosclerotic risk > 7.5%

Question 14

Good HDL Level

Answer 14

HDL > 60 is neg risk factor

Look at total cholesterol:HDL (want <4.5)

Question 15

Sx in Spinal Stenosis v. Disc Herniation

Answer 15

STENOSIS
- Relief of radiculopathy w/ spine flexion (bending forward, shopping cart, sitting); worse with spine extension (standing or walking)

HERNIATION
- worse w/ anything that inc intraspinal pressure (cough, sneeze, spinal flexion of sitting)

Question 16

Work-Up for Cough

Answer 16

ONLY WORK UP IF > 1 MO

• If suspect pulmonary cause (hemoptysis, smoker)- CXR
• If signs infection - CBC
• PFTs if suspect asthma
• If still no diagnosis - bronchoscopy (see tumor, tracheal webs, foreign body)

Question 17

Wernicke Encephalopathy

Korsakoff Psychosis

Answer 17

• Wernicke - of thiamine deficiency
  
  • Nystagmus, opthalmoplegia, confusion
  • Reversible
• Korsakoff Psychosis - also thiamine deficiency
  
  • Short term memory loss and confabulation
  • Irreversible

Question 18

2 Alcohol Cessation Drugs

Answer 18

naltrexone (dec cravings; cannot use if liver disease) or acamprosate (good if liver disease)

Disulfiram only as short term

Question 19

Syncope Differential (6)

Answer 19

1 - Seizures - longer period of unconsciousness and often loss of bladder control

2 - Cardiac - arrhythmia, structural (aortic stenosis, hypertrophic cardiomyopathy)

3 - Vasovagal - light-headed, sweating, nausea, dec vision, roaring in ears; inappropriate parasympathetic response when standing

4 - Orthostatic Hypotension - diabetics, old people, prolonged bed rest, on ganglionic blockers; also no sympathetic response when stand; give Na, fluids,

5 - TIA - if vert-basilar blood distribution; usually not alone; other neuro deficits

6- Others - hypoglycemia, hyperventilation, hypovolemia

Question 20

Syncope Work-Up

Answer 20

• Cardiac v non-cardiac (ECG first)
• H&P - determine if orthostatic, vasovagal, polypharmacy (ask about meds)
• If suspect cardiac based on ECG or H&P then do further work-up - echo, halter monitor, cath
• If do not suspect cardiac (normal ECG) then work-up depends on whether this is first episode
  - First - no further testing
  - Recurrent - tilt table test and psych consult