Gen Med Board ReviewPart Deux

Obesity, Hyperlipdemia, Hypertension, Women’s health, Men’s health, ENT

Disorders and Geriatric Disorders

A 35-year-old man comes for a new patient evaluation. He takes no medications. His parents both have diabetes mellitus.On physical examination, blood pressure is 160/100 mm Hg. BMI is 31. The remainder of the examination is unremarkable.Laboratory studies, including serum electrolyte, blood urea nitrogen, and creatinine levels and urinalysis, are normal.

In addition to lifestyle modification, which of the following is the most appropriate next step in this patient’s management?

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1. Lisinopril and hydrochlorothiazide2. Metoprolol and hydrochlorothiazide3. Terazisub4. Lisinopril

Category BP TreatmentNormal <120/80

Prehypertension 120-139/80-89 Lifestyle modifications

Stage 1 HTN 140-159/90-99 1. Lifestyle modifications: for 6-12 months

2. MedicationStage 2 HTN >160/>100 Two Medications

Goals:> 80 years old: sbp <150

DM and CKD: <130/80

Lifestyle modifications:1. Weight loss2. Decrease sodium intake3. Exercise 30 min/day for 3 days/week4. Decrease alcohol consumption

USPSTF Screening:• Every 2 years for normal BP• Annual for pre-HTN

**Hypertension should be diagnosed after an average of 2 or more blood pressure readings obtained more than a minute apart at two or more visits

HYPERTENSION

Single agent ineffective at 1-3 months then add another agent or switch agents.

Comorbidities and treatment

Uncomplicated Hypertension

Thiazide

Primary Aldosteronism or Resistant

Hypertension

Aldosterone antagonists

Heart failure, Diabetes, post- MI

ACEi/ARB

CAD, angina

Beta blocker

Calcium channel blocker

Prostatic Hyperplasia

Alpha Blockers

Gout Decreased GFR and HyperK

Pregnant and HyperK

Heart block

Hypertension Treatment

A 25-year-old woman is evaluated in the urgent care department because of the recent onset of heel pain that is especially severe when jogging. She has been taking ibuprofen for the past 7 days. Her only additional medications are a low-dose oral contraceptive that she has been taking for the past 5 years and a multivitamin. She does not smoke cigarettes. She is otherwise healthy and has no history of hypertension.

On physical examination, blood pressure is 162/102 mm Hg and pulse rate is 90/min. BMI is 24. The remainder of the examination, including cardiopulmonary, funduscopic, and neurologic examinations, is normal.

Laboratory studies, including blood urea nitrogen, serum creatinine, and urinalysis, are normal.

Which of the following is the most appropriate management of this patient’s hypertension?

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1. Begin captopril and hydrochlorothiazide2. Begin hydrochlorothiazide3. Begin labetalol4. Discontinue ibuprofen

Secondary Causes of Hypertension

Chronic Kidney Disease

Primary Aldosteronism

Renovascular Disease

Fibromuscular Dysplasia

Renal Artery Stenosis

Pheochromocytoma

Medications

**OCPs, NSAIDs, calcineurin inhibitors, epo, sympathomimetic agents

**Hypokalemic metabolic alkalosis with low renin

**High renin

White coat hypertension: diagnose with ambulatory bp monitoring

Evaluate in:1. Young patients with no RF2. Rapid onset of significant HTN3. Abrupt change in BP in a patient with well

controlled HTN

A 63-year-old man is evaluated during a follow-up appointment. One month ago, he had a transient ischemic attack. Carotid ultrasound revealed a 60% left internal carotid artery stenosis, and transthoracic echocardiogram revealed left ventricular hypertrophy. He is currently asymptomatic. He has hypertension and quit smoking 10 years ago. He has no history of coronary artery disease and no family history of premature coronary artery disease. Current medications are hydrochlorothiazide and aspirin. An LDL cholesterol level 6 months ago was 138 mg/dL (3.57 mmol/L), and he has been compliant with recommended lifestyle modifications, including diet and exercise. On physical examination, blood pressure is 132/84 mm Hg. There are no focal neurologic abnormalities. Fasting lipid levels are as follows: total cholesterol 206, HDL 50, LDL 132, triglycerides 144

In addition to continuing therapeutic lifestyle changes, which of the following is the most appropriate management option for this patient?

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1. Add atorvastatin2. Add nicotinic acid3. Change hydrochlorothiazide to amlodipine4. Change hydrochlorothiazide to carvedilol

Risk Category LDL goal Initiate TLC Consider Drug Therapy

HIGH Risk: CAD or CAD equivalents (DM or atherosclerotic disease)

<100 (optional goal <70)

> 100 > 130

Moderate risk: > 2 RF < 130 >130 >160

Lower risk: 0-1 RF <160 >160 > 190

LDL goals based on major risk factors: CHOLECigarette smokingHypertension (> 140/80 or taking anti-hypertensives)Older age (men > 45, women > 55)Low HDL (<40)Elder family history of premature coronary artery disease (male first degree relative <55, women <65)

HDL > 60 removes one RF

Screen: lipid panel after 12 hour fast in men > 35 yo or women > 45 yo

ATP III treatment priority:

LDL Non-HDL Cholesterol (hypertrigylceridemia)

No specific HDL goal, but raise HDL in those

with CAD

Hyperlipidemia

TreatmentAgent Effectiveness Notes Adverse Effects

Statins Lowers LDL, Raise HDL, Lowers trig

DOC for elevated LDL

Elevated LFTs, myalgias.

Bile Acid Binders- cholestyramine, colestipol)

Lowers LDL DOC for children and women with child-bearing potential and Liver disease

Avoid if trig > 300 or GI motility disorder.

Ezetimibe Lowers LDL and trig

AVOID with acute liver disease or elevated LFTs

Nicotinic Acid Lowers trig, raises HDL and lowers LDL

DOC to raise HDL Flushing, liver tox, nausea, gout, and elevated uric acid levels

Fibrates Lower trig, raise HDL

DOC for elevated trig

Caution in renal disease or gallbladder disease

If myalgia present and statin must be used, add coenzyme Q10 to help resolve symptoms.

A 51-year-old woman is evaluated during a routine physical examination. She has no history of hypertension and has never used tobacco. There is no family history of heart disease. Her only medication is daily oral conjugated estrogens combined with medroxyprogesterone acetate for intolerable hot flushes. Physical examination is normal. BMI is 31. Fasting lipid panel: total cholesterol 218, HDL 42, LDL 128; triglycerides 240

Which of the following is the most appropriate next step in the management of this patient?

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1. Calculate Framingham risk score2. Calculate non-HDL cholesterol level3. Prescribe atorvastatin4. Prescribe gemfibrozil

Triglycerides >500

Triglycerides > 200

Check Non-HDL

Cholesterol

Treat hypertriglyce

ridemia

Don’t treat

Don’t treat

Treat hypertriglyceridemia

No Yes

NoYes

Above goal Below goal

Hypertriglyceridemia Treatment

Non-HDL Cholesterol= Total Cholesterol- HDL

Non HDL Cholesterol is really just the LDL + VLDL. If LDL at goal, then VLDL or triglycerides are above goal.

Risk Category LDL goal Non-HDL Cholesterol Goal

HIGH Risk: CAD or CAD equivalents

<100 (optional goal <70)

> 130

Moderate risk: > 2 RF < 130 >160

Lower risk: 0-1 RF <160 > 190

A 30-year-old woman is evaluated during a routine appointment. She has no symptoms other than fatigue, which she attributes to long work hours. She denies daytime somnolence and a history of snoring. She is a lawyer and, owing to stress at work, she finds it difficult to eat healthy foods and get exercise. She gained 9.1 kg (20 lb) with the birth of her first child last year and has been unable to lose the weight. The patient had gestational diabetes. She states that her menstrual periods are normal. She is taking no medications. Vital signs are normal. She is 177.8 cm (70 in) tall. BMI is 32. Her thyroid examination is normal. She has normal hair distribution and normal skin color with no evidence of striae. In addition to a fasting plasma glucose, lipid panel, and thyroid-stimulating hormone assay, which of the following should be done next?

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1. 24 hour urine cortisol2. Pelvic ultrasound3. Serum insulin like growth factor concentration4. Waist circumference measurement

ObesityBMI Category

20-24.9

25-29.9 Overweight

30-34.9 Class I Obese

35-39.9 Class II Obese

>40 Class III Obese, Morbid Obesity

Treatment:• Screen for secondary causes:

• Medications: thiazolidinediones, oral hypoglycemics, insulin; TCA’s, SSRIs, lithium and antipsychotics, valproic acid and carbamazepine

• Endocrine disorders: hypothyroidism, cushings, growth hormone deficiency, PCOS, hypothalamic damage

• Diet and exercise; behavioral therapy• Pharmacologic:

• Orlistat• Sibutramine- avoid in poorly controlled hypertension

• Surgical: BMI > 40 or > 35 with comorbidities

Metabolic Syndrome

• Metabolic Syndrome identifies pt at high risk for developing diabetes and cardiovascular disease

• ANY person with metabolic syndrome is a candidate for aggressive therapeutic lifestyle changes

Risk Factor Defining Level

Abdominal Obesity >40 in in men, >35 in in women

Triglycerides > 150

HDL < 40 in men, < 50 in women

Blood Pressure > 130/85

Fasting glucose > 110

*Presence of 3= Metabolic Syndrome

A 56-year-old woman is evaluated for hot flushes that have been interfering with her sleep and causing discomfort while at work. She wants some relief from her symptoms, which have been persistent since she experienced menopause 3 years ago. She is a nonsmoker and has no history of thromboembolic disease and no personal or family history of cancer.Which of the following is the most appropriate treatment?

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1. Black Cohosh2. Bupropion3. Estrogen Replacement therapy4. Raloxifene

Menopause

• Dx: Clinical. – Only check FSH if occurring in younger patients or

unsure of diagnosis• Vasomotor symptoms:– Tx: low dose estrogen (add progesterone if still has

uterus); SSRI, clonidine, venlafaxine, gabapentin• Vaginal dryness – Tx: estrogen cream

Estrogen Estrogen + Progesterone

Breast Cancer

Endometrial Cancer

Ovarian Cancer

Colorectal Cancer

Fracture Risk

VTE, Heart Disease, Stroke

Hormone Replacement Therapy

**Estrogen alone causes endometrial hyperplasia and increase risk of endometrial cancer- must use combination estrogen progesterone in women with a uterus

HRT is NOT recommended for prevention of chronic disease after menopause.

AVOID HRT in smokers, CAD, history of breast cancer, high risk of thromboembolic disease, undiagnosed vaginal bleeding or who are well past menopause.

A 40-year-old woman presents with a history of heavy painless menstrual bleeding for the past 4 days. Her last period was 20 days ago, but before that, her periods had become more irregular over the previous 2 years, with lighter than usual bleeding. She has been sexually active with her husband, but had a tubal ligation after the birth of her fourth child 6 years ago.

On physical examination, the vital signs are normal. There is no evidence of hypovolemia or conjunctival pallor. The skin examination is negative for ecchymoses and petechiae. The bimanual pelvic examination reveals a nontender, normal-sized, and regular uterus. Speculum examination reveals a normal-appearing cervix with dark blood in the cervical os but no other abnormalities. A Pap smear is performed. A urine pregnancy test is negative.

Which of the following is the most appropriate next step in the management of this patient?

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1. Endometrial Biopsy2. Measurement of luteinizing hormone and follicle stimulating

hormone3. Oral Contraceptive4. Pelvic Ultrasound

Abnormal Uterine Bleeding• Physical exam with pelvic and pap

– If pelvic abnormal or difficult 2/2 body habitus pelvic US• Labs:

– Pregnancy test– Thyroid function test– Prolactin: galactorrhea or cycle length varies in length– Platelets/aPTT/bleeding time: excessive bleeding since menarche, FHx of bleeding

disorder or easy bruising• ENDOMETRIAL BIOPSY in women > 35 years old• Treatment in young women:

– High dose estrogens to reset the cycle then:• Cyclical progesterone• OCP• Levonorgesterel IUD• NSAIDs

A 24-year-old woman is evaluated for a 2-week history of vaginal itch and a discharge. She has tried douching and an over-the-counter vaginal cream without success. She and her partner have been together for 2 years, and they have been considering getting pregnant. Current medications are a vaginal benzocaine cream and an oral contraceptive. On speculum examination, she has a cloudy, thin discharge coating the vaginal walls with a fishy odor to the discharge when potassium hydroxide is applied. The cervix appears normal. A bimanual examination is normal. The vaginal discharge has a pH level of 5.0. Clue cells are seen on wet mount. Which of the following is the most appropriate management option for this patient?

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1. Clotrimazole for patient and partner2. Clotrimazole for patient only3. Lactobacillus intravaginal suppositories4. Metronidazole orally for patient and partner5. Metronidazole orally for patient only

Cause Diagnosis Treatment

Bacterial Vaginosis

imbalance of normal (Lactobacillus and Gardnerella) flora.

Fishy odor, smooth white discharge, ph >4.5 whiff test positive, clue cells

po metronidazole 500mg BID x1week & don’t treat partners

Vulvovaginal candidiasis

Common in dm or after abx

Cottage cheese discharge, ph <4.5, KOH with hyphae

fluconazole po 150mg x1; miconazole or clotrimazole cream

Trichomoniasis Trichomonas vaginalis

Strawberry cervix, mobile trichomads on wet mount

po metronidazole 2 g x1; consider treating partner

Vaginitis

Contraception• OCP:

– Increased risk of MI, but reduced estrogen has improved this– May increase risk of hypertension– Increased risk of stroke (small)– Increased risk of venous thromboembolic disease **especially for smokers– Reduced risk of ovarian and endometrial cancer (opposite of HRT)– Increased risk of cervical cancer– Conflicting data with breast cancer

• IUDs: increase risk of PID• Male and Female condoms: help with prevention of STDs (not HIV)• Sterilization: in women who become pregnant with tubal ligations, rate of ectopic

pregnancies is high• Emergency contraception:

– Oral levonorgestel- take 2 doses within 5 days of intercourse– Oral mifepristone- only approved for termination of pregnancy– Copper IUD- most effective; insert within 5 days of intercourse and can be kept in place

for up to 10 years

A 49-year-old woman is evaluated after noticing a small lump in her right breast 3 weeks ago. It is painless and has not changed in size. She has no other pertinent medical history and did not use oral contraceptives. She had menarche at age 12 years and is still menstruating. Her last menstrual period was 2 weeks ago. She has two children, the first at age 25 years and the second at age 30 years. Her mother had breast cancer at age 55 years; there is no other family history of cancer. On physical examination, vital signs are normal. There is a 1.0 cm × 1.5 cm firm, discrete, mobile mass in the upper outer quadrant of the right breast. There is no lymphadenopathy or other abnormalities on examination. A mammogram done 18 months ago was normal. A bilateral mammogram does not reveal any suspicious lesion in either breast.Which of the following is the most appropriate management option for this patient?

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1. Aspiration or biopsy2. Clinical reevaluation in 1 month3. MRI of both breast4. Repeat mammogram in 6 months

< 30 years old > 30 years old

Thickening or asymmetry

Unilateral mammo

Bilateral mammo

Skin Changes

Tx for mastitis if no change, Bilateral mammo with biopsy

Bilateral mammo with biopsy

Nipple Discharge

• Bilateral, milky: pregnancy test and endocrine eval

• Unilateral, serous/bloody: mammo and surgical biopsy

Lump or mass

Ultrasound or observe for 1-2 months

Bilateral mammo + ultrasound with surgical biopsy

Ultrasound:1. Cystic:

A. Asymptomatic: observeB. Symptomatic: aspirate +

bx2. Solid: mammogram with

tissue dx*3. Not seen: mammogram with

tissue dx**Tissue diagnosis: FNA, core bx or surgical excision

Evaluation of a Breast Mass

A 64-year-old man is evaluated for a 1-year history of slow urinary stream, urinary hesitancy, and postvoid dribbling. Previously, he got up once a night to urinate, but in the past 2 months, his nocturia has increased to three times per night. His American Urological Association prostate symptom score is 9 (score >7 indicates moderately severe symptoms).

On physical examination, temperature is normal, blood pressure is 146/80 mm Hg, and pulse rate is 74/min. Abdominal examination is normal without tenderness or masses or evidence of a distended bladder. Digital rectal examination reveals a slightly enlarged prostate without discrete nodules or tenderness. Routine laboratory studies and urinalysis are normal. Prostate-specific antigen level is 1.0 ng/mL (1.0 µg/L). A urine culture shows no growth.

In addition to decreasing total fluid intake and voiding just before bedtime, which of the following is the most appropriate treatment for this patient?

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1. Doxazosin2. Finasteride3. Saw Palmetto4. Transurethral microwave therapy

Treatment Options

Watchful Waiting

Medications

Alpha antagonists: tamsulosin, doxazosin, terazosin, alfuzosin

5 alpha reductase inhibitors : finasteride, dutasteride

TURP

Evaluation: 1. Rectal exam and abdominal exam 2. Check a UA and if pyuria or hematuria urine culture 3. PSA in those with > 10 year life expectancy or in those who it would change management (BPH raises it mildly)

*act within 48hrs

**urinary retention, UTI, bladder stones, hydronephrosis, no reponse to medications

BPH**Does not increase chance of prostate cancer.

A 19-year-old man is evaluated for increasing pain in the left testicular region for 2 days. It is tender when he palpates the scrotum or moves. He has had some mild dysuria but has not noted any urethral discharge. He is taking no medications, has not had any procedures or trauma to the region, and has no history of similar symptoms. He feels generally ill today with some mild nausea and a poor appetite but no vomiting.

On physical examination, temperature is 38.4 °C (101.2 °F) and other vital signs are normal. There is mild erythema overlying the left side of the scrotum. There is no edema of the scrotum. An area superior and posterior to the left testicle is moderately tender to palpation, with mild fullness and bogginess. The left testicle is nontender, similar in size to the right testicle, and sits lower in the scrotum than the right testicle. The cremasteric reflex is intact bilaterally. The penis and right testicle are normal.

Which of the following is the most likely diagnosis?

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1. Epididymitis2. Hernia 3. Orchitis 4. Testicular Torsion

A 65-year-old man with chronic stable angina is evaluated for a 1-year history of erectile dysfunction. His libido is intact and he would like to resume sexual activity. He experiences occasional exertional chest pain after quickly walking six to eight blocks or three flights of stairs, but has no chest pain at rest or with usual activities and no dyspnea. This symptom has been stable for the past few years, and he has not used any nitroglycerin for it. He has hypertension. He has no history of myocardial infarction or diabetes mellitus. He does not smoke or drink alcohol. Current medications are aspirin, metoprolol, atorvastatin, and enalapril.

Results of physical examination and laboratory studies are unremarkable. An electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy with no ischemic changes.

Which of the following is the most appropriate management option for this patient?

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1. Cardiac stress test2. Serum testosterone level3. Start a phosphodiesterase-5 inhibitor4. Start yohimbine5. Advise against treatment of erectile dysfunction

Men’s HealthErectile Dysfunction• Causes:

1. Organic causes: vascular disease, dm, thyroid disease, smoking, alcohol

2. Medications: SSRIs, Beta blockers, thiazides, clonidine, aldactone

3. Psychogenic causes: depression, usually younger patients

• Evaluation:– Obtain glucose, BUN/Cr, lipids, TSH and EKG

to identify systemic causes – Total or free testosterone and PSA

controversial- obtain if signs of hypogonadism– Nocturnal penile tumescence not routinely

recommended• Treatment:

1. Lifestyle modifications2. PDE-5 inhibitors (sildenafil)

• Contraindications: nitrates, hypotension, unstable angina, HOCM, AS, CHF

3. Intracavernous injection and transurethral alprostadil in pts who cannot use PDE5 or fail to respond to them

Andropause• Symptoms:

– Decreased sexual function– Decreased bone mineral

density– Decreased muscle mass– Decreased muscle strength– Decreased mentation

• Treat if testosterone <200 • Do NOT screen elderly men and

don’t treat asymptomatic men

A 51-year-old woman has a 2-year history of involuntary leakage of small amounts of urine. Episodes are more frequent after coughing or exercising. There is no urinary frequency, dysuria, or nocturia. The patient is gravida 3, para 3. All three pregnancies were uncomplicated and resulted in normal vaginal deliveries. She has not had a menstrual period for the past 3 years.

On physical examination, vital signs are normal. BMI is 32. Abdominal examination is unremarkable except for moderate obesity, and pelvic examination is normal except for some vaginal atrophy and mild uterine prolapse. Results of complete blood count, blood chemistry studies, and urinalysis are normal.

Which of the following is the best treatment at this time?

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1. Bladder training2. Oral estrogen therapy3. Oxybutynin4. Pelvic floor muscle exercises5. Retrograde suspension surgery

Type Symptoms Mechanism Treatment

Urge sense of urgency Uncontrolled bladder contractions Bladder trainingOxybutinin NO SURGERY

Stress inc intraabdominal pressure causes leakage of urine

Urethra can’t maintain pressure gradient; associated with multiple deliveries, pelvic surgery

Kegel exercisesDuloxetineSurgery- suspension or slings

Overflow Incomplete bladder emptying; leakage after void

Underactive bladder with trouble contracting Alpha blockers for men; intermittent caths

INCONTINENCE

D- drugsI- infectionA- atrophic vaginitisP- psychiatric/CNSE- endocrine/metabolicR- restricted mobilityS- stool impaction

**Urodynamic testing unnecessary in uncomplicated UI

**If you suspect overflow incontinence, obtain postvoid residual volume:

Normal 50-100Abnormal > 200-300

Assessment Screening/Prevention Normal Aging Notes

Hearing Whisper Test or Audioscope

Presbycusis- bilateral sensorineural high frequency loss

Weber and Rinne are NOT used

Vision Snellen Eye Chart Presbyopia- diminished ability of lens to accommodate

Falls Periodically ask about fall history

If fall reported: 1. Get up and Go test 2. Check 25-(OH)2-vitamin D if weak

Dementia MMSE or MiniCog Benign senescent forgetfulness- decline in memory, acquire and retain new info

No consensus about neuropsych testing and neuroimaging

Pressure Ulcer

Specialized foam mattress or overlays, specialized sheepskin overlays

Air filled boots, water gloves, regular sheepskin, and doughnut devices should NOT be used

Screening in the Elderly

Diagnosis Notes Treatment

Otitis Media PO Amoxicillin; Macrolides for PCN Allergic. Augmentin for failure

Otitis Externa TOPICAL antimicrobials

Sinusitis Tx if 2 of the following are present: 1. sx> 7days2. facial pain3. purulent nasal discharge

PO Amoxicillin

Allergic Rhinitis Skin prick test to confirm; Test for asthma

Intranasal Steroids (fluticasone, mometasone)

Pharyngitis Centor criteria: 1. Fever2. No cough3. Tender anterior cervical LAD4. Tonsillar exudates Rapid strep for +2, treat for 3+ or 4+

PO Penicillin V; Erythromycin for PCN allergic

ENT

Oral Lesions

• Candidiasis: white plaques on erythematous base which can be scrapped away– Denture candidiasis: erythema in denture areas with angular cheilitis.– Tx: topical nystatin or clotrimazole. Po fluconazole if unresponsive or pt with HIV

• Herpes Labialis: vesicles along vermilion border of lip. Vesicles rupture and crust within 48-72hrs– Tx: don’t use topical antivirals, use po antivirals – Prophylaxis: po antivirals

• Aphthous ulcer: painful, well-defined circular ulcerations on buccal and labial mucosa – Tx: chlorhexidine mouth rinse and topical corticosteroids in dental paste– Risk of recurrence reduced with smoking cessation

• Lichen planus: white, lace-like striae on buccal mucosa or hyperkeratosis or painful erosive changes. May be associated with increased risk of oral cancer.– Tx: topical steroids for symptomatic mouth lesions

• Leukoplakia and erythroplakia: white or red patches/plaques; common in smokeless tobacco users. Usually precancerous.