generalizations: general internal medicine board review

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