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  1. When is MRI (for CNS) best?
    • Demyelinating disease (MS)
    • Spinal/Nerve root disease
    • HIV-related CNS disease
    • Metastatic disease
  2. What are contraindications to MRI?
    • Cardiac pacemaker
    • Metallic implants
    • Metal in the orbit
  3. What are the uses of Spiral CT (Helical CT)?
    • Best studied for evaluation of PE
    • Less inter-observer variability in reading V/Q scan
    • Negative predictive value of a normal scan: 98%
  4. TC99 Bone scans
    What increases uptake?
    Normal bone scans?
    Decreased uptake?
    • Increased uptake
    • 1. Fractures
    • 2. Osteomyelitis
    • 3. Malignancy (osteoblastic)

    • Normal bone scans
    • 1. MM
    • 2. Eosinophilic granuloma

    • Decreased uptake
    • 1. Avascular necrosis
  5. What would be the Iodine uptake result in someone who is taking thyroid meds for weight loss?
  6. What is the function of Radioactive Iodine Uptake?
    • Helpful in separating Graves disease from thyroiditis, and in surreptitious steroid intake
    • Can be used to determine hot versus cold nodule
    • Contraindicated in pregnant patients
  7. What is the effect of PPI on thyroid absorption?
    It can decrease thyroid hormone absorption by as much as 33%
  8. What medications interact with warfarin to increase PT (decrease metabolism)?
    • P-E-A-K BMI
    • Bactrim
    • E-mycin
    • Amiodarone
    • Propafenone
    • Ketoconazole/Fluconazole
    • Itraconazole
    • Metronidazole
  9. What drugs can increase digoxin level?
    • Q-V-A-P
    • Quinidine
    • Verapamil/Diltiazem
    • Amiodarone
    • Propafenone
  10. What drugs can increase Theophylline level?
    • QTEC
    • Cimetidine
    • E-mycin
    • Quinolones
    • Ticlopidine
  11. What statin med has the most interaction with other drugs? Whick one has the least likely interaction?
    • Simvastatin has the most interaction. Lovastatin is similar
    • Pravastatin has the least
  12. What two statin meds would you avoid when taking amiodarone?
    • Simvastatin
    • Lovastatin
  13. What drugs have major interactions with statins?
    • AM-FAG
    • Fibrates (Gemfibrozil >> Fenofibrate)
    • Amiodarone
    • Macrolides
    • Azole antifungals
    • Grapefruit juice
    • Pravastatin probably the safest choice
  14. Bactrim
    What is it associated with in HIV patients?
    • High-dose bactrim has been associated with hyperkalemia in patients with HIV disease
    • Hyperkalemia has been reported in elderly patients receiving oral TMP/sulfa
    • The elevation may be severe
    • Mechanismis is due to trimethoprim blockage of amiloride-sensitive Na/K channels
  15. What diabetes medication should not be given to pts with CAD and h/o CHF?
    Rosiglitazone/pioglitazone can cause a trigger or worsen CHF in a pt with underlying heart failure.
  16. Rosiglitazone/Pioglitazone
    What can they cause?
    What group of pts should not be on these meeds?
    • Both thioglitazones can cause edema
    • Dilutional anemia can occur
    • Worsening sx or CHF can occur in pts at risk for, or with, documented CHF
    • Best to avoid these medication in pts with CHF or pts with renal failure
  17. What medications can cause CHF exacerbation?
    • NSAIDs - can cause CHF exacerbation especially in those history of CAD
    • Pioglitazone and rosiglitazone
  18. What drugs can increase serum uric acid?
    • diuretics
    • Niacin
    • Cyclosporine
    • Ethambutol/pyrazinamide
  19. What can cause anion gap metabolic acidosis?
  20. What can cause Osmolar Gap and Gap acidosis?
    • Methanol
    • Ethylene glycol
  21. A pt who is inebriated, with anion gap acidosis and osmolar gap, and with pancreatitis. What is the cause?
    How about if the pt has renal dysfunction?
    • Methanol toxicity
    • Ethylene glycol can cause renal dysfunction and urinary oxalate crystals
  22. A pt who appears inebriated with anion gap acidosis, osmolar gap acidosis and the following on the urinalysis. What is the diagnosis?
    Image Upload 1
    • Ethylene glycol poisoning
    • Calcium oxalate dihydrate crystals typically are colorless squares whose corners are connected by intersecting lines (resembling an envelope)
    • Image Upload 2
  23. Pearls about Ethylene Glycol poisoning
    • Oxalate crystals in urine
    • Renal insuff
    • Urine may fluoresce with Wood's lamp
    • Fomepizole is an appropriate therapy
  24. Aspirin
    What are early manifestations?
    What would the ABG look like?
    • Early manifestations: n/v, tinnitus, listlessness, and hyperventilation
    • Respiratory alkalosis is followed by severe metabolic acidosis, hypokalemia, and hypoglycemia
    • Seizures, hyperpyrexia, and coma
    • Cerebral and pulmonary edema and death are more common in patient with subacute toxicity
  25. Treatment of Salicylate Overdose?
    • Lavage (beware of bezoars)
    • Check serial salicylate levels
    • Activated charcoal
    • Forced alkaline diuresis
    • Occasionally -- charcoal hemoperfusion or dialysis
  26. Management of Cyclic Antidepressant Overdose?

    What are its effects?
    How do you block absorption?
    What is the antidote?
    • Effects: CV toxicity, CNS effects, anticholinergic effects
    • Protect the airway
    • Block absorption: charcoal, lavage, charcoal
    • Antidote: Sodium Bicarb (not physostigmine!)
    • Drug levels do not rule out significant toxicity
  27. Management of Tylenol overdose?
    • Gastric emptying if within 2 hours of ingestion
    • Activated charcoal if within 4 hours of ingestion
    • N-acetylceisteine (17 doses) orally maximally effective if given within 16 hours of ingestion or
    • IV NAC for 21 hours
    • Administration of NAC even late appears to be helpful in patients with acute liver failure
  28. Charcoal is not effective for the ff:
    • Caustics
    • Cyanide
    • Electrolytes
    • Alcohols
    • Hydrocarbons
    • Heavy metals
  29. What is the absolute contraindication to charcoal?
    Caustic acid or alkali ingestions
  30. What is the antidote for nitrate poisoning?
    Methylene blue
  31. What is the antidote for Organophosphate poisoning?
    Atropine / Pralidoxime
  32. What are the key features of Pseudotumor Cerebri?
    • Female
    • Obesity
    • Isotretinoin
    • Transient visual obstruction
    • Headache
  33. What is the cup-to-disc ratio in glaucoma?
    • approx. 80% or more.
    • Normal is 50%
    • Image Upload 3
  34. A pt goes into the movie theater and started having headaches, nausea, vomiting once the movie started. What do you think is the cause?
    Angle-closure glaucoma
  35. What is the cause of sudden visual loss with pain?
    • Endophthalmitis
    • There is decreased red reflex on ophthalmologic exam
    • Image Upload 4
  36. Sudden visual loss with cherry red spot on ophthalmologic exam, no pain
    Image Upload 5
    Retinal artery occlusion
  37. Sudden visual loss with retinal hemorrhage on ophthalmologic exam, no pain
    Image Upload 6
    • Retinal vein occlusion
    • Image Upload 7
  38. Sudden visual loss with no pain, no ophthalmologic findings
    Image Upload 8
    Occipital cortex infarct
  39. What is the finding on the ophthalmologic exam below?
    Image Upload 9
    Proliferative diabetic retinopathy
  40. Bilateral ptosis will make you think of what disease?
    Image Upload 10
    Myasthenia gravis
  41. A pt present with unilateral ptosis with eye deviated downward. No c/o diplopia until the affected eyelid is lifted up. What is the diagnosis?
    • CN III palsy
    • Image Upload 11
  42. A pt with unilateral ptosis. What is your differential diagnosis, and how do you separate the two?
    • Horner's syndrome, or
    • CN III palsy

    Differentiate the two by the size of the pupils. Horners will be pinpointed, and dilated for CN III
  43. What is the initial intervention?Image Upload 12
    warm compress
  44. Eye is red and painful. What is your differential diagnosis?
    • iritis
    • keratitis
    • acute glaucoma
  45. Red eye with photophobia. What is your differential diagnosis?
  46. Red eye with visual change. What is your differential diagnosis?

    What is your intervention?
    • Differential diagnosis is iritis or acute glaucoma.
    • Need ophthalmology evaluation stat
  47. Treatment of postherpetic neuralgia?
    • Gabapentin
    • Carbamazepine
    • TCA (avoid if BPH/CHF)
    • Capsaicin
    • Narcotics
  48. Uveitis disease associations?
    G-R-A-S cause uveitis

    • Ankylosing spondylitis
    • Reiter's syndrome
    • Sarcoidosis
    • Granulomatous infection
  49. What are the ophthalmologic emergencies?
    • Alkali burn
    • Retinal artery occlusion
    • Angle-closure glaucoma
    • Penetrating injury
    • Endophthalmitis
    • Retinal detachment
  50. What is "Multiple Sensory Deficit" syndrome?
    • Combination of decreased vision and hearing sensation, and orthopedic problems can cause disequilibrium
    • Symptoms improve when pt uses their hands (holds on to someone's arm, uses a cane or walker)
  51. Explain the use of the following hearing tests:
    • Rinne test: conductive hearing loss. Bone conduction > air conduction
    • Weber test: sound perceived in middle = normal hearing or symmetrical hearing loss. Sound materializes = conductive hearing loss in ipsilateral ear or sensorineural loss in opposite ear
  52. What are the causes of conductive hearing loss?
    • External canal obstruction
    • Otitis externa and media
    • Cholesteatoma
    • Otosclerosis
    • Trauma
    • Middle ear masses
  53. What is your intervention for acute hearing loss?
  54. What radiologic study would you order for Acute sinusitis?
    • Limited sinus CT
    • this is better than sinus X-ray
  55. Acute Sinusitis Therapy
    What is the initial approach?
    When do you use antibiotics, and what is front-line?
    What do you if there is treatment failure?
    • Decongestants/saline irrigation
    • 1st line: Amoxicillin or Bactrim (use if infection ongoing without improvement for 7 days or more)
    • Amoxicillin-clavulanate or 2nd generation cephalosporins used for treatment failures
  56. When should BP be treated in pregnancy?
    SBP > 150, DBP > 100 in women with our end-organ damage
  57. What are the lab abnormalities in Preeclampsia/Eclampsia?
    • Proteinuria
    • Increased Cr
    • Increased uric acid
    • Increased transaminases
    • Decreased platelets
    • Decreased antithrombin III
  58. Drugs to absolutely avoid during pregnancy:
    • Isotretinoin
    • ACE inhibitors
    • ARBs
    • Benzodiazepines
    • Quinolones
    • Tetracyclines
    • Nitroprusside
    • Warfarin
  59. HIV and Pregnancy

    What is the current recommendations?
    How about if the mother does not need HAART?
    What HIV meeds should you avoid?
    What is recommended if pt has viral load >1,000 near time of delivery?
    • Risk of vertical transmission is 25%, reduced to 8% with use of zidovudine in mother. Rate < 1% with 3-drug therapy.
    • Current recommendations are to treat mother with appropriate 3-drug therapy for HIV. Use zidovudine if at all possible. If mother does not need HAART, then it should be started by 28 weeks.
    • Do resistance testing in all pts with a positive viral load before starting therapy.
    • Avoid D4T + DDI-containing regimens. Avoid efavirenz in the first trimester and nelfinavir
  60. Livedo Reticularis

    What is it associated with in SLE?
    • SLE: associated with antiphospholipid syndrome, recurrent thrombosis, stroke
    • Primary antiphospholipid syndrome
    • Atheromatous emboli syndrome
    • Polyarteritis nodosum
  61. What is the target HbA1C for pregnant women, or those who are trying to become pregnant?
    • 6 or less
    • Need tight control for 1-2 months before stopping birth control
  62. Restless leg syndrome
    • Occurs more frequently with advancing age, up to 19% in those > 80
    • Symptoms at rest, especially in bed, usually below the knees
    • Symptoms relieved by movement
    • Check for Fe deficiency in all patients
    • Treatment: stretching, dopaminergic agents, gabapentin, FeSO4 if Fe-deficient (treat if ferritin < 50)
  63. What is the appropriate intervention?
    Image Upload 13
    • This is Koilonychia (spoon nails)
    • Check ferritin. Most common cause is Fe deficiency.
  64. Who should receive drug therapy for osteoporosis?
    • Postmenopausal women with T score < -2.5 in the absence of risk factors
    • Postmenopausal women with T-score < -2.0 in the presence of risk factors
    • -Peronal family history of fracture after age 40
    • -Family history of fracture in a first-degree relative
    • -Current cigarette smoking
    • -Body weight < 127 lbs., regardless of height
  65. Osteoporosis therapy
    • Premenopausal:
    • Calcium 1.2 gm + Vitamin D 800 u/day

    • Postmenopausal:
    • Calcium / Vit D and HRT (can use raloxifene in women with breast ca Hx) or bisphosphonate
  66. What are contraindications to bisphosphonates?
    • Recent dental procedure
    • Non-healing fractures in the mouth
    • Esophageal strictures
  67. What is a contraindication to raloxifene?
    • History of DVT
    • Not beneficial for hip fractures, but has shown benefit for vertebral fracture
    • Good option in women with osteoporosis and breast ca history
  68. What are the implications of Vitamin D Deficiency?
    • Extremely common in NH pts
    • Higher fall risk, fracture risk
    • Also likely cause of LE pain
  69. Therapeutic Approach to falls?
    • Start with H&P, "Get up and go" test, observe walking
    • If evidence of lower extremity weakness: strength training of LE
    • If evidence of balance problems: gait and balance training
    • If medication risks: drug withdrawal/substitution
    • If orthostatic hypotension: drug reduction or withdrawal, drug/meal separation, stockings
    • Consider hip protectors in high-risk patients
  70. Diabetes Treatment in the Elderly

    What creat level in men, and women should make you avoid using metformin?
    What anti-diabetic meeds should not be used on pts with CHF?
    • Hypoglycemia related to sulfonylureas least with glipizide
    • Hesitate to use of metformin in women with Cr > 1.3, men with Cr > 1.4: need to measure Cr Cl in all pts > 65 before starting the drug. Avoid in pts with decompensated CHF.
    • Pioglitazone and rosiglitazone should not be used in pts with CHF
  71. What are the two most common causes of wide pulse pressure in elderly patients?
    • Hyperthyroidism
    • Aortic insufficiency
  72. What is the difference on the treatment for hypothyroidism of a young person vs. an elderly pt (>65)?
    Young pts with hypothyroidism can be started immediately on the goal dose, whereas old pts need to be started slowly at 0.025 mg
  73. What are the CNS effects of quinolones?
    • Insomnia
    • Nightmares
    • Psychosis
    • Hallucinations
  74. What is the treatment for BPH?
    • 1st line: Alpha blockers
    • -Terazosin
    • -Doxazosin
    • -Tamsulosin (alpha 1a blocker)

    • 2nd line
    • -Finasteride (5-alpha-reductase inhibitor

    • 3rd line
    • -TURP
  75. What is the side effect of prazosin?
    This medication is avoided as treatment for BPH due to many side effects including orthostatic hypotension
  76. Alpha-blockers for BPH
    • Tamsulosin: fewest side effects
    • Prazosin: greatest side effects
  77. Erectile dysfyfunction therapy
    • Sildenafil, Vardenafil, Tadalafil contraindicated with nitrates
    • Penile injections: Alprostadil and/or papaverine
    • Vacuum device: Safe but time-consuming
    • Penile implants: Use only after other therapies
  78. Dyspareunia

    What is the usual cause in the elderly?
    • Usually due to atrophic vginitis in the elderly
    • Treat with oral/topical estrogen or lubricant
  79. What can cause delayed orgasm?
    SSRIs -- up to 30% of pts on SSRI can experience this
  80. What is beneficence?
    To act in the best interests and welfare of the patient had the health of society
  81. What is nonmaleficence?
    The duty to do no harm to the patient
  82. Cardiac Risk Assessment
    • Know high-risk patients: unstable angina, decompensated CHF, severe valve disease; especially AS, recent MI, major arrhythmias
    • Know major surgeries: MAJOR VASCULAR
    • Young patients almost never need a workup unless they are i a high-risk group
  83. What is the role of preoperative Beta-blockers?
    • AHA Guidelines: who to given them to
    • Class 1 recommendations
    • Continue in patients already receiving for anger, arrhthymia, or hypertension
    • Vascular surgery patients with positive pre-op stress test
    • Could possibly cause harm in lower-risk cardiac patients
  84. When is Pre-op Cardiac Evaluation indicated?
    • Young patients with no risk history can have minor surgery without evaluation
    • Low/moderate-risk patients having low/medium-risk surgery usually do not meed stress testing
    • Pre-operative coronary revascularization does not appear to reduce perioperative risk in pts with significant but stable CAD; medical therapy should be optimized for these pats, including the application of beta-blockers in high-risk vascular surgery patients with positive stress tests
    • Red flags for needing cardiac testing: major vascular surgery, unstable angina, decompensated CHF, recent MI, severe valvular disease
  85. Important Screening Exams to Know
    • BP: Check every 2 years and at every clinic visit
    • Smoking counseling: Each visit in smokers
    • Cholesterol: Men 35-65, Women 45-65, every 5 yrs
    • FOBT: Annually after 50, unless colonoscopy done
    • Flex sig: Every 3-5 years after age 50
    • Mammography: Annually after age 50, offer after age 40
  86. What are the recommendations for Pap Smear Screening?
    • Start about age 18 or at onset of sexual activity
    • After 3 negative annual Pap tests, can screen every 3 years
    • If patient has dysplastic pap, should do annual screening
    • If normal q 3-yr paps, can stop screening at age 65 (unless they have frequent new sexual partner)
  87. Who does not need Pap smear screening?
    • Women who have never been sexually active
    • After hysterectomy for benign disease
    • After qge 65 with repeatedly normal smears (and stable sexual partner)
  88. When do you stop PSA screening?
    Once patient is above 70
  89. Colorectal Cancer Screening
    • USPSTF recommends annual FOBT or flex sig every 5 years or both in adults age > 50
    • Medicare now pays for screening colonoscopy making it an appropriate choice
    • AGA recommends annual FOBT and flex sig every 5 years starting at age 50 (age 40 if FH in a 1st degree relative).
  90. Breast Cancer Screening
    • Mammogram annually after age 50, upper age limit not clear -- should be based on comorbid conditions
    • Mammograms for age 40-50 are controversial. ACS recommends yearly, ACP: based on risk factors and discussions
    • VERY IMPORTANT: Know the false-positive risk in this age group -- estimated 30% chance of breast biopsy if woman has annual exams from 40 to 50.
  91. Immunization schedule for young adults?
    • Completion of childhood immunizations (MMR, DPT, polio, hep A and B)
    • Tdap booster q 10 years
    • HPV vaccine women 9-26
  92. What are the Immunization Don'ts?

    A. For pregnant women?
    B. HIV pts?
    • Pregnancy: Do not give attenuated LIVE vaccines (MMR, oral polio, yellow fever, typhoid, varicella, nasal influenza)
    • HIV: Can probably give all vaccines except small pox; but MMR should be avoided in individuals with very severe immunosuppression (CD4 counts well under 100)
  93. Recommended immunizations in patients with HIV?
    • Annual influenzae
    • Pneumovax (repeat q 6 years)
    • Td booster as indicated
    • Consider hep B and hep A, based on risk
  94. What is a contraindication to smallpox vaccine?
  95. Who gets the Hepatitis A vaccine?
    • Travelers to endemic areas
    • Patients with Hep C
    • Military personnel
    • Day care workers
    • Consists of two-dose series separated by 6 to 12 months
  96. What is the recommended treatment for traveler's diarrhea (not E. coli 0157:H7)?
    Ciprofloxacin and loperamide

    There was a randomized study with 88 adults seeking treatment for dysentery in Thailand. Was randomized to cipro vs. cipro and loperamide. Duration of diarrhea was 42 hours in the former and 19 hours in the latter. No adverse effects.
  97. Bulimia nervosa

    What are the clinical features?
    What lab abnormalities do you see?
    Epidemiology: Usually women age 20-30 (older than anorexia pts)

    • Clinical features
    • -Erosion of dental enamel
    • -Reflux symptoms
    • -Mallory-Weiss tears

    • Lab abnormalities
    • -Hypokalemia
    • -Hypochloremia
    • -Low urinary chloride
  98. Anorexia Nervosa

    What are the clinical features?
    • Weight loss of 15% under ideal
    • Preoccupation with food
    • Intense fear of becoming fat
    • Distorted self-image
    • Loss of menstrual cycles
    • Bradycardia, anemia, low albumin
  99. What is the treatment for Panic disorder?
    • SSRI is the mainstay
    • OK to use short-term benzo when starting treatment, or longer term use in patients who are not adequately treated with SSRI.
    • Longer acting drug like clonazepam is preferable to short-acting alprazolam
    • Cognitive behavioral therapy can be a good option
  100. What antidepressant has almost no sexual side effect?
    • Buproprion (Wellbutrin)
    • -this is a good alternative to SSRI if pt cannot tolerate due to its sexual side effect
  101. What antidepressant class can cause hyponatremia?
    SSRI, especially in older pts.
  102. What sexual side effect is seen in SSRIs?
    Delayed ejaculation in 30 -- 50%
  103. What antidepressants are avoided in pts with CAD, history of MI, arrhtymia and BPH?
    • TCA
    • (Amitrytyline, Nortryptyline)
  104. What conditions will make you avoid giving buproprion in a pt with depression?
    • seizure disorder
    • eating disorder
    • alcoholism
  105. What is the risk to consider before ordering SSRIs?
    • Increased bleeding risk due to negative effect on platelets
    • Sexual side effect
  106. What antidepressant is best option for pt who had weight gain with other antidepressants in the past?
    • Buproprion
    • Venlafaxine
  107. What antidepressants can cause weight gain?
    • MAOI (very likely)
    • TCA (very likely)
    • Paroxetine (more likely than other SSRIs)
    • Mirtazapine (likely)

    Buproprion and Venlafaxine is weight neutral
  108. What is a good addition to SSRIs if pt has no improvement after SSRI dose is maximized?
  109. What medication is appropriate to add if no improvement in depression sx with SSRI and buproprion?
    • T3 (cytamel)
    • Lithium -- but T3 is better tolerated
  110. What are etiologies of Neuroleptic Malignant Syndrome?
    • Discontinuation of anti-Parkinson meds
    • Neuroleptics:
    • -Haldol
    • -Chlorpromazine
    • -Clozapine
  111. What are the hallmarks of X-linked inheritance?
    • Inheritance of trait is male >> female
    • All daughters of affected male will be carriers
    • Males never pass gene on to sons
    • Heterozygoes will usually be unaffected
  112. What is Penetrance?
    • A measure of how often one sees a characteristic phenotype in an individual who possesses the gene that causes the phenotype
    • A penetrance of 1 (100%) means all gene carriers will show phenotype
    • Age-related penetrance, i.e., Huntington disease
  113. What are the common causes of low magnesium?
    • heavy ETOH intake
    • diuretics
    • cisplatinum
  114. When is LDH useful?
    • Evaluating for PCP
    • Evaluating for lymphoma, following lymphoma patients
  115. Causes of Increased alkaline phosphatase?
    • 1. Hepatic
    • -Primary biliary cirrhosis
    • -Primary sclerosing cholangitis (IBD history)
    • -Cholecystitis / impacted stones
    • -Medication-induced cholestasis
    • -Parenchymal liver disease
    • 2. Pregnancy - placenta
    • 3. Bone
    • -Metastatic disease
    • -Paget's
  116. Gilbert Syndrome

    What is the prevalence?
    What is the defect?
    What lab results would you expect?
    • Prevalence: 5-7% of population
    • Defect: decreased UDP--glucuronyl transerase activity
    • Bilirubin levels: usually < 3, unless fasting or hemolysis
    • Prognosis: normal
  117. Differential diagnosis of very high ALT?
    • Viral hepatitis
    • -Hep A > Hep B > Hep C


    • Toxin
    • -Acetaminophen > mushroom
  118. How do you treat generalized anxiety disorder?
    • Psychotherapy and pharmacotherapy are effective in treating patients with GAD, and cognitive-behavioral therapy is the psychotherapy of choice in these patients.
    • SSRIs are the most effective pharmacologic agents for treating generalized anxiety disorder.
  119. How do you treat allergic rhinitis?
    • Intranasal corticosteroids are the most efficacious therapy
    • Oral second-generation (nonsedating) antihistamines (for example, fexofenadine) can either be used alone or as additional therapy for control of mild symptoms, but not as effective with severe symptoms.
    • Oral decongestants, including pseudoephedrine, also relieve nasal congestion but not rhinorrhea, itching, or sneezing.
  120. How do you manage hypertriglyceridemia?
    • In patients with a triglyceride level between 200 mg/dL and 500 mg/dL (2.26 and 5.65 mmol/L), the need for medication to lower the triglyceride level is determined by calculating the non-HDL cholesterol level.
    • When a patient has a high triglyceride level as well as a non–HDL cholesterol value that is more than 30 mg/dL (0.78 mmol/L) above the LDL cholesterol goal, medication is indicated to treat the high triglyceride level as well as the dyslipidemia associated with it.
  121. How do you screen for colorectal cancer?
    Acceptable colorectal cancer screening methods for average-risk patients include:

    • 1. Annual home stool testing (fecal occult testing)
    • 2. Colonoscopy every 10 years
    • 3. Flexible sigmoidoscopy every 5 years together with high-sensitivity fecal occult blood testing every 3 years.
  122. How do you treat a chronic cough of unclear etiology?
    When the etiology of a chronic cough is unclear, the American College of Chest Physicians recommends initial treatment with a first-generation antihistamine/decongestant combination to treat UACS.
  123. UACS (Upper airway cough syndrome, formerly known as post-nasal drip)

    What is the clinical description?
    What are the s/s?
    How do you treat it?
    What is the next intervention if the pt does not respond to treatment?
    • Refers to a recurrent cough triggered when mucus draining from the sinuses through the oropharynx triggers cough receptors.
    • Most patients with UACS have symptoms or evidence of one or more of the following: postnasal drainage, frequent throat clearing, nasal discharge, cobblestone appearance of the oropharyngeal mucosa, or mucus dripping down the oropharynx.
    • First-generation antihistamines, in combination with a decongestant, are the most consistently effective form of therapy
    • The avoidance of allergens and daily use of intranasal corticosteroids or cromolyn sodium are recommended for patients with allergic rhinitis.
    • Patients who do not respond to empiric therapy should undergo sinus imaging to diagnose “silent” chronic sinusitis.
  124. How do you treat delirium in a terminally ill patient?
    • initiate haloperidol
    • Antipsychotic medications in small doses are effective treatment for delirium in a terminally ill pt.
    • As benzodiazepines, including lorazepam, can cause or worsen delirium, they should only be used if there is a strong component of patient anxiety or if the antipsychotic medication is ineffective after upward titration.
  125. How do you manage a pt interested in smoking cessation?
    For smoking cessation, bupropion and nortriptyline appear to be equally effective and of similar efficacy to nicotine replacement therapy but less effective than varenicline.
  126. How do you manage recurrent falls in an elderly patient?
    • Check serum 25-hydroxyvitamin D level
    • If the vitamin D level is low, this patient should take ergocalciferol or cholecalciferol, 50,000 units weekly for 6 to 8 weeks, followed by 800 to 1000 units of vitamin D daily along with calcium supplementation (at least 1200 mg of elemental calcium [diet plus supplementation]).
    • Although vitamin D deficiency is common in the elderly, routine vitamin D level screening is not recommended.
    • Vitamin D plus calcium supplementation is recommended for all elderly persons.
  127. What are symptoms of low vitamin D level in the elderly?
    muscle weakness, functional impairment, and increased risk of falls and fractures.
  128. An elderly pt comes to the office with complaint of one episode of fall recently. What is your initial intervention?
    Patients who report a single fall should undergo balance and gait screening with the “get up and go” test. This test is appropriate for screening because it is a quantitative evaluation of general functional mobility. Persons are timed in their ability to rise from a chair, walk 10 feet, turn, and then return to the chair. Most adults can complete this task in 10 seconds, and most frail elderly persons, in 11 to 20 seconds.
  129. What is the function of hip protectors in the elderly?
    A Cochrane systematic review concluded that hip protectors are ineffective in preventing hip fractures in elderly persons who fall, partly as a result of limited patient acceptance and adherence because of discomfort.
  130. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

    How does it manifest?
    Any diagnostics?
    What is the treatment?
    • CP/CPPS is manifested by genitourinary/pelvic pain and voiding symptoms.
    • There are no diagnostic physical or laboratory findings. Urine cultures are typically negative, and the presence or absence of leukocytes in the urine has limited clinical utility in diagnosis or in predicting treatment response.
    • Alpha-blockers such as terazosin are most appropriate.
  131. Emergency contraception

    What is the preferred method?
    What about the usual contraindications to OCPs?
    Is a routing follow-up visit required?
    • Two types of pills are available for emergency contraception. Both must be taken as soon as possible, or within 5 days of a risked pregnancy, and a second dose is taken 12 hours later.
    • Levonorgestrel (Plan B) is the preferred formulation of emergency contraception because it is more efficacious and has fewer side effects (nausea 20% and vomiting 6%) than the other option, which is a combination of ethinyl estradiol and levonorgestrel.
    • The usual contraindications to oral hormonal contraceptives are not applicable to women using the two-dose method for emergency contraception. Specifically, emergency contraception with oral levonorgestrel is believed to have acceptable risks in patients with cardiovascular disease, thrombophilic disorders, migraine, liver disease, and for patients who are breastfeeding.
    • A routine follow-up office visit is not required after taking emergency contraception with either of these two methods.
  132. 1. What is scleritis?
    2. What is episcleritis?
    • 1. a serious eye condition that can lead to permanent visual loss or globe rupture and should be treated urgently in consultation with an ophthalmologist. Presents with severe bilateral eye pain that is described as deep and boring, and has associated photophobia, tearing, and eye findings of raised erythema localized to the sclera.
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    • 2. an inflammation of the superficial blood vessels overlying the sclera. Patients may present with no symptoms or mild ocular pain and redness, which may occur abruptly. The blood vessels appear prominent and engorged, but normal white sclera may be visible between the blood vessels, helping to distinguish this from scleritis.
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  133. What is the appropriate herpes zoster vaccination strategy?
    It is indicated in all patients age 60 years and older without contraindications, regardless of history of prior chickenpox infection.
  134. What is piriformis syndrome?
    The piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve, causing pain in the buttocks and referring pain along the course of the sciatic nerve. This referred pain, called "sciatica", often goes down the back of the thigh and/or into the lower back. Patients generally complain of pain deep in the buttocks, which is made worse by sitting, climbing stairs, or performing squats
  135. A common source of sciatic nerve pain resulting from irritation and hypertrophy.
    • A likely diagnosis in patients with sciatic pain when examination findings localize to the sciatic notch and there are no other signs of neurologic compromise of the piriformis muscle.
    • The management is conservative, with NSAIDs and stretching exercises.
  136. How do you confirm trochanteric busitis?
    can be confirmed in patients in whom hip adduction intensifies the pain or in those in whom the examination reveals pain and tenderness over the bursa, which is located over the lateral projection of the greater trochanter.
  137. How do you evaluate pulsatile tinnitus?
    • Patients with frequent or constant pulsatile tinnitus should be referred for otorhinolaryngologic evaluation and may require CT angiography or MR angiography.
    • Often vascular in origin and may be due to an arteriovenous fistula, arteriovenous malformation, arterial aneurysm, tumor, or atherosclerotic disease.
  138. How do you manage olecranon bursitis?
    Olecranon bursitis is typically associated with painful full elbow flexion; acute crystalline or infectious synovitis is usually associated with pain on any passive joint motion.
  139. When is screening for Fasting blood sugar recommended?
    Fasting blood sugar (FBS) for screening purposes is recommended for patients with hypertension according to the USPSTF, because lower blood pressure goals reduce cardiovascular risk in patients with diabetes. Similarly, screening for type 2 diabetes in adults with dyslipidemia should be considered because diabetes is one of the conditions that lowers LDL cholesterol target levels. The American Diabetes Association (ADA) recommends a screening FBS in adults older than 45 years and in those 45 years or younger if they are overweight (BMI ≥25) and have one or more additional risk factors for diabetes. The ADA recommends that adults older than 45 years who have normal weight and no risk factors should be screened every 3 years; adults of any age who are overweight and have additional risk factors should be screened annually.
  140. What is a cholesteatoma?
    • a growth of desquamated, stratified, squamous epithelium within the middle ear. It is typically visible on otoscopy as an opaque or ivory colored mass behind the tympanic membrane. With growth, the cholesteatoma may erode the ossicles, resulting in a conductive hearing loss. If left untreated, erosion into the inner ear may cause sensorineural hearing loss. Patients may present with otorrhea, pain, hearing loss, or neurologic symptoms.
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  141. What is otosclerosis?
    • a bony overgrowth that involves the footplate of the stapes, eventually resulting in total fixation and inability to transmit vibration from the tympanic membrane along the ossicular chain. This results in a gradually progressive conductive hearing loss.
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  142. What is Eustachian tude dysfunction?
    Eustachian tube dysfunction can cause muffled hearing and intermittent popping sounds in the ear. The Weber test is typically normal.
  143. What is "sudden sensorineural hearing loss?"
    is defined as hearing loss that occurs in 3 days or less. Patients often report immediate or rapid loss of hearing or find that they cannot hear upon awakening. Approximately 90% of patients have unilateral hearing loss, and some have tinnitus, ear fullness, or vertigo. Weber test lateralizes to the good ear.
  144. What is the diagnostic criteria of bulimia nervosa?
    • Diagnostic criteria for bulimia nervosa are episodes of bingeing with loss of control occurring a minimum of two times per week for 3 months, followed by purging or other compensatory behavior.
    • Patients with bulimia usually have normal weight, but many have depression or anxiety.
    • Clues for the presence of bulimia include low serum potassium or high serum bicarbonate levels in otherwise healthy patients.
  145. What is the diagnostic criteria for anorexia nervosa?
    Diagnostic criteria for anorexia nervosa consist of refusal to maintain weight within 15% of normal, fear of weight gain, distorted body image, and amenorrhea or lack of onset of menstruation.
  146. What is "binge-eating disorder?"
    Binge-eating disorder is present in patients who binge at least 2 days per week for 6 months, bingeing with rapid eating, eating until uncomfortable, and feeling disgusted or guilty after the binge. Binge-eating disorder does not involve purging.
  147. What is the established guideline for referring patients for bariatric surgery?
    BMI ≥40 or ≥35 with medical comorbidities such as sleep apnea, obesity-related cardiomyopathy, severe arthritis, hyperlipidemia, diabetes, or glucose intolerance
  148. How do you manage episodic allergic rhinitis?

    What are most effective once symptoms have occurred?
    • Intranasal cromolyn sodium is effective for symptom prevention, and the protective effect can last for 4 to 8 hours.
    • Intranasal corticosteroids are the most effective therapy once symptoms have occurred but do not prevent attacks of episodic allergic rhinitis. Other agents that can be administered once symptoms develop are topical decongestants for short-term use, intranasal antihistamines, intranasal anticholinergic agents, and oral antihistamines.
  149. Diseases that can cause Erythema nodosum:
    • Sarcoidosis
    • IBD
    • Infection - TB, strep, fungal
    • Drugs - OCP, sulfas, PCN
  150. What is the treatment for an oral lesion that appear as white, lace-like striae on the buccal mucosa with painful, erosive changes of the oral cavity
    Topical corticosteroids may be used. Topical calcineurin inhibitors have been used for patients with hightly symptomatic disease responding poorly to topical corticosteroids.
  151. What is the guideline for screening for osteoporosis?
    Recommendation for women is from age 65 years and older, and in women 60-64 years old who are at increased risk for osteoporosis
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