General Medicine Board Review

1. General Medicine Board Review June 12, 2009 Internal Medicine Morning Report Sally Ravanos, MD

2. MKSAP Question #1 • 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.

3. MKSAP Question #1 (cont’d) • Which of the following is the most appropriate initial management of this patient? • Referral to orthopedics • Bed rest for 7 days • MRI of lumbar spine • NSAIDs • Back exercises

4. Answer #1: D • 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 • People who get MRIs are more likely to undergo surgery unnecessarily

5. MKSAP Question #2 • 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.

6. MKSAP Question #2 (cont’d) • Which of the following is the most appropriate diagnostic imaging evaluation for this patient? • CT of lumbar spine • MRI of lumbar spine • Radiography of lumbar spine • PET scan • Radionuclide bone scan

7. Answer #2: B • Caudaequina syndrome • Urinary retention • Saddle anesthesia • Radiculopathy • All resulting from epidural spinal cord compression caused by metastatic prostate cancer • 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

8. Definition of Acute Low Back Pain • Defined as pain < 6 weeks in duration • Differential Diagnosis • Mechanical • Musculoligamentous injuries/DJD • Herniated disks • Spinal stenosis • Compression fractures • Nonmechanical • Infections • Neoplasia • Inflammatory arthritis • Visceral • Pelvic organ dysfunction • Renal disease • Vascular disease • GI disease

9. Diagnosis of Acute Low Back Pain • 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

10. MKSAP Question #3 • 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 1-2 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.

11. MKSAP Question #3 (cont’d) • Which of the following is the most likely diagnosis in this patient? • Acephalic migraine • Meniere’s disease • Acoustic neuroma • Benign positional vertigo • Vestibular neuritis

12. Answer #3: B • Meniere’s disease is the most common cause of recurrent disabling attacks of vertigo • Common findings • Tinnitus • Fluctation hearing loss • Severe vertigo • 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 • Acute-Meclizine, benzos, antiemetics • Prophylactic-Diuretics and low-salt diet • Pathophys seems to involve increased endolymphatic fluid volume

13. Other Causes of Vertigo • Benign positional vertigo • Brief (5-15 sec) episodes of vertigo triggered by changes in head position • Usually not associated with vomiting • Vestibular neuritis • Single episode of disabling vertigo that resolves in a few days to a week • Rarely chronic or episodic • No association with hearing loss • Labyrinthitis • Acute episode of dizziness associated with unilateral hearing loss • Rare causes • Cerebrovascular disease • Brain tumors • Multiple sclerosis

14. MKSAP Question #4 • 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? • Placement of a progesterone IUD • Uterine artery embolization • Endometrial biopsy • Repeated transvaginal ultrasound

15. Answer #4: C • 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

16. Abnormal Uterine Bleeding • Infrequent menses • Excessive flow • Prolonged duration of menses • Intermenstrual bleeding • Postmenopausal bleeding • Evaluation should always include: • H and P • Pelvic exam • Pap smear • Pregnancy test if premenopausal • Other testing should be considered based on age and other medical history • GC, chlamydia, CBC, TSH, glucose, coags, prolactin level

17. Abnormal Uterine Bleeding • 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 • Treatment options for fibroids • Uterine artery embolization • Myomectomy • Hysterectomy • Refer to gynecology at any point

18. MKSAP Question #5 • 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? • Levofloxacin • Doxycycline • Dicloxacillin • Cephalexin

19. Answer #5: B • MRSA abscess/cellulitis • 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

20. Bacterial Skin Infections • Cellulitis • 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 • Rx with warm compresses and oral Abx

21. Bacterial Skin Infections • 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

22. MKSAP Question #6 • 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? • Oral bactrim • IV bactrim • Oral augmentin • Oral levofloxacin • IV levofloxacin

23. Answer #6: D • 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

24. Urinary Tract Infections • Uncomplicated • 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 • Complicated • UTI associated with a condition that increases the risk of therapy failure • 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 • 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

25. MKSAP Question #7 • 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 nonvalvularatrial 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? • Continue warfarin at usual dose and target INR for both procedures • Reduce warfarin dose to achieve a lower target INR of 1.3 to 1.5 • Stop the warfarin and perform surgery when the INR is normal for both procedures • Stop warfarin and use therapeutic enoxaparin until 12 hours before surgery

26. Answer #7: A • 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

27. Perioperative Anticoagulation Management • Surgery with moderate to high risk of bleeding • 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 • 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 • 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 • 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

28. Perioperative Anticoagulation Management • 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 • Superficial Dermatologic Procedures/Cataract Surgery • Continue usual warfarin dose • Dental Procedures • Continue usual warfarin dose • Give tranexamic acid or epsilon aminocaproic acid mouthwash for local hemostasis

29. MKSAP Question #8 • 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.

30. MKSAP Question #8 (cont’d) • Which of the following is the most appropriate management option in addressing the current symptoms? • Assess hearing and vision • Discontinue HCTZ • Initiate sertraline • Schedule neuropsychological testing

31. Answer #8: A • 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

32. Screening Tests in the Elderly • Vision screening • Hearing tests • Whispered voice test, Hearing Handicap Inventory for the Elderly, audioscope • MMSE • Three item recall test, animal naming test, clock-completion test • Five-Item Geriatric Depression Scale • 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? • Review of prescription drugs • Rapid gain test (walk 10ft, turn, walk back) • If takes longer than 10 seconds, pt has significant chance of having difficulty with ADLs in the next year • Fall risk assessment • Incontinence screening • Weight loss/nutrition screening

33. Falls in the Elderly • Falls occur in 30-40% of older adults each year • Risk factors • 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 • Get up and Go test • 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. • Orthostatic evaluation • Carotid sinus hypersensitivity assessment • Review of environmental factors • Vision/hearing screening • Lower extremity sensory function testing • Medication review • Interventions • Muscle strengthening/balance retraining • Home hazard modification • Withdrawal of psychotropic meds • Vit D supplementation • Cardiac pacing when indicated

34. MKSAP Question #9 • 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.

35. MKSAP Question #9 (cont’d) • Which of the following is the most appropriate management option for this patient? • Donepezil • Depression screening • MRI of the head • RPR, serum folate, and B12 measurement

36. Answer #9: D • Benign memory loss of aging • Always check for reversible causes • Depression • Hypercalcemia • B12/folate deficiency • B12 deficiency doesn’t always have hematologic abnormalities • Benign memory loss does not have cognitive impairment on objective tests

37. Pressure Ulcers • 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 • Intact skin, but has evidence of pressure changes including changes in temperature, consistency, or sensation • Stage 2 • Superficial wound, with partial thickness skin loss involving the epidermis or dermis • Stage 3 • Full thickness skin loss extending into the subcutaneous tissues • Stage 4 • Extensive destruction, including to the muscle, bone, or supporting structures

38. Prevention/Treatment of Pressure Ulcers • Prevention • 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

39. References • MKSAP 14 • Up to Date 2009