General Internal Medicine In-Training Objectives

1. Calculate the number needed to treat.

a. The NNT is the number of patients required to receive an intervention in order
for one patient to benefit from it. It is the reciprocal of the absolute risk
reduction (ARR)
b. communicates the effectiveness of a health-care intervention
i. NNT = 1/ARR
ii. ARR = Control event rate - Experimental event rate

2. Counsel a patient about the risks of a low-carbohydrate diet.

a. the findings from trials show that very low carbohydrate diets (eg, Atkins) are
safe with regard to serum lipids and are more effective for short-term weight
loss than low fat diets (eg, low glycemic load [eg, Zone], very low fat [eg, Ornish].
b. Some concerns of Low Carb High Fat Diets may include increases in Serum
Cholesterol, Osteoporosis and Kidney Stones may urinate more calcium than
normal.
c. However, the optimal mix of macronutrients for longer-term weight loss or
weight loss maintenance is unknown and likely depends upon individual factors.
d. Severe carbohydrate restrictions can result in ketosis. This results from insufficient
sugars/glucose, the body then proceeds to break down stored fats causing elevation of
ketones.
i. Symptoms of ketosis include nausea, headache, mental and physical fatigue,
and bad breath.
3. Determine negative predictive value.
a. Negative predictive value is the probability that subjects with a negative
screening test truly don't have the disease

Positive disease Negative disease

Positive test True positive (A) False positive (B) PPV: a/(a+b)
Negative test False negative (C) True negative (D) NPV: d/(c+d)
Sensitivity: a/(a+c) Specificity: d/(b+d)
• PPV: positive predictive value
• NPV: negative predictive value

NPV = TN / (TN + FN)

4. Diagnose arrhythmogenic syncope.

1. Arrrythmogenic syncope Hx is usually presented as suddenly with associated
symptoms including palpitation, dizziness, chest pain, lightheadedness. Are a
subcategory of cardiovascular syncopes, usually occurring without significant
prodromal symptoms and during exertion.
 b. Most Important thing in patients with Syncope is Hx and Physical Examination
findings.
c. Cardiac causes of syncope, tachyarrhythmias and bradyarrhythmias, are the second
most common cause of syncope and only account for 10% to 20% of all syncopal
episodes.
d. Usually caused by an abrupt drop in cardiac output and typically occurs within the
first few seconds of onset of the arrhythmia.
e. 1st Step Resting 12 lead ECG ideally while symptoms are present .

f. 2nd Step Read Through Hx to determine next

step
1. If a young black male with Syncope.
Physical Examination Systolic
Murmur Increase with Valsalva
(Structural Heart Dz)
▪ ECHOCARDIOGRAM
g. Recurrent episodes: Holter/Loop recorder
1. Depends on duration and frequency
of symptoms

5. Diagnose at-risk drinking patterns:

a. Men: > 14 drinks/week, or > 4 drinks per occasion
b. Women, adults > 65 yr old: > 7 drinks/week, or >3 drinks per occassion
c. Alcohol misuse screening: number of drinks (quantify), not CAGE or AUDIT-C

HAZARDOUS OR AT-RISK DRINKING-> When the above thresholds are exceeded

6. Diagnose malignant melanoma

ABCDEs of melanoma and the "ugly duckling" rule:
a. A – Asymmetry: One half of the lesion does not mirror the other half.
b. B – Border: The borders are irregular or indistinct.
c. C – Color: The color is variegated; the pigment is not uniform,
and there may be varying shades and/or hues.
d. D – Diameter: Classically, any pigmented lesion greater than 5-6
mm in diameter is concerning, although melanomas may also be
smaller.
e. E – Evolving: Notable change in a lesion over time raises
suspicion for malignancy. Ulceration and bleeding should prompt biopsy.
 Next Step:
• Wide Local Excision Depending on Size of Melanoma
o 0.5cm for In Situ melanomas
o 1cm for Melanomas < 1mm deep
o 2 cm for Melanomas with Deeper Invasion > 1mm
• ALWAYS Sentinel Lymph Node Biopsy if:
o 1mm thick, tumor ulceration or Mitotic rate >1/mm2
• Stage III Melanomas: wide excision, lymph node dissection, adjuvant interferon alfa
• Stage IV Melanomas: is treated with chemotherapy or immunotherapy. (IL-2(-),Nivolumab)

Prevention: sun avoidance, sun-protective clothing

7. Diagnose Osgood-Schlatter disease.

a. Classical Hx of a young 15-30 y/o Active patient who comes to the office with a CC of
pain in her knees especially with physical activity and walking up and down the
stairs.
b. Its is defined as a traction apophysitis at the level of the tibial tubercle due to
repetitive strain on the secondary ossification center of the tibial tuberosity
c. Physical Exam:
a. Tenderness to palpation and/or bony prominence at the tibial tubercle.
b. Pain reproduced by extending the knee against resistance,
i. stressing the quadriceps, or squatting with the knee in full flexion.
d. Dx: Osgood Schlatter is a clinical Dx and does not warrant radiographs

8. Diagnose panic disorder.

a. Panic disorder is characterized by recurrent, unexpected, and abrupt surges of
extreme anxiety that peak within minutes and is accompanied by four or more of
the following symptoms:
o palpitations, sweating, trembling, dyspnea, choking sensation, chest pain,
nausea or abdominal pain, lightheadedness, chills or heat sensations,
numbness or tingling, feeling detached from oneself, and fear of losing
control or dying.
b. Diagnosis requires that an attack be followed by at least 1 month of worry by the
patient that he or she will experience a recurrent attack.
c. It is important to rule out other physiological mimics: hyperthyroidism,
pheochromocytoma, substance use or cardiopulmonary disorders
d. Tx: 1st Cognitive Behavioral Therapy then 2nd Line SSRI
o short-acting benzodiazepines can be used while titrating SSRI
9. Diagnose plantar fasciitis.
a. Classical Hx is a 40-60 y/o patient who complains of pain in his/her feet usually
worse in the mornings and after prolongued rest.
b. Risk Factors: obesity, pes planus, and a sedentary lifestyle.
c. Physical exam: characterized by pain and tenderness near medial plantar heel
surface.
o Pain elicited with passive dorsiflexion of the toes (Windlass test).
d. Dx: Clinical Dx (no further tests are necessary)
e. Tx: Multimodal
o Application of Ice, Patient Education, Arch Support/Soles for Pes planus
o Heel Stretches, Pharmacotherapy NSAID sor APAP

10. Diagnose trochanteric bursitis.

a. Classical Hx is a 50-60 y/o overweight patient who complains of pain in his/her Hip
(on the side) radiating towards her knee or buttocks and is worse when lying on the
affected side.
b. Dx is solely by Hx and Physical Exam:
a. Pinpoint tenderness over trochanteric bursa.
b. Pain reproducible when patient wakes a step up.
c. Treatment: symptomatic

11. Manage a hyperplastic colonic polyp.

a. Hyperplastic colonic polyps are the most common type of serrated polyp, they are
non-neoplastic and are composed of normal mucosal elements.
b. If <10-mm rectosigmoid hyperplastic polyps => Next colonoscopy 10 yrs
c. If >10-mm hyperplastic polyps => Next Colonoscopy 3 years
d. If <10-mm sessile serrated polyps => Next colonoscopy 5 yrs

12. Manage acute prostatitis.

a. Commonly presents male patient 30-50 y/o with a CC of Dysuria, Increased
frequency, lower abdominal pain and perineal pain with voiding.
b. Dx: Digital rectal exam or PSA
c. Tx: Depends on Age and Risk for STD
o Low risk for STD: Oral fluoroquinolone (levofloxacin or ciprofloxacin) for 4 to
6 weeks
o High risk for STD: Age < 35y/o
▪ Single dose of ceftriaxone 250 mg intramuscularly
▪ Doxycycline, 100 mg twice daily for 10 days or single dose
azithromycin
13. Manage benign prostatic hyperplasia
a. BPH is the most common cause of lower urinary tract symptoms (LUTS)
b. For most patients conservative treatment is sufficient (reduce fluid intake, stop
contributing medications [diuretics, anticholinergics]).
c. The two major BPH drug classes include:
• α-adrenergic blockers (terazosin, tamsulosin, doxazosin, alfuzosin, and
prazosin)
• 5-α reductase inhibitors (finasteride, dutasteride)

14. Manage episcleritis.

a. Definition: Nonpainful dilation of superficial vessels
b. Not associated with visual impairment
c. Tx: Self-limited; no treatment required

15. Manage epistaxis.

a. 90% originate along the Anterior nasal septum (kiesselbach plexus)
b. 10% originate from Posteriorly (behind the posterior middle turbinate)
c. Anterior bleeds are obvious || posterior bleeds may be asymptomatic
d. Causes:
o nose picking, intranasal medication use, dry nasal mucosa, rhinosinusitis,
hemophilia, anticoagulants and neoplasms.
e. Treatment:
✓ 1st Step: Conservative measures:
o Patient-exerted compression of the nasal ala against the septum for at
least 15 minutes, which will stop most anterior bleeds
o Patient blows their nose to remove blood and clots.
✓ 2rd Step: Nasal packing
o Packing typically remains 4-5 days and Abx is given to prevent
sinusitis/otitis
✓ 3 Step: If bleeding site is found silver nitrate or a vasoconstrictor
rd

(oxymetolazone)
✓ 4th Step: If all these fail electric cautery by ENT.

16. Manage immunizations in a patient with cardiovascular disease.

a. 2011 AHA/ACCF guideline on secondary prevention, which recommends that all
patients with CVD should receive an annual influenza vaccination.

17. Manage mechanical low back pain.

a. Low back pain may be acute (lasting <4 weeks)
b. Subacute (lasting 4-12 weeks)
c. Chronic (lasting >12 weeks)
d. Most patients who present with back pain do not require additional imaging or
testing and will recover with supportive measures.
 i. Diagnostic studies:
1. Severe or progressive neurologic deficits
2. Serious underlying condition is suspected
3. No improvement after 4 to 6 weeks of conservative management
e. Surgery referral:
i. Cauda equina syndrome
ii. Severe neurologic deficits
iii. Suspected spinal cord compression
iv. Neuromotor deficits
v. Significant pain that persists after 6 weeks of therapy
f. Treatment (focus on symptom management and maintaining function)
i. Most patients with acute low back pain recover quickly no matter what
therapeutic intervention is used, usually within 4 weeks
ii. Nonpharmacologic
1. Maintain daily activities. Avoid bed rest.
2. Heat, massage, acupunture, exercise
3. Interdisciplinary rehabilitation (subacute & chronic)
iii. Pharmacologic
1. 1st line: NSAIDs (caution: nephrotoxicity & GI ulcer) or skeletal
muscle relaxants
a. Give at the lowest possible dose and for the shortest possible
2. 2nd line: Second-line agents include nonbenzodiazepine muscle relaxants
3. Opioids and tramadol should be avoided in acute low back pain if possible

iv. Interventional & Surgical treatment

1. Epidural glucocorticoid injections (short-term in patients with
radiculopathy)
2. Surgery: benefits only for
a. Discectomy: disk herniation causing persistent radiculopathy
b. Decompressive laminectomy: painful spinal stenosis
c. Prompt decompression: cauda equina

18. Manage pharmacotherapy for depression.

a. Major Depressive Disorder
i. Presence of at least five of the following symptoms during the same 2-week
period, at least one of which is depressed mood or loss of interest or
pleasure
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure activities
3. Significant weight loss or weight gain
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
 7. Feelings of worthlessness or excessive inappropriate guilt
8. Diminished ability to think or concentrate nearly every day
9. Recurrent thoughts of death; recurrent suicidal ideation; suicide
attempt
ii. Severity of depression with PHQ-9
1. Mild: 5 to 9
2. Moderate: 10 to 14
3. Moderately severe: 15 to 19
4. Severe: ≥20
o Treatment: Mild or moderate depression are treated by primary care physicians
▪ Trial of ~6 weeks (full-dose antidepressant monotherapy) prior to
change to either same or different class of drug, adding a second
antidepressant, or adding psychotherapy (aripiprazole or quetiapine
with any antidepressant, and olanzapine with fluoxetine).
o Initial treatment with CBT or second-generation antidepressants SSRIs, SNRIs,
and selective serotonin norepinephrine reuptake inhibitors
▪ Prevent relapse: continuation therapy (4 to 9 months) for patients with
unipolar depression who respond to acute therapy
▪ Life-long treatment: Severe depression or ≥ two depressive episodes
o DO NOT stop abruptly instead tapered gradually to avoid discontinuation
syndromes
o SSRIs: most widely prescribed
▪ Adverse sexual side effects (reduced libido, anorgasmia, delayed orgasm)
o SNRIs: helpful in patients with pain syndromes
o Bupropion: alternative for SSRIs/SNRIs with sexual side effects
▪ Contraindicated in seizure disorders
o MOAIs:
▪ Serotonin syndrome when using SSRIs, SNRIs, and MAOIs:
• Characterized by altered mental status, autonomic instability, and
neuromuscular hyperactivity and is potentially lethal.
19. Manage pityriasis rosea.
a. Reactive eruption of unknown cause associated with a previous viral eruption (HHSV
6 -7)
b. Presents with one scaling patch that is a few centimeters wide (herald patch).
1. Typically mistaken for an area of tinea corporis or contact dermatitis.
c. Many 0.5- to 2.0-cm red scaling patches then erupt along skin cleavage lines in a
“Christmas tree” distribution on the back a few days later and last 1 to 3 months.
The eruption is often mildly pruritic.
d. The clinical appearance of scaling papules and plaques is similar to that of secondary
syphilis, although PR typically spares the face, palms, and soles, whereas the rash of
secondary syphilis often affects the palms and soles.
1. Testing should be performed if there is any clinical concern for syphilis
▪ r/o syphilis as part of work up
e. Treatment:
1. Usually self limited
2. Topical glucocorticoids and antihistamines may help with the pruritus.

20. Manage tinnitus.

a. Tinnitus is the conscious perception of sound (whistling, buzzing, ringing) in one or
both ears that is not associated with an external stimulus.
b. Common causes include:
 1.Excessive noise exposure (both acute and chronic)
2.Otosclerosis
3.Barotrauma
4.Infection
5.Vascular insufficiency
▪ Pulsatile (coinciding with the patient’s heartbeat)
✓ Auscultation for bruits over the neck, periauricular area, orbits
and mastoid.
▪ AVMs, atherosclerosis, carotid artery disease, aneurysm,
paraganglioma
6. Meniere disease
7. Metabolic disorders
▪ Hypo/hyperthyroidism, anemia, hyperlipidemia, zinc and B12
deficiencies
8. Ototoxic medications
▪ Aminoglycosides, Loop diuretics (>400 mg/day)
▪ Only ototoxic at high doses or toxic levels.
▪ Usually reversible, with the exception of platinum-based
chemotherapeutic agents and aminoglycosides.
c. Non-pulsatile tinnitus
1. Time of onset, laterality, associated symptoms
2. Presbycusis: Tinnitus + progressive hearing loss in an older patient.
3. Acoustic neuroma: Tinnitus + unilateral sensorineural hearing loss
4. Unilateral tinnitus: Otitis media or cerumen impaction
d. Management:
1. History
2. Physical Exam
▪ Similar to that for hearing loss
▪ Cranial nerves → examine for evidence of brainstem involvement
▪ Auscultation for bruits
3. Audiometry evaluation
▪ If unilateral and hearing loss is confirmed → MRI to examine
acoustic neuroma.
▪ If tinnitus is associated with sudden hearing loss, otorrhea,
vestibular dysfunction, or focal neurologic deficits → Urgent
evaluation by ENT, this may suggest vascular cause.
4. Labs
▪ Thyroid studies, CBC, Lipid panel, Zinc and Vitamin B-12 levels
5. Imaging studies
▪ Most patients do not require neuroimaging, with exception of:
 ▪ Unilateral or pulsatile tinnitus, asymmetric hearing loss, or focal
neurologic abnormalities
6. Treatment
▪ Mild tinnitus that is minimally bothersome to the patient may not
require treatment.
▪ Bothersome tinnitus is directed toward the underlying disorder.
▪ Medications are largely ineffective in the treatment of tinnitus.
▪ Neurocognitive interventions (including cognitive-behavioral
therapy)
▪ Sound-masking noise generators

21. Manage vasovagal syncope.

a. Vasovagal Syncope falls within Neurally-mediated syncope
1. Neurally mediated syncope are the #1 most common etiology
2. Usually associated with Prodrome
▪ Nausea, lightheadedness, warmth
b. Guideline directed evaluation for syncope
1. Initial evaluation:
▪ Detailed history taking
▪ Detailed physical examination
• Orthostatic BP and HR
• Auscultation for valvular heart disease
▪ 12-lead electrocardiogram
c. Treatment for neurally-mediated syncope:
1. If prodrome exist educate to avoid triggers and adopt physiologic counter
pressure maneuvers i. e. legs crossing, lower body muscle tensing, lying down
2. Reassurance, education
3. Avoid Hypotensive agents

22. Manage viral conjunctivitis.

a. Red eye is the most frequent eye disorder, and Conjunctivitis is the most common
cause of red eye
b. May be bacterial, viral or non-infectious
o Viral Conjunctivitis: #1 etiology is Adenovirus
o Acute, Unilateral, URI exposure and sick contacts
o Contagious as long as eye has discharge
▪ 3-7 days
 c. Viral conjunctivitis treatment:
o Supportive care
▪ Cold Compresses
▪ Artificial tears
o Food handlers and health care providers should
NOT work until symptoms subside

23. Order appropriate immunizations in an adolescent.

a. Influenza
o Annually after >6 mo old
b. Tetanus, diphtheria, Pertussis
o TDAP booster x1 after 11 y/o
o TD booster every 10 years afterwards
o Pregnant women Tdap x1 (27-36 GWA)
c. Pneumococcal
o 19-64 y/o on persons with risk factors:
▪ Immunocompetent with high risks:
• CHF, COPD, DM, CSF leak, CLD, smokers
▪ Functional or anatomic asplenia
▪ Immunocompromised:
• Sickle cell, congenital immunodefifiency
HIV, CKD, lymphoma/leukemia
malignancy, organ transplant, MM
o Every adult > 65
d. Measles, Mumps, Rubella
o One MMR dose
▪ Second may be provided if needed at college students
e. Meningococcal
o One dose for first-year college students at dormitories
f. Hepatitis A&B
o High risk, requesting immunization
g. 9-valent human papillomavirus (HPV): 2 doses 6mo apart 11-12yo – 26 y/o men and
women
o May vaccinate up to

24. Prevent recurrent lower extremity cellulitis.

a. Patients with cellulitis have an annual recurrence rate between 8% to 20%
b. Treating predisposing factors such as obesity, diabetes, lower extremity edema,
venous insufficiency and/or tinea pedis might decrease recurrence.
 o Examine interdigital spaces and treat for tinea infection, maceration, and
fissuring.
c. Patients with more than 3 episodes of cellulitis per year consider prophylactic
antibiotics (low-dose penicillin) to prevent recurrence.

25. Prevent urinary tract infection.

a. 1st: Consider alternate method of contraception in patients using condoms,
diaphragms.
b. 2nd: antimicrobial prophylaxis with nitrofurantoin or trimethoprim-
sulfamethoxazole daily
o Does not alter the long-term risk for recurrence after prophylaxis is
discontinued
c. Another alternative is taking a single dose of nitrofurantoin or TMP-SMX after
sexual intercourse if recurrent UTI is clearly linked to sexual intercourse.
d. An additional, non-preventive strategy is for patients with previously diagnosed
cystitis to self-diagnose and self-treat at the onset of symptoms.
e. In postmenopausal women, two small studies have shown the use of topical vaginal
estrogens reduces the number of UTIs compared with placebo.

26. Recognize indications for human papillomavirus immunization in male patients

a. Men aged 11-12y/o *
b. Men aged 13 - 26 y/o who have not been previously vaccinated
c. two HPV vaccines are licensed for use in males (quadrivalent and nine-valent)
d. HPV genotypes 16 and 18 are responsible for causing most cases of cervical cancer
and many cases of vulvar, vaginal, anal, penile, and oropharyngeal cancers. HPV
genotypes 6 and 11 cause most cases of genital warts.

27. Screen a patient for alcohol misuse.

a. According to the USPSTF, all adults should be screened for alcohol misuse
b. Recommended screening tools include the Alcohol Use Disorders Identification Test (AUDIT)
the abbreviated AUDIT-Consumption (AUDIT-C), and the single-question screen “How many
times in the past year have you had five [four for women and adults older than age 65 years]
or more drinks in 1 day?”
c. Single question screen and AUDIT-C Test are preferred over AUDIT Test and CAGE questions.
d. AUDIT C Screening
o How often do you drink alcohol?
a) Never
b) Monthly or less Positive in Men Score >4
c) 2-4 times a month
d) 2-3 times a week
e) 4 or more times a week
Positive in Women Score >3
o How many drinks do you have on a
typical day when you are drinking?
 a) 1 or 2
b) 3 or 4
c) 5 or 6
d) 7 to 910 or more
o How often do you have 6 (4 for women) or more drinks on 1 occasion?
▪ Never
▪ Less than monthly
▪ Monthly
▪ Weekly
▪ Daily or Almost daily
o Score on a Scale 0-12 A= 0 pts, B = 1 pts, C = 2 pts, D = 3 pts, E = 4pts

28. Screen for cervical cancer.

a. Women ages 21 to 65 years screened every 3 years with cytology (Pap smear)
b. Women ages 30 to 65 years lengthen the screening interval cytology and human
papillomavirus (HPV) testing can be performed every 5 years.
c. Women > 65 years who are not at high risk
o adequate prior Pap smears (three consecutive negative cytology results or
two consecutive negative cytology results
o hysterectomy with removal of the cervix with no history of a precancerous
d. Screening NOT recommended: Younger than 21 years

29. Screen for osteoporosis.

a. USPTF Recommends to screening in:
▪ Women >65 y/o
▪ Glucocorticoid therapy for more than 3 months
▪ Primary hyperparathyroidism
▪ Hx of fracture suspected Osteoporotic
▪ Postmenopausal women and Age 50-69 y/o based on risk factor profile
• Low body weight (BMI < 17)
• Family hx of hip fracture
• Cigarette smoking
• Excess alcohol intake
b. Treatment:
▪ If Risk of Major Osteoporotic Fracture > 20% or >3% hip Fracture => Tx
c. Always screen for 2ary causes of Low Bone Density if confirmed Osteoporosis
▪ CBC, CMP, TSH, Vit D 25 OH Levels
d. Repeating after 15 years may be reasonable if the hip T-score is normal (>−1),
while retesting at 2 years may be considered if the hip T-score is −2 to −2.4.
 30. Treat allergic rhinitis.
a. Classical Hx of a 40y/o patient who comes CC of sneezing, congestion,
rhinorrhea) associated with a season, environment, or exposure.
b. Treatment – avoid precipitating factor
i. Pharmacotherapy
1. First line Tx recommended seasonal allergic rhinitis
a. leukotriene inhibitor (strong recommendation)
Montelukast
2. Other alternative treatments
a. Glucocorticoid nasal spray
b. Second generation antihistamine
c. Nasal saline
ii. Allergen avoidance
iii. Allergen immunotherapy

Rhinitis medicamentosa - is chronic rhinitis resulting from the inappropriate long-term use of
topical nasal decongestants. Treatment consists of cessation of the decongestant and intranasal
glucocorticoids when needed

31. Treat contact dermatitis.

Occurs with repeated exposure to a chemical, a pruritic eczematous
dermatitis develops on the exposed area.
Tx:
1st Step: avoidance of the causative chemical.
2nd Step: Topical corticosteroids and emollients are used empirically
e. Not involving face or flexural areas high-potency corticosteroids
▪ Fluocinonide or betamethasone dipropionate
f. Involving face and flexural areas medium- or low-potency topical corticosteroids
▪ Triamcinolone and bethamesone

32. Treat cutaneous psoriasis.

a. Topical therapy is the preferred choice for localized disease.
i. Medium- to high-potency topical glucocorticoids
either alternating with or in conjunction with topical
vitamin D analogues or keratolytic agents.
ii. “Steroid holidays” recommended to avoid atrophy
and striae.
b. Calcineurin inhibitors used “off-label” for psoriasis of axilla, perineum or under
breasts (“inverse psoriasis”).
c. Patients with psoriasis covering >10% body surface area or those with psoriatic
arthritis, recalcitrant palmoplantar psoriasis, pustular psoriasis, or psoriasis in
groin, scalp, (“difficult” areas) may be considered for systemic therapy
(retinoids, methotrexate, cyclosporine), or biologic agents [(TNF)-α inhibitors
and interleukin-12 or interleukin-23 inhibitors)].
33. Treat obesity with medical complications.
a. BMI ≥ 35 with comorbidities Hypertension, Diabetes, OSA
i. The Roux-en-Y gastric bypass, Gastric Balloon
1. These procedures generally produce a 30–35% weight loss that is
maintained in about 40% of pts at 4 years.

34. Treat obesity. (first step asses BMI and comorbidities)

a. BMI ≥25 kg/m2 Diet, exercise, and behavior therapy recommended
o Diet
o Increased physical activity
▪ Low-intensity exercise walking 30 min/day helpful maintaining weight
▪ High intensity workouts produce greater benefits for weight loss
o Behavioral therapy: Establishing a weight loss goal
b. BMI of 30 or higher or BMI > 27 with comorbidities: Pharmacologic therapy
o Before starting any medications important to explain possible side-effects.
o Orlistat(120 mg po tid)--> is an inhibitor of gastric and pancreatic lipases that
results in malabsorption of approximately 30% of ingested fat.
▪ Diarrhea and oily stools are common side effects
▪ should take vitamins A, D, and E
o Metformin, exenatide, and liraglutide decrease body weight in pts with
obesity and type 2 diabetes mellitus (NOT INDICATED IF NOT DIABETIC)
c. BMI of 35 or higher with obesity-related comorbid conditions
o Bariatric surgery
d. BMI ≥ 40 without comorbidities: Surgical approach:
o The Roux-en-Y gastric bypass, Gastric Balloon

35. Treat symptoms of restless legs syndrome.

a. Restless legs syndrome (RLS) is a common movement disorder characterized by an urge
to move the legs. Patients report an uncomfortable sensation that is worse at rest and
at night and is transiently relieved by movement.
b. Should be screened for iron deficiency and receive iron supplements in the
presence of deficiency or even low-normal serum ferritin levels.
c. Dopamine agonists, specifically pramipexole, ropinirole, and the rotigotine
patch.

36. Understand why family members cannot act as interpreters.

• Family members may have personal agendas
• Lack of understanding of medical terminology
• Not neutral
• Inaccurate Interpretations
• No guarantee of confidentiality
37. Use root cause analysis to address a problem in health care.
Root cause analysis is a method used to discover the factors that contributed to an error
and involves talking to all stakeholders involved in the error. A technique used in root
cause analysis is the Five Whys, which involves asking the question “Why?” successively
to drill down to the real root of a problem. To organize the root causes, a cause-and-
effect diagram (also known as a fishbone diagram or Ishikawa diagram) can be used. The
problem, or error, forms the backbone of the diagram and root causes are branched off
like ribs
Additional Objectives from Prior Years:

1. Diagnose lateral femoral cutaneous nerve entrapment.

• Meralgia paresthetica, a compressive neuropathy of the lateral femoral cutaneous
nerve.
• Symptoms: isolated anterolateral thigh numbness without weakness
• Diagnosis: Clinical
• Tx: Conservative

2. Diagnose lumbar spinal stenosis.

• LSS is clinically manifested by neurogenic claudication, a syndrome of bilateral, often
asymmetric pain, sensory loss, and/or weakness affecting the legs.
• Pain occurs during certain activities such as walking or standing upright
• Feeling relieved by rest (sitting or lying down) and/or any flexed forward position.
• In a few patients, more fixed nerve root injury may occur, causing lumbosacral
radiculopathy, cauda equina syndrome, or conus medullaris syndrome.
• The diagnosis of LSS requires a neuroimaging study. Magnetic resonance imaging of the
lumbosacral spine is the test of choice for most patients.

3. Diagnose trochanteric bursitis.

• Presents with aching sensation over the greater trochanteric bursa (lateral hip) that
may radiate to the buttock or knee and is often worse when lying on the affected
side.
• Dx is made by hx and by eliciting pain with palpation over the greater trochanter or
reproduction of the pain when the patient takes a step up.

4. Manage a varicocele.
• Varicoceles are a leading cause of infertility.
• Repair (open inguinal varicocelectomy, laparoscopic varicocelectomy, and
subinguinal microscopic varicocelectomy) may be warranted in men with abnormal
sperm counts who desire children, although a Cochrane review did not confirm
increased fertility with repair.
• Conservative care is adequate for men who do not desire children and are otherwise
asymptomatic.

5. Manage benign paroxysmal positional vertigo.

• The Epley maneuver also known as the canalith repositioning procedure, is an
effective and safe treatment. Serves for diagnosis and treatment.
6. Manage subacute cough.
• Subacute cough most commonly develops after an infection, including B.
pertussis infection. In endemic or sporadic cases of pertussis, patients present
with a cough lasting at least 2 weeks plus at least one other clinical finding:
paroxysms of coughing, inspiratory “whoop,” or post-tussive emesis with no
other apparent cause. If infection is unlikely, consider common causes of chronic
cough. Inhaled ipratropium may be beneficial in treating subacute cough if there
is no airway hyperreactivity.

7. Screen for domestic abuse.

Screen for domestic violence and home safety in women of childbearing age (14-46
years of age).

8. Select appropriate preoperative testing for a patient at low risk.

• Routine diagnostic testing is not indicated preoperatively in healthy patients
undergoing elective or low-risk surgery (such as eye surgery) or obtaining
preoperative chest radiography in the absence of cardiopulmonary symptoms.
• Patient-specific factors determine diagnostic testing needs, like serum
electrolytes in patients who will undergo diuresis, and kidney function studies in
those with chronic kidney disease (CKD), are reasonable testing indications.
• The American Society of Anesthesiology (ASA) does not recommend repeating
laboratory studies obtained within 6 months of surgery in the absence of a
clinical change

9. Manage colonic polyp