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General IM Board Review

General IM Board Review. Outline. Question break down Urology Pre-Op Ophthalmology ENT Women’s Health Mental Health. Question Breakdown. Total 240 questions – 4 sections You will have 2 hours for each section Normally there are 20 or so “test questions” that will not be graded

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General IM Board Review

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  1. General IM Board Review

  2. Outline • Question break down • Urology • Pre-Op • Ophthalmology • ENT • Women’s Health • Mental Health

  3. Question Breakdown • Total 240 questions – 4 sections • You will have 2 hours for each section • Normally there are 20 or so “test questions” that will not be graded • Passing is a little complicated – but on average you need to get 60% or better • 220*.6 = 132; so you can get 88 wrong?

  4. A glimmer of hope…

  5. Urology • Incontinence • Urge – detrusor overactivity • Usually due to a CNS problem • May be due to cystitis • Tx = • behavioral therapy (delay voiding by 5-10minutes/day until reach a goal of 2-3 hours) • Antimuscarinics – relax detrusor but have anticholinergic side effects • Oxybutynin, tolterodine

  6. Urology • Incontinence • Stress – outlet incompetence • Unable to maintain pressure gradient with increased abdominal pressure (cough/jumping) • Usually occurs in combo with urge incontinence • Urethral hypermobility • Sphincter problem • Many times due to atrophic relaxation of vaginal wall  lack of urethral support • Tx = • Kegel exercises • Conjugated steroid cream to external urinary meatus

  7. Urology • Incontinence • Overflow – outlet obstruction • Anticholinergics, detrusor underactivity, psychogenic retention • Usually men – prostatic hypertrophy; rare in women • Can be medication-induced by anticholinergics • Detrusor underactivity – usually areflexic – diabetic neuropathy, MS, trauma/lesion to sacral/pelvic nerves

  8. Urology • QUESTION: 78 y/o female is seen in clinic w/ c/o incontinence * sev. months. She is unable to hold her urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain associated with these episodes, though she finds them distressing. She is o/w independent and performs all ADLs. • Which of the following is true? • The abrupt onset of sx should promote cystoscopy. • First-line tx for this condition consists of desmopressin. • Indwelling catheters are rarely indicated for this disorder. • Referral to GU surgeon is indicated for correction. • Urodynamic testing must be performed before rx of antispasmodic meds.

  9. Urology • QUESTION: 78 y/o female is seen in clinic w/ c/o incontinence * sev. Months. She is unable to hold her urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain associated with these episodes, though she finds them distressing. She is o/w independent and performs all ADLs. • Which of the following is true? • The abrupt onset of sx should promote cystoscopy. • First-line tx for this condition consists of desmopressin. - Behavioral therapy is first line • Indwelling catheters are rarely indicated for this disorder. • Referral to GU surgeon is indicated for correction. • Urodynamic testing must be performed before rx of antispasmodic meds.

  10. Urology • QUESTION: 75 y/o female is evaluated for symptoms UI which has increased over the last several months. She has frequent urge and difficulty controlling her urine flow. She was recently diagnosed with depression and started taking nortryptiline. Her PMHx is sig. for TAH for h/o fibroids and HTN for which she takes nifedipine and atenolol. PE is unremarkable. UA is normal. • What is the most appropriate next step? • Replace nortriptyline with another class of antidepressants • Replace atenolol with another anti-HTN • Replace nifedipine with another anti-HTN • Begin oxybutynin • Begin po estrogen

  11. Urology • QUESTION: 75 y/o female is evaluated for symptoms UI which has increased over the last several months. She has frequent urge and difficulty controlling her urine flow. She was recently diagnosed with depression and started taking nortryptiline. Her PMHx is sig. for TAH for h/o fibroids and HTN for which she takes nifedipine and atenolol. PE is unremarkable. UA is nl. • What is the most appropriate next step? • Replace nortriptyline with another class of antidepressants • Replace atenolol with another anti-HTN • Replace nifedipine with another anti-HTN • Begin oxybutynin • Begin po estrogen ***In general  Never add another med on the boards – always find one to remove/replace/withdraw, etc…

  12. Urology • QUESTION: 81 yo male is evaluated for 3 month h/o difficulty controlling urine. Pt notes frequent urge to urinate requiring him to wear pads during the day and night. After a trial oxybutynin, the patient had dry mouth and stopped the drug. PMH includes Alzheimer’s, CVA, and HTN. PE: prostate is normal and neurologic findings are non-focal. MMSE 20/30. Labs including UA and chemistries are wnl. • Which of the following is most appropriate? • Tolterodine • Doxepin • Midodrine • Duloxetine

  13. Urology • QUESTION: 81 yo male is evaluated for 3 month h/o difficulty controlling urine. Pt notes frequent urge to urinate requiring him to wear pads during the day and night. After a trial oxybutynin, the patient had dry mouth and d/c’d the drug. PMH includes Alzheimer’s, CVA, and HTN. PE: prostate is nl and neurologic findings are non-focal. MMSE 20/30. Labs including UA and chemistries are wnl. • Which of the following is most appropriate? • Tolterodine (Cochrane Review showed less SE including dry mouth & only crosses BBB in negligible amounts) • Doxepin (TCA uses off-label for urge incontinence) • Midodrine (alpha adrenergic agonist use off-label for stress incontinence) • Duloxetine (selective serotonin and NE reuptake inhibitor useful for stress incontinence)

  14. Urology • BPH • Tx options: TURP, alpha-1A blockers, 5-alpha reductase blockers • Alpha blockers – symptomatic improvement achieved quickly (terazosin, tamsulosin, alfuzosin) • Tamulosin / Flomax has more specificity for alpha 1A receptor which are found in postrate stroma • Less systemic side effects (postural hypotension) • Finasteride blocks conversion of testosterone to DHT • May take up to one year for symptomatic improvement

  15. Urology • ED • Etiologies: • Organic – neurogenic (DM mc, MS, ALS, Parkinson’s), vascular (DM, CVDx), hormonal (space-occupying tumor, decreased androgens, hypothyroid), normal aging • Meds – b blockers, methyldopa, thiazides, lipid-lowering agents, NSAIDs • Psych – younger pts, acute onset; nocturnal and AM erections present

  16. Urology • ED • Treatment: • Sildenafil (viagra) / Vardenafil (levitra) – inhibits phosphodiesterase V, (which would normally inactivate cGMP) • CI = concurrent nitrates; relative CI = CHF, hypotension, unstable angina, HCM, severe AS • Tadalafil (Cialis) – longer half-life (may improve ED for 36h) • Other options: Vacuum devices, yohimbine (natural alpha blocker), trazadone, alprostadil (PG E1) injections into corpora cavernosa (useful if etiology neurologic), penile implants

  17. Urology • Question: A 45 yo black man is evaluated for concerns about prostate cancer. A good friend was recently diagnosed with extensive disease. The pt requests a screening test. He reports only nightly nocturia but no hesitancy, frequency or dribbling. • Which of the following is most appropriate? • PSA • PSA and DRE • TR U/S • TR U/S and bx • Discussion of risks/benefits of PSA testing

  18. Urology • Question: A 45 yo black man is evaluated for concerns about prostate cancer. A good friend was recently diagnosed with extensive disease. The pt requests a screening test. He reports only nightly nocturia but no hesitancy, frequency or dribbling. • Which of the following is most appropriate? • PSA • PSA and DRE • TR U/S • TR U/S and bx • Discussion of risks/benefits of PSA testing • (with cutoff of 4 ug/L) a PSA has a sens of 70-80% and a Spec of 60-70%. In asx pts the PPV is 30%

  19. Pre-OP Evaluation • Want you to be cost-effective • Essentially need to memorize algorithm • Will be based on 2002 guidelines (update in 2007 similar) • Likely to see – low risk pt, moderate risk pt, major risk pt

  20. ACC/AHA guidelines: stepwise approach to preoperative cardiac assessment-I • Major predictors: • UA • Decomp CHF • Severe valve dx • Sig. arrhythmia • Recent MI (7-30 days) • *** preferable to wait 4-6 weeks after MI • ***longer if drug-eluding stent placed

  21. ACC/AHA guidelines: stepwise approach to preoperative cardiac assessment-I Intermediate Predictors: 1.Stable angina 2. Prior MI 3. DM 4. Compensated CHF • High risk surgery: emergent, vascular (aorta & CEA & peripheral vasc), head/neck, prolonged with lg volume shifts • Intermediate risk surgery: Intraperitoneal, intrathoracic, ortho, prostate

  22. ACC/AHA guidelines: stepwise approach to preoperative cardiac assessment-I • Low risk: • Elderly • H/O CVA • CABG w/in last 5 years • EKG changes: ST changes, LBBB, LVH, or rhythm other than SR • Low functional capacity • Uncontrolled HTN

  23. Pre-Op • Beta Blockers (Circ 99 & NEJM 05): • Revised Cardiac Index (One point each) • Ischemic heart disease • CHF • CVA/TIA • Preoperative insulin treatment • Preoperative creatinine>2 • High risk surgery • BB use: • RCRI score 0 & 1 – RR 1.36 & 1.09 • RCRI score 2,3,4 – RR 0.88, 0.71, 0.58

  24. Pre-Op • Beta Blockers ACC guidelines: • Class 1: rec’d for patients already on & vascular surgery patients with ischemia • Class 2a: Probably useful for: vascular surgery pts with multiple risk factors for CAD, intermediate risk or high risk surgery in patients with multiple risk factors for CAD • Class 2b: Could consider for: intermediate and high risk surgery pts with single risk factor or vascular surgery patients with low cardiac risk

  25. Pre-Op • Stents: • In-stent re-thrombosis common if surgery performed before endothelialization • 4 week wait rec’d for bare metal stents • 12 month wait rec’d for drug eluding stents • Consider if: pt has standard indication for stent & noncardiac surgery can be delayed for up to 4 weeks after stent and 6 months if drug-eluding stent placed

  26. Pre-Op ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery:Executive Summary

  27. Pre-Op 72 yo man presents 3 weeks prior to colectomy for recurrent diverticulitis. PMHx: HTN, CHF. Echo: EF 40%. Ischemia evaluation negative a 1 ½ year ago. Started on ACE-I and diuretic (also on statin, glucosamine and naprosyn for arthritis) and has been stable and able to walk up to 3 blocks. BP: 110/75 and P85 • Next step is? • Stop zocor • Repeat echo • Begin metoprolol 25mg bid now • Stop glucosamine • Stop naprosyn

  28. Pre-Op 72 y/o man presents 3 weeks prior to colectomy for recurrent diverticulitis. PMHx: HTN, CHF. Echo: EF 40%. Ischemia eval negative a 1 ½ year ago. Started on ACE-I and diuretic (also on statin, glucosamine and naprosyn for arthritis) and has been stable and able to walk up to 3 blocks. BP: 110/75 and P85 • Next step is? • Stop zocor • Repeat echo • Begin metoprolol 25mg bid now - He gets one point for: CHF, ischemic heart dx, high risk surgery (surprainguinal, vascular, intrathoracic, intraperitoneal) = 3 points therefore would benefit • Stop glucosamine • Stop naprosyn

  29. Pre-Op A 70 y/o female with hypothyroidism fell and fractured her hip. During preop she c/o fatigue and RUQ abdominal pain after eating. She takes 75 mcg of Synthroid daily. PE is notable for moderate obesity. Labs: Hgb 11/Hct 34%/ TSH 11.2/ T4 7.2/ triiodothyronine uptake is 45%. Liver chemistries are normal. What is the most appropriate management? • Proceed to OR • Increase Synthroid and delay surgery until TSH nl • Give IV thyroid hormone and proceed to OR • Give IV thyroid hormone + hydrocortisone and proceed to OR

  30. Pre-Op A 70 y/o female with hypothyroidism fell and fx’d her hip. During preop she c/o fatigue and RUQ abdominal pain after eating. She takes 75 mcg of synthroid daily. PE is notable for moderate obesity. Labs: Hgb 11/Hct 34%/ TSH 11.2/ T4 7.2/ triiodothyronine uptake is 45%. Liver chemistries are normal. What is the most appropriate management? • Proceed to OR • Increase synthroid and delay surgery until TSH nl • Give IV thyroid hormone and proceed to OR • Give IV thyroid hormone + hydrocortisone and proceed to OR Overall, if severe hyper/hypo and surgery elective  delay surgery. If severe and surgery emergent  consult endo.

  31. Pre-Op 68 y/o male with adenoca of cecum undergoes pre-op eval. His PMH includes inoperable CAD, CHF with LVEF of 35%, HTN, HLP. Angina is stable occurring monthly. No orthopnea or PND. Meds: lisinopril, carvedilol, furosemide, simvastatin, asa. He plays golf 3*/week using a cart and walks 2 miles 3-4 */week. PE reveals JVP of 6 cm. CV – regular without an S3. No peripheral edema. Labs are normal. EKG unchanged with NSR and old inferior infarct. • What is the next most appropriate step for pre-op? • BNP check • Echo • Exercise stress test • Nuclear imaging • No further evaluation

  32. Pre-Op 68 y/o male with adenoca of cecum undergoes pre-op eval. His PMH includes inoperable CAD, CHF with LVEF of 35%, HTN, HLP. Angina is stable occurring monthly. No orthopnea or PND. Meds: lisinopril, carvedilol, furosemide, simvastatin, asa. He plays golf 3*/week using a cart and walks 2 miles 3-4 */week. PE reveals JVP of 6 cm. CV – regular without an S3. No peripheral edema. Labs are normal. EKG unchanged with NSR and old inferior infarct. • What is the next most appropriate step for pre-op? • BNP check • Echo • Exercise stress test • Nuclear imaging • No further eval – intermediate marker for intermediate surgery with > 4mets  proceed to OR

  33. Pre-Op • 65 yo male comes in for evaluation prior to aorto-bifemoral bypass for severe peripheral vascular disease which limits his ambulation. PMH: DMII, HTN; MEDS: ASA, Glipizide, Norvasc / BP 156/88 and P 88 / Exam: R carotid bruit and absent LE pulses BL • What is the next step in assessment? • Exercise Tolerance Test • Cardiac Cath • Atenolol and titrate to P<70 pre-op and continue peri-op • Noninvasive testing for ischemia

  34. Pre-Op • 65 y/o male comes in for eval prior to aortobifemoral bypass for severe PVDx which limits his ambulation. PMHx: DMII, HTN / MEDS: ASA, Glipizide, Norvasc / BP 156/88 and P 88 / Exam: R carotid bruit and absent LE pulses BL • What is the next step in assessment? • Exercise Tolerance Test • Cardiac Cath • Atenolol and titrate to P<70 pre-op and continue peri-op • Noninvasive testing for ischemia He’s intermed risk (DMII) for high risk surgery (vascular) and likely has poor to moderate mets

  35. OPHTHALMOLOGY • In general – relating to acute vision loss • The more sudden, the more urgent! • Pain suggests acute angle closure glaucoma, or optic neuritis • Painless suggests vascular event, hemorrhage, or RD

  36. Who Needs to See the Eye Doctor Now?? (1) A red eye with PAIN!! (2) Any acute vision loss with MG pupil / APD (3) Ruptured globe or hyphema (4) Corneal ulcer (or red painful eye in contact lens wearer) (5) Suspected acute glaucoma (red painful eye, high pressure) (6) Alkali chemical injury (7) Suspected temporal arteritis (8) Acute proptosis (9) Suspected retinal detachment (10) CRAO

  37. OPHTHALMOLOGY • Glaucoma – • Primary Open angle – MC • Unnoticed gradual loss of peripheral vision • Elevated intraocular pressure • Abnormal cup:disc ration (>50%) • Ciliary Flush • Tx= topical beta blocker (decrease IOP) / adrenergic agonist (decrease production of aqueous humor & later inc outflow) / cholinergic agonists (stimulate parasympathetic receptors & open trabecular network) / carbonic anhydrase inhibitors

  38. OPHTHALMOLOGY • Glaucoma – • Primary closed angle – ocular emergency • Most common in Asians • Decreased vision, narrow anterior chamber, conjuctival hyperemia, fixed, mid-dilated pupil • Tx= pupil constriction with pilocarpine, pressure lowering (oral sorbitol or IV mannitol + topical beta blockers) + relief of obstruction (laser iridectomy) • If ophthalmologist not available: • Topical pilocarpine: 2% q5min *3 • Topical timolol: 0.5% *1 • Oral or IV acetazolamide 500mg *1  then find ophtho

  39. OPHTHALMOLOGY • Retinal Artery Occlusion:Ocular emergency • Usually embolic • Sudden, painless, unilateral blindness • Retinal edema  “cherry red spot” in macula • Tx= ocular massage, paracentesis of anterior chamber, carbogen (O2 + CO2) inhalation to dilate retinal vessels • Place in trendelenburg while awaiting for ophtho • Evaluation for embolic and carotid disease

  40. OPHTHALMOLOGY • Retinal Vein Occlusion: • Sudden, painless, near-total loss of vision • Etiologies: HTN, PCV, Waldenstrom’s • “blood and thunder” fundus with multiple hemorrhages • NOT an emergency due to no effective acute treatments

  41. OPHTHALMOLOGY • Macular Degeneration • Presents with vision loss, fading colors, difficulty seeing in dark • Age-related atrophic or ‘dry’ is leading cause of irreversible acquired blindness • Age-related neovascular or ‘wet’ – amenable to treatment with laser photocoagulation & photodynamic therapy • RF = smoking, low dietary anti-oxidants and zinc

  42. OPHTHALMOLOGY • Vitreous hemorrhage • Sudden, painless loss of vision • Due to tearing a retinal vessel or breakage of a fragile vessel in diabetics with the neovascularization

  43. OPHTHALMOLOGY • Red eye differential: • Blepharitis/ chalazion • Acute angle-closure glaucoma • Conjunctivitis • Iritis • Keratitis • HSV • Orbital cellulitis

  44. Blepharitis/ Chalazion • Chronic red eye • Crusting, debris on lashes • Treatment: Lid scrubs to get rid of: • Desquamating scales • Oily debris • Staph + Demodex

  45. Chalazion • Chronically clogged, sterile,oil gland of eyelid, commonly resulting from blepharitis • Hordoleum – clogged, infected gland (internal vs external = stye) • Treatment – warm compress four times per day

  46. Acute Conjunctivitis • Hyper - purulent conjunctivitis – think GC! • If severe, copious discharge – refer to optho • If GC – IM/IV ceftriaxone • If Chlamydia – doxy/erythro for 2 weeks • Others (mild d/c) – Staph, Strep, HI, M catarrhalis • (Most conjunctivitis is viral or allergic) • Classic “pink eye” often has assoc URI sx &/or preauricular or submandibular LAD • Lid edema, serous d/c • Adenovirus MC (contagious for 12-14 days) • Rx – hand washing, topical lubrication • Likely to see lateral erythema without ciliary flush

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