generalizations: general internal medicine board review
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Generalizations: General Internal Medicine Board Review. Jimmy Stewart, MD Professor of Medicine and Pediatrics Division of General Internal Medicine and Hypertension Program Director, Med/ Peds Program University of Mississippi Medical Center. Preventive Medicine. Screening Vaccinations - PowerPoint PPT PresentationTRANSCRIPT
Generalizations:General Internal Medicine
Board ReviewJimmy Stewart, MD
Professor of Medicine and PediatricsDivision of General Internal Medicine and Hypertension
Program Director, Med/Peds ProgramUniversity of Mississippi Medical Center
Preventive Medicine• Screening• Vaccinations• Prophylaxis• Education
Colorectal Ca• All adult ages 50-75 yo
• 40+ or 10 years prior to relative
• FOBT, flex sig for “average risk”
• Colonoscopy - every 5-10 years for high risk
Prostate Ca• PSA - NOT recommended for routine
screening• Greatest sens in AA or high risk group
Lipids• High Risk (CAD or equivalent) – statin
• LDL > 190 mg/dL – statin
• ASCVD risk > 7.5 % - statin
Attenuated Live Vaccines• MMR*• Oral Polio• Nasal influenza• Yellow fever• Smallpox
• Typhoid• BCG• Varicella (including
Zostavax)
HIV vaccinations• HBV• Influenza• Pneumococcal• Hib• MMR/Td
Strep Pneumo Asplenia >65 yo every 5 years Chronic disease (including DM)
Influenza• Yearly >50 yo• Healthcare workers• Childcare workers• Household contacts of above
Zostavax• >55 yo?• History of zoster not important
Others• Meningococcal - not against “B”,
college freshmen• Cholera - DOESN’T WORK
Traveler’s diarrhea: Prevention
Flouroquinolones Azithromycin Must take daily
Traveler’s diarrhea• Mild: 1-2 stools/day - loperamide• Mod: 3 stools/day - single dose Abx• Sev: 6 stoos/day - Abx x 3 days with
loperamide
Traveler’s diarrhea: Treatment
Flouroquinolones Azithromycin
Malaria Chloroquine-resistant - Mefloquin
(neuro SE’s) Chloroquine Others - doxy, primaquine, azithromycin
Gray - resistant; Blue - sensitive
Meningococcal Rifampin Cipro Rocephin - pregnancy
Education - what works... Smoking cessation Firearm safety Bladder Cancer Folate supplementation Osteoporosis CVA
Drug Overdose Isopropyl (rubbing
alcohol) Methanol (wood
alcohol) Ethylene Glycol Salicylates Acetaminophen Theophylline
• Lithium• Tricyclics• PCP• Anticholinergics• Cholinergics• CO• Cyanide• Pb• Insecticides
Isopropyl CNS depression Osmolal gap Early lavage Hemo/peritoneal dialysis
Methanol Visual changes AG met acidosis Treat with ETOH, folate, dialysis,
fomepizole
Ethylene glycol Ca oxalate crystals AG met acidosis Treat with ETOH, bicarb, calcium,
dialysis, fomepizole
Calcium Oxalate: “folded box”
Salicylates AG met acidosis Classic presentation: AG with pH 7.4
and history Treatment - lavage, alkalinization,
hemodialysis, charcoal
Acetaminophen N - acetylcysteine Early gastric emptying Normogram
Theophylline Seizures Treat with diazepam, lavage, charcoal,
cathartic
Lithium MS changes, Parkinsonian DO NOT GIVE CHARCOAL Lavage, electrolytes/fluids, hemodialysis
Tricyclics Tachycardia, long QT, PR, QRS Hemodialysis INEFFECTIVE Alkalize Lidocaine/phenytoin
PCP Agitation, seizures, dystonia, HTN Give ammonium Cl to acidify the urine Diazoxide for HTN
Anticholinergics “Red as a beet, dry as a bone, blind as
a bat, mad as a hatter, and hot as a hare”
Supportive care Physostigmine
Anticholinergics Scopolamine Antihistamines Antipsychotics Antispasmotics Cyclic antidepressants Mydriatics
Cholinergics “SLUDGE” “DUMBELS” Skin cleansing Atropine 2-PAM for organophosphates
Carbon monoxide CNS depression mild-mod: 15-30% mod-sev: >30% Fatal: >50% O2
Cyanide Almond breath, bright red venous blood Amyl nitrate 3% Na nitrite Sodium thiosulfate
Ethics Principles Autonomy Beneficence Nonmaleficence Cultural differences Confidentiality Brain death - NO EEG REQUIRED!
Perioperative Evaluation Clinical Risk Functional Capacity Risk of Surgery
Clinical Risk History PE ECG (men >40 yo, women >55 yo,
CAD)
Functional Capacity Excellent: >7 METs Moderate: 4-7 METs (angina walking
>2 blocks) Poor <4 METs (angina walking 1-2
blocks)
Surgical Risk Low - endoscopy, local biopsy, breast
biopsy, vasectomy, cataract Mod - CEA, intraperitoneal,
intrathoracic, orthopedic, prostate, head and neck
High - emergencies, long procedures/fluid shifts, CVS (cross-clamping aorta or bypass
Who to Test? Moderate risk with poor functional
capacity Moderate risk with good functional
capacity and high risk surgery High Risk - all
Tests Exercise stress treadmill Dipyridamole thallium Dobutamine stress echo
Scenarios... Low risk patient goes directly to surgery
without testing Moderate risk patient with good
functional capacity goes directly to nonvascular surgery
High risk patient need further workup
Ophthalmology Glaucoma Retinal Detachment Retinal Vascular
Occlusion Optic Neuritis Vitreous
Hemorrhage Alkali/Trauma
• Iridocyclitis• Keratoconjunctivitis• Viral conjunctivitis• Bacterial
conjunctivitis• Neisseria
conjunctivitis• Endophthalmitis
Closed Angle glaucoma Asian American with severe acute
nausea, headache while in movie theater
Ocular emergency Pupillary constriction
Retinal Detachment Acute trauma to head/globe Flashes/streaks of light, showers of
black dots Ocular emergency
Retinal Artery Occlusion Sudden, PAINLESS BLINDNESS Mostly embolic Ocular emergency
Optic Neuritis Ocular pain with eye movement, loss of
vision MS
Vitreous Hemorrhage Sudden painless loss of vision Must look for retinal detachment
Alkali/Trauma VA Anterior chamber: hyphema, corneal
laceration, subconjunctival hemorrhage, pupil distortion
Irrigation for alkali Referral
Red Eye: Red Flags VA decreased Pain Photophobia Pre-auricular adenopathy Discharge
Iridocylitis Ocular pain,
photophobia, ciliary flush
Emergent referral Behcet’s AK IBD JRA Reiter’s Syndrome
• Sarcoid• Syphillis• TB• Lyme disease
Keratoconjuncitivis(noninfectious)
Elderly, middle-age women Graves disease RA Sarcoid
Viral Conjuncitivis Most common cause of red eye Pre-auricular LAD
Bacterial Conjunctivitis Staph, strep, H. flu, Pseudomonas,
Moraxella Antibiotic treatment: Polytrim, gent,
tobra, fluoroquinolones
Neisseria Conjunctivitis Hyperacute course MUST TREAT WITH SYSTEMIC ABX! 3rd generation Cephalosporin IM/IV
Endophthalmitis Eye pain with movement Chemosis Hypopyon Fever Eye discharge
Treat Emergently and Refer Alkali Trauma Orbital Cellulitis Central retinal artery occlusion Acute angle closure glaucoma Optic nerve infarction in giant cell
arteritis
Refer Without Treatment Penetrating injury Endophthalmitis Retinal detachment Keratitis/keratoconjunctivitis
Refer in 1-2 Days Cental Retinal vein occlusion Optic neuritis Vitreous detachment/hemorrhage