Internal Medicine Summer
Board Review
Mashkur Husain
General Medicine
Goals
 High Yield Topics Review from Board
Basics 3
 General Medicine 3 sessions
 Total of 21 topics
MKSAP Questions
Question 1
A 46-year-old woman is evaluated during a routine examination. Her 72-yearold mother was just diagnosed with lung cancer, so the patient asks you for
help with quitting smoking. She has a 27-pack-year smoking history. She made
one previous quit attempt several years ago using over-the-counter nicotine
gum, but she was unable to quit for more than a few days. Medical history is
significant for seizure disorder. Review of systems discloses mild shortness of
breath with exertion and occasional wheezing. Medications are a multivitamin
and phenytoin.
On physical examination, vital signs are normal. Lung examination reveals
occasional wheezing and a prolonged expiratory phase. The rest of the
examination is normal.
Answer Choice
In addition to counseling regarding tobacco
use, which of the following is an appropriate
adjunct to increase her likelihood of
successful smoking cessation?
A benzodiazepine
B Bupropion
C Electronic smokeless cigarette use
D Nicotine replacement therapy
Answer Choice
In addition to counseling regarding tobacco
use, which of the following is an appropriate
adjunct to increase her likelihood of
successful smoking cessation?
A benzodiazepine
B Bupropion
C Electronic smokeless cigarette use
D Nicotine replacement therapy
Explanation
Although
both counseling and pharmacotherapy are effective strategies for
smoking cessation, the combination of counseling with medication use is more
effective than either intervention alone. Nicotine replacement is effective for
smoking cessation; its availability in multiple formulations (gum, lozenge, patch,
aerosol) allows for alternative options in patients who have not benefited
from one type of therapy, as in this patient. Although centrally acting agents
(bupropion, varenicline) are also effective treatment options, bupropion would
be contraindicated in this patient with an underlying seizure disorder. The
choice of cessation method is less important than that an effective method is
used correctly by the patient; the array of treatment options allows for
individualization based on patient preference, previous experience, cost, and
potential side effects. Counseling may be brief or intensive; the two most
effective counseling components include practical problem-solving skills and
social support.

Many smokers indicate that stress reduction is a primary reason for their
tobacco use. Although selected individuals with true anxiety disorders may
benefit from anxiolytic therapy, the use of benzodiazepines as a smoking
cessation medication has not been documented.

Electronic smokeless cigarettes deliver a warmed aerosol through a
cigarette-like device that bears the appearance, physical sensation, and
possibly the taste of tobacco smoke, with the intention of helping smokers
maintain the activities associated with smoking but without the harmful
effects. However, their use in smoking cessation has not been established.
Key Point and Education Objective
Counsel a patient regarding methods for
smoking cessation.
 Smoking cessation is achieved more
effectively with a combination of
counseling and anti-smoking medication
use than with either intervention alone.

Therapy
Smoking cessation reduces all-cause mortality by up to 50%. The Five A's and the 5 R's are two
motivational interviewing techniques to use when counseling for behavior change.
Study Table:
Behavioral Interventions for Smoking Cessation
Five A’s
Five R's
Ask about tobacco use.
Encourage patient to think of Relevance of quitting smoking to
their lives.
Advise to quit.
Assist patient in identifying the Risks of smoking.
Assess willingness to quit.
cessation.
Assist the patient in identifying the Rewards of smoking
Assist in attempt to quit.
cessation.
Discuss with the patient Roadblocks or barriers to attempting
Arrange follow-up.
Repeat the motivational intervention at all visits.
Study Table:
Pharmacologic Therapies for Smoking Cessation
Agent
Notes
Nicotine gum, patch, spray, inhaler, lozenges
Bupropion
Varenicline
Increases smoking cessation 1.5 times more than control.
Avoid with recent MI, arrhythmia, and unstable angina.
Increases smoking cessation rates about 2 times more than
control. Avoid with seizure disorder and eating disorder.
May be associated with suicidal ideation. Safety in
pregnancy is unclear.
Increases smoking cessation rates about 3.5 times more
than control and almost 2 times more than bupropion.
Associated with suicidal ideation and increased risk of
cardiovascular events.
Don't Be Tricked
SSRIs show no significant benefit for smoking cessation.
Question 2
A 30-year-old man is evaluated during a routine examination.
He is asymptomatic. He is a nonsmoker and has no history of
illicit drug use. He has had two lifetime female sexual partners
and is sexually active in a monogamous relationship with a
woman for the past 5 years. His father is 58 years old and has
hypertension; his mother is 57 years old and has hyperlipidemia.
Results of the physical examination, including vital signs, are
normal. Results of a fasting lipid panel 4 years ago were normal.
Answer Choice
Which of the following is the most
appropriate screening test to obtain?
A Fasting lipid panel
B Fasting plasma glucose
C HIV enzyme immunoassay antibody
testing
D Thyroid-stimulating hormone level
Answer Choice
Which of the following is the most
appropriate screening test to obtain?
A Fasting lipid panel
B Fasting plasma glucose
C HIV enzyme immunoassay antibody
testing
D Thyroid-stimulating hormone level
Explanation
According to guidelines published by the Centers for Disease Control and Prevention (CDC), this man
should be screened for HIV infection using enzyme immunoassay antibody (EIA) testing. The guidelines
recommend that all persons between the ages of 13 and 64 years be screened for HIV infection. This
recommendation is based on evidence from several studies that have demonstrated that screening for HIV
is effective even in low-prevalence settings. This is particularly true when screening is coupled to the
availability of antiretroviral therapy. All positive results using EIA testing should be confirmed by Western
blot testing. Western blot testing should not be used as the initial screening test owing to its high rate of
false-positive and false-negative results. In contrast to the CDC guidelines, the U.S. Preventive Services Task
Force (USPSTF) assigns a C grade to HIV screening, making no recommendation for or against routine HIV
screening.
The National Cholesterol Education Program (NCEP) recommends that screening be initiated at the age of
20 years and then continued at least every 5 years thereafter if normal. This patient's lipid levels were
normal 4 years ago; therefore, it would not be appropriate to screen him according to the NCEP guideline.
The USPSTF recommends lipid screening for all men 35 years or older and for men 20 to 35 years of age
with increased cardiovascular risk. Because this patient is not at increased risk for atherosclerotic heart
disease, according to the USPSTF guidelines, screening for hyperlipidemia should begin at the age of 35
years.
The USPSTF recommends diabetes screening for all adults with a sustained blood pressure of 135/80 mm
Hg or greater. In contrast, the American Diabetes Association recommends screening all adults who are
45 years and older and all adults who have a BMI of 25 or greater who have one or more additional risk
factors (gestational diabetes, hypertension, hyperlipidemia, family history of type 2 diabetes mellitus in a
first-degree relative). Screening for diabetes would be inappropriate in this patient owing to his age,
absence of hypertension or obesity, and lack of other risk factors.
There is no agreement among major groups related to screening for hypothyroidism. The American
Academy of Family Physicians and the American Association of Clinical Endocrinologists recommend
screening for hypothyroidism in older women. The American Thyroid Association recommends
screening adults by measuring thyroid-stimulating hormone (TSH) beginning at age 35 years, but the
USPSTF does not recommend routine screening. This patient is not in a high-risk group defined by
either age or sex, and screening for thyroid disease with a TSH level is not appropriate.
Key Point and Education Objective
Screen for HIV infection
 The Centers for Disease Control and
Prevention recommend that all persons
between the ages of 13 and 64 years be
screened for HIV infection.

Study Table:Routine Adult Immunizations
Vaccine
Recommendation
Hepatitis A
Occupational (travelers to endemic areas or food handlers)
Chronic liver disease
Men who have sex with men
Users of illicit drugs
Safety of vaccine during pregnancy uncertain
Hepatitis B
Same populations as hepatitis A
All children up to 18 years
End-stage kidney disease
Safe in pregnancy
HPV
Male and female patients aged 9-26 years regardless of sexual activity,
presence of genital warts, or previous positive HPV infection
Not indicated in pregnant women
Influenza
All adults wishing to reduce their likelihood of influenza infection
(including pregnant women)
Inactivated vaccine appropriate for all except persons allergic to eggs or
to those with a history of Guillain-Barré syndrome
Intranasal live vaccine limited to nonpregnant patients aged <50 years
Intranasal live vaccine is contraindicated if patient has close contact with
immunosuppressed persons (home, work) as well as patients
with chronic metabolic diseases, diabetes mellitus, kidney dysfunction,
hemoglobinopathies, or immunosuppression
Study Table:Routine Adult Immunizations
MMR (mumps, measles, rubella)
Adults born after 1956 without proof of immunity
Contraindicated during pregnancy
Pneumococcal
All adults aged ≥65 years
Residents of long-term care facilities
Adults with risk factors (asthma, cardiovascular disease, COPD, diabetes
mellitus, chronic liver disease, chronic kidney disease, nephrotic syndrome,
functional/anatomic asplenia, immunosuppressive conditions,
chemotherapy)
Patients who smoke cigarettes
One-time revaccination for patients aged >65 years if vaccinated more
than 5 years ago and were age <65 years at the time of primary
vaccination as well as for adults with risk factors
Safety of vaccine during pregnancy unknown
Tdap
All adults who have not completed primary series
Single dose of Tdap for patients aged 19-64 years regardless of scheduled
Td booster (may administer in place of Td booster if patient is due)
Any wound if primary series not completed or status unknown
Dirty wound if primary series completed >5 years previously
Booster every 10 years
Meningococcal
Travelers, college dormitory residents, Safety during pregnancy unknown
Varicella
Persons aged >13 years without previous chickenpox infection
Contraindicated in immunocompromised patients
Contraindicated during pregnancy
Zoster vaccine
Persons aged >60 years regardless of previous episode of zoster (do not measure
antibodies)
Contraindicated in immunocompromised patients
Contraindicated during pregnancy
Travel Immunizations

Routine vaccines are recommended for a patient whose vaccines are not up to date, including influenza,
pneumococcal, varicella (chickenpox), MMR, and Tdap booster. Select the following vaccinations when
appropriate:

polio, hepatitis A and/or immune globulin, and typhoid for travelers to all developing countries

yellow fever for travelers to Africa and South America

meningococcal for travelers to sub-Saharan Africa

rabies for extended-stay travelers or those who will have difficulty accessing postexposure treatment in endemic
areas, including Asia, Africa, and South and Central America
Don't Be Tricked

For pregnant women, do not select live vaccines, including MMR,
intranasal influenza, yellow fever, varicella, and zoster vaccines.
Study Table:USPSTF-Recommended
Screening

Recommendations for General Population

Height and weight (periodically)

Blood pressure (every 2 years)

Problem drinking

Depression

Diabetes mellitus (if blood pressure >135/80 mm Hg)

Total and HDL cholesterol (every 5 years for men aged ≥35 years, women aged ≥45 years who are at increased
cardiovascular risk, others with cardiovascular risk factors)

Colorectal cancer screening (average-risk men and women aged ≥50 years)

Mammogram ± clinical breast examination (every 1-2 years for women aged ≥50 years)

Pap test (at least every 3 years starting at age 21 until age 65 years). The USPSTF suggests combination Pap
smear and HPV testing every 5 years for women aged 30 years or older who wish to increase the interval of
screening.

Chlamydia (sexually active women aged ≤24 years and older at-risk women)

Bone mineral density test (women aged ≥65 years and women aged <65 years whose fracture risk is equal to or
greater than that of a 65-year-old white woman who has no additional risk factors for fracture using the WHO
FRAX algorithm)

AAA screening (one-time screening for men aged 65-75 years who ever smoked)
Question 3
A
42-year-old-man is evaluated for obesity. His weight has gradually
increased over the past two decades and is currently 168.2 kg (370 lb). Five
years ago, he was diagnosed with type 2 diabetes mellitus, hypertension, and
hyperlipidemia. Over the past 6 months, he has unsuccessfully tried diet and
exercise therapy for his obesity. He tried over-the-counter orlistat but could
not tolerate the gastrointestinal side effects. Medications are metformin,
lisinopril, and simvastatin. His total weight loss goal is 45.4 kg (100 lb).
On
physical examination, temperature is normal, blood pressure is 130/80
mm Hg, pulse rate is 80/min, and respiration rate is 14/min. BMI is 48. Waist
circumference is 121.9 cm (48 in). There is no thyromegaly. Heart sounds are
normal with no murmur. There is no lower extremity edema.
Results
of complete blood count, thyroid studies, and urinalysis are
unremarkable.
Answer Choice
Which of the following is the most
appropriate management of this patient?
A Bariatric surgery evaluation
B Prescribe phentermine
C Reduce caloric intake to below 800
kcal/d
D Refer to an exercise program
Answer Choice
Which of the following is the most
appropriate management of this patient?
A Bariatric surgery evaluation
B Prescribe phentermine
C Reduce caloric intake to below 800
kcal/d
D Refer to an exercise program
Explanation
This
patient should be referred for bariatric surgery. For patients with class III obesity (BMI ≥40) or
class II obesity (BMI 35.0-39.9) with obesity-related complications, the National Institutes of Health
Consensus Development Conference recommends consideration of bariatric surgery if diet,
exercise, and/or medication are ineffective. Patients should be motivated and well informed about
this option and undergo multidisciplinary evaluation by a medical, surgical, psychiatric, and
nutritionist team. The most common procedure is gastric bypass surgery, but laparoscopic banding is
becoming common, as well. Bariatric surgery results in more dramatic and sustained weight loss
than nonsurgical interventions and leads to improvement in obesity-related complications (diabetes
mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia). This patient has not attained his
goal weight loss after a 6-month trial of diet and medication and has obesity-related complications
that likely will improve with weight loss.
Phentermine
is a sympathomimetic drug that is FDA-approved for short-term use (up to 12 weeks)
as an adjunctive treatment of obesity. This patient's weight loss goal is 45.4 kg (100 lb), which will
take much longer than 12 weeks. In addition, most persons regain any weight that is lost with this
medication upon its discontinuation.
Restricting
caloric intake to below 800 kcal/d (a very-low-calorie diet) is no more effective for
long-term weight loss than a moderate strategy of restricting intake to 500-1000 kcal/d below what
is estimated to maintain current body weight. In addition, long-term compliance with a very-lowcalorie diet is nearly impossible.
Exercise
is an important part of a comprehensive weight loss program that focuses on lifestyle
modification. However, the patient has already not benefited from an exercise program. It is unlikely
that exercise alone will meet his weight loss goals.
Key Point and Education Objective
Manage obesity with bariatric surgery.
 Bariatric surgery should be considered
for patients with BMI of 40 or greater or
BMI of 35.0 to 39.9 with obesity-related
complications in whom diet, exercise,
and/or medication are ineffective.

Obesity
Diagnosis
Study Table:Obesity Definitions
Diagnosis
BMI
Overweight
25-29.9
Obese
Class I
30-34.9
Class II
35-39.9
Class III
≥40
Screen patients diagnosed with obesity for evidence of secondary diseases. In the occasional patient in whom a
secondary cause of obesity is found, the most common causes are hypothyroidism, Cushing syndrome, and polycystic
ovary syndrome.
Obesity
Therapy
Discontinue nonessential medications associated with weight gain. Behavioral therapies, including dietary and
exercise interventions, are effective approaches. Both low-carbohydrate and low-fat diets work in the short term.
Exercise is helpful as an adjunct to diet change but not as monotherapy. Drug treatment is offered if a 5% threshold
in weight loss has not been reached by the end of 3 months of therapy. Orlistat inhibits pancreatic lipases and alters
fat digestion. Major side effects include cramping, flatus, oily stool, and fecal incontinence. Treatment is associated with
an average weight reduction of 2.9 kg; reduced incidence of diabetes; and better blood pressure, lipid levels, and
glycemic control. Locaserin is a selective serotonin receptor agonist that induces the feeling of early satiety. Its use is
associated with an average weight loss of 5.8 kg and improvement in glycemic control. The combination medication
phentermine, a stimulant/appetite suppressant, and topiramate, an anticonvulsant with a weight-loss effect, has been
approved for pharmacological treatment of obesity. Locaserin and phentermine-topiramate are indicated for use in
adult patients with a BMI ≥30 or ≥27 with ≥1 obesity-related comorbidity.
Bariatric surgery is considered for patients with a BMI >40 and also for BMI >35 with serious obesity-related
comorbidities (severe sleep apnea, diabetes, severe joint disease). Bariatric surgery is associated with a 29% reduction
in mortality.
Study Table: Bariatric Surgery
Complications
Surgery
Complications
Banding procedures
Intractable nausea and vomiting
Marginal ulcers, stomal obstruction
Severe GERD
Pulmonary embolism
Gastric bypass
Stomal stenosis
Cholelithiasis
Deficiencies of vitamin B12, iron, calcium, folic acid, 25-hydroxyvitamin D,
magnesium, copper, zinc, vitamin A, other B-complex vitamins, and vitamin
C
Pulmonary embolism
Question 4
A
28-year-old woman is evaluated for a 3-month history of fatigue and muscle cramps. She states
that she is eating well, drinking plenty of fluids, and exercising regularly, but the fatigue is starting to
interfere with her ability to complete her daily 3-mile run. She has a previous history of anorexia
nervosa diagnosed at age 16 years requiring two inpatient hospitalizations. She has had a normal
weight and menstrual cycle for the last 4 years. She currently takes daily calcium and vitamin D
supplements.
On
physical examination, temperature is 36.6 °C (98.0 °F), blood pressure is 106/64 mm Hg,
pulse rate is 66/min, and respiration rate is 12/min. BMI is 22. She has poor dentition with multiple
dental caries. The remainder of the examination is normal. Pregnancy test is negative.
Laboratory
studies:
Complete blood count Normal
Electrolytes
Sodium
132 meq/L (132 mmol/L)
Potassium
3.2 meq/L (3.2 mmol/L)
Chloride
95 meq/L (95 mmol/L)
Bicarbonate
31 meq/L (31 mmol/L)
Blood urea nitrogen
6 mg/dL (2.1 mmol/L)
Creatinine
0.8 mg/dL (70.7 µmol/L)
Thyroid-stimulating hormone
2.5 µU/mL (2.5 mU/L)
Answer Choice
Which of the following is the most likely
diagnosis?
A
Anorexia nervosa, binge-eating/purging
subtype
B
Binge-eating disorder
C
Bulimia nervosa, purging subtype
D
Night-eating syndrome
Answer Choice
Which of the following is the most likely
diagnosis?
A
Anorexia nervosa, binge-eating/purging
subtype
B
Binge-eating disorder
C
Bulimia nervosa, purging subtype
D
Night-eating syndrome
Explanation

This patient most likely has bulimia nervosa, which is an eating disorder characterized by recurrent episodes of binge eating with
subsequent compensatory behavior aimed at preventing weight gain. The compensatory behaviors may include self-induced vomiting
and misuse of medications, such as laxatives (purging subtype), or fasting and excessive exercise. The purging subtype of bulimia
nervosa may be suspected by metabolic abnormalities, including hypokalemia, hypomagnesemia, and metabolic alkalosis, as seen in this
patient. Diagnostic behavior includes engaging in bingeing and compensatory behaviors at least twice a week for 3 months, and having
one's self-perception be excessively influenced by body weight and shape. Most patients with bulimia nervosa have a normal weight;
the presence of dental caries, enlarged salivary glands, and scarring on the dorsum of the hand are highly suggestive of purging
behaviors.

Anorexia nervosa is characterized by an abnormally low body weight (<85% of expected) in association with an intense fear of gaining
weight, an overemphasis of body weight on self-evaluation, and amenorrhea for three consecutive menstrual cycles. The restricting
subtype of anorexia nervosa is associated with regular caloric restriction; the binge-eating/purging subtype is characterized by bingeeating, which may or may not be associated with self-induced vomiting or the misuse of medications. This patient's normal body
weight and regular menses are more suggestive of bulimia nervosa rather than anorexia nervosa. Notably, 30% of patients with the
restricting subtype of anorexia nervosa go on to develop bulimia nervosa, as seen with this patient.

Binge-eating disorder is more common than either anorexia nervosa or bulimia nervosa, affecting 2% to 3% of the general population.
It is differentiated from bulimia nervosa in that there is no associated compensatory behavior after the binge.

Night-eating syndrome is characterized by excessive eating at night, difficulty sleeping, and morning anorexia. It is a prevalent disorder
in obese patients and those seeking bariatric surgery.
Key Point and Education Objective
Diagnose bulimia nervosa.
 Bulimia nervosa is an eating disorder
characterized by recurrent episodes of
binge eating with subsequent
compensatory behavior aimed at
preventing weight gain.

Eating Disorder Diagnosis
Anorexia nervosa consists of two types:
restricting, in
binge
which patients restrict intake (anorexia nervosa)
eating/purging, in which patients binge and purge to control weight (bulimia nervosa)
Diagnostic criteria for the restricting type of anorexia consist of refusal to maintain weight within 15% of normal
level, fear of weight gain, distorted body image, and amenorrhea or lack of onset of menstruation. The medical
complications include anemia, osteopenia, hypotension, and arrhythmias. During the first few weeks of eating, patients
are at risk for the refeeding syndrome, which can include cardiac arrest and delirium caused by exacerbation of
hypophosphatemia and hypokalemia.
Diagnostic criteria for bulimia nervosa are episodes of binging with loss of control occurring minimally 2 times per
week for 3 months, followed by purging (vomiting, diuretic or laxative abuse), fasting, or excessive exercise. Patients
usually have normal weight. The medical complications can involve acid-induced dental disease, esophageal tears, and
electrolyte derangements (low chloride and potassium). Laboratory clues include metabolic alkalosis.
Therapy
For anorexia nervosa, daily supplementation with calcium and vitamin D is used to treat osteopenia. Cognitive
behavioral therapy is considered first-line treatment. Psychotropic drugs have minimal efficacy in underweight
patients with anorexia.
Patients with bulimia respond to cognitive behavioral therapy, and antidepressants (fluoxetine or imipramine) and
nutritional rehabilitation are effective adjunctive therapy.
Don't Be Tricked
Do not choose bupropion for eating disorders because of the increased incidence of
tonic-clonic seizures.
Question 5
An 85-year-old man is admitted to a nursing home. He has
diabetes mellitus, coronary artery disease, chronic heart
failure, and dementia. On physical examination, vital signs
are normal. He has a full thickness 5 × 8 cm pressure
ulcer on his left buttock covered with a thick eschar. There
is visible subcutaneous fat beneath the eschar; no bone or
tendon is exposed. His skin is dry and there is evidence of
mild dehydration and malnutrition. He has urinary but not
fecal incontinence. His current medications are lisinopril,
metformin, hydrochlorothiazide, glipizide, and carvedilol.
Answer Choice
Which of the following is the most appropriate
management of this patient's ulcer?
A
Debridement
B
Hyperbaric oxygen therapy
C
Negative-pressure wound vacuum therapy
D
Oral vitamin C and zinc supplementation
E
Surgical flap therapy
Answer Choice
Which of the following is the most appropriate
management of this patient's ulcer?
A
Debridement
B
Hyperbaric oxygen therapy
C
Negative-pressure wound vacuum therapy
D
Oral vitamin C and zinc supplementation
E
Surgical flap therapy
Explanation

This patient has a stage III or IV pressure ulcer, and debridement is the most appropriate management. Both stage III and stage IV
pressure ulcers include full-thickness tissue loss. In stage III ulcers, subcutaneous fat may be visible but bone, tendon, and muscle are
not exposed, whereas in stage IV ulcers, bone, tendon, or muscle is exposed and undermining and tunneling are often present. The
eschar covering this patient's wound precludes the definitive differentiation of a stage III from a stage IV ulcer.

Treatment of pressure ulcers is best managed with an interdisciplinary team approach, with a care plan directed toward addressing
the factors that predisposed to the development of the ulcer. Dressings should be chosen to maintain a moist wound environment
and manage exudates. When present, infection should be controlled with topical therapies and the addition of systemic antibiotics
when cellulitis is present. The possibility of underlying osteomyelitis should be considered. Surgical or nonsurgical debridement of
eschar and nonviable tissue may be needed. Wet-to-dry dressings may aid in debridement but caution must be used to avoid removing
excessive viable tissue with dressing changes.

Cochrane reviews do not support a role for electromagnetic therapy, ultrasound therapy, or hyperbaric oxygen therapy in pressure
ulcer treatment.

Negative-pressure wound vacuum healing has been used for stage IV ulcers. However, three clinical trials have not shown superiority
to standard therapy. Wound vacuum therapy may be more convenient due to less frequent dressing changes but is also very costly. It
is not the recommended first line therapy.

Although frequently utilized, vitamin C and zinc oral supplements have not been shown to aid in ulcer healing.

Referral for surgical flap and repair may be necessary for refractory pressure ulcers but is usually reserved for patients in whom
conservative treatment has failed.
Key Point and Education Objective

Stage III pressure ulcers, defined by fullthickness tissue loss but without
exposure of bone, tendon, or muscle,
generally require debridement, proper
dressing selection, and treatment of
infection, if present.
Pressure Ulcers
Diagnosis
Pressure ulcers are ischemic soft tissue injuries resulting from pressure, usually over bony prominences. The external
appearance of a pressure ulcer may underestimate the extent of injury.
Therapy
Study Table: Pressure Ulcer Staging and Therapy
Ulcer Stage
Therapy
Stage 1: The skin is intact with nonblanchable redness
For all ulcer stages: positioning and support to minimize
tissue pressure
Stage 2: Shallow ulcer with a red-pink wound bed or serum-filled blister Occlusive or semipermeable dressing that
will maintain a moist wound environment
Stage 3: Subcutaneous fat may be visible
Pain control, correction of nutritional deficiencies
(supplements, tube feeding, or hyperalimentation if
necessary), debridement, topical or systemic antibiotics
Stage 4: Exposed bone, tendon, or muscle
Same as Stage 3
Dressings should maintain a moist wound environment and manage exudates. Use systemic antibiotics when cellulitis
is present; consider the possibility of underlying osteomyelitis. Debridement of eschars and nonviable tissue may be
needed. Air-fluidized beds improve healing compared with other pressure-relief devices.
Don't Be Tricked
Hyperbaric oxygen therapy is not effective in the treatment of pressure ulcers.
Question 6
A 72-year-old woman is evaluated in the emergency department after an episode of syncope. While
watching a movie, the patient felt palpitations; the next thing she remembers is being on the floor. She
experienced a similar episode about 1 month ago. History is significant for hypertension, hypothyroidism,
osteoporosis, and chronic kidney disease. Medications are amlodipine, lisinopril, levothyroxine, and calcium
supplements. She currently feels well.
On physical examination, temperature is normal, blood pressure is 148/78 mm Hg, pulse rate is 84/min and
regular, and respiration rate is 12/min. Oxygen saturation on ambient air is normal. There is no thyromegaly,
carotid upstrokes are +2 without bruits, and there is no jugular venous distention. Cardiac auscultation
reveals a grade 2/6, early peaking, crescendo-decrescendo systolic murmur at the right upper sternal border
with occasional extra beats. The remainder of the physical examination is normal.
A resting electrocardiogram and rhythm strip show a sinus rate of 85/min with occasional premature
ventricular contractions but no sustained arrhythmia, normal axis and intervals, and no ischemic changes.
Answer Choice
Which of the following is the most likely
cause of this patient's syncope?
A Aortic stenosis
B Cardiac arrhythmia
C Myocardial ischemia
D Transient ischemic attack
Answer Choice
Which of the following is the most likely
cause of this patient's syncope?
A Aortic stenosis
B Cardiac arrhythmia
C Myocardial ischemia
D Transient ischemic attack
Explanation

In this elderly woman, given the short prodrome, palpitations, and history of a
previous event, a cardiac arrhythmia is the most likely cause of syncope. Arrhythmias
are the most common causes of syncope in the elderly population. Patients with an
arrhythmogenic cause of syncope usually have had only one or two episodes. A
prodrome is usually brief or absent. The patient often experiences palpitations
immediately preceding the episode.

Aortic stenosis may cause syncope; however, despite a low-grade systolic murmur,
this patient's carotid upstrokes are normal and her episode occurred at rest and
not with exertion, making aortic stenosis unlikely.

Myocardial ischemia is a rare cause of syncope, especially in the absence of typical
ischemic symptoms. Myocardial ischemia is a consideration in patients with an
arrhythmia leading to presyncope or syncope as ischemic myocardium may be
arrhythmogenic. However, myocardial ischemia as a cause of hypoperfusion in a
patient without symptoms at rest would likely not account for her clinical
presentation.

This patient has several risk factors for a possible transient ischemic attack (TIA).
However, TIAs typically present with focal neurologic symptoms and findings, and
are rarely a cause of syncope.
Key Point and Education Objective
Diagnose the cause of a syncopal episode.
 Arrhythmia is a common cause of
syncope in the elderly; arrhythmogenic
syncope is characterized by a brief or
absent prodrome and palpitations
immediately preceding the event.

Syncope
Diagnosis
An uncomplicated faint (vasovagal or neurocardiogenic syncope) is common and can be diagnosed by the history and
absence of any suggestion of heart disease from the physical examination and ECG. Look for the 3 P's:
posture (prolonged standing)
provoking factors (blood draw, pain, emotion)
prodromal symptoms (sweating, nausea, feeling warm)
Patients with uncomplicated faint can be discharged home without additional evaluation.
A history of heart disease, significant cardiac risk factors, or exertional syncope suggests structural cardiac disease or
arrhythmias as the cause of syncope. Causes of exertional syncope include AS, HCM, mitral stenosis, and pulmonary
hypertension (especially due to acute PE). Patients with suspected cardiac causes of syncope should be admitted to
the hospital. Syncope caused by arrhythmias occurs without presyncopal symptoms and irrespective of patient
position.
Study Table:Causes of Syncope
If you see this…
Diagnose this…
A prodrome of nausea, diaphoresis, and pallor
Uncomplicated faint (vasovagal or neurocardiogenic syncope)
Preceding pressure on the carotid sinus
(tight collar, sudden turning of head)
Carotid sinus hypersensitivity
Association with specific activities
(urination, cough, swallowing, defecation)
Situational syncope (neurocardiogenic)
Upon assuming an upright position
Orthostatic hypotension caused by hypovolemia, pharmacologic
agents, or autonomic nervous system disorders (e.g., parkinsonism,
diabetes)
Brainstem neurologic signs and symptoms
Posterior circulation vascular disease; consider subclavian steal
syndrome if preceded by upper extremity exercise
Witnessed “seizure”
Syncope can cause tonic-clonic jerking of extremities; primary
seizure is unlikely if findings of diaphoresis or nausea before the
event, a brief episode of unconsciousness, and immediate
postsyncopal orientation are present
Related to exercise or associated with angina
Obstruction to left ventricular outflow: AS, HCM, PE, and
pulmonary hypertension
Syncope with sudden loss of consciousness without
prodrome
Arrhythmia, sinoatrial and AV node dysfunction (ischemic heart
disease and associated with use of β-blockers, calcium channel
blockers, and antiarrhythmic drugs)
Syncope following a meal
Postprandial syncope, often in older adult patient
Consider the appropriate indications for the following diagnostic tests:
ECG: Done in all cases. The finding of an arrhythmia and conduction block may establish the diagnosis, but a normal
ECG does not rule out a cardiac etiology.
Echocardiography: Obtain if structural heart disease is suspected.
Ambulatory ECG recording: Indicated if cardiac arrhythmia is suspected or the cause is unclear. The choice of the
recording device is determined by the frequency of the patient's symptoms (See Cardiovascular Medicine,
Arrhythmia Recording).
Stress testing: Indicated for patients with exercise-associated syncope or those with significant risks for ischemic
heart disease.
Carotid sinus massage: For suspected carotid sinus syncope or for unexplained syncope in those aged >60 years.
Tilt-table testing: Reserved for presumed neurocardiogenic syncope only if it is recurrent or represents high risk for
injury and to assess whether it is associated with asystole.
Electrophysiologic testing: Rarely helpful and almost always the incorrect answer.
Don't Be Tricked
Do not order carotid vascular studies to diagnose cause of syncope.
Do not order brain imaging, cardiac enzymes, or EEG to evaluate syncope.
Therapy
Treatment of structural cardiac disease and arrhythmias is covered in the Cardiovascular Medicine section. For
hypovolemia or orthostatic syncope, eliminate α- and β-blockers and anticholinergic agents, if possible. Increase fluid
and sodium intake and consider compression stockings. As a last resort, add mineralocorticoids and α-adrenergic
receptor agonists. For recurrent neurocardiogenic syncope, choose β-blockers.
Question 7
A 78-year-old-woman is evaluated in the emergency department after she fell
at home last night. She has long-standing sleeping difficulties and last night got
out of bed and fell in her hallway. She had no loss of consciousness and notes
left hip pain. She has hypertension, hyperlipidemia, and gastroesophageal reflux
disease. Her current medications are lisinopril, simvastatin, and omeprazole.
On physical examination, she is afebrile. Blood pressure is 142/82 mm Hg
supine and 138/76 mm Hg standing, and pulse rate is 76/min supine and
78/min standing. She appears frail with generalized weakness. There is mild
tenderness in the left lateral hip and weakness of the quadriceps muscles
bilaterally. There are no ecchymoses in the left hip area. She is slow getting up
from a chair and has a slow walking speed but no ataxia. Distance vision using
glasses without bifocal lenses evaluated with a Snellen chart is normal. There
is mild difficulty with near vision evaluated using a near-vision testing card.
Lungs are clear. The heart rhythm is regular with no murmur. There is no focal
neurologic deficit. Radiograph of the left hip and femur reveals no fracture.
Acetaminophen is prescribed for pain. Arrangements are made for home
physical therapy and for a visiting nurse to perform a home safety evaluation.
Answer Choice
Which of the following is the most
appropriate additional management of this
patient?
A Discontinue lisinopril
B Prescribe vitamin D
C Prescribe zolpidem at bedtime
D Refer for prescription glasses with
bifocal lenses
Answer Choice
Which of the following is the most
appropriate additional management of this
patient?
A Discontinue lisinopril
B Prescribe vitamin D
C Prescribe zolpidem at bedtime
D Refer for prescription glasses with
bifocal lenses
Explanation

In this patient with generalized weakness as well as leg muscle weakness, slow gait, and a recent
fall, it is appropriate to prescribe vitamin D.Vitamin D deficiency increases the risk for falls in the
elderly and vitamin D supplementation reduces this risk. According to U.S. Preventive Services
Task Force recommendations, vitamin D supplementation can be prescribed without first
obtaining a serum vitamin D level for patients with an increased risk of falling. The proposed
mechanism of action of vitamin D is its beneficial effect on muscle strength and function and on
gait. Although calcium supplementation may have a beneficial effect on bone loss, there is no
clear benefit to adding calcium in reducing falls.

Discontinuing lisinopril is not appropriate because she does not demonstrate orthostatic blood
pressure changes that would account for her fall, and discontinuing antihypertensive medication
would likely result in elevated blood pressure.

Zolpidem is a nonbenzodiazepine sedative hypnotic with a short half-life that can be prescribed
for a limited time period for insomnia. Caution must be exercised, however, because of adverse
effects, including an increased risk for falls, especially among older adults. Reviewing sleep
hygiene would be a better first step in managing her insomnia.

Although this patient demonstrates a mild near-vision deficit, it is not likely that this deficit
contributed significantly to her fall. Furthermore, bifocal lenses are associated with an increased
risk for falling. If needed, reading glasses could be obtained.
Key Point and Education Objective
Manage a fall in an elderly patient.
 Vitamin D supplementation reduces the
risk for falls in elderly patients, and can be
prescribed without obtaining a serum
vitamin D level in patients with an
increased risk of falling.

Falls
Prevention
The number of falls increases with the number of risk factors. Risk factor reduction has been shown to reduce falls.
Medications are the most readily modifiable risk factor. Psychotropic agents lead the list of implicated drugs.
Diagnosis
Look for risk factors, including loose rugs, poor lighting, lack of hand rails, four or more medications, visual acuity
<20/60, cataracts, and SBP <110 mm Hg. Remember to perform the “Timed Up and Go” test. Ask the patient to rise
from a chair without using his or her arms, walk 10 feet, turn around, and return to the chair. Completion of the test
in >10 seconds indicates increased risk for falls, with >14 seconds associated with high risk; aggressive fall prevention
interventions should be implemented in these patients.
Therapy
Discontinue contributing medications. Multidisciplinary treatment programs that include assessment for risk factors
(medications, sensory deficits), physical therapy, and risk factor modification are the most effective nonpharmacologic
interventions for older patients. Vitamin D supplementation reduces the frequency of falls in older patients who are
vitamin D deficient.
Don't Be Tricked
Hip protectors in older people who fall are ineffective in preventing hip
fractures.
Question 8

A 55-year-old man is evaluated during a follow-up appointment for a 6month history of nonproductive cough. The cough predictably comes after
meals, at bedtime, or any time he lies down, but it can occur at other times
as well. He experiences heartburn throughout the day. He has no
shortness of breath, dyspnea on exertion, fever, chills, postnasal drip, recent
upper respiratory tract infection, or wheezing. Omeprazole was prescribed
2 weeks ago but he reports no change in his cough or heartburn
symptoms. He is a nonsmoker, does not drink alcohol, and takes no other
medications.

Vital signs are normal, as is the remainder of the physical examination.
Chest radiograph is normal.
Answer Choice
Which of the following is the most
appropriate treatment?
A Amoxicillin-clavulanate
B Continue omeprazole
C Inhaled albuterol
D Loratadine with pseudoephedrine
Answer Choice
Which of the following is the most
appropriate treatment?
A Amoxicillin-clavulanate
B Continue omeprazole
C Inhaled albuterol
D Loratadine with pseudoephedrine
Explanation

Omeprazole should be continued in this patient. He presents with chronic cough (>8 weeks) most likely due to
gastroesophageal reflux disease (GERD). Although typical heartburn symptoms are absent in more than onethird of patients with GERD-related cough, this patient's clinical profile and symptoms of heartburn and cough
exacerbated by the recumbent position are classic for GERD. The treatment of chronic cough due to GERD is
challenging. If lifestyle modification (weight loss, elevation of the head of the bed, avoidance of tobacco and
alcohol) is unsuccessful, targeted and prolonged treatment with histamine blockers or proton pump inhibitors
(PPIs) is recommended. In a recent Cochrane review, patients who were treated with PPIs experienced a
significant improvement in cough scores. There was no significant difference in total resolution of cough,
however (odds ratio [OR] 0.46, 95% CI 0.19-1.15, intention to treat analysis). The duration of therapy was 2 to 3
months. As this patient has been on therapy for only 2 weeks and his clinical picture is without any interim
change, continuation for 8 to 12 weeks would be recommended.

The American College of Chest Physicians recommends a symptom-guided, systematic, algorithmic approach to
chronic cough. There is no evidence of infection, and therefore, antibiotics are not indicated. The patient does
not present with symptoms or signs of upper airway cough syndrome (postnasal drainage, frequent throat
clearing, nasal discharge, cobblestone appearance of the oropharyngeal mucosa, or mucus dripping down the
oropharynx). The use of antihistamines and decongestants, such as loratadine with pseudoephedrine, should be
reserved until the empiric trial of treatment for GERD is completed and found to be ineffective.

Cough-variant asthma (cough is the predominant symptom) occurs in up to 57% of patients with asthma.
Cough-variant asthma is suggested by the presence of airway hyperresponsiveness and confirmed when cough
resolves with asthma medications. The treatment of cough-variant asthma is the same as asthma in general, but
the maximum symptomatic benefit may not occur for 6 to 8 weeks in cough-variant asthma. This patient does
not have asthma and has a reasonable alternative explanation for his chronic cough; therefore treatment with an
inhaled bronchodilator such as albuterol is not indicated at this time.
Key Point and Education Objective
Treat chronic cough due to
gastroesophageal reflux disease.
 The duration of empiric proton pump
inhibitor therapy for a patient with
gastroesophageal reflux disease-related
cough is 8 to 12 weeks.

Chronic Cough
Diagnosis
Chronic cough lasts ≥8 weeks. UACS (previously called postnasal drip), asthma, and GERD are responsible for
approximately 90% of cases of chronic cough but are responsible for 99% of cases of chronic cough in patients who are
nonsmokers, have a normal chest x-ray, and are not taking an ACE inhibitor.
All patients should undergo chest x-ray. Smoking cessation and discontinuation of ACE inhibitors is indicated for 4 weeks
before additional evaluation.
Study Table:
Causes and Therapy of Chronic Cough
Question 9

A 42-year-old woman is evaluated for chest pain that started a few days ago. It is
midsternal, sharp, constant, and worsens with deep inspiration and recumbency. It
does not radiate to the back and does not worsen with physical activity. The pain
has increased slightly over the past day. She has no recent fevers or chills, cough,
joint pain, or rash. Two weeks ago, she had symptoms consistent with acute
tracheobronchitis.

On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is
122/80 mm Hg, pulse rate is 88/min, and respiration rate is 17/min. BMI is 32. She is
uncomfortable lying down and prefers to sit forward for the examination. Cardiac
auscultation demonstrates normal heart sounds with no murmur or rub. The
remainder of the examination is normal.

Electrocardiogram is shown. Chest radiograph is normal.
Question 9
Answer Choice
Which of the following is the most likely
diagnosis?
A Acute coronary syndrome
B Acute pericarditis
C Acute pleuritis
D Acute pulmonary embolism
Answer Choice
Which of the following is the most likely
diagnosis?
A Acute coronary syndrome
B Acute pericarditis
C Acute pleuritis
D Acute pulmonary embolism
Explanation

This patient most likely has acute pericarditis. Characteristic findings in acute pericarditis include
sharp, pleuritic retrosternal chest pain that is more prominent in the recumbent position, a
pericardial friction rub, widespread ST-segment elevation or PR-segment depression on
electrocardiogram (ECG), and new or worsening pericardial effusion. This patient has pleuritic
chest pain that worsens with recumbency and improves with sitting forward and widespread
concave-upward ST-segment elevation, making acute pericarditis the likely diagnosis. The
presence of a friction rub is helpful if present but its absence does not exclude the diagnosis.
Etiologies of acute pericarditis include infection (especially viral infection, as is likely in this
patient), autoimmune disease, neoplasia, uremia, and trauma.

The patient has no risk factors for ischemic heart disease and her description of her chest pain
is atypical for that of coronary artery disease. The widespread concave-upward ST- segment
ECG changes are more consistent with acute pericarditis rather than ischemia, in which changes
localized to leads associated with the specific regions of the involved myocardium would be
expected.

Like pericarditis, the pain of acute pleuritis worsens with inspiration, may be positional, and can
be accompanied by dyspnea. However, pleuritic chest pain is not confined to the retrosternal
area, as it is in pericarditis, and ECG changes would not be expected with pleuritis.

Although the chest pain that accompanies a pulmonary embolism is typically pleuritic,
pulmonary embolism is not associated with widespread ST-segment elevation or PR-segment
depression on ECG.
Key Point and Education Objective
Diagnose acute pericarditis.
 The chest pain of acute pericarditis is
typically sharp, pleuritic, retrosternal,
worsened by recumbency, and improved
by sitting forward.

Question 10

A 19-year-old man is evaluated for a 2-day
history of sore throat, cough, fever, and chills.
On physical examination, temperature is 38.9
°C (102.0 °F), blood pressure is 122/82 mm
Hg, pulse rate is 88/min, and respiration rate is
14/min. The pharynx is erythematous with
tonsillar enlargement and exudates bilaterally.
There is no cervical lymphadenopathy.
Answer Choice
Which of the following is the most
appropriate management?
A Obtain throat culture and start
penicillin therapy
B Perform rapid antigen detection
testing
C Start penicillin therapy
D No further testing or treatment
indicated
Answer Choice
Which of the following is the most
appropriate management?
A Obtain throat culture and start
penicillin therapy
B Perform rapid antigen detection
testing
C Start penicillin therapy
D No further testing or treatment
indicated
Explanation

This patient should be given a rapid streptococcal antigen test before beginning antibiotic
therapy. The patient's primary symptoms (fever, cough, and sore throat) are compatible with
either a viral upper respiratory tract infection or streptococcal pharyngitis. The Centor criteria
(presence of fever >38.1 °C [100.5 °F], tonsillar exudates, tender cervical lymphadenopathy;
absence of cough) predict the likelihood of streptococcal pharyngitis and is a reasonable way to
triage patients with pharyngitis to empiric treatment with antibiotics, symptomatic treatment
only, or testing with treatment if the test is positive. Patients with all four criteria have a 40% or
greater chance of having group A β-hemolytic streptococcal (GABHS) pharyngitis; patients with
zero or one criterion have a low (<3%) probability of GABHS pharyngitis. Patients with two
criteria, such as this patient, or three criteria have an intermediate probability of GABHS
pharyngitis; for these patients, some guidelines recommend throat culture and others
recommend the rapid antigen detection test (RADT) with confirmation of negative results. The
advantage of RADT is the immediate availability of the results. RADT has comparable sensitivity
and specificity to throat culture. The throat swab for either culture or RADT should be
obtained from both tonsils or tonsillar fossae and the posterior pharyngeal wall. In high-risk
patients, a negative antigen test should be confirmed by throat culture.

No guidelines recommend antibiotic treatment without further testing. Some recommend
treating patients with three or four Centor criteria while test results are pending, although
guidelines differ on this point.
Key Point and Education Objective
Manage acute pharyngitis.
 Use of the four-point Centor criteria is a
reasonable way to triage patients with
pharyngitis to empiric treatment with
antibiotics, symptomatic treatment only,
or testing with treatment if the test is
positive.

Pharyngitis
Diagnosis
Use the 4-point Centor criteria to stratify adult patients according to risk of group A streptococcal pharyngitis:
fever: subjective
absence of cough
tender anterior cervical lymphadenopathy
tonsillar exudates
Patients with 0 or 1 criterion should neither be tested nor treated with antibiotics. Evaluate adults with 2 or 3
criteria with a confirmatory test (rapid antigen detection test [RADT] or culture, but not both) and treat based on
results. Follow-up testing of negative tests with a throat culture is not recommended. Treat patients without testing
who have 4 criteria.
Fusobacterium necrophorum infection should be considered in adolescents and young adults with a negative RADT
and an unusually prolonged and severe pharyngitis. F. necrophorum is the causative agent of Lemierre syndrome,
septic thrombophlebitis of the internal jugular vein resulting in metastatic pulmonary infections.
Drug Therapy
Select oral penicillin for 10 days. Choose a macrolide for patients allergic to penicillin. F. necrophorum is treated with
ampicillin-sulbactam.