INTERNAL MEDICINE IN-REVIEW STUDY GUIDE Companion to the Online Study System InReviewIM.com Senior Editor Norman H. Ertel, MD Associate Editors James M. Horowitz, MD Miguel A. Paniagua, MD, FACP Available through support from the makers of Powered by © 2013 Educational Testing & Assessment Systems. All Rights Reserved. This document contains proprietary information, images, and marks of Educational Testing & Assessment Systems. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. The questions and answers, statements or opinions contained in this Study Guide or Web Site have not been approved by McNeil Consumer Healthcare Division of McNEIL-PPC, Inc., the makers of TYLENOL®. 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No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. INTERNAL MEDICINE IN-REVIEW STUDY GUIDE MODULE 1 © 2013 Educational Testing & Assessment Systems. All Rights Reserved. This document contains proprietary information, images, and marks of Educational Testing & Assessment Systems. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. 1 General Internal Medicine Fred Buckhold, MD Contents 1.1 ROUTINE CARE OF THE HEALTHY PATIENT . 2 1.2 GERIATRIC MEDICINE . .4 1.3 PERI-OPERATIVE MEDICINE . 5 1.4 PATIENT SAFETY . 6. 1.5 PROFESSIONALISM AND ETHICS . .6 1.6 PALLIATIVE CARE . 7 1.7 COMMON SYMPTOMS . 8 1.8 MEN'S HEALTH . 13 GENERAL INTERNAL MEDICINE 1 © 2013 Educational Testing & Assessment Systems. All Rights Reserved. This document contains proprietary information, images, and marks of Educational Testing & Assessment Systems. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. 1.1 ROUTINE CARE OF THE HEALTHY PATIENT Screening Assessing patients for risk or presence of asymptomatic disease and identifying lifestyle choices that have health consequences. • Often based on prevalence of diseases • The United States Preventative Services Task Force (USPSTF) has recommendations on which screening measures are effective Screening During History and Physical Exam • Measure height and weight (for BMI/obesity) • Measure blood pressure (for hypertension) • Assess for tobacco, alcohol, and drug use • Detailed sexual history, including risk factors for STDs Screening Tests • Papanicolaou test every 3 years starting at age 21, stopping age 65 • Chlamydia for sexually active women under age of 25 • Routine HIV screening for ages 13 to 64 • Biennial mammograms for women age 50 to 74 • Cholesterol screening (Total and HDL) every 5 years in men >35 years and women >45 years • Fasting glucose if sustained blood pressure >135/80 mmHg • Colonoscopy every 10 years above age of 50 until age 74; may also have occult blood testing yearly or flexible sigmoidoscopy every 5 years • Abdominal aortic aneurysm for male adults between 65 to 75, if history of smoking present • Osteoporosis (via BMD) in women >65, or 60 to 64 if body weight below 70 kg Family History Taking a Family History • Screen for diseases that family members have • Inquire specifically about early onset cardiovascular disease and 1st and 2nd degree relatives with cancer (and what type/age of onset) Genetic Testing • More useful for high risk populations, or if suspected • Testing should aid in diagnosis and/or management ° BRCA or FAP mutation may lead to aggressive screening and interventions 2 INTERNAL MEDICINE IN-REVIEW l INREVIEWIM.COM © 2013 Educational Testing & Assessment Systems. All Rights Reserved. This document contains proprietary information, images, and marks of Educational Testing & Assessment Systems. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. Immunizations Table 1.1: Immunizations Vaccine Frequency Indications (blank indicates universal) Hepatitis A 2 doses once • Men who have sex with men • Injection drug users • Occupational (food handlers) • Travel to endemic areas • Chronic liver disease Hepatitis B 3 doses • Sexually active young adults • Healthcare or public safety workers • Travel Human papillomavirus vaccine Females 19-26 years, males 19-21 years, consider 22-26 – 3 doses Influenza Annually Measles-Mumps-Rubella Should have as a child May have to check serologies if unsure of history; adults born before 1957 considered immune Meningococcal vaccine 1 dose • 1st year college students • HIV or asplenia Pneumococcal vaccine 1 or 2 doses • Age >65 • Chronic lung disease, diabetes, chronic liver disease, asplenia Tetanus-Diphtheria-Acellular Every 10 years • Tdap booster once, followed Pertussis (Td or Tdap) by Td every 10 years Varicella 2 doses Zoster 1 dose Age 60 and above Lifestyle Risk Factors Behavioral Counseling • Brief interventions at office visits can be effective • Use the 5 “A”s: Assess, Advise, Agree, Assist, Arrange Physical Inactivity • Should encourage 30 minutes of aerobic exercise 5 times weekly • Strengthening exercise at least twice weekly • Medical screening not needed in asymptomatic patients • Encourage activity to reduce sedentary behavior for those with chronic disease or in ages >65 years Substance Use Disorders • Tobacco ° Assess at each visit ° Brief counseling and possibly medication • Routinely screen for alcohol misuse and abuse—most frequently in young adults and smokers ° Can use CAGE questionnaire GENERAL INTERNAL MEDICINE 3 © 2013 Educational Testing & Assessment Systems. All Rights Reserved. This document contains proprietary information, images, and marks of Educational Testing & Assessment Systems. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of Educational Testing & Assessment Systems. If you feel you have obtained this illegally, please contact Educational Testing & Assessment Systems immediately. ° If at-risk—brief counseling ° If dependence—referral to treatment • Illicit drugs: Look for behavior changes, legal troubles, and medical sequelae ° Referral or brief counseling Sexual Behavior • History oriented to high risk practices (men who have sex with men, multiple partners, contact with sex workers) • Counsel of safe sex practices (use of barrier protection vs. birth control for prevention of STDs) • Offer screening for STDs as appropriate Domestic Violence • Screen if suspected • Intervene if possible; assessing for safety, clear documentation of injuries, and providing resources 1.2 GERIATRIC MEDICINE Functional Assessment • Hearing loss screening ° Patient reported ° Test by whispering in ear while using distraction in other ear • Screen for vision loss • Screen for depression • Probe for deficits in activities of daily living • Inquire for falls ° “Get up and go” good for screening ° To reduce risk of falls: • Monitor meds, stop centrally acting ones • Muscle