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Gen Med Board Review Part Deux Obesity, Hyperlipdemia, Hypertension, Women’s health, Men’s health, ENT Disorders and Geriatric Disorders.

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Presentation on theme: "Gen Med Board Review Part Deux Obesity, Hyperlipdemia, Hypertension, Women’s health, Men’s health, ENT Disorders and Geriatric Disorders."— Presentation transcript:

1 Gen Med Board Review Part Deux Obesity, Hyperlipdemia, Hypertension, Women’s health, Men’s health, ENT Disorders and Geriatric Disorders

2 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? 1.Lisinopril and hydrochlorothiazide 2.Metoprolol and hydrochlorothiazide 3.Terazisub 4.Lisinopril

3 CategoryBPTreatment Normal<120/80 Prehypertension120-139/80-89Lifestyle modifications Stage 1 HTN140-159/90-991.Lifestyle modifications: for 6-12 months 2.Medication Stage 2 HTN>160/>100Two Medications Goals: > 80 years old: sbp <150 DM and CKD: <130/80 Lifestyle modifications: 1.Weight loss 2.Decrease sodium intake 3.Exercise 30 min/day for 3 days/week 4.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

4 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

5 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? 1.Begin captopril and hydrochlorothiazide 2.Begin hydrochlorothiazide 3.Begin labetalol 4.Discontinue ibuprofen

6 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 RF 2.Rapid onset of significant HTN 3.Abrupt change in BP in a patient with well controlled HTN

7 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? 1.Add atorvastatin 2.Add nicotinic acid 3.Change hydrochlorothiazide to amlodipine 4.Change hydrochlorothiazide to carvedilol

8 Risk CategoryLDL goalInitiate TLCConsider 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: CHOLE Cigarette smoking Hypertension (> 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

9 Treatment AgentEffectivenessNotesAdverse Effects StatinsLowers LDL, Raise HDL, Lowers trig DOC for elevated LDL Elevated LFTs, myalgias. Bile Acid Binders- cholestyramine, colestipol) Lowers LDLDOC for children and women with child-bearing potential and Liver disease Avoid if trig > 300 or GI motility disorder. EzetimibeLowers LDL and trig AVOID with acute liver disease or elevated LFTs Nicotinic AcidLowers trig, raises HDL and lowers LDL DOC to raise HDLFlushing, liver tox, nausea, gout, and elevated uric acid levels FibratesLower 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.

10 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? 1.Calculate Framingham risk score 2.Calculate non-HDL cholesterol level 3.Prescribe atorvastatin 4.Prescribe gemfibrozil

11 Triglycerides >500 Triglycerides > 200 Check Non-HDL CholesterolTreat hypertriglyceridemiaDon’t treat Treat hypertriglyceridemia No Yes No Yes Above goalBelow 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 CategoryLDL goalNon-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

12 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? 1.24 hour urine cortisol 2.Pelvic ultrasound 3.Serum insulin like growth factor concentration 4.Waist circumference measurement

13 Obesity BMICategory 20-24.9 25-29.9Overweight 30-34.9Class I Obese 35-39.9Class II Obese >40Class 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

14 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 FactorDefining 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

15 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? 1.Black Cohosh 2.Bupropion 3.Estrogen Replacement therapy 4.Raloxifene

16 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

17 EstrogenEstrogen + 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.

18 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? 1.Endometrial Biopsy 2.Measurement of luteinizing hormone and follicle stimulating hormone 3.Oral Contraceptive 4.Pelvic Ultrasound

19 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

20 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? 1.Clotrimazole for patient and partner 2.Clotrimazole for patient only 3.Lactobacillus intravaginal suppositories 4.Metronidazole orally for patient and partner 5.Metronidazole orally for patient only

21 CauseDiagnosisTreatment 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 TrichomoniasisTrichomonas vaginalis Strawberry cervix, mobile trichomads on wet mount po metronidazole 2 g x1; consider treating partner Vaginitis

22 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

23 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? 1.Aspiration or biopsy 2.Clinical reevaluation in 1 month 3.MRI of both breast 4.Repeat mammogram in 6 months

24 < 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: observe B.Symptomatic: aspirate + bx 2.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

25 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? 1.Doxazosin 2.Finasteride 3.Saw Palmetto 4.Transurethral microwave therapy

26 Treatment OptionsWatchful WaitingMedications 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.

27 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? 1.Epididymitis 2.Hernia 3.Orchitis 4.Testicular Torsion

28 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? 1.Cardiac stress test 2.Serum testosterone level 3.Start a phosphodiesterase-5 inhibitor 4.Start yohimbine 5.Advise against treatment of erectile dysfunction

29 Men’s Health Erectile 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 modifications 2.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

30 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? 1.Bladder training 2.Oral estrogen therapy 3.Oxybutynin 4.Pelvic floor muscle exercises 5.Retrograde suspension surgery

31 TypeSymptomsMechanismTreatment Urgesense of urgencyUncontrolled bladder contractionsBladder training Oxybutinin NO SURGERY Stressinc intraabdominal pressure causes leakage of urine Urethra can’t maintain pressure gradient; associated with multiple deliveries, pelvic surgery Kegel exercises Duloxetine Surgery- suspension or slings OverflowIncomplete bladder emptying; leakage after void Underactive bladder with trouble contractingAlpha blockers for men; intermittent caths INCONTINENCE D- drugs I- infection A- atrophic vaginitis P- psychiatric/CNS E- endocrine/metabolic R- restricted mobility S- stool impaction **Urodynamic testing unnecessary in uncomplicated UI **If you suspect overflow incontinence, obtain postvoid residual volume: Normal 50-100 Abnormal > 200-300

32 AssessmentScreening/PreventionNormal AgingNotes HearingWhisper Test or Audioscope Presbycusis- bilateral sensorineural high frequency loss Weber and Rinne are NOT used VisionSnellen Eye ChartPresbyopia- diminished ability of lens to accommodate FallsPeriodically ask about fall history If fall reported: 1. Get up and Go test 2. Check 25-(OH) 2 -vitamin D if weak DementiaMMSE or MiniCogBenign 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

33 DiagnosisNotesTreatment Otitis MediaPO Amoxicillin; Macrolides for PCN Allergic. Augmentin for failure Otitis ExternaTOPICAL antimicrobials SinusitisTx if 2 of the following are present: 1. sx> 7days 2. facial pain 3. purulent nasal discharge PO Amoxicillin Allergic RhinitisSkin prick test to confirm; Test for asthma Intranasal Steroids (fluticasone, mometasone) PharyngitisCentor criteria: 1.Fever 2.No cough 3.Tender anterior cervical LAD 4.Tonsillar exudates Rapid strep for +2, treat for 3+ or 4+ PO Penicillin V; Erythromycin for PCN allergic ENT

34 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.

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